异基因造血干细胞移植后人巨细胞病毒再激活的主要分子事件

异基因造血干细胞移植(allo-HSCT)所致的机体免疫缺陷是引起潜伏状态人巨细胞病毒(HCMV)再激活的始动因素。allo-HSCT受者HCMV再激活的危险因素包括供受者HCMV血清学状况、人类白细胞抗原(HLA)匹配程度及预处理方式等。HCMV再激活与病毒基因组中主要即刻早期启动子/增强子(MIEP)过表达诱发的系列病毒裂解增殖蛋白的表达相关。本文就引起allo-HSCT术后HCMV再激活的危险因素、维持HCMV潜伏感染相关的分子变化、MIEP过表达在HCMV再激活过程中的关键作用、参与allo-HSCT术后HCMV再激活的分子通路进行综述,探讨allo-HSCT后HCMV再激活的主要分子事件,为allo-HSCT后巨细胞病毒病(CMVD)的防治提供参考。     

Risk factors and severe outcome in thrombotic microangiopathy after allogeneic hematopoietic stem cell transplantation

BACKGROUND: Thrombotic microangiopathy (TMA) has been described as severe complication after hematopoietic stem cell transplantation (HSCT). The principal aim of this study was to focus the incidence and the outcome of TMA in the era of more complex HSCTs. METHODS: We analyzed the role of some predicting factors for the incidence and the outcome of TMA after HSCT. We enrolled 539 consecutive patients (307 males, median age 31 years) undergoing HSCT from match or mismatch human leukocyte antigen family donor (314) or match/mismatch unrelated (195) and haploidentical donor (30) for malignant or nonmalignant diseases. TMA diagnosis was performed by homogeneous clinical and laboratory criteria. RESULTS: Sixty-four of 539 patients presented TMA (11,87%) and the five-year cumulative incidence of TMA was 14% (HR=0.13). Fifty nine of 64 patients were affected by malignant and 5/64 by non-malignant diseases. On multivariate analysis, TMA occurrence was influenced by graft versus host disease >grade II (P=0.0001), donor type (P=0.029), gender (P=0.0233), total body irradiation based conditioning regimen (P=0.0041). Three factors for TMA outcome proved to be statistically significant by multivariate analysis: age (P=0.009), donor type (P=0.0187) and TMA index (P=0.029). The TMA mortality rate was 50%. The outcome was influenced by defibrotide (P=0.02 in univariate analysis). CONCLUSIONS: The study underlines the possibility of finding out which patients are more prone to developing post-HSCT TMA, and identifies which risk factors are more frequently associated with a dismal outcome after TMA.     

Increased incidence of cytomegalovirus retinitis after allogeneic hematopoietic stem cell transplantation

Six cases of cytomegalovirus retinitis (CMVR) after allogeneic hematopoietic stem cell transplantation were diagnosed between 2002 and 2005 in our center, whereas only one case was diagnosed between 1985 and 2001. Cumulative incidence reaches 2.2%, whereas this complication has been rarely described after hematopoietic stem cell transplantation. We aimed to describe clinical and biologic features of CMVR and search for risk factors associated with CMVR. CMVR was diagnosed on specific funduscopic examination in all patients either on visual symptoms (n=3) or on systematic ophthalmologic examination (n=3). CMVR occurred in the context of unrelated transplantation in patients with profound immune defect and multiple episodes of cytomegalovirus (CMV) reactivation. The combination of a CMV-seropositive recipient and CMV-seronegative donor was the leading risk factor.     

Incidence,risk factors,and clinical outcomes associated with Epstein-Barr virus-DNAemia and Epstein-Barr virus-associated disease in patients after haploidentical allogeneic stem cell transplantation: A single-center study

