Immunologic Research

, Volume 47, Issue 1–3, pp 65–77 | Cite as

High-dose, post-transplantation cyclophosphamide to promote graft-host tolerance after allogeneic hematopoietic stem cell transplantation

  • Leo Luznik
  • Ephraim J. FuchsEmail author


Graft-versus-host disease, or GVHD, is a major complication of allogeneic hematopoietic stem cell transplantation (alloHSCT) for the treatment of hematologic malignancies. Here, we describe a novel method for preventing GVHD after alloHSCT using high-dose, post-transplantation cyclophosphamide (Cy). Post-transplantation Cy promotes tolerance in alloreactive host and donor T cells, leading to suppression of both graft rejection and GVHD after alloHSCT. High-dose, post-transplantation Cy facilitates partially HLA-mismatched HSCT without severe GVHD and is effective as sole prophylaxis of GVHD after HLA-matched alloHSCT. By reducing the morbidity and mortality of alloHSCT, post-transplantation Cy may expand the applications of this therapy to the treatment of autoimmune diseases and non-malignant hematologic disorders such as sickle cell disease.


Bone marrow transplantation Graft-versus-host disease Graft-versus-leukemia effect Cyclophosphamide Human leukocyte antigens T lymphocytes 



The research described herein was supported by grant CA15396 from the National Cancer Institute.


