741860

research-article2017
TAH0010.1177/2040620717741860Therapeutic Advances in HematologyL Hill, A Alousi

Therapeutic Advances in Hematology Review

New and emerging therapies for acute and

Ther Adv Hematol

2018, Vol. 9(1) 21­–46

chronic graft versus host disease DOI: 10.1177/

https://doi.org/10.1177/2040620717741860
https://doi.org/10.1177/2040620717741860
2040620717741860

© The Author(s), 2017.

Reprints and permissions:
LaQuisa Hill, Amin Alousi, Partow Kebriaei, Rohtesh Mehta, Katayoun Rezvani http://www.sagepub.co.uk/
journalsPermissions.nav
and Elizabeth Shpall

Abstract: Graft versus host disease (GVHD) remains a major cause of morbidity and mortality
following allogeneic hematopoietic stem-cell transplantation (HSCT). Despite the use of
prophylactic GVHD regimens, a significant proportion of transplant recipients will develop
acute or chronic GVHD following HSCT. Corticosteroids are standard first-line therapy, but are
only effective in roughly half of all cases with ~50% of patients going on to develop steroid-
refractory disease, which increases the risk of nonrelapse mortality. While progress has
been made with improvements in survival outcomes over time, corticosteroids are associated
with significant toxicities, and many currently available salvage therapies are associated with
increased immunosuppression, infectious complications, and potential loss of the graft versus
leukemia (GVL) effect. Thus, there is an unmet need for development of newer treatment
strategies for both acute and chronic GVHD to improve long-term post-transplant outcomes
and quality of life for HSCT recipients. Here, we provide a concise review of major emerging
therapies currently being studied in the treatment of acute and chronic GVHD.

Keywords:  acute graft versus host disease, allogeneic stem-cell transplantation, chronic graft
versus host disease, GVHD

Received: 20 July 2017; revised manuscript accepted: 10 October 2017.

Introduction of grade III–IV acute GVHD between 1999 and Correspondence to:
Elizabeth Shpall
Allogeneic hematopoietic stem-cell transplanta- 2012.6 Overall survival (OS) and treatment- Department of Stem
tion (HSCT) is a potentially curative treatment related mortality (TRM) were also noted to have Cell Transplantation and
Cellular Therapy, The
for both benign and malignant hematologic con- improved during this time frame for patients University of Texas MD
ditions. Unfortunately, graft versus host disease treated with tacrolimus-based prophylactic regi- Anderson Cancer Center,
1515 Holcombe Boulevard,
(GVHD) remains a major cause of morbidity and mens. This is encouraging data for both clinicians Unit 0423, Houston,
mortality following HSCT. Despite prophylactic and HSCT patients, as despite increasing age of TX 77030-4000, USA
eshpall@mdanderson.org
treatment, acute GVHD (aGVHD) affects 30– transplant recipients, increasing use of alternative
LaQuisa Hill
70% of recipients and chronic GVHD (cGVHD) donors, and use of more reduced-intensity condi- Center for Cell and Gene
occurs in 20–50% of recipients depending on the tioning regimens over time, there has been Therapy, Baylor College
of Medicine, Houston,
type of transplant, patient characteristics, and improvement in transplant outcomes.7,8 As we TX, USA
GVHD prophylaxis regimen.1–5 GVHD is a sys- continue to investigate potentially more effective Amin Alousi
Partow Kebriaei
temic inflammatory condition primarily mediated preventive and treatment strategies, hopefully we Rohtesh Mehta
by the transplanted immune system that can lead can continue to make a meaningful impact on Katayoun Rezvani
Department of Stem
to severe multiorgan damage. The need for transplant outcomes. Cell Transplantation
increased and prolonged immunosuppression to and Cellular Therapy,
The University of Texas
treat GVHD, in addition to the immunosuppres- We briefly discuss current knowledge of emerging MD Anderson Cancer,
sive effects of the disease itself, increases the risk mechanistic targets for treatment of aGVHD and Houston, TX, USA
of: infection, organ impairment, poor quality of cGVHD, and novel therapies that are showing
life and ultimately, mortality. promising efficacy in both upfront and steroid-
refractory (SR) settings. However, most of these
A large registry analysis by Khoury and colleagues agents are still in early-phase clinical studies and
recently reported a 20% decline in the proportion have yet to be evaluated in large, late-phase

journals.sagepub.com/home/tah 21
Therapeutic Advances in Hematology 9(1)
randomized controlled trials. Many of these
agents are also being investigated in preventive
trials; however, that is beyond the scope of this
review.
Acute graft versus host disease
aGVHD is an immunologically mediated process
due to mature donor T cells interacting with host
and donor antigen presenting cells (APCs), lead-
ing to release of pro-inflammatory cytokines,
which in turn results in the proliferation and hom-
ing of activated T cells to aGVHD target tissues,
ultimately causing host tissue damage.9–11 Recent
comprehensive reviews of aGVHD biology have
be performed by Magenau and colleagues12 and
Zeiser and colleagues,13 and are beyond the scope
of this review. A number of major histocompati-
bility complex (MHC)-independent mechanisms
have recently been implicated in GVHD patho-
genesis based on findings in murine models. These
will be discussed in more detail below.
Corticosteroids (steroids) remain the first-line of
therapy for both aGVHD and cGVHD despite
suboptimal response rates of 40–60%.14–16 The
likelihood of response to treatment in aGVHD
decreases with increasing severity of disease.2 For
patients who develop SR disease, the long-term
prognosis is very poor, with a mortality rate of
approximately 70–80%,14,17 as response rates
with second-line treatments are low.2,18,19 To
date, no second-line therapy has been proven
superior to another20 for the treatment of
SR-aGVHD, and choice of therapy is often based
on patient specific characteristics, side-effect pro-
file, and physician preference.
Such suboptimal outcomes underscore the need
for new treatment strategies. One newly proposed
treatment paradigm is risk stratifying patients for
treatment based on clinical staging of aGVHD
and blood biomarkers. This has been proposed in
an attempt to spare those likely to respond to ster-
oids from excessive toxicity, and to identify those
who are less likely to respond and require aggres-
sive upfront therapy to improve nonrelapse mor-
tality (NRM). The aGVHD risk score, which
classifies patients into high risk or standard risk
categories at the time of diagnosis, was developed
by the Minnesota group to identify patients
unlikely to respond to upfront treatment with
steroids.21 Patients with high risk (HR) GVHD
were less likely to respond to therapy and had a
twofold increased risk of TRM.
22 journals.sagepub.com/home/tah
The risk score was recently refined, based on vali-
dated data from a multicenter cohort totaling 1723
patients. Standard risk was defined as single-organ
involvement [stage 1–3 skin or stage 1–2 gastroin-
testinal (GI)] or two-organ involvement (stage 1–3
skin plus stage 1 GI or stage 1–3 skin plus stage
1–4 liver); all others were defined as high risk
(Table 1). Standard-risk patients had a day 28
overall response rate (ORR) rate of 69% versus
43% in high-risk patients (Table 2). The 6-month
NRM was 22% versus 44%, respectively.
Levine and colleagues also recently validated the
Ann Arbor biomarker risk score based on plasma
levels of tumor necrosis factor receptor-1 (TNFR-
1), regenerating islet-derived 3-alpha (REG3α)
and suppression of tumorigenicity 2 (ST2).22 A
risk score of 3 demonstrated a 46% ORR com-
pared with AA1/AA2 patients who had an 81%
and 68% response rate, respectively. A risk score
of 3 was also associated with a less durable
response (defined as a complete response for ⩾6
months without recurrence of symptoms), higher
likelihood of later developing SR lower GI GVHD
and had an NRM of 46% at 6 months regardless
of clinical severity of GVHD (Table 2). By utiliz-
ing new therapies based on risk stratification
models, we may be able to improve outcomes,
while minimizing toxicity.
Steroid-free acute graft versus host disease
therapy
Sirolimus
Sirolimus (also known as rapamycin) is a mam-
malian target of rapamycin (mTOR) inhibitor
that has immunosuppressive activity in addition
to its antineoplastic properties.23 Inhibition of
mTOR impairs T-cell signaling, and its use as a
prophylactic agent and as a second-line agent for
SR-GVHD have been previously reported.24–27
However, a recent retrospective analysis evalu-
ated the use of sirolimus monotherapy as upfront
treatment in 32 patients with newly diagnosed
aGVHD who were poor candidates for steroids
due to older age, high risk of toxicity, or at high
risk for relapse.28 A total of 27 patients were iden-
tified as Minnesota standard risk and five were
high risk. Of note, no patients with grade IV
aGVHD were included in this cohort. A total of
16 (50%) patients achieved a complete response
(CR) with sirolimus versus 59% of patients from a
matched cohort treated with steroids. These data
indicate that use of sirolimus as a steroid-free
 Table 1. Graft versus host disease organ staging categories and graft versus host disease risk.16

