Abstract
Studies have suggested an association between pretransplant serum levels of ferritin and C-reactive protein (CRP) and complications of allogeneic hematopoietic stem cell transplantation (HSCT). To evaluate the prognostic impact of these biomarkers on the development of acute and chronic graft-versus-host disease (GVHD), we retrospectively studied 211 patients who underwent allogeneic HSCT for hematologic diseases at our institution. The cumulative incidence rate of chronic GVHD at 3 years was 40.7 %. In the multivariate analysis, elevated CRP levels (≥2 mg/L) were significantly associated with a high incidence of chronic GVHD, whereas high ferritin levels (≥880 ng/mL) showed a tendency, though not statistically significant, to association with a low incidence of chronic GVHD. No significant association was observed between the pretransplant serum ferritin or CRP levels and the incidence of acute GVHD. Multivariate analysis indicated that high pretransplant serum ferritin levels were significantly associated with increases in treatment-related mortality and relapse rates. Overall, an elevated pretransplant serum ferritin level, but not an elevated serum CRP level, is a strong risk factor for overall mortality (hazard ratio, 2.16; P = 0.002). Our results also indicate that pretransplant serum CRP levels may be a useful biomarker for predicting the risk of chronic GVHD.
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References
Majhail NS, Lazarus HM, Burns LJ. Iron overload in hematopoietic cell transplantation. Bone Marrow Transpl. 2008;41(12):997–1003.
Altes A, Remacha AF, Sureda A, Martino R, Briones J, Canals C, et al. Iron overload might increase transplant-related mortality in haematopoietic stem cell transplantation. Bone Marrow Transpl. 2002;29(12):987–9.
Armand P, Kim HT, Cutler CS, Ho VT, Koreth J, Alyea EP, et al. Prognostic impact of elevated pretransplantation serum ferritin in patients undergoing myeloablative stem cell transplantation. Blood. 2007;109(10):4586–8.
Pullarkat V, Blanchard S, Tegtmeier B, Dagis A, Patane K, Ito J, et al. Iron overload adversely affects outcome of allogeneic hematopoietic cell transplantation. Bone Marrow Transpl. 2008;42(12):799–805.
Kataoka K, Nannya Y, Hangaishi A, Imai Y, Chiba S, Takahashi T, et al. Influence of pretransplantation serum ferritin on nonrelapse mortality after myeloablative and nonmyeloablative allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transpl. 2009;15(2):195–204.
Mahindra A, Bolwell B, Sobecks R, Rybicki L, Pohlman B, Dean R, et al. Elevated pretransplant ferritin is associated with a lower incidence of chronic graft-versus-host disease and inferior survival after myeloablative allogeneic haematopoietic stem cell transplantation. Br J Haematol. 2009;146(3):310–6.
Wahlin A, Lorenz F, Fredriksson M, Remberger M, Wahlin BE, Hagglund H. Hyperferritinemia is associated with low incidence of graft versus host disease, high relapse rate, and impaired survival in patients with blood disorders receiving allogeneic hematopoietic stem cell grafts. Med Oncol. 2011;28(2):552–8.
Lim ZY, Fiaccadori V, Gandhi S, Hayden J, Kenyon M, Ireland R, et al. Impact of pre-transplant serum ferritin on outcomes of patients with myelodysplastic syndromes or secondary acute myeloid leukaemia receiving reduced intensity conditioning allogeneic haematopoietic stem cell transplantation. Leuk Res. 2010;34(6):723–7.
Black S, Kushner I, Samols D. C-reactive Protein. J Biol Chem. 2004;279(47):48487–90.
Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflammation. N Engl J Med. 1999;340(6):448–54.
Artz AS, Wickrema A, Dinner S, Godley LA, Kocherginsky M, Odenike O, et al. Pretreatment C-reactive protein is a predictor for outcomes after reduced-intensity allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transpl. 2008;14(11):1209–16.
Fuji S, Kim SW, Fukuda T, Mori S, Yamasaki S, Morita-Hoshi Y, et al. Preengraftment serum C-reactive protein (CRP) value may predict acute graft-versus-host disease and nonrelapse mortality after allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transpl. 2008;14(5):510–7.
Remberger M, Mattsson J. C-reactive protein levels before reduced-intensity conditioning predict outcome after allogeneic stem cell transplantation. Int J Hematol. 2010;92(1):161–7.
Kanda J, Mizumoto C, Ichinohe T, Kawabata H, Saito T, Yamashita K, et al. Pretransplant serum ferritin and C-reactive protein as predictive factors for early bacterial infection after allogeneic hematopoietic cell transplantation. Bone Marrow Transpl. 2011;46(2):208–16.
Giralt S, Ballen K, Rizzo D, Bacigalupo A, Horowitz M, Pasquini M, et al. Reduced-intensity conditioning regimen workshop: defining the dose spectrum. Report of a workshop convened by the center for international blood and marrow transplant research. Biol Blood Marrow Transpl. 2009;15(3):367–9.