Human leukocyte antigen (HLA)-haploidentical hematopoietic stem cell transplantation (haplo-HSCT) is an effective alternative to HLA-matched transplantation. However, Epstein-Barr virus (EBV) infection causes morbidity and mortality in patients undergoing haplo-HSCT. Here, we retrospectively evaluated the incidence and risk factors of EBV-DNAemia and EBV-associated diseases in 131 patients who underwent haplo-HSCT. Patients were classified into the no EBV infection groups, EBV-DNAemia group and EBV-associated disease group. Cumulative incidences of acute graft-vs-host disease, EBV infections, overall survival (OS), and relapse were analyzed. The cumulative incidences of EBV-DNAemia and EBV-associated disease were 26.9% and 33.3%, respectively. In multivariate analysis, cytomegalovirus (CMV)-DNAemia was confirmed as an independent risk factor associated with EBV-DNAemia and EBV-associated disease. Patients with EBV-associated disease had higher transplant-related mortality (TRM) rates and lower OS rates, but similar relapse rates. Overall, these findings demonstrated the cumulative incidences of EBV-DNAemia and EBV-associated disease and identified correlations of EBV infection with TRM, relapse, and OS. Additionally, CMV-DNAemia was a risk factor for EBV-DNAemia and EBV-associated disease.     

异基因造血干细胞移植后巨细胞病毒的检测及临床意义

目的 为了降低异基因造血干细胞移植（allo-HSCT）后巨细胞病毒（CMV）感染的相关死亡率，寻求一种更快捷、更特异的诊断CMV感染的分子生物学方法。方法 2001年4月至2003年4月，从79例接受异基因造血干细胞移植的患者中采集了135份外周血标本。采用巢式聚合酶链反应（nested-PCR）方法检测患者外周血中CMVgB DNA，阳性标本做酶切分型，部分行序列测定。结果CMVgB DNA检测中有42例患者（53．9％）的66份标本（48．9％）阳性；对其中阳性患者的45份标本进行了酶切分型，结果 CMV gB1型21例（46．7％），CMV gB2型14例（31．1％），CMV gB3型7例（15．6％），CMV gB4型3例（6．7％）。先后有2种型别的CMV感染者有3例（3．8％）。经分析，CMV gB阳性和CMV gB阴性患者GVHD的发生率分别为81．0％和32．4％（P＜0.01）；CMV gB1、gB2、gB3以及gB4型Ⅱ～Ⅳ度急性GVHD及慢性GVHD的发生率分别为：81．0％、50．0％、42．9％和0。结论 Nested-PCR方法可快捷特异地检测CMV感染。CMVgB1、2型中，重度急性GVHD和慢性GVHD发生率较高。CMV gB基因分型检测可有效地指导临床抗病毒治疗，且对移植后患者的临床转归有一定的预测价值。     

Chimerism in pediatric hematopoietic stem cell transplantation and its correlation with the clinical outcome

Hematopoietic stem cell transplantation (HSCT) is the only hope to cure many inherited and acquired hematological disorders in children. Monitoring of chimerism helps to predict the post-transplantation events, with the intention to enhance the long-term disease free survival (DFS). The study aimed to investigate the importance of early chimerism detection to predict the clinical outcome following HSCT. The study included nine recipients (six β-thalassemia and three severe aplastic anemia patients) and their 10/10 HLA identical sibling donors. Chimerism detection was performed by analysis of short tandem repeat (STR) polymerase chain reaction (PCR) for detection and quantification of the relative amounts of donor and recipient cells present on day + 28. Peripheral blood (PB) was the main stem cell source for HSC transplantation. Disease free survival (DFS) was 71.4% while overall survival was 85.7% for PBSC transplants at the median follow up period of 4 years. The early detection of chimerism by PCR-STR analysis for children with β-thalassemia and aplastic anemia correlated with the outcome of HSCT in 8 (88.8%) patients. Complete chimerism was associated with disease-free survival while mixed chimerism and autologous patterns were associated with poor prognosis. In conclusion, early chimerism testing is clinically important in prediction of outcome after allogeneic HSC transplantation.     

Analysis of HLA haplotype and clinical factors during hematopoietic stem cell transplantation

