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Prepublished online as a Blood First Edition Paper on July 25, 2002; DOI 10.1182/blood-2002-04-1033.
CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS
From the Hematology Department and Bone Marrow
Transplant Unit and the Biostatistics Department (INSERM U444),
Hôpital Saint Louis, Paris, France; and Center for
Cell Therapy, Faculty of Medicine of Ribeirão Preto,
Brazil.
We made the hypothesis that donor and recipient gene polymorphisms
that drive the host response to microorganisms could be associated with
infections after bone marrow transplantation (BMT). HLA-identical BMT
was performed for patients with acute (n = 39) or chronic leukemia
(n = 68). Genotyping was performed in 107 D/R DNA pairs for gene
polymorphisms of cytokines (tumor necrosis factor- Early infection, engraftment, and graft-versus-host
disease (GVHD) are major determinants of early outcomes after
allogeneic stem cell transplantation (SCT). Risk factors affecting
these complications depend on patient- (such as age, disease,
cytomegalovirus [CMV] status), donor- (such as HLA compatibility,
type of donor, sex), and treatment- (intensity of conditioning regimen,
GVHD prophylaxis, source of stem cells) related factors.
Huge advances in human genomics and in the understanding of the
inflammatory response have led to an expanding list of genetic risk
factors associated with inflammatory and infectious diseases in the
past 5 years. In allogeneic SCT, genetic factors such as donor and
recipient gene polymorphisms of pro- and anti-inflammatory cytokines
have been associated with the incidence and severity of GVHD in
HLA-identical bone marrow transplantation (BMT).1,2 However, the influence of such donor and recipient gene polymorphisms on other outcomes, including engraftment and infection after SCT, has
not been described.
Recently, candidate gene studies and human genome analyses have been
used to identify genes implicated in susceptibility or resistance to
infectious agents. Rarely has a single gene defect been directly
related to devastating consequences, such as interferon-gamma receptor
mutations leading to fatal infections with ubiquitous mycobacteria.3 More often, disease susceptibility is
multifactorial. Genetic variants that modify the level or function of
the mediators have been associated with susceptibility to and outcome
of severe sepsis and septic shock. For example, in bacterial
infections, Fc gamma receptor (Fc Myeloperoxidase (MPO) is an enzyme that plays an important role in
human defense against microorganisms7; however,
MPO gene polymorphisms have not been associated with
infectious episodes, though it has been recently associated with the
risk for lung cancer.8,9
We hypothesized that donor and recipient polymorphisms of genes that
have a central role in innate immunity or phagocyte biology could
influence the incidence of bacterial, viral, and fungal infections and
other outcomes after HLA-identical BMT. We thus studied a panel of
candidate gene polymorphisms (TNF- Patient, donor, and transplantation characteristics
Graft-versus-host disease prophylaxis, conditioning regimen, and
supportive therapy
All patients were isolated in laminar airflow rooms. Irradiated and leukocyte-depleted blood products were used for all patients. Patients received transfusions of red blood cells (RBCs) or platelets when the hemoglobin level was lower than 8 g/dL and the platelet count was less than 20 × 109/L, respectively. Selective gut decontamination with oral antibiotics and viral/fungal/parasitic prophylaxis was performed according to local policy, which remained constant during the 6-year study period. Preemptive treatment with ganciclovir or foscarnet for CMV reactivation based on CMV antigenemia screening was used from January 1994. Beginning before day +7, prophylactic hematopoietic growth factors (HGFs) were administered in 11 (10%) patients because of their inclusion in a randomized clinical trial. Graft collection, manipulation, and stem cell content Bone marrow was harvested from both posterior iliac crests after the patient was administered general anesthesia. Marrow was aspirated with plastic syringes in aliquots of 2 to 10 mL and was diluted with heparinized tissue culture medium RPMI 1640 or acid-citrate dextrose (ACD). Automated cell counts and CD34+ cell quantification were performed before and after processing, but only the latter was taken into account in this study. CD34+ cell quantification was performed as previously described by fluorescence analysis.10Gene polymorphism analysis After informed consent was received, all donor and recipient genotypes were screened blind to the clinical outcome of each transplantation procedure. Peripheral blood leukocytes from patients and donors were stored in liquid nitrogen and were used as a source of DNA, which was extracted through the salting-out method.11Previously published polymerase chain reaction (PCR) and
restriction-digestion protocols were used to identify the We developed a method for PECAM-1 genotyping using the primers
5'-ACGGTGCAAAATGGGAAGAA-3' and 5'-AGAGGGTGATGGGTGGAGAG-3'. PCR was
performed at 94°C for 3 minutes followed by 35 cycles at 94°C for