Przepiorka D, Weisdorf D, Martin P, Klingemann HG, Beatty P, Hows J, et al. 1994 Consensus conference on acute GVHD grading. Bone Marrow Transpl. 1995;15(6):825–8.
Sullivan KM, Agura E, Anasetti C, Appelbaum F, Badger C, Bearman S, et al. Chronic graft-versus-host disease and other late complications of bone marrow transplantation. Semin Hematol. 1991;28(3):250–9.
Gooley TA, Leisenring W, Crowley J, Storer BE. Estimation of failure probabilities in the presence of competing risks: new representations of old estimators. Stat Med. 1999;18(6):695–706.
Storb R, Deeg HJ, Pepe M, Appelbaum F, Anasetti C, Beatty P, et al. Methotrexate and cyclosporine versus cyclosporine alone for prophylaxis of graft-versus-host disease in patients given HLA-identical marrow grafts for leukemia: long-term follow-up of a controlled trial. Blood. 1989;73(6):1729–34.
Deeg HJ, Lin D, Leisenring W, Boeckh M, Anasetti C, Appelbaum FR, et al. Cyclosporine or cyclosporine plus methylprednisolone for prophylaxis of graft-versus-host disease: a prospective, randomized trial. Blood. 1997;89(10):3880–7.
Ratanatharathorn V, Nash RA, Przepiorka D, Devine SM, Klein JL, Weisdorf D, et al. Phase III study comparing methotrexate and tacrolimus (prograf, FK506) with methotrexate and cyclosporine for graft-versus-host disease prophylaxis after HLA-identical sibling bone marrow transplantation. Blood. 1998;92(7):2303–14.
Ferrara JL, Levine JE, Reddy P, Holler E. Graft-versus-host disease. Lancet. 2009;373(9674):1550–61.
Van Der Meer IM, De Maat MP, Hak AE, Kiliaan AJ, Del Sol AI, Van Der Kuip DA, et al. C-reactive protein predicts progression of atherosclerosis measured at various sites in the arterial tree: the Rotterdam Study. Stroke. 2002;33(12):2750–5.
Haverkate F, Thompson SG, Pyke SD, Gallimore JR, Pepys MB. Production of C-reactive protein and risk of coronary events in stable and unstable angina. European Concerted Action on Thrombosis and Disabilities Angina Pectoris Study Group. Lancet. 1997;349(9050):462–6.
Pasceri V, Willerson JT, Yeh ET. Direct proinflammatory effect of C-reactive protein on human endothelial cells. Circulation. 2000;102(18):2165–8.
Devaraj S, Davis B, Simon SI, Jialal I. CRP promotes monocyte-endothelial cell adhesion via Fcgamma receptors in human aortic endothelial cells under static and shear flow conditions. Am J Physiol Heart Circ Physiol. 2006;291(3):H1170–6.
Recalcati S, Invernizzi P, Arosio P, Cairo G. New functions for an iron storage protein: the role of ferritin in immunity and autoimmunity. J Autoimmun. 2008;30(1–2):84–9.
Matzner Y, Hershko C, Polliack A, Konijn AM, Izak G. Suppressive effect of ferritin on in vitro lymphocyte function. Br J Haematol. 1979;42(3):345–53.
Broxmeyer HE, Cooper S, Levi S, Arosio P. Mutated recombinant human heavy-chain ferritins and myelosuppression in vitro and in vivo: a link between ferritin ferroxidase activity and biological function. Proc Natl Acad Sci USA. 1991;88(3):770–4.
Cardier J, Romano E, Soyano A. Effect of hepatic isoferritins from iron overloaded rats on lymphocyte proliferative response: role of ferritin iron content. Immunopharmacol Immunotoxicol. 1995;17(4):719–32.
Gray CP, Franco AV, Arosio P, Hersey P. Immunosuppressive effects of melanoma-derived heavy-chain ferritin are dependent on stimulation of IL-10 production. Int J Cancer. 2001;92(6):843–50.
Gray CP, Arosio P, Hersey P. Heavy chain ferritin activates regulatory T cells by induction of changes in dendritic cells. Blood. 2002;99(9):3326–34.
St Pierre TG, Clark PR, Chua-anusorn W, Fleming AJ, Jeffrey GP, Olynyk JK, et al. Noninvasive measurement and imaging of liver iron concentrations using proton magnetic resonance. Blood. 2005;105(2):855–61.
Acknowledgments
The authors would like to thank Rie Goi and Mika Kobayashi for their expert data management and secretarial assistance, and all the staff of our transplant team for their dedicated care of the patients and donors. This work was supported in part by a grant-in-aid for scientific research from the Ministry of Education, Culture, Sports, Science and Technology of Japan.
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The authors declare that they have no conflict of interest.
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Sakamoto, S., Kawabata, H., Kanda, J. et al. Differing impacts of pretransplant serum ferritin and C-reactive protein levels on the incidence of chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Int J Hematol 97, 109–116 (2013). https://doi.org/10.1007/s12185-012-1229-0
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DOI: https://doi.org/10.1007/s12185-012-1229-0