GVHD categories grouped by day n Day 28 OR of day p value Relative risk p value Relative p value GVHD
28 CR/PR CR/PR 28 CR/PR of mortality risk of TRM risk
(95% CI) (95% CI) (95% CI)
Stage 1–3 skin only** 901 68% 1.0 1.0 1.0 StdR
Upper GI only 115 78% 1.6 (1.0–2.6) 0.04 0.6 (0.4–0.9) 0.02 0.5 (0.3–0.9) 0.03 StdR
Stage 1–2 lower GI only 100 73% 1.3 (0.8–2.1) 0.29 1.2 (0.8–1.7) 0.41 1.6 (1.0–2.3) 0.04 StdR
Stage 1–3 skin + upper GI 90 69% 1.0 (0.6–1.6) 0.89 0.9 (0.6–1.4) 0.64 0.9 (0.6–1.5) 0.71 StdR
Stage 1–3 skin + stage 1 lower GI 71 61% 0.7 (0.4–1.2) 0.16 1.1 (0.7–1.8) 0.60 1.3 (0.8–2.1) 0.35 StdR
Stage 1 lower GI + upper GI 64 64% 0.8 (0.5–1.4) 0.42 1.2 (0.7–1.9) 0.54 1.4 (0.9–2.4) 0.18 StdR
Stage 1–3 skin + stage 1–4 liver 51 71% 1.1 (0.6–2.1) 0.71 1.3 (0.8–2.0) 0.30 1.4 (0.9–2.3) 0.17 StdR
Stage 1–3 skin + stage 1 lower 62 61% 0.6 (0.4–0.9) 0.12 0.6 (0.3–1.1) 0.11 0.6 (0.3–1.3) 0.18 StdR
GI + upper GI
Stage 1–2 lower GI + stage 1–3 12 50% 0.4 (0.1–1.4) 0.15 2.9 (1.4–6.3) 0.005 3.2 (1.5–7.0) 0.003 HR
liver
Stage 1–3 skin + (stage 1–2 lower 23 35% 0.2 (0.1–0.6) 0.001 3.0 (1.7–5.1) <0.001 3.2 (1.8–5.6) <0.001 HR
GI or upper GI) + stage 1–3 liver
Stage 3 lower GI only 65 55% 0.5 (0.3–0.9) 0.02 2.1 (1.4–3.1) 0.003 2.7 (1.8–4.2) <0.001 HR
Stage 1–3 skin + stage 2 lower GI 54 52% 0.5 (0.3–0.9) 0.01 1.5 (1.0–2.3) 0.08 1.6 (1.0–2.6) 0.06 HR
Stage 3–4 lower GI + (stage 1–3 55 36% 0.2 (0.1–0.4) <0.001 2.5 (1.7–3.6) <0.001 3.0 (2.0–4.5) <0.001 HR
skin or liver stage 1–4)
Stage 1–4 liver alone 25 48% 0.3 (0.2–0.8) 0.01 1.0 (0.5–2.3) 0.96 1.7 (0.8–3.8) 0.19 HR
Stage 1–3 skin + stage 3–4 lower 13 8% 0.1 (0.01–0.3) 0.002 4.3 (2.3–8.2) <0.001 7.4 (3.6–15.2) <0.001 HR
GI + stage 1–4 liver
Stage 4 skin only 13 38% 0.3 (0.1–0.8) 0.02 0.8 (0.2–3.1) 0.71 2.2 (0.7–6.9) 0.16 HR
Stage 4 lower GI only 22 22% 0.1 (0.03–0.7) 0.02 3.5 (1.5–7.9) 0.003 3.1 (1.2–8.1) 0.02 HR
GVHD, graft versus host disease; CR, complete response; PR, partial response; CI, confidence interval; TRM, treatment-related mortality; GI, gastrointestinal; StdR, standard risk; HR,
high risk.

journals.sagepub.com/home/tah 23
L Hill, A Alousi et al.
Therapeutic Advances in Hematology 9(1)
Table 2.  Day 28 response rate and 6-month nonrelapse mortality by risk scoring systems.
Refined Day 28 RR
Minnesota aGVHD
Risk Score CR PR
StdR 48% 21%
HR 27% 16%
Ann Arbor GVHD CR/PR
Risk Score
1 81%
2 68%
3 46%
aGVHD, acute graft versus host disease; CR, complete response; CI, confidence interval; HR, high risk; NRM, nonrelapse
mortality; PR, partial response; RR, response rate; StdR, standard risk.
primary therapy would potentially be safe and
effective for aGVHD. The Bone Marrow
Transplant Clinical Trials Network (BMT CTN)
1501 trial is a phase II trial investigating the use of
single-agent sirolimus versus prednisone for front-
line treatment of standard-risk aGVHD by refined
Minnesota risk criteria, with further confirmation
based on the Ann Arbor biomarker risk score
[ClinicalTrials.gov identifier: NCT02806947].
Kinase inhibitors
Janus kinases
The Janus kinase (JAK) family is composed of
four tyrosine kinases that function as signal trans-
ducers of cytokine-mediated pathways to control
cellular proliferation, survival and differentia-
tion.29 JAKs associate with a variety of cytokine
receptors, and activation of JAK leads to phos-
phorylation of signal proteins of the signal trans-
ducers and activators of transcription (STAT)
family, which act as transcription factors for pro-
inflammatory genes.30 JAK1 and JAK2 are both
widely expressed, and their inactivation leads to
impairment of immune function via cytokine-
induced intracellular signaling of lymphocytes.31
While inhibition of JAK1/2 (nonspecific inhibi-
tion) significantly reduces T-cell function, recent
evidence suggests that specific inhibition of JAK1
may be the primary mediator of response.32 More
specific targeting may ameliorate off-target effects
such as myelosuppression which is primarily
mediated by inhibition of JAK2-associated recep-
tors required for hematopoietic cell development
and proliferation.33 There is also evidence that
24 journals.sagepub.com/home/tah
6-month NRM n
% 95% CI
22 20–24 1454
44 38–50 269
 8  3–16 74
27 20–34 165
46 33–58 61
JAK inhibition impairs the differentiation and
function of dendritic cells, the most important
APCs, causing reduced T-cell activation.34,35
These data support the potential role of JAK inhi-
bition for treatment of GVHD.
Ruxolitinib.  Ruxolitinib is a JAK 1/2 inhibitor that
has been shown to have a significant role in signal-
ing pathways mediating inflammation in acute and
chronic GVHD,36 in addition to roles in adaptive
and innate immune responses. It has been shown
that interferon gamma receptor (INFγR) signaling
is mediated via JAK1/JAK2 and is upregulated in
activated Tcells.37 T cells deficient in INFγR cause
significantly less GVHD compared with wild-type
T cells, and pharmacologic inhibition of JAK1/2
in mouse models leads to less GVHD, in addition
to preserving anti-leukemic effects previously
reported.37,38 Spoerl and colleagues showed that
JAK 1/2 inhibition led to reduction of pro-inflam-
matory cytokines and an increase in the frequency
of regulatory T cells (Tregs) in mouse models with
improved survival in mice who developed acute
GVHD and reduced histopathological grading.30
Based on this observation, they trialled six patients
with heavily treated SR-aGVHD with ruxolitinib.
Two patients with GI GVHD had complete resolu-
tion of symptoms during treatment, one patient
with liver GVHD had complete normalization of
bilirubin, and all four patients with skin GVHD
had a response to ruxolitinib therapy. All patients
also had a reduction in serum levels of pro-inflam-
matory cytokines [interleukin-6 (IL-6) and IL-2R],
and the amount of corticosteroids required.
In a multicenter survey study done in centers
throughout Europe and the US, 54 patients with
 L Hill, A Alousi et al.

