Immune profile differences between chronic GVHD and late acute GVHD: results of the ABLE/PBMTC 1202 studies

Abstract

Human graft-versus-host disease (GVHD) biology beyond 3 months after hematopoietic stem cell transplantation (HSCT) is complex. The Applied Biomarker in Late Effects of Childhood Cancer study (ABLE/PBMTC1202, NCT02067832) evaluated the immune profiles in chronic GVHD (cGVHD) and late acute GVHD (L-aGVHD). Peripheral blood immune cell and plasma markers were analyzed at day 100 post-HSCT and correlated with GVHD diagnosed according to the National Institutes of Health consensus criteria (NIH-CC) for cGVHD. Of 302 children enrolled, 241 were evaluable as L-aGVHD, cGVHD, active L-aGVHD or cGVHD, and no cGVHD/L-aGVHD. Significant marker differences, adjusted for major clinical factors, were defined as meeting all 3 criteria: receiver-operating characteristic area under the curve ≥0.60, P ≤ .05, and effect ratio ≥1.3 or ≤0.75. Patients with only distinctive features but determined as cGVHD by the adjudication committee (non-NIH-CC) had immune profiles similar to NIH-CC. Both cGVHD and L-aGVHD had decreased transitional B cells and increased cytolytic natural killer (NK) cells. cGVHD had additional abnormalities, with increased activated T cells, naive helper T (Th) and cytotoxic T cells, loss of CD56bright regulatory NK cells, and increased ST2 and soluble CD13. Active L-aGVHD before day 114 had additional abnormalities in naive Th, naive regulatory T (Treg) cell populations, and cytokines, and active cGVHD had an increase in PD-1- and a decrease in PD-1+ memory Treg cells. Unsupervised analysis appeared to show a progression of immune abnormalities from no cGVHD/L-aGVHD to L-aGVHD, with the most complex pattern in cGVHD. Comprehensive immune profiling will allow us to better understand how to minimize L-aGVHD and cGVHD. Further confirmation in adult and pediatric cohorts is needed.

Graphical abstract

Figure 1.

Patient populations enrolled in the ABLE/PBMTC 1202 network study.

Figure 2.

Evaluation of immune profiles at day 100 in patients who went on to develop late aGVHD or cGVHD. Volcano plots showing significant markers that meet all 3 criteria of a (1) P ≤ .05 (y-axis), (2) ROC AUC of ≥0.60 (circle, ≥0.60; cross, <0.6), and (3) effect ratio ≥1.3 or ≤0.75 (x-axis). The subfigures correspond to (A) cGVHD compared with no-cGVHD controls; (B) late aGVHD compared with no-cGVHD controls, and (C) cGVHD compared with late aGVHD. Cell population are identified by color, with dark blue representing B cells, orange myeloid populations, yellow NK cells, purple NK_reg cells, green T cells, light blue T_reg cells, and dark red plasma cytokines. We note the following clinical variables were modeled as confounding factors in the logistic regression model: (1) prophylaxis or treatment with either alemtuzumab or ATG, (2) prophylaxis or treatment with rituximab, (3) recipient age, (4) the use of a peripheral blood donor product or not, and (5) whether the donor was HLA identical or not.

Figure 3.

Evaluation of the impact of previously resolved early aGVHD on immune profiles at day 100 in patients who will develop late aGVHD or cGVHD. Volcano plots showing significant markers that meet all 3 criteria: P ≤ .05 (y-axis), ROC AUC ≥0.60 (circle, ≥0.60; cross, <0.6), and effect ratio ≥1.3 or ≤0.75 (x-axis). The subfigures correspond to (A) active late aGVHD compared with tolerant patients, (B) late aGVHD compared with patients who has clearly resolved aGVHD, (C) cGVHD compared with tolerant patients, and (D) cGVHD compared with patients with previous resolved early aGVHD. Cell population are identified by color, with dark blue representing B cells, orange myeloid populations, yellow NK cells, purple NK_reg cells, green T cells, light blue T_reg cells, and dark red plasma cytokines. We note the following clinical variables were modeled as confounding factors in the logistic regression model: (1) prophylaxis or treatment with either alemtuzumab or ATG, (2) prophylaxis or treatment with rituximab, (3) recipient age, (4) the use of a peripheral blood donor product or not, and (5) whether the donor was HLA-identical or not.

Figure 4.

Differences between active late aGVHD and active cGVHD between days 100 and 114 and patients at risk for future late aGVHD. Volcano plots showing significant markers that meet all 3 criteria of a P ≤ .05 (y-axis), ROC AUC of ≥0.60 (circle, ≥0.60; cross, <0.6), and effect ratio ≥1.3 or ≤0.75 (x-axis). The subfigures correspond to (A) active late aGVHD compared with patients that have no later cGVHD, (B) active late aGVHD compared with tolerant patients with no cGVHD and no previous aGVHD, (C) active cGVHD that occurred before day 114 compared with the cGVHD cohort (same as in Figure 2A) that will develop cGVHD after day 114. Cell population are identified by color, with dark blue representing B cells, orange myeloid populations, yellow NK cells, purple NK_reg cells, green T cells, light blue T_reg cells, and dark red plasma cytokines. We note the following clinical variables were modeled as confounding factors in the logistic regression model: (1) prophylaxis or treatment with either alemtuzumab or ATG, (2) prophylaxis or treatment with rituximab, (3) recipient age, (4) the use of a peripheral blood donor product or not, and (5) whether the donor was HLA-identical or not.

Figure 5.

Impact of age and time on immune profiles at day 100 of patients that went on to develop cGVHD. (A) Evaluation of the impact of the recipient age on the day-100 immune profile. Volcano plots showing significant markers that meet all 3 criteria of a P ≤ .05 (y-axis), ROC AUC ≥0.60 (circle, ≥ 0.60; cross, <0.6), and effect ratio ≥1.3 or ≤0.75 (x-axis). Cell populations are identified by color, with dark blue representing B cells, orange myeloid populations, yellow NK cells, purple NK_reg cells, green T cells, light blue T_reg cells, and dark red plasma cytokines. We divided each of the subject groups (cGVHD and controls) at their respective median age (∼12.5 years and 9 years) and repeated the above analysis for younger cGVHD vs younger controls. We restricted our analysis to the markers that were significant in the initial analysis (Figure 1A). The younger age group is represented by a solid circle the older age group by an open circle. (B) Evaluation of the impact of the time of onset of cGVHD on the day-100 immune profile. To examine the effect of cGVHD onset time, we divided the cGVHD subjects into 2 onset groups. The early-onset group (solid circles) was less than or equal to the median onset time, and the later onset group (open circles) was greater than the median onset time (166 days after HSCT). We contrasted each onset group against the group that did not develop cGVHD. (C) Group difference visualization with t-SNE. Each patient is represented as a point, where patients with similar marker values are projected onto similar locations in the t-SNE plot. Patients who later developed cGVHD are in blue, those with late aGVHD are in yellow, and non-cGVHD controls are in orange. The ellipses correspond to 1 standard deviation of from the mean of each group.

Figure 6.

Summary of late aGVHD and cGVHD immune profile differences and progression in pediatric and adolescent patients.