30 seconds, 55°C for 30 seconds, and 72°C for 60 seconds, and a
final extension at 72°C for 7 minutes. The 364-bp product was
digested with AluI and was electrophoresed on 2.5% agarose. For the identification of the G>C polymorphism at Genotyping for Fc IL-10 A>G polymorphism at The A>T ICAM-1 polymorphism was genotyped by amplification of a 130-bp segment using primers 5'-TGTCCCCCTCAAAAGTCATCCTG-3' and 5'-TTCCCAGGCAGGAGCAACTCCTT-3'.18 PCR was performed at 94°C for 3 minutes followed by 35 cycles at 94°C for 40 seconds, 65°C for 40 seconds, and 72°C for 40 seconds, and a final extension at 72°C for 7 to 10 minutes. The product was digested with NlaIII and was electrophoresed on 20% acrylamide. The 3 polymorphisms of exon 1 of MBL at positions 1045, 1052, and 1061 of GenBank sequence AF080508 End point definitions The dates of the first episodes of severe bacterial, viral, and invasive fungal infections of all patients were analyzed together (overall first infections) and separately.Severe bacterial infections. We considered severe bacterial infection to have developed when sepsis, pneumonia, or septic shock was diagnosed according to previously published criteria.19 Bacterial pneumonia was also diagnosed when clinical and radiologic signs of pneumonia improved after empiric antibacterial, but not antifungal, therapy in the absence of positive findings on blood culture or bronchoalveolar lavage (BAL).20 Viral infections and diseases. CMV infection was defined by a positive antigenemia level (presence of 2 or more positive nuclei per 200 000 leukocytes). CMV was diagnosed according to previously published criteria.21 Herpes simplex virus (HSV) was defined as a respiratory, digestive, or neurologic disease with the isolation of the HSV virus in culture. Probable adenovirus disease was defined through biopsy as the presence of adenovirus in 2 or more sites regardless of technique, except immunohistochemistry. Definitive adenovirus disease required histochemistry evaluation of positive findings on biopsy specimen or culture (except gastrointestinal) or cerebrospinal fluid sample and blood. Other viral infections were considered severe when a virus was isolated from the site of disease and necessitated antiviral treatment. Invasive fungal infections. Candidemia was defined by one or more positive findings on blood culture for Candida spp. Disseminated candidosis was defined by clinical or radiologic signs of fungal infection with one or more positive blood cultures for Candida spp. Probable invasive aspergillosis was defined by histopathologic or cytopathologic evidence of Aspergillus spp from needle aspiration or biopsy, with evidence of associated damaged tissue or positive culture obtained by a sterile procedure with clinical or radiologic signs consistent with infection. We considered clinical and radiologic signs of invasive aspergillosis with positive antigenemia (but without microbiologic identification) as probable invasive aspergillosis. Definitive invasive aspergillosis was defined as a clinical illness and as isolation of Aspergillus spp from a sterile site, hyphae consistent with Aspergillus spp on biopsy, or aspiration plus culture of Aspergillus spp from the same organ, radiologic pulmonary lesions not attributable to other factors, and BAL fluid culture findings positive for Aspergillus spp.22 Other outcomes Neutrophil recovery was defined as having occurred on the first of 3 consecutive days when neutrophil levels were higher than 0.5 × 109/L within the first 42 days of transplantation. Platelet recovery was defined as having occurred on the first of 7 days when unsupported platelet levels were higher than 20 × 109/L within the first 180 days of transplantation. Acute and chronic GVHD were diagnosed and graded according to published criteria.23,24 All patients were considered evaluable for acute (aGVHD) at day +1 after transplantation. Chronic GVHD (cGVHD) was evaluated among patients who survived with sustained engraftment from day +100 after transplantation. Transplantation-related mortality (TRM) was calculated from the time of transplantation to death related to transplantation, not to relapse, until day 180. Survival was calculated from the time of transplantation to death from any cause.Statistical analysis The reference date was March 1, 2000. Univariate and multivariate analyses were used to identify independent risk factors for death and TRM by means of log-rank tests and Cox proportional hazards models, respectively. The predictive effects of recipient and donor gene polymorphisms were assessed by TNF- ,
TNF- , IL-1Ra, IL-6, IL-10, PECAM-1, Fc RIIa, IIIa, and IIIb, MBL,
and MPO. Because of the low prevalence of ICAM-1 variant alleles in the
group analyzed, this gene polymorphism was not included in the risk
factors analysis. Other clinically related variables analyzed were
recipient and donor ages, recipient and donor sexes, sex match, female
donor to male recipient, recipient weight, recipient and donor CMV
serology and match, ABO compatibility, ABO major incompatibility,
diagnosis of chronic leukemia, diagnosis of acute leukemia, stage of
disease, use of a radiation-based conditioning, use of BuCY, nucleated cell doses, and CD34+ marrow cell doses.