Table 3.  Clinical trials of tyrosine kinase inhibitors (registered through ClinicalTrials.gov).

Trial number Study design Diagnosis Intervention Location Status

Ruxolitinib  
NCT02953678 Phase II SR-aGVHD Ruxolitinib + USA Recruiting
CCS
NCT03147742 Open label, SR-aGVHD / Ruxolitinib USA Recruiting
expanded access SR-cGVHD
NCT03112603 Phase III SR-cGVHD Ruxolitinib USA Not yet
versus BAT recruiting
NCT02997280 Phase II SR-aGVHD / Ruxolitinib Russia Recruiting
SR-cGVHD
NCT02396628 Phase II SR-aGVHD BAT Germany Recruiting
+/–ruxolitinib
NCT02913261 Phase III SR-aGVHD Ruxolitinib Europe, Asia, Recruiting
versus BAT Australia, Canada
SR, steroid refractory; aGVHD, acute graft versus host disease; cGVHD, chronic graft versus host disease; BAT, best
available therapy; CCS, corticosteroids.

SR-aGVHD (grade III or IV) were treated with off-
label use of ruxolitinib39 at a dose of 5–10 mg orally
twice daily. The ORR was 81.5% (44/54) with 25
(46.3%) patients achieving a CR. The median time
to response was 1.5 (range 1–11) weeks, and only 3
patients experienced a GVHD-relapse, suggesting
durable response was achievable. The 6-month sur-
vival was 79%. Cytomegalovirus (CMV) reactiva-
tion and cytopenias were the most common adverse
events (AEs) observed. CMV reactivation occurred
in 33% of patients, all of which responded to antivi-
ral treatment. Grade III/IV cytopenias, a previously
established side effect of ruxolitinib, occurred in
33% of patients. Several phase II and III trials are
currently ongoing for SR-aGVHD (Table 3).
Itacitinib.  Results from a phase 1 trial of selective
JAK1 inhibitor itacitinib (INCB039110) in
patients with aGVHD were reported at the 2016
American Society of Hematology Meeting
(ASH).40 Patients with grades II–IV aGVHD
were randomized 1:1 to a dose of 200 or 300 mg
orally once daily of INCB039110 combined with
steroids, and were stratified based on treatment-
naïve (n = 14) versus SR (n = 17) disease. Pre-
liminary results showed a day 28 ORR of 88.3%
when used in the first-line setting as treatment for
aGVHD, and 64.7% for SR disease. GRAVI-
TAS-301 is a phase III trial currently recruiting
for front-line treatment of aGVHD with itacitinib
versus placebo in combination with steroids [Clin-
icalTrials.gov identifier: NCT03139604]. A phase
II trial of upfront use of a JAK1 inhibitor or
placebo in combination with steroids is currently
being planned through the BMT CTN.
Proteasome inhibitors
Proteasome inhibitors (PIs) are drugs that inhibit
the proteasome, which are enzyme complexes
that are responsible for regulating protein turno-
ver within cells. They have been shown to have
immune-modulating effects in murine models of
aGVHD and cGVHD, including deletion of allo-
reactive T cells, inhibition of APCs, inhibition of
IL-6, increased survival of Tregs, and decrease in
levels of B-cell activating factor (BAFF).41 Several
PIs have been US Food and Drug Administration
(FDA) approved for the treatment of multiple
myeloma.
Bortezomib
Bortezomib is a first-generation, reversible PI that
directly induces apoptosis of tumor cells by sup-
pressing tumor-survival pathways and arresting
cell growth.42 It is a potent inhibitor of nuclear
factor-kappa B, which regulates the transcription
of multiple pro-inflammatory genes, and is impor-
tant for T-cell proliferation, activation and
survival.43
Several preclinical and early-phase studies have
shown bortezomib to be effective in preventing
aGVHD,44–47 although in one murine study,
delayed or prolonged administration was

journals.sagepub.com/home/tah 25
Therapeutic Advances in Hematology 9(1)
associated with severe colonic toxicity.45 Given
the critical role of T cells and pro-inflamma-
tory cytokines in the development of aGVHD,
bortezomib would be a potential therapeutic
candidate.
Results of a small phase II study [ClinicalTrials.
gov identifier: NCT00408928] evaluating the use
of bortezomib for SR-aGVHD, the largest to date,
were recently reported by Wagner and col-
leagues.48 Eleven patients were treated on study
with eight patients being evaluable for response.
Two patients (25%) achieved a CR, and two
patients had a partial response (PR). However, 10
patients died, with the majority of deaths attrib-
uted to infection (60%), followed by progressive
disease (20%). One patient also died of hemor-
rhage and pulmonary complication, respectively.
The authors were unable to determine if any of
the deaths were related to the use of bortezomib.
While bortezomib appears to have some activity in
treating aGVHD, additional studies are needed to
better determine the safety and toxicity profile.
Cytokine modulation
Alpha-1 antitrypsin
Alpha-1 antitrypsin (AAT) is a serine protease
inhibitor that is able to modulate immune and
inflammatory functions through alteration of
cytokine profiles.49 Low AAT plasma levels in
human donors were found to be associated with a
higher rate of aGVHD in recipients50 and GVHD
severity increased with decreasing AAT levels as
well. An inverse relationship between AAT levels
and GVHD was noted, with high levels of ATT
exerting a protective effect against GVHD while
maintaining, or even enhancing, graft versus leu-
kemia (GVL) activity50 and decreasing mortality
in mouse models.51 Donors treated with ATT
had an increase in Tregs, as well as a 50-fold
increase of IL-10, favoring an anti-inflammatory
profile.
Based on these observations, a prospective phase
I/II dose-escalation study was performed to eval-
uate the use of ATT in the treatment of
SR-aGVHD. Twelve patients were enrolled in
the first two cohorts (all grade III or IV GVHD
with stage 3–4 lower gastrointestinal (LGI)
involvement), and eight patients achieved a
response, with four patients achieving a CR.52
There are currently two clinical trials underway to
further evaluate the use of ATT for GVHD. One
26 journals.sagepub.com/home/tah
is a phase II/III study for treatment of newly diag-
nosed LGI aGVHD in combination with steroids
[ClinicalTrials.gov identifier: NCT02956122],
and the other is an early-access trial for patients
with SR-aGVHD [ClinicalTrials.gov identifier:
NCT03172455]. A pilot study for use of ATT in
SR-aGVHD has completed enrollment, but
results are not yet available [ClinicalTrials.gov
identifier: NCT01700036].
Interleukin-22
IL-22 is a cytokine produced by cells from both
the adaptive and the innate system including
CD4+ T cells, CD8+ T cells, natural killer cells,
and gamma-delta (γδ) T cells.53 It serves an essen-
tial role in host defense against extracellular path-
ogens, strengthens epithelial barrier function by
acting upon intestinal stem cells (ISCs), and helps
with tissue repair and wound healing. In addition
to its protective properties, it has pro-inflamma-
tory properties when produced in excess.53,54
Studies of murine models transplanted with
IL-22-deficient grafts showed loss of ISCs, devel-
opment of more severe aGVHD and increased
mortality compared with wild-type models.55,56
Lindemans and colleagues showed that treatment
of murine models with IL-22 in vivo reduced
intestinal pathology and mortality from GVHD.57
There is also a potential relationship between
IL-22 and the microbiome, as microbacteria has
been shown to induce IL-22 secretion that then
induces the production of antimicrobial pro-
teins.57–59 There is currently a phase I/II clinical
trial underway [ClinicalTrials.gov identifier:
NCT02406651] evaluating the safety and feasi-
bility of use of IL-22 in combination with corti-
costeroids for the treatment of newly diagnosed
grade II–IV acute LGI GVHD.
Monoclonal antibodies
Natalizumab
Natalizumab is a humanized monoclonal anti-
body (mAb) against α4-integrin containing adhe-
sion molecules which are widely expressed on
leukocytes, primarily lymphocytes.60 Based on
studies done in inflammatory bowel disease
(IBD), it has been recognized that the endothe-
lium plays a key role in the pathogenesis of inflam-
mation and in mucosal immune trafficking.61
Natalizumab inhibits adhesion molecules, pre-
venting leukocyte migration from the circulation
into inflamed gut mucosa.60,62 It is currently FDA

