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New Strategies for the Prevention and Treatment of Graft vs. Host Disease (GVHD). Simrit Parmar, MD Stem Cell Transplant & Cellular Therapy BTG2013, Hong Kong. Risk Factors for Acute GVHD. HLA disparity Increasing age Donor and recipient gender disparity - PowerPoint PPT Presentation
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New Strategies for the Prevention and Treatment of Graft vs. Host Disease (GVHD)
Simrit Parmar, MDStem Cell Transplant & Cellular Therapy
BTG2013, Hong Kong
Risk Factors for Acute GVHD
• HLA disparity • Increasing age • Donor and recipient gender disparity • Type and status of underlying disease • Amount of radiation and intensity of the
transplant conditioning regimen • Doses of methotrexate and cyclosporine or
tacrolimus
Acute GVHD: Pathophysiology1. Recipient conditioning
2. Donor T cell activation
3. Cellular and Inflammatory Effectors
Acute GVHD• Acute GVHD
– Typically occurs around the time of engraftment.– Previously mis-defined as GVHD which occurs prior to day
100 post-transplant.
– Three main organs involved:• Skin: macularpapular rash• GI system: Nausea / Vomiting and Diarrhea• Liver Abnormalities: typically cholestatic (jaundice).
– Incidence of 9-50% of sib transplants.
Vigorito et al. Blood 2009
Acute GVHD: Survival and Relapse
• Grade 0 acute GVHD — hazard ratio (HR) for TRM: 1.0 • Grade I — HR 1.5 (95% CI 1.2-2.0) • Grade II — HR 2.5 (95% CI 2.0-3.1) • Grade III — HR 5.8 (95% CI 4.4-7.5) • Grade IV — HR 14.7 (95% CI 11-20)
• Grade 0 acute GVHD — hazard ratio (HR) for relapse 1.0 • Grade I — HR 0.94 (95% CI 0.8-1.2) • Grade II — HR 0.60 (95% CI 0.5-0.8) • Grade III — HR 0.48 (95% CI 0.3-0.8) • Grade IV — HR 0.14 (95% CI 0.02-0.99)
DEATH
RELAPSE
“Be good or I’ll send you to transplant”
“”I am telling you, by the time they get done with you, you’ll be
wearing diapers”“Do you want a little vidaza or total body skin
sloughing?”
GVHD Prophylaxis
“No Free Lunch” Principle
GVHD
• Relapse• Rejection• Delayed Immune Reconstitution
GVHD
Immune Function in HCT
• Dysfunctional immune responses are common in clinical medicine
• Major mechanism of disease control due to GVT reactions, yet major limitation of allogeneic HCT is GVHD
• Controlling GVHD could lead to use of allogeneic HCT in other clinical settings such as treatment of autoimmune diseases and tolerance induction for organ transplantation
Risk of GVHD in Two Eras
Gooley et al. N. Engl. J Med 363:2091, 2010
In vivo tracking of light emitting donor cells
Allogeneic HCT
B
TM
BM BMBM
B
T
Bone Marrow
Splenocytes
FVB/N
WT
luc+Balb/c
H-2q/Thy1.1H-2d/Thy1.2
CD4+
CD8+
B220+
NK1.1+
Gr-1/Mac-1+
2x105 cells/well Absolute light emission
0.00 0.05 0.10 0.15
Luciferase 2A eGFPbAct
luc+ reporter mouse
Acute Graft-vs-Host Disease Development
Beilhack, A. et al. Blood. 2005. 106:1113
The Evolution of acute GVHD
Approaches to the Prevention of GVHD
• Pharmacologic– CNI/MTX– CNI/MTX vs Rapa/MTX
• Graft source– BM vs PBPC– MRD vs URD vs UCB
• T Cell depletion– CD34 Selection– ATG, Campath
• Immune regulation
Regulation of Immune Function
• Critically important in health and disease
• Compartmentalization of immune responses
• Cytokines• Regulatory T cells (Treg, NK-T, iTreg, others)
RegulationReactivity
T regulatory cell T effector cell
CD4+ T Cell Subsets
CD4+CD25+ Regulatory T Cells• Major population of cells which regulate immune
reactions
• Express transcription factor FoxP3
• Deficiency or mutation of FoxP3 has autoimmune consequences in animal models and humans
• Cell contact-dependent suppression of alloreactive responses in mixed lymphocyte reactions (MLR)
• Prevent organ specific autoimmune diseases in animal models (e.g. IBD, diabetes)
• IL-10 and TGF- implicated in mediating suppressive effect in vivo
Regulatory T-cells• Allogeneic HCT recipients with aGVHD had Treg
frequencies 40% less than those without aGVHD.
• Treg frequencies decreased linearly with acute GVHD severity.
• The frequency of Tregs at acute GVHD onset predicted response to therapy.
Magenau et al. BBMT. 2010.
Magenau et al. BBMT. 2010.
