Anexo 1. Regime de Condicionamento e Profilaxia da DECH
Condicionamento de Altas Doses com Doador Aparentado
· Irradiacao Corporal Total e Ciclofosfamida
o TBI 12 Gy em oito fracoes de 1,5 Gy 12/12h do dia -8 ao dia -5 o Etoposide 40mg/Kg IV, 1x ao dia no dia -4
o Ciclofosfamida 60mg/kg IV, 1x ao dia nos dias -3 e -2 o Descanso no -1
· Bussulfan, Etoposide e Ciclofosfamida
o Bussulfano 1mg/kg vo 6/6h durante 4 dias, do dia -8 a -5 (dose total = 16mg/kg)
o Etoposide 40mg/Kg IV , 1x/dia no dia -4
o Ciclofosfamida 60mg/kg IV, 1x ao dia nos dias -3 e -2 o Descanso no -1
· Bussulfan e Ciclofosfamida
o Bussulfano 1mg/kg vo 6/6h do dia -7 a -4
o Ciclofosfamida 60mg/kg IV, 1x ao dia nos dias -3 e -2 o Descanso no -1
78 · Bussulfan e Fludarabina
o Bussulfano 1mg/kg vo 6/6h do dia -7 a -4 o Fludarabina 30mg/m2 IV do dia -7 a -4 o Descanso no -1
Condicionamento de Altas Doses com Doador Nao Aparentado
· Bussulfan, Etoposide, Ciclofosfamida e Timoglobulina
o Bussulfano 1mg/kg vo 6/6h durante 4 dias, do dia -8 a -5 (dose total = 16mg/kg)
o Etoposide 40mg/Kg IV , 1x/dia no dia -4
o Ciclofosfamida 60mg/kg IV, 1x ao dia nos dias -3 e -2
o Timoglobulina 1mg/kg no dia -3, 2mg/kg no dia -2 e 3mg/kg no dia -1
· Bussulfan, Ciclofosfamida e Timoglobulina
o Bussulfano 1mg/kg vo 6/6h do dia -7 a -4 (dose total = 16mg/kg)
o Ciclofosfamida 60mg/kg IV, 1x ao dia nos dias -3 e -2
o Timoglobulina 1mg/kg no dia -3, 2mg/kg no dia -2 e 3mg/kg no dia -1 Condicionamento de Baixas Doses com Doador Aparentado
· Fludarabina e Bussulfan
o Bussulfan 1mg/kg vo 6/6h nos dias -5 e -4 (dose total = 8mg/kg) o Fludarabina 30mg/m2 IV dos dias -5 a -2 (dose total = 120mg/m2) o Descanso no -1
79 · Fludarabina e Melfalano
o Fludarabina 30mg/m2 IV dos dias -5 a -2 (dose total = 120mg/m2) o Melfalano 70mg/m2 nos dias -3 e -2 (dose total = 140mg/m2)
o Descanso no -1
· Fludarabina e TBI
o Fludarabina 30mg/m2 IV dos dias -4 a -2 (dose total = 90mg/m2) o Irradiacao Corporal Total de 200 cGy no dia -1
80 Anexo 2. Profilaxia da DECH
· Ciclofosfamida e Metotrexato
o Ciclosporina 12mg/kg a partir do dia -1
o Metotrexate 15mg/m2 no dia +1 e 10mg/m2 nos dias +3, +6 e +11
· Ciclofosfamida e Micofenolato Mofetil
o Ciclosporina 12mg/kg a partir do dia -1
81 Anexo 3. Parecer do Comitê de Ética Médica
84 Anexo 4: Artigo submetido
Pre-transplant β2-microglobulin can predict the development of acute graft-versus-host- disease after hematopoietic cell transplant
Authors: Carolina Costa-Lima 1,2, Eliana Cristina Martins Miranda 2, Marcos Paulo Colella 2, Francisco Jose Penteado Aranha 2, Carmino Antonio de Souza 1,2, Afonso Celso Vigorito 2, Erich Vinicius De Paula 1,2
Running title: β2-microglobulin and acute GVHD
Affiliations: 1 Faculty of Medical Sciences, University of Campinas, Campinas, SP, Brazil; 2 Hematology and Hemotherapy Center, University of Campinas, Campinas, SP, Brazil Word count: title: 118 words; abstract: 185 words; text: 1,200 words
Figure/table count: 2 tables Reference count: 21 references
Corresponding author: Erich V De Paula, MD, PhD Faculty of Medical Sciences University of Campinas Rua Carlos Chagas, 480 Campinas, SP, Brazil 13083-878
Phone: +55 19 3521 8655 Email: erich@unicamp.br
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Key points:
· Pre-transplant β2-microglobulin correlates with the HCT comorbidity index
· Pre-transplant β2-microglobulin is an independent predictor of grades II-IV acute GVHD
Abstract
The risk of acute Graft-versus-Host Disease (aGVHD) can be estimated by the hematopoietic cell transplant (HCT) comorbidity index (HCT-CI), which can be further refined by the incorporation of pre-HCT serum levels of inflammatory biomarkers such as ferritin and albumin. β2-microglobulin (β2-m) is a key component of MHC class-I complex, which is independently