approved for use in multiple sclerosis and Crohn’s
disease. Despite its proven efficacy in these dis-
eases, use has been limited due to the possible
side effect of progressive multifocal leukoenceph-
alopathy (PML) – a potentially life-threatening
demyelinating neurologic disease. There has been
a reported incidence of 4.2 cases per 1000 patients
treated.63,64
Acute GI GVHD is often propagated after intes-
tinal damage from transplant-conditioning regi-
mens, leading to significant inflammation in the
gut lining. Therefore, it would seem plausible
that natalizumab might be able to mitigate GI
GVHD by preventing homing of leukocytes to the
GI tract. Patients are currently being recruited for
two phase II studies evaluating the safety and effi-
cacy of natalizumab for treatment of GVHD. One
study is evaluating its use in combination with
steroids for initial treatment of acute GI GVHD
[ClinicalTrials.gov identifier: NCT02176031].
The second study is evaluating the combination
for treatment of high-risk aGVHD (based on Ann
Arbor risk score) with the primary outcome being
rate of CR at day 28 [ClinicalTrials.gov identifier:
NCT02133924].
Vedolizumab
Vedolizumab is a mAb that specifically inhibits
α4β7 integrins located on activated T cells from
interacting with MAdCAM-1 (located on gut epi-
thelium) preventing homing to the intestinal
mucosa.65,66 It is currently FDA approved for the
treatment of Crohn’s disease and ulcerative coli-
tis. Several preclinical murine studies have shown
that α4β7 integrins play an important role in the
development of intestinal GVHD.67–69 A recent
case series describing the off-label use of vedoli-
zumab for treatment of SR-aGVHD of the GI
tract showed promising results.70 Five patients
with clinical grade IV GI GVHD were treated;
four patients had isolated GI manifestations and
one patient had multiorgan involvement.
Four patients were able to discontinue systemic
steroids after receiving three doses of vedoli-
zumab, and two patients were off all immunosup-
pressant medications at the time of last follow up.
Clinical responses were noted within 7–10 days
with patients receiving a variable number of infu-
sions.70 The median time to follow up was 10
months, with four patients alive and receiving
outpatient care. No associated toxicities were
mentioned. Safety and toxicity, in addition to
journals.sagepub.com/home/tah 27
L Hill, A Alousi et al.
clinical efficacy will need to be confirmed in phase
II/III trials. A multicenter phase II study recently
opened and is recruiting [ClinicalTrials.gov iden-
tifier: NCT02993783].
Brentuximab vedotin
Brentuximab vedotin (BV) is an anti-CD30 anti-
body–drug conjugate composed of the antimicro-
tubule agent monomethyl auristatin E (MMAE)
and a human CD30 antibody. It has been
approved for the treatment of relapsed classical
Hodgkin lymphoma, systemic anaplastic large
cell lymphoma and for postautologous HSCT
consolidation of those CD30+ diseases. CD30 is
a tumor necrosis factor receptor family member
and is highly expressed on activated lymphocytes
with minimal expression on normal tissues.71
Infiltrating lymphocytes in chronic autoimmune
and inflammatory diseases such as rheumatoid
arthritis and systemic sclerosis have also been
shown to express high levels of CD30.72,73 In pre-
clinical studies, Chen and colleagues demon-
strated that patients with aGVHD had a higher
percentage of CD30 expressing CD8+ T cells,
significantly higher plasma levels of soluble
CD30, and increased CD30+ lymphocytes in
affected intestinal tissue compared with patients
without aGVHD.74
Based on these results, a multicenter phase I trial
was initiated to investigate the use of BV for the
treatment of SR-aGVHD.75 Thirty-four patients
were treated in the dose-escalating study to deter-
mine maximum tolerated dose (MTD). The
study initially had a schedule of weekly dosing for
3 weeks followed by maintenance dosing every 3
weeks for four additional doses. However, after
treatment of six patients with death of two patients
from neutropenic sepsis, the study was revised to
dosing every 2 weeks for four doses with cohorts
of five patients per dose level (0.6 mg/kg, 1.0 mg/
kg, and 1.2 mg/kg). The dose-limiting toxicity
(DLT) was defined at 0.8 mg/kg after one patient
developed sepsis and multiorgan failure. Grade
III toxicities included neutropenia, headache,
hypoxia, ileus and elevated bilirubin. No periph-
eral neuropathy of any grade was observed.
The day 28 ORR was 38.2% with five (14.7%)
patients achieving a CR and eight (23.5%)
patients achieving a very good PR (VGPR). At
day 56, seven additional patients had achieved
CR; three of whom had previously achieved
VGPR. Responses were not significantly different
Therapeutic Advances in Hematology 9(1)
for individual organ involvement: intestinal (n =
10; 42%), liver (n = 5; 45%), and skin (n = 5;
28%), however the study was not designed to
assess efficacy. The OS at 6 and 12 months follow
up was 41% and 38%, respectively. Of those
patients (n = 16) who did not respond to BV,
only one remained alive at 12 months. Causes of
death in the other patients were: GVHD (n =
11), infection (n = 3), and disease relapse (n =
1). Larger randomized trials are needed to con-
firm efficacy.
Multiple mAbs targeting different pathways in
the pathophysiology of aGVHD have been evalu-
ated in the past. The responses and toxicities of
several of the older agents compared with newer
aAbs are summarized in Table 6. However, cross
comparison of these studies is limited due to
multiple factors, including differences in study
design (the majority of reports are retrospective
series), varying definitions of SR-aGVHD,
heterogeneous patient populations, variation in
time-to-response assessments, and use of succes-
sive salvage agents.
Adoptive cell therapy
Mesenchymal stromal cells
Mesenchymal stromal cells (MSCs) are pluripo-
tent stem cells that are able to differentiate into
multiple cell lineages of mesenchymal origin
including osteoblast, chondrocytes, and adipo-
cytes.76–79 They have been shown to inhibit B-
and T-cell activation, block the function of APCs,
inhibit natural killer cells, and increase
Tregs.78,80,81 MSCs can be isolated and expanded
ex vivo from bone marrow, umbilical cord blood,
adipose tissue, and placenta.76,78,82 MSCs do not
express class II human histocompatibility leuko-
cyte antigens (HLA) and therefore do not pro-
voke immunologic responses in HLA-mismatched
recipients.
MSC therapies have been studied in phase I and
II trials for the treatment of SR-aGVHD with
overall responses ranging from 60–75%.83–86
Results from two multicenter, randomized phase
III trials led by Osiris Therapeutic were reported,
in abstract form only, on the use of MSCs for
treatment of de novo aGVHD and SR-aGVHD.82,87
Neither trial reached its primary endpoint of
durable CR ⩾28 days. However, patients with SR
liver and GI GVHD treated with Prochymal, the
Osiris product, were reported to have significantly
28 journals.sagepub.com/home/tah
improved response rates (76% versus 47% and
82% versus 68%, respectively; p = 0.03 for both).
Hashmi and colleagues performed a systematic
review and meta-analysis to assess response and
survival in patients with SR-aGVHD treated with
MSCs.88 Thirteen nonrandomized studies includ-
ing 336 patients were included, and six studies (n
= 119) provided data on primary outcome of
6-month survival following treatment with MSCs.
The weighted 6-month survival was 63% [confi-
dence interval (CI) 50–74%] compared with the
weighted average of 49% from 29 non-MSC
studies of American Society of Blood and Marrow
Transplantation (ASBMT) that were used to for-
mulate guidelines for recommended second-line
therapies. However, this must be interpreted with
caution as there were many limitations of the
study, including differences in timing of adminis-
tration of MSCs, heterogeneity of study popula-
tions, variable definitions of SR disease, and
variability in the dose and quality of the MSC
product. Thus, direct comparison of MSCs with
other second-line agents in prospective, rand-
omized trials are needed to reach a definitive con-
clusion on survival advantage. There are currently
four studies for upfront use and nine studies for
SR-aGVHD underway utilizing MSCs for treat-
ment of aGVHD (Table 5).
Microbiome restoration
Fecal microbiota transplantation
Alteration of intestinal homeostasis, via disrup-
tion and damage to the gastrointestinal epithe-
lium, has emerged as having a critical role in the
development and severity of acute GVHD involv-
ing the GI tract.89,90 Dysbiosis, or loss of intesti-
nal diversity, has been associated with increased
TRM.91–93 Obligate anaerobes, particularly mem-
bers of the Clostridiales order, have been identi-
fied as important mediators of intestinal
homeostasis by upregulation of intestinal Tregs
and inhibition of inflammation by producing anti-
inflammatory cytokines.94 Increased abundance
of intestinal Blautia (a member of the Clostridia
class) has been associated with reduced GVHD
mortality and improved OS.95
Two recent small case series utilized fecal micro-
biota transplants (FMTs) in an attempt to
restore normal intestinal flora. The first study
evaluated the safety and efficacy of FMT in
patients with SR or steroid-dependent aGVHD.