BackgroundThe human leukocyte antigen (HLA) haplotype of the recipient in hematopoietic stem cell transplantation (HSCT) is a key factor in its success or failure. We analyzed the relationship between HLA haplotype frequency and associated clinical factors in HSCT patients.MethodsPatients who underwent allogeneic HSCT between 2000 and 2019 at our institution were enrolled in this study. The HSCT composition was 77 bone marrow transplantations (BMT), 38 peripheral blood stem cell transplantations (PBSCT), and 36 cord blood transplantations (CBT). Patients were classified into three groups according to their donor HLA haplotype frequency in the Japan Population: group A, top 1–10 haplotypes; group B, top 11–100 haplotypes; and group C, haplotype 101-. We then compared various items including clinical biomarkers with the HLA haplotype frequency.ResultsA significant negative correlation was identified between older persons and length of survival. There are also significant correlations between survival and levels of immunoglobulin G, D-dimer, and C-reactive protein, as well as the platelet-large cell ratio before transplantation. A total of 96, 30, and 25 patients were classified into groups A, B, and C, respectively. The HSCT match rate was significantly higher in group A patients than in those of groups B and C. In contrast, the death rate, D-dimer level, and length of time for engraftment were significantly higher in group B and C patients than in those of group A.ConclusionAn assessment of transplant-related complications is important in improving the performance of HSCT. The present data suggest that a special therapeutic strategy is necessary for HSCT using low-frequency HLA haplotypes.     

Favorable long-term outcome of nephrotic syndrome after allogeneic hematopoietic stem cell transplantation

BACKGROUND: The development of nephrotic syndrome (NS) after allogeneic hematopoietic stem cell transplantation (HS-CT) is a rare complication with few long-term outcome data. PATIENTS: Clinical course and long-term outcome of three adult patients and one child with NS after HSCT (total number of transplants n = 533) are presented. RESULTS: The median age at onset of NS was 35 years (range 15 - 56), occurring at a median of 17 months (range 11 - 21) after HSCT. Discontinuation of cyclosporine A (CSA) prior to onset of NS was a consistent feature and occurred a median of 6 months (range 2 - 10 months) prior to the development of NS. The histopathological lesion was membranous nephropathy (n = 3) and membranoproliferative glomerulonephritis Type 1 (n = 1). History of acute or concomitant clinically apparent chronic graft versus host disease (GVHD) was present in all cases except the pediatric patient who had abundant DR-activated cytotoxic T cells without evidence of viral reactivation. Long-term immunosuppression for 11 - 36 months with steroids (n = 1), combined steroids and CSA (n = 2) or CSA alone in steroid-refractory NS (n = 1) resulted in sustained remission of the NS in all patients (12 months - 8 years off immunosuppression). CONCLUSION: NS after HSCT seems to be etiologically related to subclinical or overt chronic GVHD, which flares up after discontinuation of CSA. However, resumption of immunosuppression can reverse NS as well as GVHD and induce favorable sustained long-term remission.     

异基因造血干细胞移植后严重的出血性膀胱炎多因素分析

目的 探讨异基因造血干细胞移植（allo-HSCT）后严重的（≥Ⅱ度）出血性膀胱炎（HC）的危险因素。方法 对1997年4月至2004年12月期间的114例allo-HSCT患者的资料进行回顾性分析。以预处理实施之日为观察起点，至移植后＋180 d随访中止。选择11个临床参数，即：年龄、性别、疾病类型、供者类型、预处理方案、移植时疾病状态、急性移植物抗宿主病（aGVHD）、aGVHD的预防、预处理方案中抗胸腺细胞球蛋白（ATG）的应用、中性粒细胞及血小板植活时间做Cox单因素分析。将在单因素分析中P＜0.1作为有统计学意义的因素进行Cox多因素回归分析。移植后180 d内HC累计发生率的计算应用Kaplan-Meier法。结果 （1）114例患者中有29例发生HC，＋180 d内HC的累计发生率为26％，其中Ⅱ级12例，Ⅲ级11例，Ⅳ级6例。（2）单因素分析表明，以下因素与HC的发生密切相关；男性（RR=2.885，P=0.021）、年龄≤25岁（RR=3.265，P=0.002）、Ⅲ～Ⅳ度aGVHD（RR=4.039，P=0.002）、非血缘供者（RR=4．347，P=0.000）、加强的GVHD预防方案（RR=2.218，P=0.045）、疾病进展期（RR=2.668，P=0.009）。（3）对上述有统计学意义的因素进行Cox多因素分析，只有男性（RR=2.993，95％CI 1.218～7.358；P=0.017）和非血缘供者（RR=4.478，95％CI 2.049～9.786；P=0.000）为HC的独立危险因素。结论 男性受者和非血缘供者的造血干细胞移植后发生HC的危险性显著增加。     