  1. 1.
    Little MT. Storb R: history of haematopoietic stem-cell transplantation. Nat Rev Cancer. 2002;2:231–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Barnes DWH, Corp MJ, Loutit JF, Neal FE. Treatment of murine leukaemia with X-rays and homologous bone marrow. Preliminary communication. Br Med J. 1956;2:626.CrossRefPubMedGoogle Scholar
  3. 3.
    Weiden PL, Flournoy N, Thomas ED, et al. Antileukemic effect of graft-versus-host disease in human recipients of allogeneic-marrow grafts. N Engl J Med. 1979;300:1068–73.PubMedGoogle Scholar
  4. 4.
    Horowitz MM, Gale RP, Sondel PM, et al. Graft-versus-leukemia reactions after bone marrow transplantation. Blood. 1990;75:555–62.PubMedGoogle Scholar
  5. 5.
    Anasetti C, Beatty PG, Storb R, et al. Effect of HLA incompatibility on graft-versus-host disease, relapse, and survival after marrow transplantation for patients with leukemia or lymphoma. Hum Immunol. 1990;29:79–91.CrossRefPubMedGoogle Scholar
  6. 6.
    Szydlo R, Goldman JM, Klein JP, et al. Results of allogeneic bone marrow transplants for leukemia using donors other than HLA-identical siblings. J Clin Oncol. 1997;15:1767–77.PubMedGoogle Scholar
  7. 7.
    Reisner Y, Kapoor N, Kirkpatrick D, et al. Transplantation for acute leukaemia with HLA-A and B nonidentical parental marrow cells fractionated with soybean agglutinin and sheep red blood cells. Lancet. 1981;2:327–31.CrossRefPubMedGoogle Scholar
  8. 8.
    Prentice HG, Blacklock HA, Janossy G, et al. Depletion of T lymphocytes in donor marrow prevents significant graft-versus-host disease in matched allogeneic leukaemic marrow transplant recipients. Lancet. 1984;1:472–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Ho VT, Soiffer RJ. The history and future of T-cell depletion as graft-versus-host disease prophylaxis for allogeneic hematopoietic stem cell transplantation. Blood. 2001;98:3192–204.CrossRefPubMedGoogle Scholar
  10. 10.
    Storb R, Thomas ED. Graft-versus-host disease in dog and man: the seattle experience. Immunol Rev. 1985;88:215–38.CrossRefPubMedGoogle Scholar
  11. 11.
    Powles RL, Clink HM, Spence D, et al. Cyclosporin A to prevent graft-versus-host disease in man after allogeneic bone-marrow transplantation. Lancet. 1980;1:327–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Storb R, Deeg HJ, Farewell V, et al. Marrow transplantation for severe aplastic anemia: methotrexate alone compared with a combination of methotrexate and cyclosporine for prevention of acute graft-versus-host disease. Blood. 1986;68:119–25.PubMedGoogle Scholar
  13. 13.
    Fay JW, Wingard JR, Antin JH, et al. FK506 (Tacrolimus) monotherapy for prevention of graft-versus- host disease after histocompatible sibling allogenic bone marrow transplantation. Blood. 1996;87:3514–9.PubMedGoogle Scholar
  14. 14.
    Liu J, Farmer J, Lane WS, et al. Calcineurin is a common target of cyclophilin-cyclosporin A and FKBP-FK506 complexes. Cell. 1991;66:807–15.CrossRefPubMedGoogle Scholar
  15. 15.
    Bolwell B, Sobecks R, Pohlman B, et al. A prospective randomized trial comparing cyclosporine and short course methotrexate with cyclosporine and mycophenolate mofetil for GVHD prophylaxis in myeloablative allogeneic bone marrow transplantation. Bone Marrow Transplant. 2004;34:621–5.CrossRefPubMedGoogle Scholar
  16. 16.
    Cutler C, Li S, Ho VT, et al. Extended follow-up of methotrexate-free immunosuppression using sirolimus and Tacrolimus in related and unrelated donor peripheral blood stem cell transplantation. Blood. 2007;109:3108–14.PubMedGoogle Scholar
  17. 17.
    Nash RA, Johnston L, Parker P, et al. A phase I/II study of mycophenolate mofetil in combination with cyclosporine for prophylaxis of acute graft-versus-host disease after myeloablative conditioning and allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant. 2005;11:495–505.CrossRefPubMedGoogle Scholar
  18. 18.
    Ratanatharathorn V, Nash RA, Przepiorka 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;92:2303–14.PubMedGoogle Scholar
  19. 19.
    Jenkins MK, Schwartz RH, Pardoll DM. Effects of cyclosporine A on T cell development and clonal deletion. Science. 1988;241:1655–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Jenkins MK, Chen CA, Jung G, Mueller DL, Schwartz RH. Inhibition of antigen-specific proliferation of type 1 murine T cell clones after stimulation with immobilized anti-CD3 monoclonal antibody. J Immunol. 1990;144:16–22.PubMedGoogle Scholar
  21. 21.
    Li Y, Li XC, Zheng XX, et al. Blocking both signal 1 and signal 2 of T-cell activation prevents apoptosis of alloreactive T cells and induction of peripheral allograft tolerance. Nat Med. 1999;5:1298–302.CrossRefPubMedGoogle Scholar