associated with mortality and frailty in the general population. We took advantage of our institutional protocol that includes measurement of pre-HCT β2-m serum levels in all patients, to
investigate whether pre-transplant β2-m levels were associated with the risk of aGVHD. One
hundred-three consecutive patients submitted to allogeneic HCT, of which 26 developed grades II-IV aGVHD, were included in the analysis. β2-m was significantly associated with age and HCT-
CI. Higher levels of β2-m were observed in patients who developed aGVHD (p=0.01). In the
multivariate Cox regression model, β2-m remained significantly associated with the risk of
developing aGVHD in different models considering several relevant covariates. In conclusion, the association between β2-microglobulin and the occurrence of aGVHD suggests that the
measurement of this protein before HCT might represent a novel parameter for risk stratification of aGVHD.
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Introduction
Acute graft-versus-host disease (aGVHD) is one of the major complications of allogeneic hematopoietic cell transplant (allo-HCT) 1,2. The HCT comorbidity index (HCT-CI) reliably predicts the development and severity of aGVHD 3. A recent report demonstrated that the incorporation of classical inflammatory biomarkers such as ferritin and albumin to the HCT-CI increases the index performance 4. β2-microglobulin (β2-m) is a component of the MHC class I, critical to the stabilization of the tertiary structure of this complex. In addition to its prognostic role in several lymphoproliferative conditions 5,6, β2-m was also identified as an independent predictor of mortality in the Atherosclerosis Risk in Communities (ARIC) Study 7, and in other long-term prospective study 8. Here we analyzed the prognostic role of pre-HCT β2-m in a population of consecutive patients submitted to allo-HCT.
Study design
All 103 consecutive patients submitted to allo-HCT between January 2010 and February 2014 at our center were included in this retrospective observational study, which was approved by the local IRB and conducted in accordance with the Declaration of Helsinki. As part of our local pre- HCT evaluation protocol, serum β2-m levels were measured in all patients in the last outpatient visit before HCT, in the absence of any acute illness. β2-m measurements were performed by immunonephelometry using the same system (BN II, Siemens Healthcare). HCT-CI 9, as well as an augmented version of this index (HCT-CIaug) that incorporates ferritin, platelet count and albumin 4 were retrospectively calculated. Conditioning regimes were classified as high (HD) or low dose (LD) 10. Low-risk diseases included non-malignant hematological disorders, acute leukemia in 1st complete remission and chronic myeloid leukemia in 1st chronic phase. aGVHD was diagnosed and graded according to classical criteria 11–13 and reviewed by two investigators.
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Lymphoproliferative disorders were defined as lymphomas, chronic lymphocytic leukemia, myeloma and acute lymphoblastic leukemia. β2-m levels were analyzed both as a continuous and categorical (≥0.25 mg/dl) variable. Cumulative incidences of aGVHD and transplantation- related-mortality (TRM) were used to estimate the probability of these events using the Gray’s test 14, considering the following competing risks: deaths without GVHD (up to day +100) and relapse, for the incidence of aGVHD; and relapse, for TRM. A p-value < 0.1 was used to select covariates for the multivariate analysis. SPSS version 21.0 was used for major statistical analysis, and cumulative incidences were calculated using STATA version 12.0 (Statistical Software).