For assessment of prognostic factors of neutrophil and platelet recovery, acute GVHD (grades II-IV or grades III- IV), chronic GVHD, first episode of infection (all types), first viral infection, first bacterial infection, and first invasive fungal infection, a similar methodology was used in a competing-risks setting, with death treated as a competing event. Univariate and multivariate analyses were then performed using the proportional subdistribution hazard regression model of Fine and Gray.25 A stepwise backward procedure was used construct a set of independent predictors of each end point. All predictors achieving P < .15 were considered, and predictors were sequentially removed if, in the multiple model, P > .05. All tests were 2-sided, and the type 1 error rate was fixed at 0.05. Statistical analyses were performed using SAS 8.1 (SAS, Cary, NC) and Splus2000 (MathSoft, Seattle, WA) software packages.
Frequency of donor and recipient gene polymorphisms and corresponding phenotypes Results of donor and recipient gene polymorphisms, their prevalence, and their corresponding phenotypes are listed in Table 2. According to the literature, the frequency of the different gene polymorphisms studied were similar to those reported in a white population.
Association of donor and recipient gene polymorphisms with the incidence of infections: univariate and multivariate analyses Table 3 shows the cumulative incidence of severe overall infections and separate bacterial, viral, and fungal infections and of transplantation-related deaths within 180 days of HLA-identical BMT according to donor and recipient gene polymorphisms. Table 4 shows multivariate analysis results considering patient-, donor-, and transplantation-related factors for hematopoietic recovery, acute and chronic GVHD, infections, early TRM, and survival.
Overall first infection At day 180 after transplantation, 60 patients had experienced at least one episode of microbiologically or clinically documented first severe bacterial (n = 22), first viral (n = 34), or first fungal infection (n = 4). Infection was directly responsible for 17 of 36 (47%) transplantation-related deaths in the whole period of follow-up. The cumulative incidence rate of any first infection by day 180 was 56%. In univariate analysis, recipient CD31 (L/L) (P = .04) and recipient FcRIIa R-131
(P = .07) genotypes were associated with an increased
incidence of severe infection (Table 3). In univariate analysis, other
factors increasing the risk for severe infection were adult patients
(P = .02), recipient positive CMV serology
(P = .005), and advanced stage of disease at
transplantation (P < 10 4). In
multivariate analysis, recipient FcRIIa R-131 (HR = 1.92; 95%
confidence interval [CI] = 1.02-3.61; P = .04] and
recipient-positive CMV serology (HR = 2.82; 95% CI = 1.61-4.97;
P = .0005) statistically increased the risk for first
infection (Table 4).