38%
63%
Circulating Tregs predict OS
d15 Death fromGVHD
100
5000
1000
20000
Time [d] post BMT
Rel
ativ
e S
igna
l Int
ensi
ty
Sur
viva
l [%
]
TCD BM only, n = 14
TCD BM + Tcon, n = 15
TCD BM + Tcon + Treg n = 9
Control of GVHD with Retention of GVL
TconBM only Tcon + Treg
500
5000
d5
Edinger et al. Nature Medicine 9:1144, 2003
Challenges for Clinical Translation of Treg
• Treg are rare cell populations• Paucity of unique markers for isolation and
availability of clinical grade reagents• Marginal functional assays in humans• Regulatory requirements
Expanded CB Tregs show FOXP3 demethylation and suppress alloMLR
3rd Party CB Tregs Prevent GVHD
In vivo tracking of Treg transduced with GFP and Firefly Luciferase
Treg Treg+PBPC
Day -1
Day 0
Day 3
Day 10
dorsal
Treg Treg+PBPC
Day -1
Day 0
Day 3
Day 10
dorsal
Treg Treg+PBPC
Day -1
Day 0
Day 3
Day 10
dorsal
Treg Treg+PBPC
Day -1
Day 0
Day 3
Day 10
dorsal
Treg Treg+PBPC
Day 3
Day 10
ventral
Proposed phase I Clinical Trial
Treg Doses to be Studied
Dose Cohort Treg Dose
Dose Level 1 1 × 105 Tregs/kg
Dose Level 2 5 × 105 Tregs/kg
Dose Level 3 1 × 106 Tregs/kg
Dose Level 4 5 × 106 Tregs/kg
Dose Level 5 1 × 107 Tregs/kg
Next Step: Adoptive Therapy with Treg
Day -8
Day-7
Day-6
Day-5
Day-4
Day-3
Day-2
Day-1 0 +1 +2
Day+3
Day+4
Day+6
BUTestDose
32mg/m2
Rest BU BU BU BU BMT Infusionof
Ex-vivoExpanded
TregsFLU40
mg/m2
FLU40
mg/m2
FLU40
mg/m2
FLU40
mg/m2
CY**50
mg/kg
CY**50
mg/kg
Day-6
Day-5
Day-4
Day-3
Day-2
Day-1
0MEL BU BU BU Infusion of
Ex-vivoExpanded
Tregs
BMT
FLU40
mg/m2
FLU40
mg/m2
FLU40
mg/m2
FLU40
mg/m2
MMF+Sirolimus
Individual clinical outcome of patients who received a Treg dose > 30x105/kg
Haploidentical Transplant Schema (Stanford)
Mel, TT, Flu +Thymoglobulin@
0 +14 +16Day -10
CD34+ cell selected
graft
CD4+CD25+
Treg
CD4+/CD8+ Tcon
Cell Dose
5-10 x 106/kg
105/kg
3x105/kg
106/kg
Endpoints:
Chimerism
Immune reconstitution
Acute and chronic GVHD
EFS, OS
BB IND13923
Selection of CD4+CD25+ Tregs (U. Perugia)
Cells (x109) 1060 (540-1370) 280 (202- 390)
%CD4CD25 3.0 (1.5-7.45) 92.4 (90-97.1)N° cells (x 106) 330 (221-1020) 256 (185.6-365.4)
%CD4CD25high 0.3 (0.12- 0.89) 33.6 (14.4-39.6)N° cells (x 106) 36.12 (19.98 - 84) 68.6 (20.9-143)
Starting fraction Final fraction
CD
25
CD127
CD4
FoxP3
Gate on CD4CD25+high
Gate on CD4CD25+
Fox P3+ cells 71.9 ± 15 %
ImmunomagneticSelection of
CD4+CD25+Cells
1st step:Depletion of CD8+/CD19+cells
2ndstep:Enrichment of CD25+ cells
>50 >100 >2000
50
100
150
200
CD4/l
Days p
ost
BM
T
>50 >100 >2000
20
40
60
80
100
CD8/l
Days p
ost
BM
T
Recovery of CD4+ and CD8+ T cell subpopulations
0
50
100
150
200
250
1 2 3 4 5 6 7 8 9 10 11 12
Sp
ectr
atyp
e co
mp
exit
y S
core
Donors
Months after transplant
Com
ple
xity
sco
re
Spectratyping
Pattern of immunoreconstitution
Evaluable Patients
Patients with CMV reactivation
0-30 31-60 61-90 91-120 121-150 151-180 181-365 >3650
10
20
30
40
50
60
70
80
90
100100
96
8275
67
5648
2928
50
34
22
9 91 1
0-30 31-60 61-90 91-120 121-150 151-180 181-365 >3650
5
10
15
20
25
30 27
21
16
109
5
212
5
1 0 0 0 0 0
Days after transplant
Days after transplant
CMV reactivation episodes
Tregs Group
Control Group
p<0.05
Outcomes – U. of Perugia
Event-Free Survival 12/26 (46%)
• Regimen Related Toxicities:– Veno-occlusive disease (3)– Multi-organ failure (1)
• Acute GVHD grade III-IV (2)• Serious infections (7)
• Relapse (AML 1)
Median follow-up 18.5 months (range 16.1-27.6)
D’Ianni et al. Blood 2011
Conclusions
• GVHD remains the most significant complication following allogeneic HCT
• Murine studies have demonstrated that immune regulatory mechanisms play a significant role in controlling dysfunctional immune responses including GVHD
• Clinical translation is ongoing with promising early results