Out of a total of four patients, three had achieved
complete resolution of symptoms at day 28
GVHD assessment, and one had a PR.96 In a
study evaluating three patients with SR-acute GI
GVHD who received FMT on a compassionate
use basis; two patients had resolution of all signs
and symptoms of GVHD and one patient had
partial resolution.97 No significant severe AEs,
including infection, were attributed to the proce-
dure in either study. In the latter study, all three
patients ultimately died from non-GVHD causes
with duration of response lasting 8–9 weeks at
time of death. Early-phase trials are currently in
development at MD Anderson Cancer Center
and Memorial Sloan Kettering to determine if
these results are reproducible.
Chronic graft versus host disease
While aGVHD is driven mainly by mature donor T
cells, cGVHD has been discovered to involve a
more complex immune reaction with both T and B
cells contributing to the underlying pathology.
Although donor antibodies to recipient antigens are
known to play a role in cGVHD, the exact mecha-
nisms of how these cells contribute to the underly-
ing pathology are still being investigated. BAFF has
been identified as a key regulator of B-cell homeo-
stasis, and high levels have been shown to rescue
self-reactive B cells from peripheral deletion,98 pro-
moting survival and differentiation. Sarantopoulos
and colleagues showed that patients with active
cGVHD had significantly elevated levels of BAFF
and increased signaling through the ERK and AKT
pathways (both of which are activated via BAFF)
which was associated with decreased apoptosis of
activated B cells.99,100
In addition, distinct subsets of B cells known as
regulatory B cells (Bregs) have been identified101
to have immunosuppressive effects via IL-10 pro-
duction that inhibit CD4+ T-cell proliferation
and cytokine production.102 Sarvaria and col-
leagues demonstrated that patients with cGVHD
had reduced levels of circulating Bregs and
impaired IL-10 production compared with
patients without cGVHD102,103 suggesting Breg
therapy might be a potential therapeutic target.
In-depth reviews of cGVHD biology have been
recently published by Im and colleagues41 and
Reddy and colleagues.12 A better understanding
of potential mechanisms contributing to the
pathophysiology of cGVHD has led to develop-
ment of targeted therapies that will be discussed
below.
journals.sagepub.com/home/tah 29
L Hill, A Alousi et al.
Chronic GVHD is a multiorgan disease associ-
ated with significant immunodeficiency which
makes treatment with immunosuppressive medi-
cations challenging due to the increased risk of
severe, life-threatening infections.3–5 As previ-
ously mentioned, steroids are the most widely
used first-line therapy for treatment of moderate-
to-severe cGVHD with or without the addition of
other immunosuppressive agents.4 If patients fail
to respond or have progressive disease with ster-
oid therapy, second-line treatment is required.
The response rate to second-line therapy is
reported to be 25–50% based primarily on phase
II trials, with no single therapy being better than
any other.104,105 Choice of therapy is generally
based on patient comorbidities, organs involved,
and physician experience.
Kinase inhibitors
Janus kinase inhibitors
In addition to mechanisms previously elucidated
above, it has been demonstrated that patients
with cGVHD have upregulated IFN-inducible
genes and elevated levels of INF-induced
chemokines which are involved in CXCR3+-
mediated lymphocyte trafficking.106 JAK1/JAK2
are mediators of INFγR signaling and inhibition
of the JAK pathway results in decreased expres-
sion of CXCR3, reduced GVHD, and improved
survival in murine models.37 Data from preclini-
cal studies and observational human studies have
identified JAK-STAT inhibition as an exciting
therapeutic target.
Ruxolitinib. In the previously mentioned multi-
center survey study, 41 patients with moderate-
to-severe SR-cGVHD were also included. The
ORR was 85.4% with 32 (78%) patients achiev-
ing a PR and three patients achieving a CR. The
median time to response was 3 (range 1–25)
weeks, with responses noted in all involved organ
systems. Only two patients (5.7%) experienced a
GVHD relapse, and 14.6% (6/41) of patients had
no response. CMV reactivation was and cytope-
nias were observed in 17% and 14.6% of patients,
respectively. However, caution must be taken
when interpreting these results due to potential
recall bias, as the reported response rates were
based on retrospective chart review. Evaluation
and assessment of responses in cGVHD, based on
the National Institutes of Health (NIH) consen-
sus criteria,107 requires extensive examination and
detailed documentation in order to capture
Therapeutic Advances in Hematology 9(1)
accurate responses. It often takes 4–6 weeks to
note objective improvement in cGVHD following
initiation of therapy, although they reported
observing improvements as early as 1 week after
treatment was started.
Larger, prospective randomized controlled trials
are needed to determine the true response rate
based on standardized grading of responses, and
to determine the optimal dosing schedule and
duration of treatment required for long-term con-
trol of GVHD. Several phase II and III trials are
currently ongoing (Table 3).
Baricitinib.  Baricitinib is an oral JAK1/2 inhibitor
developed for the treatment of rheumatoid arthri-
tis (RA), atopic dermatitis, and systemic lupus
erythematosus (SLE). It received its first global
approval in February 2017 for refractory RA in
the European Union. There is a phase I/II
study underway evaluating its use in the treat-
ment of SR-cGVHD [ClinicalTrials.gov identi-
fier: NCT02759731].
Ibrutinib
Ibrutinib is an irreversible inhibitor of Bruton’s
tyrosine kinase (BTK) and IL-2 inducible T-cell
kinase (ITK). BTK is primarily responsible for
the activation of signaling pathways involved in
B-cell proliferation, trafficking and adhesion,
while ITK is involved in the secretion of IL-2 and
T-helper 2 cytokines. While the exact involve-
ment of BTK and ITK in the pathogenesis of
cGVHD is not known, given the role of T- and
B-cell dysregulation in the development of
cGVHD,108–110 there have been investigations
into targeting the B-cell receptor (BCR) and
T-cell receptor (TCR) signaling pathways.
In studies of murine models of cGVHD, treat-
ment with ibrutinib was shown to delay disease
progression, increase GVHD progression-free
survival, and improve both clinical and pathologi-
cal findings in the T-cell mediated model.
Improved pulmonary function and tissue immu-
noglobulin deposition was noted in an alloanti-
body-driven model that induced bronchiolitis
obliterans (BO).111 In contrast to murine studies
by Schutt and colleagues that showed prophylac-
tic ibrutinib to be effective in preventing cGVHD
in mice,112 Dubovsky and colleagues did not see
any reduction in cGVHD in their mouse model
when treated with ibrutinib prophylactically start-
ing day –2 through day 28.111
30 journals.sagepub.com/home/tah
Ibrutinib was recently granted FDA approval,
the first drug to ever be approved for treatment
of cGVHD, based on results from a multicenter
phase II study evaluating the safety and efficacy
of its use in patients with cGVHD who had failed
one to three lines of prior systemic therapy.113
Forty-two patients with steroid-dependent or
-resistant cGVHD were treated with a daily dose
of 420 mg of ibrutinib. The ORR was 67%
(28/42 patients; 21% CR; 45% PR). A total of
71% of responders had a sustained response of
at least 20 weeks. Approximately one third of
patients who responded were able to reduce the
dose of steroids to ⩽0.15 mg/kg/day during the
course of the study, and five patients were able
to completely discontinue steroid therapy.
Improvement occurred in multiple organ sys-
tems, with 42% (5/12) of patients with at least
three involved showing a response in at least
three organs, which were associated with
improvement in quality of life.
Importantly, the drug was not without toxicity,
with the most common AEs observed being
fatigue (57%), diarrhea (36%), muscle spasms
(29%), nausea (26%) and bruising (24%).
Serious AEs occurred in 22 patients (52%) with
⩾grade III occurring in 17 patients (40%). Two
deaths were reported due to multilobular pneu-
monia and bronchopulmonary aspergillosis.
There is currently a phase III trial [ClinicalTrials.
gov identifier: NCT02959944] underway evalu-
ating the efficacy of corticosteroids plus ibruti-
nib versus placebo for the frontline treatment of
new-onset moderate-to-severe cGVHD.
Spleen tyrosine kinase inhibitors
Spleen tyrosine kinase (Syk), predominantly
expressed in hematopoietic cells, has recently
been identified as being necessary for both TCR
signaling activation,114 and activation of BCR
signaling pathways leading to B-cell proliferation
and survival.115 Syk activation also leads to acti-
vation of multiple immune cells (mast cells, mac-
rophages, neutrophils) leading to production and
release of pro-inflammatory cytokines. Based on
these early observations, Syk inhibitors were ini-
tially tested in murine models and early stage
clinical trials of various autoimmune diseases
such as SLE, RA, and IgA nephropathy with var-
ying degrees of success.116–120 Also, there are cur-
rently several phase I/II trials evaluating the
safety and efficacy of two different orally availa-
ble Syk inhibitors, fostamatinib and entospletinib