  22. 22.
    Beschorner WE, Hess AD, Shinn CA, Santos GW. Transfer of cyclosporine-associated syngeneic graft-versus-host disease by thymocytes. Resemblance to chronic graft-versus-host disease. Transplantation. 1988;45:209–15.CrossRefPubMedGoogle Scholar
  23. 23.
    Santos GW, Hess AD, Vogelsang GB. Graft-versus-host reactions and disease. Immunol Rev. 1985;88:169–92.CrossRefPubMedGoogle Scholar
  24. 24.
    Wagner JE, Thompson JS, Carter SL, Kernan NA. Effect of graft-versus-host disease prophylaxis on 3-year disease-free survival in recipients of unrelated donor bone marrow (T-cell depletion trial): a multi-centre, randomised phase II-III trial. Lancet. 2005;366:733–41.CrossRefPubMedGoogle Scholar
  25. 25.
    Eapen M, Logan BR, Confer DL, et al. Peripheral blood grafts from unrelated donors are associated with increased acute and chronic graft-versus-host disease without improved survival. Biol Blood Marrow Transplant. 2007;13:1461–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Bacigalupo A, Lamparelli T, Gualandi F, et al. Increased risk of leukemia relapse with high dose cyclosporine after allogeneic marrow transplantation for acute leukemia: 10 year follow-up of a randomized study. Blood. 2001;98:3174.CrossRefGoogle Scholar
  27. 27.
    Schwartz R, Dameshek W. Drug-induced immunological tolerance. Nature. 1959;183:1682–3.CrossRefPubMedGoogle Scholar
  28. 28.
    Berenbaum MC. Prolongation of homograft survival in mice with single doses of cyclophosphamide. Nature. 1963;200:84.CrossRefPubMedGoogle Scholar
  29. 29.
    Santos GW, Owens AH. Production of graft-versus-host disease in the rat and its treatment with cytotoxic agents. Nature. 1966;210:139–40.CrossRefPubMedGoogle Scholar
  30. 30.
    Mayumi H, Himeno K, Tokuda N, Nomoto K. Drug-induced tolerance to allografts in mice. VII. Optimal protocol and mechanism of cyclophosphamide-induced tolerance in an H-2 haplotype-identical strain combination. Transplant Proc. 1986;18:363–9.PubMedGoogle Scholar
  31. 31.
    Eto M, Mayumi H, Tomita Y, et al. Sequential mechanisms of cyclophosphamide-induced skin allograft tolerance including the intrathymic clonal deletion followed by late breakdown of the clonal deletion. J Immunol. 1990;145:1303–10.PubMedGoogle Scholar
  32. 32.
    Mayumi H, Umesue M, Nomoto K. Cyclophosphamide-induced immunological tolerance: an overview. Immunobiology. 1996;195:129–39.PubMedGoogle Scholar
  33. 33.
    Luznik L, Jalla S, Engstrom LW, Iannone R, Fuchs EJ. Durable engraftment of major histocompatibility complex-incompatible cells after nonmyeloablative conditioning with fludarabine, low-dose total body irradiation, and posttransplantation cyclophosphamide. Blood. 2001;98:3456–64.CrossRefPubMedGoogle Scholar
  34. 34.
    Luznik L, O’Donnell PV, Symons HJ, et al. HLA-haploidentical bone marrow transplantation for hematologic malignancies using nonmyeloablative conditioning and high-dose, posttransplantation cyclophosphamide. Biol Blood Marrow Transplant. 2008;14:641–50.CrossRefPubMedGoogle Scholar
  35. 35.
    Nomoto K, Eto M, Yanaga K, Nishimura Y, Maeda T. Interference with cyclophosphamide-induced skin allograft tolerance by cyclosporin A. J Immunol. 1992;149:2668–74.PubMedGoogle Scholar
  36. 36.
    Mielcarek M, Martin PJ, Leisenring W, et al. Graft-versus-host disease after nonmyeloablative versus conventional hematopoietic stem cell transplantation. Blood. 2003;102:756–62.CrossRefPubMedGoogle Scholar
  37. 37.
    Burroughs LM, O’Donnell PV, Sandmaier BM, et al. Comparison of outcomes of HLA-matched related, unrelated, or HLA-haploidentical related hematopoietic cell transplantation following nonmyeloablative conditioning for relapsed or refractory Hodgkin lymphoma. Biol Blood Marrow Transplant. 2008;14:1279–87.CrossRefPubMedGoogle Scholar
  38. 38.
    Devetten MP, Hari PN, Carreras J, et al. Unrelated donor reduced-intensity allogeneic hematopoietic stem cell transplantation for relapsed and refractory Hodgkin lymphoma. Biol Blood Marrow Transplant. 2009;15:109–17.CrossRefPubMedGoogle Scholar
  39. 39.
    Kanda Y, Chiba S, Hirai H, et al. Allogeneic hematopoietic stem cell transplantation from family members other than HLA-identical siblings over the last decade (1991–2000). Blood. 2003;102:1541–7.CrossRefPubMedGoogle Scholar
  40. 40.
    Kasamon YL, Luznik L, Leffell MS et al.: Nonmyeloablative HLA-haploidentical BMT with high-dose post-transplantation cyclophosphamide: effect of HLA disparity on outcome. Biol Blood Marrow Transplant. 2010 (Epub ahead of print).Google Scholar
  41. 41.
    Pocock SJ, Assmann SE, Enos LE, Kasten LE. Subgroup analysis, covariate adjustment and baseline comparisons in clinical trial reporting: current practice and problems. Stat Med. 2002;21:2917–30.CrossRefPubMedGoogle Scholar