Results and discussion
Ninety-seven patients, with a median follow-up of 30 (13-56 months) were included in the analysis (6 patients submitted to > 1 allo-HCT were excluded) (table 1). Development of grades II-IV aGVHD was evaluated in 77/97 patients, due to the occurrence of competitive events in 20 patients. In total, 26 (34%) presented aGVHD at a median of 62 days (20-140) after HCT, yielding a cumulative incidence of 29% (95%CI: 19-29%) in 140 days. There were no significant differences between patients with or without aGVHD with respect to patient age, graft type, or disease risk. Patients with a higher HCT-CI index were overrepresented in the aGVHD group (p=0.016), which also included more patients using LD conditioning (p= 0.013) and with lymphoproliferative disorders (p= 0.006). Overall survival at 12 and 60 months was 60% (95% CI: 50-70%) and 44% (95% CI: 30-58%), respectively. TRM at 12 months was 20% (95% CI: 12- 28%).
Pre-HCT serum β2-m levels (available for 83 patients) were higher in patients who developed aGVHD (0.38 mg/dl ± 0.40) than in those without aGVHD (0.25 mg/dl ± 0.12; p= 0.01). β2-m
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levels were also higher in patients older than 40 yo (p= 0.025), with high-risk disease (p= 0.04), and submitted to LD conditioning (p= 0.005). Interestingly, pre-HCT β2-m levels presented a
positive correlation with HCT-CI (r=0.26; p=0.02), HCT-CIaug (r=0.24; P=0.04) and age (0.53; P<0.001), and a negative correlation with albumin (r=-0.21; p=0.05).
To estimate the effect of β2-m on the probability of aGVHD, univariate Cox analyzis was performed for the following covariates: gender, graft source, conditioning intensity, donor type, disease risk category, diagnosis of lymphoproliferative disease, presence of non-malignant disease, age, HCT-CI, HCT-CIaug, ferritin, albumin and platelet count. A multivariate model was then built introducing β2-m, age, conditioning intensity, HCT-CI and diagnosis of lymphoproliferative disorders. β2-m and the HCT-CI were identified as the only independent predictors of aGVHD, and β2-m remained the only significant variable when the model was adjusted for age or the presence of lymphoproliferative disease (table 2). β2-m levels were not associated with 12-month OS (normal β2-m vs. abnormal β2-m: 62% vs. 37%, p= 0.21) or TRM (normal β2-m vs. abnormal β2-m, p= 0.22).
β2-m levels is a well-konwn prognostic marker of lymphoproliferative disorders, but recent data also demonstrate its role as a predictor of mortality and frailty in other contexts 7,8,15–17. In a large prospective cohort, β2-m was more informative than C-reactive protein as a predictor of mortality
8. In the ARIC study, with a 10-year follow-up of 9,988 participants, β2-m presented a strong and
independent association with mortality, coronary heart disease, heart failure and end-stage renal disease 7.
We took advantage of a peculiar aspect of our pre-HCT evaluation protocol, which is the measurement of β2-m levels for all patients prior to HCT, and investigated the association between this marker and the probability of aGVHD development. Our most relevant conclusion was that serum levels of β2-m were independently associated with the risk of grade II-IV
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aGVHD, even after adjustment for age, disease risk, conditioning and the presence of lymphoproliferative disorders.
Two hypothesis could be raised to explain our results. β2-m is critical to the stability of MHC class I, and mice lacking β2-m lack CD8 cytolytic T cells 18. Increased levels of β2-m could thus reflect a subclinical state of immune activation in patients with occult inflammation or organ damage. The statistical correlation between β2-m with HCT-CI favours this hypothesis. A second explanation involves potential direct effects of β2-m on cellular responses to stress. β2- m was shown to stimulate cancer cell proliferation and migration via HFE/HIF-1α pathways 19. One could speculate that in the pro-inflammatory environment of HCT, β2-m could trigger analogous pathways, thereby influencing imune system function. Interestingly, β2-m was recently identified as a direct mediator of age-related complications in a study using animal and human models of aging 20.
Although the clinical validation of β2-m as a risk stratification tool for aGVHD will require larger studies, initial exploratory studies aiming the identification of disease markers are best performed in more controlled environments, so that relevant associations are not shadowed by multiple covariates 21. Considering that measurement of pre-HCT β2-m is not common practice in HCT centers, such studies would be difficult to put together at present. In this context, we believe that the fact that our data was collected from patients undergoing a standardized HCT protocol, and that β2-m was measured in a non-biased fashion (i.e. same laboratory method, fixed time-points) should be regarded as strengths of our study design. Of course, multi-center prospective studies are required to clinically validate our findings.