异基因造血干细胞移植治疗慢性活动性EB病毒感染患者的护理

目的总结异基因造血干细胞移植治疗成人慢性活动性EB病毒感染的护理经验。方法回顾性分析7例成人慢性活动性EB病毒感染患者异基因造血干细胞移植的治疗及护理方法。结果 5例患者获得完全缓解,2例死亡。结论慢性活动性EB病毒感染患者病情严重,治疗难度大且预后不佳,异基因造血干细胞移植可改善患者预后。做好患者治疗期间的情绪管理、症状管理及并发症防护是护理的关键。     

异基因造血干细胞移植后并发出血性膀胱炎的高危因素和防治措施

目的 评估改良的水化碱化方案对预防和治疗非亲缘异基因造血干细胞移植(URD-HSCT)后出血性膀胱炎(HC)的效果及安全性,探讨URD-HSCT后并发HC的危险因素.方法 151例血液系统恶性疾病患者接受了URD-HSCT,所有患者移植前均接受白消安+环磷酰胺(BuCy2)方案预处理.在使用环磷酰胺(Cy)过程中,所有患者均接受改良的水化碱化输液方案,分别在静脉滴注Cy后0、3、6、9、12 h分5次静脉注射美司钠,总量为Cy总量的120%～160%;于开始使用Cy时至结束后24 h(共计72 h)经中心静脉持续输液,输液量5000 ml·m-2·d-1,匀速输注,每500 ml液体中加入50 g/L碳酸氢钠20 ml,间断应用利尿剂,保持液体出入量平衡;每小时测尿pH值,保持尿pH值＞7.5.结果 URD-HSCT后共有26例患者发生HC,发生率为17.2%(26/151),中位发病时间为40d(8～89 d),无患者发生早发性HC.移植后26例HC患者再次接受改良的水化碱化尿液治疗,部分患者接受膀胱持续冲洗,所有患者均治愈,无患者因HC而死亡.经统计分析表明,以下因素与HC的发病明显相关:男性患者,相关系数(OR)值=3.093,95%可信区间(CI)为1.145～8.353,P＜0.05;急性GVHD,OR值=18.044,95%CI为3.952～82.392,P＜0.01;≥30岁,OR值=6.077,95%CI为1.585～23.299,P＜0.01.结论 改良的水化碱化方案是预防和治疗URD-HSCT后HC的安全有效的措施,尤其是由Cy预处理引起的早发性HC;男性患者、年龄≥30岁以及移植后并发急性GVHD是引起HC的危险因素.

Abstract：

Objective To investigate the efficacy and safety of the optimal alkalized hydration solution for hemorrhagic cystitis (HC) following unrelated donor allogeneic hematopoietic stem cell transplantation (URD-HSCT), and the risk factors and prophylaxis measures about HC.Methods The clinical data of 151 HC patients who underwent URD-HSCT were retrospectively analyzed. All patients were given busulfan/cyclophosphamide (BuCy)-based conditioning regimen.During Cy therapy, all patients were given the optimal alkalized hydration solution to prevent HC.MESNA was given intravenously after administration of Cy at 0, 3, 6, 9, 12 h, and its total dose was administration of Cy to 24 h under the ECG monitoring. Each 500 ml liquid contained 50 g/L sodium bicarbonate 20 ml. Urinary pH value was monitored every one hour (keeping urine pH＞7. 5). Results None of early onset HC occurred. Twenty-six of 151 (17. 2 %) patients developed late onset HC, and the median onset time was 40 (8～89) days after transplantation. During the therapy, no symptoms of the circulatory system, no congestive heart failure and no acid-base electrolyte imbalance occurred. All HC patients after re-hydration, diuretic, and (or) continuous bladder irrigation and other indwelling catheter after treatment, were cured. The statistical analysis showed that the following factors were significantly associated with HC: male (OR = 3. 093, 95 % CI, 1. 145～8.353, P＜0. 05), acute graft versus host disease (aGVHD) (OR= 18. 044, 95 % CI, 3. 952～～82. 392, P＜0. 01), and ≥30-yearold (OR = 6. 077, 95 0% CI, 1. 585～23. 299, P＜0. 01). Conclusion The optimal alkalized hydration solution is safe and effective to prevent early onset HC following URD-HSCT in combination with BuCy regimen. Male, aGVHD and ≥30-year-old were the risk factors for HC.     