Bacterial infection The cumulative incidence of at least one bacterial infection was 28% at day 180. Thirty patients experienced severe bacterial infection (16 sepsis, 9 pneumonia, and 5 septic shock). Gram-positive bacteria were isolated in 13 patients (Staphylococcus coagulase negative n = 10, Streptococcus pneumonia n = 2, Enterococcus faecium n = 1), and gram-negative bacteria were isolated in 11 patients (Pseudomonas aeruginosa n = 4, Klebsiella pneumonia n = 3, Enterobacter cloacae n = 1, Actinobacter sp n = 1, Bacterioidis fragilis n = 1, Stenotrophomonas maltophilia n = 1). In 6 patients no bacteria were isolated, but patients had clinical or radiologic signs of bacterial infection (see "End point definitions"). In univariate analysis, recipient and donor MPO genotypes were associated with the incidence of severe bacterial infection (Table 3). The cumulative incidence was 20% when the MPO donor genotype was GG, 38% when it was AG, and 50% when it was AA (Figure 1, Table 3). The type of clinical manifestation (pneumonia, sepsis, septic shock) or the etiology of bacterial infection (gram-positive or gram-negative) were not associated with GG or AG-AA donor genotype (data not shown). Among all other gene polymorphisms studied, there was a trend toward increased risk for bacterial infection when the recipient was CD31 (L/L), (P = .06) (Table 3). Other patient-, donor-, and transplantation-related factors increasing the risk for bacterial infection were intermediate or advanced status of leukemia (P = .04), conditioning other than BuCY (P = .04), and ABO major incompatibility (P = .01). In multivariate analysis adjusted for confounding variables, only 3 factors increased the risk for severe bacterial infection: (1) donor MPO genotype (AG-AA) (HR = 2.16; 95% CI = 1.08-4.32; P = .03); (2) conditioning regimen other than BuCY (HR = 2.15; 95% CI = 1.03-4.51; P = .04); and (3) ABO major incompatibility (HR = 2.43: 95% CI = 1.16-5.09; P = .02) (Table 4).
Viral infections and diseases The cumulative incidence of patients who experienced at least one viral infection was 39% at day 180, with a total of 44 events (CMV infection, 41; CMV disease, 1; herpes simplex virus, 1; adenovirus, 1). Genetic factors were not associated with first viral infection. In univariate analysis, the following factors were associated with an increased risk for viral infection: positive recipient CMV serology (P < 104), advanced stage of disease at
transplantation (P = .02), adult status
(P = .02), and CMV-positive donor to a negative CMV
patient (P = .03). In multivariate analysis, positive
recipient CMV serology (HR = 10.34; 95% CI = 4.30-24.85;
P = <104), positive donor CMV serology to
negative recipient CMV serology (HR = 2.28; 95% CI = 1.21-4.29;
P = .01), advanced stage of disease at transplantation
(HR = 4.49; 95% CI = 2.02-10.00;
P < 104), and adult status (HR = 5.41;
95% CI = 1.47-19.97; P = .01) were factors associated
with a higher incidence of first viral infections and diseases.
Invasive fungal infections The estimated probability for at least one invasive fungal infection (IFI) at 180 days was 12%. There were 8 invasive aspergillosis (Aspergillus spp, 3; Aspergillus fumigatus, 4; Aspergillus niger, 1), 2 candidemia (Candida spp, 1; Candida albicans, 1), 2 disseminated candidiasis, and 1 disseminated Malassesia furfur fungal infections. Gene polymorphisms were not associated with the incidence of IFI (Table 3). In univariate analysis, advanced stage of disease at transplantation (P = .05), lower nucleated cell dose (P = .03), and lower CD34 cell dose (P = .03) were associated with increased risk for IFI. In multivariate analysis, when adjusting for confounding variables, only advanced stage of disease at transplantation (HR = 6.51; 95% CI = 1.71-24.75; P = .006) and lower CD34 cell dose (HR = 1.41 per 106/kg; 95% CI = 1.01-1.97; P = .04) influenced the increased incidence of IFI.Neutrophil and platelet recoveries Three patients died in the first 28 days after transplantation without having achieved neutrophil recovery. One hundred four (97%) patients achieved an absolute neutrophil count (ANC) greater than 0.5 × 109/L at day 42. The cumulative incidence rate of recovery at day 42 was 96%. At day 20, 50% of the patients had achieved an ANC greater than 0.5 × 109/L. Two patients had late graft failure. Donor FcRIIIb gene polymorphism influenced
the time to neutrophil recovery. Bone marrow donor genotype
HNA-1a/HNA-1a was associated with a delayed neutrophil recovery (25 days) compared with a neutrophil recovery of donor HNA-1a/HNA-1b (19 days) (P = .007) (Figure 2).