In conclusion, we demonstrated that pre-HCT β2-m serum concentrations are independently associated with the risk of grades II-IV aGVHD. Larger multicenter studies are warranted to
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validate our results, and define whether the incorporation of β2-m levels into aGVHD risk stratification models could further improve these tools.
Acknowledgments
This study was financially supported by Fapesp and CNPq, Brazil. The Hematology and Hemotherapy Center - Hemocentro UNICAMP, forms part of the National Institute of Science and Technology of Blood, Brazil (INCT do Sangue CNPq / MCT / FAPESP).
Authorship contributions
CC and EVDP designed the study, collected and analyzed the data. ECMM performed the statistical analysis. MPC, FJPA, CAS and ACV conducted all HCTs and analyzed the data. CC and EVDP drafted the manuscript. All authors reviewed and approved the manuscript.
Disclosure of conflicts of interest
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Bibliographic references
1. Blazar, B., Murphy, W. & Abedi, M. Advances in graft-versus-host disease biology and therapy. Nat. Rev. Immunol. 12, 443–58 (2012).
2. Ferrara, J. L. M., Levine, J. E., Reddy, P. & Holler, E. Graft-versus-host disease. Lancet 373, 1550–61 (2009).
3. Sorror, M. L. et al. Pretransplant comorbidities predict severity of acute graft-versus-host disease and subsequent mortality. Blood 124, 287–95 (2014).
4. Vaughn, J. E. et al. Design and Validation of an Augmented Hematopoietic Cell Transplantation-Comorbidity Index Comprising Pre-transplant Ferritin, Albumin and Platelet Count for Prediction of Outcomes after Allogeneic Transplantation. Biol. Blood
Marrow Transplant. 1–7 (2015). doi:10.1016/j.bbmt.2015.04.002
5. Greipp, P. R. et al. International staging system for multiple myeloma. J. Clin. Oncol. 23, 3412–20 (2005).
6. Federico, M. et al. Prognostic relevance of serum 2 microglobulin in patients with follicular lymphoma treated with anthracycline-containing regimens. A GISL study.
Haematologica 92, 1482–1488 (2007).
7. Astor, B. C. et al. Novel Markers of Kidney Function as Predictors of ESRD,
Cardiovascular Disease, and Mortality in the General Population. Am. J. Kidney Dis. 59, 653–662 (2012).
8. Shinkai, S. et al. Beta2-microglobulin for risk stratification of total mortality in the elderly population: comparison with cystatin C and C-reactive protein. Arch. Intern. Med. 168, 200–6 (2008).
9. Sorror, M. L. et al. Hematopoietic cell transplantation (HCT)-specific comorbidity index: a new tool for risk assessment before allogeneic HCT. Blood 106, 2912–9 (2005).
10. Bacigalupo, A. et al. Defining the intensity of conditioning regimens: working definitions.
Biol. Blood Marrow Transplant. 15, 1628–33 (2009).
11. Dignan, F. L. et al. Diagnosis and management of acute graft-versus-host disease. Br. J.
Haematol. 158, 30–45 (2012).
12. Glucksberg, H. et al. Clinical manifestations of graft-versus-host disease in human recipients of marrow from HL-A-matched sibling donors. Transplantation 18, 295–304 (1974).
13. Przepiorka, D. et al. 1994 Consensus Conference on Acute GVHD Grading. Bone Marrow
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14. Fine, J. P. & Gray, R. J. A proportional hazards model for the subdistribution of a competing risk. J. Am. Stat. Assoc. 94, 496–509 (1999).
15. Amighi, J. et al. Beta 2 microglobulin and the risk for cardiovascular events in patients with asymptomatic carotid atherosclerosis. Stroke. 42, 1826–33 (2011).
16. Liabeuf, S. et al. Plasma beta-2 microglobulin is associated with cardiovascular disease in uremic patients. Kidney Int. 82, 1297–303 (2012).
17. Annweiler, C. et al. Plasma beta-2 microglobulin as a marker of frailty in older adults: A pilot study. Journals Gerontol. - Ser. A Biol. Sci. Med. Sci. 66 A, 1077–1079 (2011). 18. Zijlstra, M. et al. Beta 2-microglobulin deficient mice lack CD4-8+ cytolytic T cells. Nature
344, 742–6 (1990).
