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Chronic graft-versus-host disease (cGvHD) is a major cause of morbidity after haploidentical hematopoietic stem cell transplantation (haplo-HSCT). Strategies to help reduce the incidence of cGvHD are urgently needed.
Tao Tao, from the Department of Respiratory Medicine, The Fifth People’s Hospital of Suzhou, CN, and colleagues conducted a study1 to investigate whether cord blood infusion following haplo-HSCT, can reduce the incidence of cGvHD.
The open-label, multicenter, non-randomized, single-arm, prospective study looked at the clinical profiles of cGvHD according to the National Institutes of Health2 (NIH) criteria.
Table 1: Diagnosis of patients
Diagnosis |
N (%) |
AML |
114 (38) |
ALL |
124 (41.3) |
MDS |
28 (9.3) |
HAL |
12 (4) |
CML |
8 (2.7) |
NHL |
5 (1.7) |
Others |
9 (3) |
Table 2: Transplantation characteristics for all patients
Factor |
N (%) |
Graft type of haplo-identical donor |
|
|
47 (15.7) |
|
12 (4) |
|
241 (80.3) |
Median MNC cells, range, 108/kg |
9.93 (1.28—28.52) |
Median CD34+ cells, range, 106/kg |
3.46 (0.81—9.46) |
Table 3: Follow-up data on all patients, n = 300, 95% CI for all values. OS = overall survival; DFS = disease-free survival; GRFS = GvHD-free, relapse free survival; NRM = non-relapse mortality
Follow-up data on all patients, n = 300 (95% CI) |
||||
Time post-HSCT (years) |
OS (%) |
DFS (%) |
GRFS (%) |
NRM (%) |
1 |
71.5 (68.9~74.1) |
66.6 (63.7~69.5) |
50.8 (47.9~53.7) |
30.8 (28.1~33.5) |
2 |
65.7 (62.9~68.5) |
64.2 (61.4~67) |
45.6 (42.7~48.5) |
35.8 (33.0~38.6) |
3 |
61.1 (58.1~64.1) |
58.3 (55.0~61.6) |
44.5 (41.5~47.5) |
38.2 (35.5~41.1) |
Table 4: 2-year survival of patients who developed aGvHD
GvHD type |
2-year survival (%) |
|
Classic aGvHD |
60.6 |
95% CI, 55.2%~66.0% |
Persistent late aGvHD |
37.0 |
95% CI, 24.1%~49.9% |
De novo late aGvHD |
33.3 |
95% CI, 14.1%~52.5% |
Recurrent late aGvHD |
0.0 |
P = 0.05 |
Table 5: Treatments for patients with cGvHD receiving second-line treatments.
Treatment |
N |
Tacrolimus |
8 |
MMF |
6 |
Imatinib |
2 |
Ruxolitinib |
2 |
Sirolimus |
1 |
MTX |
1 |
Rituximab |
1 |
Table 6: Cause of death for patients with cGvHD. BOS: bronchiolitis obliterans syndrome; IFD: invasive fungal disease.
Cause |
N (%) |
Disease relapse |
6 (30) |
BOS |
4 (20) |
Multi-organ failure |
3 (15) |
IFD |
3 (15) |
Hepatic failure |
2 (10) |
Interstitial pneumonitis |
1 (5) |
Intracranial hemorrhage |
1 (5) |
Total |
20 (27.4) |
According to the Seattle criteria, 89 patients were diagnosed with cGvHD, with onset at a median of 5.7 months (range, 3.6—42).
Table 7: cGvHD overall survival (GOS)
Years |
GOS (%) |
|
1 |
76.5 |
95% CI; 71.6~81.5 |
2 |
71.6 |
95% CI; 66.2~77.0 |
3 |
67.6 |
95% CI; 61.2~74.0 |
Table 7: Cox multivariate model of factors predicting survival for patients with cGvHD (n=73). A nomogram was developed to predict GOS using the five independent covariates identified in the final Cox model.
Risk factor |
Multivariate analysis |
||
Hazard ratio |
95% CI |
P |
|
CD34+ (>3.46x106/kg vs ,3.46x106/kg) |
0.178 |
0.05~0.62 |
<0.05 |
BOS (yes vs no) |
10.93 |
2.43~49.16 |
<0.05 |
Platelet count (>100x109/L vs <100x109/L) |
13.23 |
2.99~58.55 |
<0.05 |
cGvHD response to first-line treatment |
5.25 |
1.48~18.71 |
<0.05 |
Disease relapse (yes vs no) |
17.89 |
2.79~114.67 |
<0.05 |
Relapse, thrombocytopenia, BOS and SR-cGvHD were independent risk factors for GOS, with CD34+>3.46x106/kg found to be a protective factor affecting GOS. A prognostic model and nomogram were proposed to be used to predict outcomes for patients and could be useful for clinicians and for future research.
Despite several studies demonstrating the unique tolerogenic properties of the fetal lymphoid system and the immunomodulatory effects of cellular components in the umbilical cord, the question on whether the cord has a functional role in preventing cGvHD remains. The limitations of this study has led to the requirement of randomized, controlled studies in order to validate the findings.
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