  42. 42.
    Ash RC, Horowitz MM, Gale RP, et al. Bone marrow transplantation from related donors other than HLA- identical siblings: effect of T cell depletion. Bone Marrow Transplant. 1991;7:443–52.PubMedGoogle Scholar
  43. 43.
    Petersdorf EW, Gooley TA, Anasetti C, et al. Optimizing outcome after unrelated marrow transplantation by comprehensive matching of HLA class I and II alleles in the donor and recipient. Blood. 1998;92:3515–20.PubMedGoogle Scholar
  44. 44.
    Sasazuki T, Juji T, Morishima Y, et al. Effect of matching of class I HLA alleles on clinical outcome after transplantation of hematopoietic stem cells from an unrelated donor. Japan marrow donor program. N Engl J Med. 1998;339:1177–85.CrossRefPubMedGoogle Scholar
  45. 45.
    Morishima Y, Yabe T, Matsuo K, et al. Effects of HLA allele and killer immunoglobulin-like receptor ligand matching on clinical outcome in leukemia patients undergoing transplantation with T-cell-replete marrow from an unrelated donor. Biol Blood Marrow Transplant. 2007;13:315–28.CrossRefPubMedGoogle Scholar
  46. 46.
    Anderson BE, McNiff J, Yan J, et al. Memory CD4+ T cells do not induce graft-versus-host disease. J Clin Invest. 2003;112:101–8.PubMedGoogle Scholar
  47. 47.
    Zheng H, Matte-Martone C, Li H, et al. Effector memory CD4+ T cells mediate graft-versus-leukemia without inducing graft-versus-host disease. Blood. 2008;111:2476–84.CrossRefPubMedGoogle Scholar
  48. 48.
    Chen BJ, Cui X, Sempowski GD, Liu C, Chao NJ. Transfer of allogeneic CD62L- memory T cells without graft-versus-host disease. Blood. 2004;103:1534–41.CrossRefPubMedGoogle Scholar
  49. 49.
    Luznik L, Slansky JE, Jalla S, et al. Successful therapy of metastatic cancer using tumor vaccines in mixed allogeneic bone marrow chimeras. Blood. 2003;101:1645–52.CrossRefPubMedGoogle Scholar
  50. 50.
    Dey BR, McAfee S, Colby C, et al. Anti-tumour response despite loss of donor chimaerism in patients treated with non-myeloablative conditioning and allogeneic stem cell transplantation. Br J Haematol. 2005;128:351–9.CrossRefPubMedGoogle Scholar
  51. 51.
    Rubio MT, Saito TI, Kattleman K, et al. Mechanisms of the antitumor responses and host-versus-graft reactions induced by recipient leukocyte infusions in mixed chimeras prepared with nonmyeloablative conditioning: a critical role for recipient CD4+ T cells and recipient leukocyte infusion-derived IFN-{gamma}-producing CD8+ T cells. J Immunol. 2005;175:665–76.PubMedGoogle Scholar
  52. 52.
    Symons HJ, Levy MY, Wang J et al.: The allogeneic effect revisited: exogenous help for endogenous, tumor-specific T cells. Biol Blood Marrow Transplant. 2010;14:499–509.Google Scholar
  53. 53.
    Bensinger WI, Martin PJ, Storer B, et al. Transplantation of bone marrow as compared with peripheral-blood cells from HLA-identical relatives in patients with hematologic cancers. N Engl J Med. 2001;344:175–81.CrossRefPubMedGoogle Scholar
  54. 54.
    Nash RA, Antin JH, Karanes C, et al. Phase 3 study comparing methotrexate and Tacrolimus with methotrexate and cyclosporine for prophylaxis of acute graft-versus-host disease after marrow transplantation from unrelated donors. Blood. 2000;96:2062–8.PubMedGoogle Scholar
  55. 55.
    Kansu E, Gooley T, Flowers MED, et al. Administration of cyclosporine for 24 months compared with 6 months for prevention of chronic graft-versus-host disease: a prospective randomized clinical trial. Blood. 2001;98:3868–70.CrossRefPubMedGoogle Scholar
  56. 56.
    Strauss G, Osen W, Debatin KM. Induction of apoptosis and modulation of activation and effector function in T cells by immunosuppressive drugs. Clin Exp Immunol. 2002;128:255–66.CrossRefPubMedGoogle Scholar
  57. 57.
    Luznik L, Fuchs EJ, Chen AR, et al. Post-transplantation high-dose cyclophosphamide (Cy) is effective single agent GVHD prophylaxis that permits prompt immune reconstitution after myeloablative HLA matched related and unrelated bone marrow transplantation (BMT). Biol Blood Marrow Transplant. 2007;13(2 Suppl):4.CrossRefGoogle Scholar
  58. 58.
    Brodsky RA, Luznik L, Bolanos-Meade J, et al. Reduced intensity: HLA-haploidentical BMT with post transplantation cyclophosphamide in nonmalignant hematologic diseases. Bone Marrow Transplant. 2008;42:523–7.CrossRefPubMedGoogle Scholar
  59. 59.
    Hutter G, Nowak D, Mossner M, et al. Long-term control of HIV by CCR5 Delta32/Delta32 stem-cell transplantation. N Engl J Med. 2009;360:692–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Sidney Kimmel Comprehensive Cancer Center at Johns HopkinsBaltimoreUSA

Personalised recommendations