(GS-9973), for the treatment of relapsed/refrac-
tory B-cell malignancies.
Syk inhibitors have also shown efficacy in animal
and human studies of both acute and chronic
GVHD. Leonhardt and colleagues showed
decreased aGVHD, improved survival and
reduced inflammatory cytokine profile (IL-6,
INF-γ, MCP-1) in mice treated with fostamatinib
compared with those treated with cyclosporine A
114 without affecting T-cell cytolytic function. In a
murine model of sclerodermatous cGVHD,
administration of fostamatinib led to decreased
fibrosis and a reduction in severity of scleroder-
matous changes.121 Deletion of the Syk gene in
murine donor bone marrow cells and in vivo inhi-
bition with fostamatinib both showed reversibility
of chronic lung GVHD manifestations in a mouse
model with BO.115 Inhibition of Syk also led to
apoptosis in vitro of human B cells from patients
with active cGVHD.
Based on results from early-phase clinical trials in
autoimmune diseases and preclinical data in
cGVHD, entospletinib is currently being evalu-
ated in a phase II trial in combination with sys-
temic corticosteroids for first-line treatment of
cGVHD [ClinicalTrials.gov identifier:
NCT02701634]. Fostamatinib is currently being
tested for prevention of cGVHD [ClinicalTrials.
gov identifier: NCT02611063].
Rho kinase inhibitors
Rho-associated protein kinase (ROCK) is a ser-
ine-threonine kinase primarily involved in regu-
lating cytoskeleton and cellular functions via
phosphorylation of various downstream sub-
strates.122,123 Two isoforms have been identified:
ROCK1 and ROCK2, sharing more than 90%
homology within their kinase domain. Recent
studies suggest that the ROCK2 isoform may
play a specific role in the development of autoim-
munity, as inhibition of ROCK2 in mice and
human T-cells was effective in decreasing pro-
duction of IL-17 and IL-21, both pro-inflamma-
tory cytokines that have been identified as
mediators of autoimmune disorders such as RA
and SLE.123–127
KD025 is an orally available selective ROCK2
inhibitor that downregulates phosphorylation of
STAT3 which is a transcription factor necessary
for the induction and expression of IL-17 and
IL-21.127–129 Inhibition of ROCK2 was also
journals.sagepub.com/home/tah 31
L Hill, A Alousi et al.
shown to increase regulatory T cells via phospho-
rylation of STAT5.123,127 Recently, Flynn and
colleagues were able to show reversal of cGVHD
manifestations in two murine models after tar-
geted inhibition of ROCK2, and further validated
the KD025-mediated effects on STAT3 and
STAT5 phosphorylation shifting the balance
from a pro-inflammatory balance.130 Based on
these promising preclinical findings, there is cur-
rently a phase II trial underway to evaluate the
safety, tolerability, and activity of KD025 for the
treatment of SR-cGVHD [ClinicalTrials.gov
identifier: NCT02841995].
Immune checkpoint blockade
Cytotoxic T-lymphocyte associated protein-4
Cytotoxic T-lymphocyte associated protein-4
(CTLA-4) is a negative regulator of T-cell
immune function. T-cell activation requires mul-
tiple costimulatory signals, one of which is the
binding of CD28 on T-cells with CD80 or CD86
on APCs. CTLA-4 is homologous to CD28, but
binds with a greater affinity and avidity than
CD28. It is expressed on activated T cells and
binds to CD80/CD86, thereby blocking the inter-
action with CD28, and inhibits T-cell prolifera-
tion, differentiation and survival.131 Abatacept is a
selective costimulation modulator composed of
human CTLA-4 and a fragment of the fragment
crystallizable (Fc) domain of human immuno-
globulin-G1. Given the role that activated T cells
play in GVHD, inhibition of T-cell activation via
blockade of costimulatory molecules, distinct
from direct inhibition of CTLA-4, could be a
potential therapeutic option.
Results from a phase I trial evaluating the use of
abatacept in patients with SR-cGVHD were pre-
sented at the 2016 ASH conference.132 A total of
17 patients were enrolled and 16 were treated
with a planned total of six doses of abatacept. In
all, 7/16 (44%) evaluable patients had a PR based
on the NIH consensus criteria. Prednisone dos-
age was decreased by ~51% by 1 month following
completion of the sixth dose. Severe AEs included
one grade IV pulmonary infection and three grade
III cases, all of which resolved. Other low-grade
events included gastritis, diarrhea, fatigue, rash,
and skin pain. The trial is currently ongoing.
Overall, abatacept was well tolerated and based
on these promising results, a phase II trial is being
planned. There are also several trials underway
using it in the preventive setting.
Therapeutic Advances in Hematology 9(1)
Cytokine modulation
Interleukin-2
IL-2 is a cytokine necessary for Treg develop-
ment, expansion, activity, and survival.133–135 As
previously mentioned, Tregs play an important
role in preventing cGVHD. Koreth and col-
leagues administered daily low-dose subcutane-
ous IL-2 to 29 patients with SR-cGVHD at three
different dose levels (0.3 × 106; 1 × 106 or 3 ×
106 IU/m2) for a total of 8 weeks.136 In all, 12 of
23 evaluable patients had major responses in mul-
tiple sites. Tregs were increased in all patients
with minimal effect on conventional CD4+ T
cells.136,137 The highest dose level of 3 × 106
IU/m2 was not well tolerated due to persistent
grade I constitutional symptoms (fever, malaise
and arthralgias) requiring 50% dose reduction.136
Overall, the therapy was safe and well tolerated at
the lower dose levels.
In a phase II study by the same authors, 35
patients with SR-cGVHD were treated with daily
IL-2 for 12 weeks with 61% of evaluable patients
having a clinical response in multiple organ sites,
including liver, skin, GI tract, lung, and joint/
muscle/fascia.138 The Treg cell numbers in the
blood were again noted to be significantly ele-
vated compared with baseline, with no significant
change in conventional T cells. Several clinical
trials are now recruiting to evaluate the use of
IL-2 alone or in combination with Tregs or extra-
corporeal photopheresis (ECP) for treatment of
SR-cGVHD (Table 4).
Proteasome inhibitors
Bortezomib
As previously mentioned, bortezomib inhibits
nuclear factor-kappa B which is important for
B-cell development, activation, and survival in
addition to T cells.139 Prior studies have shown
that bortezomib has inhibitory effects on acti-
vated B cells and plasma cells,140,141 and case
reports of multiple myeloma patients treated with
bortezomib for relapsed disease or maintenance
therapy following HSCT showed encouraging
improvement in cGVHD symptoms.142–144 A
phase II trial evaluating use of bortezomib in
combination with steroids for initial therapy of
cGVHD reported an ORR at week 15 of 80%
with two (10%) complete responses and 14 (70%)
PRs in 20 evaluable patients.139 Responses were
seen in most organs, and it was possible to taper
32 journals.sagepub.com/home/tah
the median steroid dose from 50 mg/day to 20
mg/day by week 15 (p < 0.001). However, pro-
gression of cGVHD was observed after cessation
of bortezomib. While these results are encourag-
ing, lack of a comparator arm makes it difficult to
discern the true impact of adding bortezomib to
steroids. Larger, well-designed randomized trials
are needed to determine if there is a true benefit.
There is currently a phase II trial underway for
upfront treatment of bronchiolitis obliterans
[ClinicalTrials.gov identifier: NCT01163786].
In a single-arm pilot study of bortezomib in
patients with steroid-dependent, -intolerant, or
refractory cGVHD, five of six (83%) patients
achieved a PR defined as a decrease in ⩾1 point
on a 0–3-point scale per NIH consensus crite-
ria.145 Most responders were also able to reduce
the dose or number of immunosuppressive thera-
pies being used during treatment with borte-
zomib. Flow cytometry revealed a significant
decrease in B cells and an increase in Tregs.
These findings suggest that proteasome inhibition
may be a potential targeted therapy but additional
studies with longer follow up are needed. A phase
II trial is underway for SR-cGVHD [ClinicalTrials.
gov identifier: NCT01158105].
Carfilzomib
Carfilzomib is an irreversible, second-generation
PI that potently inhibits the 26S proteasome. It
has been shown to have fewer off-target side
effects, specifically, less peripheral neuropathy,
compared with bortezomib.146 It is currently
being studied for treatment of SR-cGVHD in a
phase II study [ClinicalTrials.gov identifier:
NCT02491359].
Ixazomib
Ixazomib is a reversible second-generation oral
PI that inhibits the 20S proteasome.146 It has
been well tolerated in patients treated with mul-
tiple myeloma, with the main toxicity being mild
GI effects. It is being tested in a phase II trial
for SR-cGVHD [ClinicalTrials.gov identifier:
NCT02513498].
Anti-CD20 monoclonal antibodies
The role of B-cell dysregulation in the underlying
pathophysiology of cGVHD, as described above,
has led to the identification of B-cells as a thera-
peutic target in treating cGVHD.
 L Hill, A Alousi et al.