In multivariate analysis, time to neutrophil recovery was shorter when
the bone marrow donor was HNA-1a/HNA-1b, (HR = 1.77; 95%
CI = 1.24-2.52; P = .002). Other factors associated with
shorter time of recovery were early/intermediate stage of disease
(HR = 2.27; 95% CI = 1.22-4.21; P = .01), absence of
TBI (HR = 1.83; 95% CI = 1.22-2.75; P = .003), and
ABO compatibility (HR = 1.67; 95% CI = 1.03-2.73; P = .04) (Table 4).
Recipient or donor gene polymorphism did not influence time to platelet
recovery (data not shown). In multivariate analysis, the following
factors were associated with shorter time to platelet recovery: chronic
leukemia (HR = 2.08; 95% CI = 1.38-3.14;
P < 10 Acute and chronic graft-versus-host disease Forty-five patients had aGVHD of grade II or more; the cumulative rate was 42% at day 100. Eighteen patients (17%) had aGVHD of grade III or IV; the estimated incidence was 17% at day 100. In univariate analysis, the following genotypes were associated with risk for aGVHD (grades II-IV): recipient TNF- genotype (GG + AG = 30% vs
AA = 49%) (P = .05) and donor IL-1Ra genotype (absence of IL-1RN*2 = 52% vs presence of IL-1RN*2 = 30%)
(P = .03). Some other genotypes were statistically weakly
associated with the risk for aGVHD, such as donor TNF- genotype
(GG + AG = 32% vs AA = 48%) (P = .08), recipient
IL-1Ra genotype (absence of IL-1RN*2 = 49% vs IL-1RN*2 = 32%)
(P = .07), recipient IL-10 genotype (GG = 57% vs AG + AA = 38%) (P = .08), and recipient MPO genotype (GG = 49% vs AG + AA = 33%) (P = .09). Other factors
increasing the risk for aGVHD were female donor to male recipient
(P = .04) and major ABO incompatibility
(P = .04). The incidence of aGVHD grades III and IV was
not associated with donor or recipient characteristics (data not
shown). In multivariate analysis, only 2 factors were associated with
the risk for aGVHD grades II to IV: female donor to male recipient
(HR = 1.91; 95% CI = 1.05-3.47; P = .02) and donor
IL-1Ra genotype (absence of IL-1RN*2) (HR = 2.07; 95%
CI = 1.10-3.92; P = .017).
Chronic GVHD developed in 50 of 95 patients at risk. At 2 years, the cumulative incidence rate was 32%. In univariate analysis, recipient IL-10 genotype was associated with increased risk for cGVHD (GG = 58% vs AG+AA = 26%) (P = .04). There was a trend toward decreasing risk for cGVHD when recipient IL-1Ra had IL-1RN*2 than when it did not have IL-1RN*2 (26% vs 36%) (P = .07). In multivariate analysis, the following factors were associated with risk for cGVHD: recipient age (HR = 1.61 per 10 years; 95% CI = 1.42-1.82; P = .0001), recipient IL-10 (GG) (HR = 2.77; 95% CI = 1.10-6.95; P = .03), recipient IL-1Ra (HR = 1.96; 95% CI = 1.06-3.60; P = .03), and female donor to male recipient (HR = 1.92; 95% CI = 1.09-3.37; P = .02). Early transplantation-related mortality Twenty-four patients died of transplantation-related complications within the first 180 days of transplantation. At day 180, the cumulative incidence of nonleukemic death was 22%. The main causes of TRM were GVHD (n = 7, 29%), infections (n = 9, 37.5%), interstitial pneumonitis (n = 3, 12.5%), late graft failure and infection (n = 2, 8.5%), multiorgan failure (n = 2, 8.5%), and hemorrhage (n = 1, 4%). In univariate analysis, donor FcIIIb HNA-1a/HNA-1a and donor MPO AA genotypes were associated with increased
risk for nonleukemic death at day 180 (Table 3). In multivariate
analysis, the risk for early death was increased for patients with
advanced-stage disease (HR = 4.80; 95% CI = 1.37-16.90;
P = .01), older age (HR = 1.64 per 10 years; 95%
CI = 1.15-2.35; P = .006), donor MPO (AA) (HR = 5.14;
95% CI = 1.71-15.44; P = .003), and donor FcRIIIb
HNA-1a/HNA-1a or HNA- 1b/HNA-1b (HR = 2.57; 95% CI = 1.01-6.62;
P = .05). Causes of death of patients according to donor
FcRIIIb and MPO gene polymorphism are listed in Table
5.