多源化巨细胞病毒DNA定量检测在异基因造血干细胞移植后巨细胞病毒肺炎诊断中的应用

目的 研究不同来源[血浆、痰液、支气管肺泡灌洗液(BALF)]标本的巨细胞病毒(CMV)DNA定量检测对异基因造血干细胞移植后CMV肺炎的诊断价值.方法 回顾性分析接受异基因造血干细胞移植的405例受者的临床资料,其中诊断为CMV肺炎的19例受者设为CMV肺炎组,选择同期仅发生CMV血症的229例受者、接受纤维支气管镜...     

Human herpesvirus‐6 encephalopathy after hematopoietic stem cell transplantation and class I human leukocyte antigen

Human herpesvirus‐6 (HHV‐6) encephalopathy is a serious complication of allogeneic hematopoietic stem cell transplantation (allo‐HSCT). Although reactivation of HHV‐6 is often observed after allo‐HSCT, encephalopathy only affects a few patients with HHV‐6 reactivation. Human leukocyte antigen (HLA) class I is expressed by most somatic cells, and a relationship between some class I alleles and neurological diseases has been reported. The HHV‐6 load at two, three, and four weeks after allo‐HSCT was examined. HHV‐6 encephalopathy was diagnosed from symptoms, results of cerebrospinal fluid examination, and magnetic resonance imaging findings. The relation between HHV‐6 reactivation or encephalopathy and the HLA class I status of the recipients was investigated. In 130 patients, 147 allo‐HSCT transplantation procedures were carried out. HHV‐6 reactivation and encephalopathy occurred in 56 and nine procedures, respectively. HLA mismatch (p = 0.008) and unrelated donor (p = 0.001) were associated with HHV‐6 reactivation, but not with HHV‐6 encephalopathy. HHV‐6 encephalopathy was more frequent in patients with HLA‐B*40:06 (p = 0.027). In addition, HLA‐A*26:01 and HLA‐B*40:06 were found to be associated with each other (p = 0.089), while HLA‐B*40:06 and HLA‐C*08:01 showed a significant association (p < 0.001). The HLA class I alleles of recipients may be associated with the occurrence of HHV‐6 encephalopathy after allo‐HSCT.     

Both genetic and clinical factors predict the development of graft-versus-host disease after allogeneic hematopoietic stem cell transplantation.

BACKGROUND: Graft-versus-host disease is the main complication of hematopoietic stem cell transplantation. Recently, pro- and anti-inflammatory cytokines and mismatches of minor histocompatibility antigens between HLA-identical sibling donor/recipient pairs have been implicated in the development of acute graft-versus-host disease. It is not known, however, whether these factors are independent of other clinically recognized risk factors such as age and disease stage. METHODS: In this study, we searched for risk factors of acute graft-versus-host disease using multivariate Cox regression analysis in 100 consecutive patients who underwent allogeneic stem cell transplantation from an HLA-identical sibling donor. Eight polymorphisms from five different cytokine genes were studied (tumor necrosis factor alpha, tumor necrosis factor beta, interleukin (IL) 6, IL-10, and interferon gamma). Mismatches for the minor histocompatibility antigen HA-1 were searched in HLA-A*0201 individuals. In addition to these new risk factors, patient, donor, disease, and transplant risk factors were analyzed by multivariate analysis using the Cox proportional hazards model. RESULTS: Acute graft-versus-host disease was independently associated with IL-10 gene polymorphisms both from the recipient (relative risk=7.9, P<0.0001) and the donor (relative risk=3.5, P=0.02), a donor's positive serology for cytomegalovirus, and HA-1 mismatches in HLA-A*0201 individuals (relative risk=2.8, P=0.05). Chronic graft-versus-host disease was independently associated with IL-6 gene polymorphism from the recipient (relative risk=4.2, P=0.02), older age (relative risk=2.5, P=0.0009), and previous acute graft-versus-host disease (relative risk=9.7, P=0.003). CONCLUSION: In addition to previously described clinical risk factors, genetic risk factors are independently associated with the risk of developing graft-versus-host disease and may, thus, be considered for the selection of the donor.     

