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New insights into Poor Hematopoietic Reconstitution after allo-HSCT
Yuan KongPeking University People’s Hospital
Peking University Institute of HematologyBeijing Key Lab of HSCT
Peking University
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I have no personal or financial interests to declare:
I have no financial support from an industry source at the current presentation.
대한혈액학회 Korean Society of Hematology
COI disclosureName of author :Yuan Kong
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Rapid and stable hematopoiesis and immune recovery are the basis for successful allo-HSCT
Good function
Dysfunction
1. Poor Graft Function(PGF)2. Prolonged isolated
thrombocytopenia(PT)3. GVHD4. Relapse5. Infection…
DonorHSCs
RecipientBM microenvironment
60-70%
Complications:30-40%
Hematopoiesis recoveryhomingImmune recovery
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PGF:ANC ≤0.5×10E+9/L,PLT≤20×10E+9/L or hemoglobin ≤ 70 g/Lbeyond day +28 post-transplant with a transfusion requirement
PT: PLT≤20×10E+9/L
0%
20%
40%
Larocca A, et al. Haematologica. 2006Federmann B, et al. Haematologica.2012
P=0.000
No Primary Graft Failure
Graft Rejection
P=0.000
Rejection
PGF+PT
GGF
Definitions
Incidence Poor prognosis
YQ Sun,…, XJ Huang *. Ann Hematol. 2015YJ Chang,…,XJ Huang*. JHO. 2015
5-26%
4The pathogenesis of Poor Hematopoietic Reconstitution
remains poorly understood
Poor Hematopoietic Reconstitution is a life-threatening complication after allo-HSCT
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BM microenvironment plays a crucial role in regulating hematopoiesis
Endosteal niche
Vascular niche
Perivascular niche
Immune niche
Donor HSCs
Calvi LM, et al. Nature. 2003Scadden DT. Nature. 2006Ding L, et al. Nature. 2012
Mercier FE, et al. Nat Rev Immunol 2012C Riether et al.Cell Death and Differentiation.2015
Endosteal niche
Vascular niche
Perivasular niche
Immune niche
…
BM microenvironment
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01
02
03
Is the impaired BM microenvironmentcause or consequence of PGF and PT ?
Could BM microenvironment-directed interventions promote hematopoietic reconstitution?
Is there Impaired BM microenvironmentin patients with PGF and PT ?
Questions about PGF and PT
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YK,…,XJH*. Biol Blood Marrow Transplant. 2013 HD
Periv
ascu
lar
Endo
stea
lVa
scul
ar
GGF PGF
BM endosteal, vascular and perivasularmicroenvironments are impaired in PGF patients
prospective case-control studies
YK,…,XJH*. Bone Marrow Transplant. 2016
Perivascular cells ECs
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Dysfunctional BM endothelial cells in PGF and PT patients
MMS#, YK#,... XJH*. Blood. 2016YK#, MMS#, ... XJH*. AJH. 2018
Increased ROS and apoptosis
Reduced tube formation, migration,proliferation, double-positive staining
ROS
Tube formation
Double-positive staining
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Dysfunctional BM MSCs in PGF and PT patients
YK,YS,…,XJH*. British Journal of Haematology. 2018YS,…,XJH, YK*. Biol Blood Marrow Transplant. 2018
Increased ROS and senescence
Reduced proliferation and HSCs-supporting capacities
ROS Proliferation
Senescence
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Dysregulated BM T cell subsetsin PGF and PT patients
YTW#,YK#,…,XJH*. Biol Blood Marrow Transplant. 2016YK,…,XJH*. Journal of Translational Medicine. 2017YS…,XJH, YK*. Biol Blood Marrow Transplant. 2017
Increased Th1, Tc1, Th17 and Tc17
Reduced Th2 and Tc2 Increased ratios of
Th1/Th2, Tc1/Tc2 and Th17/Treg
Tc1/Tc2
Th1 Th2 Tc2Tc1 Th1/Th2
Th17/Treg
Tc1/Tc2
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Unbalanced monocyte macrophage polarizationin BM of PGF patients
HYZ,…,XJH, YK*. British Journal of Haematology. 2018
Increased M1 Reduced M2 Increased M1/M2
ratio
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BM endosteal, vascular, perivascular and immune microenvironments are impaired in
PGF and PT patients
Increased ROS are found in BM ECs and MSCs of PGF and PT patients
In summary
Patients with PGF and PThad impaired BM microenvironment
A multifaceted problem
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01
02
03
Is the impaired BM microenvironmentcause or consequence of PGF and PT ?
Could BM microenvironment-directed interventions promote hematopoietic reconstitution?