Table 4.  Clinical trials of interleukin-2 and regulatory T cells (registered through ClinicalTrials.gov).

Trial number Study design Diagnosis Intervention Location Status

NCT01937468 Phase I SR-cGVHD LD IL-2 + Tregs Dana Farber Recruiting
NCT02340676 Phase II SR-cGVHD LD IL-2 + ECP Dana Farber Recruiting
NCT03007238 Phase II SR-cGVHD LD IL-2 + ECP City of Hope Recruiting
NCT02318082 Phase II SR-cGVHD Dose-escalated Dana Farber Recruiting
IL-2
NCT02749084 Phase I/II SR-cGVHD Donor Treg DLI Italy Recruiting
NCT02385019 Phase I/II SR-cGVHD Donor Treg Portugal Recruiting
NCT02519816 Phase II SR-cGVHD TCD + Treg Canada Recruiting
Expansion
SR, steroid refractory; cGVHD, chronic graft versus host disease; DLI, donor lymphocyte infusion; ECP, extracorporeal
photopheresis; LD IL-2, low-dose interleukin-2; TCD, T-cell depletion; Tregs, regulatory T cells.

Table 5.  Clinical trials utilizing mesenchymal stem cells (registered through ClinicalTrials.gov).

Trial identifier Study design Diagnosis Intervention Location Status

NCT00603330 Phase II SR-aGVHD MSC Germany Recruiting
NCT02770430 Phase II SR-aGVHD MSC Brazil Recruiting
NCT02055625 Phase I/II Oral cGVHD MSC Sweden Recruiting
NCT02379442 Phase I/II aGVHD MSC + CCS NIH Recruiting
NCT03158896 Phase I HR or SR- MSC USA Not yet
aGVHD Recruiting
NCT02923375 Phase I SR-aGVHD MSC Australia, Recruiting
UK
NCT02241018 Phase I/II SR-aGVHD Anti-CD25 + CNI China Recruiting
+/– MSC
NCT02291770 Phase III cGVHD First-line tx +/– China Recruiting
MSC
NCT02687646 Phase I/II SR-aGVHD MSC Spain Recruiting
NCT02032446 Phase I/II SR-aGVHD MSC Italy Recruiting
NCT02359929 Phase I SR-aGVHD / MSC Emory Recruiting
SR-cGVHD
NCT02336230 Phase III SR-aGVHD MSC USA Recruiting
SR, steroid refractory for NCT03158896; aGVHD, acute graft versus host disease; cGVHD, chronic graft versus host
disease; HR, high risk; CCS, corticosteroids; CNI, calcineurin inhibitor; MSC, mesenchymal stem cells; tx, treatment;
NIH, National Institutes of Health.

Rituximab is a chimeric mouse/human IgG anti-
CD20 antibody that mediates B-cell lysis via anti-
body-dependent cellular cytotoxicity (ADCC),
complement-dependent cytotoxicity (CDC), and
induction of apoptosis. It is currently FDA
approved for treatment of CD20 positive B-cell
malignancies. Most data reported on its use in
cGVHD are based on case reports, small early-
phase trials, or retrospective studies; with ORRs
ranging from 50% to 86% reported.147 The best

journals.sagepub.com/home/tah 33
 Table 6.  Responses and toxicities of conventional therapies compared with new monoclonal antibodies.