Relapse and survival Nine patients had hematologic relapses. Median time for relapse was 450 days (range, 91-1600 days). With a median follow-up of 52 months (range, 8-119 months), 63 (59%) patients were alive on March 1, 2000. The 5-year estimate of survival for the whole population was 54%. Forty-four (41%) patients died 6 after relapse, 36 of
transplantation-related complications, and 2 of other causes. Donor and
recipient gene polymorphism did not influence the overall risk for
death. Multivariate analysis showed that ABO major incompatibility (HR = 2.45; 95% CI = 1.23-4.86; P = .01), increasing
recipient age (HR = 1.3 per 10 years; 95% CI = 1.04-1.63;
P = .02), and use of a conditioning regimen other than
BuCY (HR = 2.52; 95% CI = 1.35-4.71; P = .004)
increased the risk for death.
The impressive volume of data emerging daily from genomics and high-throughput sequencing and gene expression analysis is generating unprecedented opportunities for defining the genetic basis of susceptibility to complex diseases.46 Allogeneic SCT is an established but complex therapy for patients with hematologic malignant and nonmalignant diseases. Unfortunately, complications such as GVHD and infections still cause significant morbidity and mortality after SCT. Genetic factors related to patients and donors, such as cytokine or adhesion molecule gene polymorphisms, have been reported to modify the incidence and severity of aGVHD.1,2,35,36,47 However, their influence on infections and other outcomes after BMT have not been described. In search of donor and recipient genetic factors that could
modify the incidence or the course of bacterial, viral, and fungal infections and other outcomes In the present analysis, we associated donor and recipient
genetic factors with first episodes of severe infections and with separate bacterial, viral, and fungal infections. Interestingly, we
found that recipients with Fc In our study, a new and important finding is that donor MPO genotype
may influence the incidence of severe bacterial infections when
adjusting for other patient-, donor-, and transplantation-related factors. MPO is a lysosomal hemoprotein located in the azurophilic granules of polymorphonuclear (PMN) leukocytes and monocytes. It is
part of the host defense system of human PMN leukocytes, responsible
for microbicidal activity against a wide range of organisms. Phagocytes
deficient in MPO express in vitro a mild-to-moderate defect in
bacterial killing but a marked defect in fungal killing.52 Moreover, MPO has been shown to alter the production or effect of
nitric-oxide-derived inflammatory oxidants in activated
neutrophils.53 In a recent epidemiologic study, a
significantly higher occurrence of severe infections and chronic
inflammatory processes was noted among a group of 100 patients with
total and subtotal MPO deficiency compared with a healthy
population.54 In addition, MPO-deficient mice showed
severely reduced cytotoxicity to Candida albicans, Candida tropicalis, Trichospora asahii, and
Pseudomonas aeruginosa and a significantly delayed clearance
of Aspergillus fumigatus and Klebsiella
pneumonia.55 A single-base substitution
(G>A) in the promoter region of the MPO gene (position Importantly, we found that bone marrow donor MPO genotype AG or AA
increased the risk for bacterial infection after BMT, probably reflecting the decreased bactericidal activity of MPO in engrafted neutrophils. In multivariate analysis, the AA genotype was also associated with risk for nonleukemic death 180 days after
transplantation. However, because of the small number of patients, the
main causes of death were not identified. This finding suggests that
MPO polymorphisms may contribute to an understanding of the role of MPO
in host defenses, and they should be evaluated in other clinical