Impaired BM microenvironmentin patients with PGF and PT
Questions about PGF and PT
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YK…,XJH*. Oncotarget. 2016
Donor HSCs in frozen
Donor HSCs for PGF/GGF patients
Donor HSCs for PGF and GGF patientshad similar capabilities to reconstitute in NSG mice
Similar human Engraftment in BM
Similar human Engraftment in
Spleen
NSG mice
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YK,…,XJH*. Biol Blood Marrow Transplant. 2013 YK,…,XJH*. Bone Marrow Transplant. 2016
prospective case-control studies
Infused CD34+ CD34+ in PGF
PGF GGF PGF GGF HD
The frequency of infused donor HSCs was normal pre-HSCT, but HSCs were markedly reduced in PGF patients
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Dysfunctional HSCs in PGF patients
prospective case-control studies
G0ROS CFU
YK…,XJH*. Oncotarget. 201616
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PGF and PT patients showed defectiveBM ECs pre-HSCT
Increased ROS levelsin BM ECs
Reduced BM ECs
17YK…,XJH*. Blood advances. 2019
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The occurrence of PGF+PT
HSCs
In summary
Impaired BM microenvironment play a crucial role in the pathogenesis of PGF and PT post allo-HSCT
Increased ROS
BM endosteal, vascular, perivascular and immune microenvironments are impaired in PGF and PT patients
Dysfunctional HSCs
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01
02
03
Impaired BM microenvironment is causeof PGF and PT
Could BM microenvironment-directed interventions promote hematopoietic reconstitution?
Impaired BM microenvironment in patients with PGF and PT
Questions about PGF and PT
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N-acetyl-L-cysteine (NAC)– Reactive oxygen species (ROS) scavenger
A clinical mucolytic drug without
significant side effects
NAC could enhance HSCs engraftment
in mice
Cai H, et al. Circulation. 2000Hu L, et al. Blood. 2014
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NAC could improve HSCs ability by repairing the impaired BM ECs in PGF patients
MMS#, YK#,... XJH*. Blood. 2016
1.Repair EC in PGF patients
Increase percentage, proliferation, tube formation of ECs
Decrease ROS and apoptosis of ECs
Increase CFU ability
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NAC improved the impaired BM ECs in PT patients
2.Repair EC in PT patients
YK#, MMS#, ... XJH*. American Journal of Hematology. 2018
Increase percentage, migration, tube formation of ECs
Decrease ROS and apoptosis of ECs
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NAC could improve thrombopoiesis in PT Patients
2.Repair EC in PT patients
Increase MK polyploidy, platelets
Increase CFU-MK
23YK#, MMS#, ... XJH*. American Journal of Hematology. 2018
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Complete response: 10% (2/20)Response: 50% (10/20)Overall response: 60% (12/20)
Complete response: >100×109/LResponse: 50-100 × 109/L and atleast doubling of the baselinecountOverall response: CR+R
NAC: 400mg tid
Our clinical cohort study showed that NAC was safe and effective in PT patients
2.Repair EC in PT patients
BM ECs were improved after NAC
24YK#, MMS#, ... XJH*. American Journal of Hematology. 2018
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ROC curves showed that BM EC<0.1% pre-HSCT could identify high-risk patients with PGF and PT
3.Repair EC before HSCT
25YK…,XJH*. Blood advances. 2019
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Could prophylactic NAC reduce PGF+PT through repairing BM ECs?
3.Repair EC before HSCT
Analyze BM ECs
26YK…,XJH*. Blood advances. 2019
NCT03236220
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Prophylactic NAC enhanced the quantity of BM ECs post-HSCT
Decrease ROS levelsin BM ECs
Increase the percentage of BM ECs
3.Repair EC before HSCT
27YK…,XJH*. Blood advances. 2019
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Prophylactic NAC improved the function of BM ECs post-HSCT
28YK…,XJH*. Blood advances. 2019
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Prophylactic NAC prevented the occurrence of PGF and PT
29YK…,XJH*. Blood advances. 2019
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30YK…,XJH*. Blood advances. 2019
In summary
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BM microenvironment-directed strategiespromise to improve PGF and PT
Facilitate hematopoietic recovery in PGF or PT
Normal Hematopoiesis
Improve the impaired BM microenvironment
Effective treatment
In summary
NAC
NAC
31YK*. Seminars in Hematology. 2019
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Acknowledgement
Department of Bone Marrow Transplant Xiao-Jun Huang Xiao-Hui Zhang Kai-Yan Liu Lan-Ping XuYu Wang Huan Chen Yu-Qian Sun Chen-Hua YanYu-Hong Chen Yuan-Yuan Zhang
Department of ChemotherapyBin Jiang Qian JiangHao Jiang Jin Lu
Key Laboratory of HSCTYuan Kong Ying-Jun ChangXiang-Yu Zhao Xiao-Su Zhao Jiang-Ying Liu Min-Min Shi Yang Song Hong-Yan ZhaoXie-Na Cao Zhong-Shi Lyv Qi Wen
Supported by Key Program of National Natural Science Foundation of China
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Thanks for your attention!