Feasibility of second hematopoietic stem cell transplantation using reduced-intensity conditioning with fludarabine and melphalan after a failed autologous hematopoietic stem cell transplantation

This study was performed to determine the feasibility of second hematopoietic stem cell transplantation (HSCT) using reduced-intensity conditioning (RIC) with fludarabine and melphalan in patients with relapsed hematologic malignancies after a prior autologous HSCT. Twelve patients (multiple myeloma [n = 7], non-Hodgkin lymphoma [n = 3], and acute myeloid leukemia [n = 2] received allogeneic HSCT using RIC with fludarabine (25 mg/m² for 5 days) and melphalan (140 mg/m² for 1 day) after a failed autologous HSCT. The graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine plus a minidose of methotrexate. All patients achieved a neutrophil and platelet engraftment in a median 13.5 days and 17.5 days, respectively. The transplant-related mortality was 2 patients (16.7%). Grade II-IV acute GVHD and chronic extensive GVHD were noted in 4 (33.3%) and 1 patient (11.1%), respectively. Over a median follow-up duration of 376 days, 5 patients were alive without evidence of disease. The estimated nonrelapse mortality at 1 year was 28.4%. The estimated overall survival rate at 1 year was 58.3%, and the estimated event- free survival rate at 1 year was 41.7%. Allogeneic HSCT using RIC with fludarabine and melphalan appears to be feasible for a second HSCT in patients with relapsed hematologic malignancies after a failed autologous HSCT.     

Translating in vitro prediction of cytotoxic T cell alloreactivity to hematopoietic stem cell transplantation outcome

IntroductionPreviously we developed a weighted amino acid (AA) mismatch score predictive for cytotoxic T cell (CTL) alloreactivity (in vitro CTLp assay) based on the structure of the HLA class I molecule. The aim of this study is to confirm the clinical relevance of the CTLp assay and to validate the AA mismatch score as an alternative and easy to use tool to predict permissible mismatches in hematopoietic stem cell transplantation (HSCT).MethodsWe selected patients transplanted with a 9/10 single HLA class I mismatched graft (n = 171) at three Dutch HSCT centers. A CTLp assay was performed in 73 donor–recipient pairs. As a control we selected 168 10/10 HLA matched pairs that were matched to the 9/10 single HLA class I mismatched pairs for HSCT year, donor type, patient age and diagnosis.ResultsWe observed that pairs with negative a CTLp assay had statistically significant decreased incidence of mortality after HSCT comparable to that of 10/10 HLA matched pairs. However, the weighted AA mismatch score did not significantly predict any HSCT end point of interest.ConclusionFurther investigation is needed to unravel the mechanisms involved in causing the beneficial effect of a negative CTLp assay, before other alternative tools to predict HSCT outcome may be developed.     

Clinical tolerance after allogeneic hematopoietic stem cell transplantation: a study of influencing factors

BACKGROUND: Clinical tolerance, defined as discontinuation of immunosuppression without immunological events, is often achieved after allogeneic hematopoietic stem cell transplantation, unlike after organ transplantation. However, this phenomenon has rarely been studied. METHODS: Between September 1977 and December 1997, we evaluated 354 allogeneic hematopoietic stem cell recipients who had had more than 1 year of relapse-free survival, regarding time to discontinuation of immunosuppression. Factors such as patient age, donor age, donor sex, immunosuppressive protocols, cell dose, and graft-versus-host-disease (GVHD) were studied. RESULTS: Patients who did not develop GVHD had discontinued immunosuppression according to the protocols, within 1 year for malignant diseases and within 2 years for nonmalignant diseases. Patients given methotrexate as a single drug were off immunosuppression faster than those given cyclosporine alone (P=0.05). Children (<18 years) discontinued immunosuppression faster than adults (P=0.05). Low donor age was of greater importance than low recipient age for early discontinuation (P=0.003). Male recipients of stem cells from immunized female donors needed a longer time to discontinuation (P<0.001). Patients without acute GVHD had a shorter time to discontinuation than patients with any grade of GVHD (P=0.02). Thirteen months after hematopoietic stem cell transplantation, 54% of HLA-identical sibling marrow recipients and 36% of unrelated marrow recipients with malignant disease had discontinued immunosuppression (P=0.002). Twenty-five months after hematopoietic stem cell transplantation, the corresponding figures were 69% and 75% in the two groups, respectively. CONCLUSION: In multivariate analysis, high donor age, immunized female donor to male recipient, and grades II-IV acute GVHD were significantly associated with a longer time to clinical tolerance.