situations in which infections are a major issue We expected to find associations between infections and inflammatory and MBL gene polymorphisms. Proinflammatory cytokines such as TNF, which act as powerful agents of innate immunity against infections, have attracted considerable interest as candidate susceptibility genes in a range of infectious disease.6 It is difficult to raise hypotheses about the absence of a correlation between cytokine gene polymorphisms, specifically TNF, and infections that are mainly viral.58 As discussed above, however, gene candidates associated with infections in the general population may be different in immunosuppressed transplant recipients. Recently, Mullighan et al59 reported the influence of MBL gene polymorphisms and infections after allogeneic SCT. Almost 90 patients undergoing BMT, peripheral blood SCT, and T-cell-depleted transplantation were analyzed. They found an association between infections and MBL gene polymorphisms only after neutrophil recovery using rough statistics (Fisher exact test). Our approach was different because we analyzed only HLA nonmanipulated BMT for leukemia. Using competing-risk analysis, MBL gene polymorphisms were not associated with time to first infections independently of neutrophil recovery. These points could explain the differences in the results of both studies. In our study, one interesting and first-reported result is the
influence of donor Fc Moreover, soluble Fc Finally, we confirmed previous findings regarding the influence of donor IL-1Ra (IL-1RN*2) as a protective gene polymorphism in aGVHD.65,66 Other gene polymorphisms, such as TNF, IL-6, IL-10, and CD31, have been correlated with the risk for aGVHD.2,35,36,47,66 In our study their influence was only observed in univariate analysis. We also detected an influence of recipient IL-10 and recipient IL-1Ra genotype on the incidence of cGVHD not previously reported. The probable explanation for our results compared with those of others is that we analyzed a homogenous population of patients with leukemia with few variations in the conditioning regimen, including all the candidate genes that could influence the risk for GVHD. In addition, we used multivariate analysis taking competitive risk into account to study risk factors. This analysis considered death as a competitive risk for the other events, including GVHD, whereas most studies used rough statistics (Fisher exact test)1,67 or routine Cox proportional hazards regression models that treat death as censoring, which can produce biased estimates if the different risks in competition are not independent.2,65 One might consider, however, that even in a relatively homogenous population of patients, such as patients who undergo transplantation for leukemia, it is possible that an imbalance exists in the underlying patient population that could explain the statistically significant differences. Thus, the polymorphism might not have been a marker for outcomes after BMT but simply a chance association. Finally, and most important, MPO and Fc In conclusion, donor and recipient inflammatory and host defense
genetic factors are associated with neutrophil recovery, infections
(mainly bacterial), and acute and chronic GVHD after HLA-identical BMT.
Most important, donor genetic risk factors influencing bacterial
infections (MPO), speed of neutrophil recovery (Fc
We thank M. H. Tavela and A. G. Araujo for technical
assistance, Prof J. Bux for discussions concerning the
Fc
Submitted April 22, 2002; accepted July 3, 2002.
Prepublished online as Blood First Edition Paper, July 25, 2002; DOI 10.1182/blood-2002-04-1033.
Supported by Assistance Publique-Hopitaux de Paris, IFR Saint-Louis, Association pour la Recherche sur les Transplantations Médullaires, and Fundação de Amparo à Pesquisa do Estado de São Paulo, Brazil.
The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked "advertisement" in accordance with 18 U.S.C. section 1734.
Presented in part at the Annual Meeting of the American Society of Hematology, Orlando, FL, December 7-11, 2001. Reprints: Vanderson Rocha, Service du Pr. E. Gluckman, Hôpital Saint Louis, 1 Av Claude Vellefaux, 75010 Paris, France; e-mail: vanderson.rocha{at}sls.ap-hop-paris.fr.
1.
Middleton PG, Taylor PRA, Jackson G, Proctor SJ, Dickinson AM.
Cytokine gene polymorphisms associating with severe acute graft-versus-host disease in HLA-identical sibling transplants.
Blood.
1998;92:3943-3948 2. Socie G, Loiseau P, Tamouza R, et al. Both genetic and clinical factors predict the development of graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Transplantation. 2001;72:699-706[CrossRe | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Abstract
Introduction
308G>A TNF-