19. Josson, S. et al. β2-microglobulin induces epithelial to mesenchymal transition and confers cancer lethality and bone metastasis in human cancer cells. Cancer Res. 71, 2600–10 (2011).
20. Smith, L. K. et al. β2-microglobulin is a systemic pro-aging factor that impairs cognitive function and neurogenesis. Nat. Med. 21, 932–937 (2015).
21. Sackett, D. L. & Haynes, R. B. The architecture of diagnostic research. BMJ 324, 539–41 (2002).
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Tables
Table 1. Demographic and clinical characteristics of the study population
Caracteristics n= 97
Patient age, mean (SD), median (range), years 44 (±14), 44 (14-68) Patient gender, no. male/female 50/47 Diagnosis at HCT, n
Malignant diseases
Acute myeloid leukemia 26
Chronic myeloid leukemia 14
Acute lymphoblastic leukemia 08
Chronic lymphoblastic leukemia 05
Multiple myeloma 05
Non-hodgkin lymphoma 15
Hodgkin lymphoma 03
Myeloplastic syndrome 10
Non-malignant diseases
Severe aplastic anemia 09
Paroxysmal nocturnal hemoglobinuria 02 Donor age, mean (SD), median (range), years 41 (12-72) Donor-female/Male-recipient, n (%) 23 (23.5) Donor type, n
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HLA-matched unrelated 13
Pre-HCT disease risk category, n
Low risk 33 High risk 64 Conditioning regimen, n High dose 59 Low dose 38 Graft source, n Bone marrow 27 Mobilized blood 70
Comorbidity index HCT-CI*
0 – 1 / ≥ 2 59 / 30
GVHD prophylaxis, n
Cyclosporine plus methotrexate 84
Cyclosporine plus mycophenolate mofetil 13 Acute GVHD, n**
Grade 0-I 51
Grade II 16
Grades III-IV 10
aGVHD diagnosis day, median (range)** 45 (7-140) * n=89 (due to missing data); ** n=77 (due to the occurrence of competitive risk events)
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Table 2. Multivariate analysis of the risk of aGVHD (grades II-IV) associated with β2-m (continuous variable)
Variable HR p CI 95%
No adjustment
β2-m 4.97 0.01 1.40-17.6
HCT-CI ≥2 2.79 0.04 1.05-7.42
Adjusted for age
β2-m 3.72 0.03 1.12-12.3
Adjusted for lymphoproliferative disease
β2-m 4.44 0.03 1.12-17.5
96 To Dr. Bob Löwenberg Editor-In-Chief Blood Dear Editor,
Please find attached a manuscript entitled Pre-transplant β2-microglobulin can predict the development of acute graft-versus-host-disease after hematopoietic cell transplant that we would like to submit for publication in Blood as a “Brief Report”.
Research on the development of risk stratification tools for hematopoietic cell transplant (HCT) patients has gained momentum in the last 2 years with the demonstration by Sorror et al that a comorbidity index (HCT-CI) can predict acute GVHD development, and that inflammatory markers (ferritin and albumin measured before HCT) can further improve this index. In this report we add new original data to this field, by demonstrating for the 1st time that serum levels of β2-microglobulin measured before HCT represents an additional independent predictor of acute GVHD, even after adjustment for the HCT-CI and other relevant covariates. This result is in accordance with recent data from large population-based prospective cohort studies in which β2- microglobulin emerged as an independent predictor of mortality and mordibidity, outperforming classical inflammatory markers such as C-reactive protein. Since measuring this marker in a non-biased fashion in all HCT patients is not supposed to be common practice among HCT centers, we believe that we are in a privileged position to contribute with this data, which has not been demonstrated before.
In the manuscript, we also discuss potential mechanisms underlying this association (including a very recent paper published at Nature Medicine in which β2-
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microglobulin was identified as a direct mediator of age-related cognitive complications), as well as the limitations of our study and the steps towards a clinical validation of these findinds.
The manuscript has been reviewed and approved by all named authors. The corresponding author is empowered by all of the authors to act on their behalf with respect to submission of the manuscript. This article is original and does not infringe upon any copyright. No paper resembling the enclosed article has been published or is under editorial consideration in another journal.
Sincerely Yours,
Erich V De Paula, MD, PhD Department of Internal Medicine University of Campinas
Campinas, SP, Brazil Tel.: +55 19 3521 8756 E-mail: erich@unicamp.br