Drug/treatment Study design Line of tx n ORR CR OS Toxicities Reference

Anti-CD52  
Alemtuzumab Retrospective SR-aGVHD 18 83% 33% 55% Infections 78% Gómez-Almaguer
Grade II–IV CMV 61% et al.168
Neutropenia 43%
Therapeutic Advances in Hematology 9(1)

  Retrospective GI SR-aGVHD 20 70% 35% 50% (1 Bacterial 40% Schnitzler et al.169

Grade III–IV year) Aspergillosis 35%
EBV 15%
CMV frequent
  Phase II SR-aGVHD 10 55% 20% 0% Infections 80% Martínez et al.170
Grade III–IV CMV 70%
Cytopenias 60%
  Phase II SR-aGVHD 18 99% 28% 35% Bacterial 61% Schub et al.171
Grade III–IV Viral 44%
Fungal 22%
CMV 56%
EBV 11%
Anti-TNF  
Infliximab Retrospective SR-aGVHD Grade 21 67% 62% 38% (21 Bacterial 81% Couriel et al.172
II–IV mos) Fungal 48%
Viral 67%
  Retrospective SR-aGVHD Grade 32 59% 19% 68% Infections 72% Patriarca et al.173
II–IV CMV 41%
Etanercept Retrospective SR-aGVHD Grade 13 46% 31% 69% Bacterial 14% Busca et al.174
II–IV 8 62% 12% Fungal 19%
SR-cGVHD CMV 48%
  Phase I/II SR-cGVHD 10 60% 10% – Cause of death: Chiang et al.175
infection 10%

34 journals.sagepub.com/home/tah
 Table 6. (Continued)
Drug/treatment Study design Line of tx n ORR CR OS Toxicities Reference
Immunmodulatory  
Mycophenolate mofetil Phase II SR-aGVHD 13 31% 15% 33% (2 Gastrointestinal Kim et al.176
Grade II–IV 13 77% – years) 27%
SR-cGVHD 54% (2 Infections 23%
years) CMV 11%
  Retrospective SR-aGVHD 10 60% 0% 70% Infection 67% Krejci et al.177
Grade II–III 11 64% – – Hematologic 29%
SR-cGVHD
  Phase II SR-aGVHD 19 47% 31% 16% Cause of death: Furlong et al.178
Grade II–IV Infection 32%
Sirolimus Pilot SR-aGVHD 21 57% 24% 33% TCP 33% Benito et al.26
Grade III–IV Neutropenia 19%
TG 38%
TMA 23%
  Retrospective SR-aGVHD 34 76% 44% 44% TG 71% Hoda et al.179
TMA 21%
  Phase II SR-cGVHD 35 63% 17% 57% (3 Infections 77% Couriel et al.24
years) TMA 11%
Renal 66%
TG 18%
Pentostatin Phase I SR-aGVHD 23 77% 63% 26% TCP 4% Bolaños-Meade
Grade II–IV Infection 9% et al.180
  Retrospective SR-aGVHD 12 50% 33% 10% Bacterial 50% Pidala et al.181
Grade II–IV Fungal 25%
Viral 8%
CMV 25%
  Phase II SR-cGVHD 58 55% – 70% (2 Infection 20% Jacobsohn et al.182
years)
Cellular  
photoimmunotherapy
Extracorporeal Pilot SR-aGVHD 21 67% 60% 57% Anemia 90% Greinix et al.183
photopheresis Grade II–IV TCP 71%
CMV 52%

(Continued)

journals.sagepub.com/home/tah 35
L Hill, A Alousi et al.
 Table 6. (Continued)
Drug/treatment Study design Line of tx n ORR CR OS Toxicities Reference
  Phase I/II SR-aGVHD 9 78% 56% 56% (8 Hypotension Salvaneschi
Grade II–IV 14 64% 29% months) Anemia et al.184
SR-cGVHD 79% (36 CMV reactivation
months)
Therapeutic Advances in Hematology 9(1)

  Retrospective SR-aGVHD 23 – 52% 48% Hypotension Perfetti et al.185

Grade II–IV Anemia
TCP
  Retrospective SR-cGVHD 71 61% 20% 53% Anemia Couriel et al.186
Thrombocytopenia
Anti-α4β7 integrin  
Vedolizumab Case series SR-aGVHD 6 100% – 4/6 pts None reported Floisand et al.70
GI grade IV alive at
median
f/u 10
months
Anti-CD30  
Brentuximab vedotin Phase I SR-aGVHD 34 38% 15% 38% Neutropenia Chen et al.75
Elevated bilirubin
Headache
Ileus
Anti-CTLA4  
Abetacept Phase I SR-cGVHD 16 44% (PR) – – Pulmonary infection Nahas et al.132
Diarrhea/gastritis
Rash
aGVHD, acute graft versus host disease; cGVHD, chronic graft versus host disease; CMV, cytomegalovirus; CR, complete response; EBV, Epstein-Barr virus; f/u, follow up; GI,
gastrointestinal; ORR, overall response rate; OS, overall survival; PR, partial response; PTLD, post-transplant lymphoproliferative disease; pts, patients; ref, reference; SR, steroid
refractory; TCP, thrombocytopenia; TG, triglyceridemia; TMA, thrombotic microangiopathy; TNF, tumor necrosis factor; tx, treatment.

36 journals.sagepub.com/home/tah

response was seen primarily in patients with cuta-
neous and oral involvement. Rituximab has also
been demonstrated to be effective for GVHD
prophylaxis in a phase II study that showed a
reduction in steroid-requiring cGVHD and
improved OS in patients receiving peripheral
blood grafts.148 However, randomized trials are
still needed to confirm these findings.
Ofatumumab
Ofatumumab is a fully humanized IgG1 kappa sec-
ond-generation monoclonal antibody against CD20.
Compared with rituximab, it has more potent CDC
leading to increased B-cell destruction due to a
higher binding affinity.149 Ofatumumab is currently
FDA approved for treatment of chronic lymphocytic
leukemia. Pidala and colleagues recently demon-
strated safety of ofatumumab in combination with
steroids for the treatment of newly diagnosed mod-
erate-to-severe cGVHD.150 Twelve patients were
enrolled and two infusion reactions (grade II and III,
respectively) were observed. No grade IV infusion
reactions, constitutional symptoms, or ⩾ grade III
organ toxicities were observed; and hence no dose-
limiting toxicities occurred. A phase II study is cur-
rently in progress to assess efficacy as primary
therapy in cGVHD [ClinicalTrials.gov identifier:
NCT01680965].
Obinutuzumab
Obinutuzumab is a second-generation anti-CD20
monoclonal antibody currently FDA approved for
the treatment of follicular lymphoma. Based on the
promising activity of B-cell depletion for preven-
tion of cGVHD with rituximab, a phase II study
using obinutuzumab for prevention of cGVHD
following peripheral blood stem-cell transplanta-
tion is currently recruiting [ClinicalTrials.gov
identifier: NCT02867384].
Adoptive cell therapy
Regulatory T cells
Tregs are a subset of peripheral CD4+ T cells
(~5–10%) that are imperative for the develop-
ment of immune tolerance in healthy individu-
als.151–154 Reduction or loss of this population of
T cells is associated with loss of immune toler-
ance and development of autoimmunity. Rezvani
and colleagues reported that donor Treg content
is predictive of aGVHD post-transplant, with a
high Treg content associated with a lower risk of
journals.sagepub.com/home/tah 37
L Hill, A Alousi et al.
GVHD following HLA-matched allogeneic
HSCT.155 Several phase I/II studies have also
shown that infusion of native donor Tregs and
ex vivo-expanded umbilical-cord-blood-derived
Tregs are associated with a lower incidence of
aGVHD and improved immune reconstitution
compared with historical controls.156–158 In one
study, no patients who received Treg infusion
developed cGVHD at 1 year versus 14% in the
control group.158 Parmar and colleagues were
able to show in animal models that infusion of
fucosylated Tregs to improve engraftment and
homing lead to longer in vivo persistence and
decreased aGVHD at a lower cell dose compared
with untreated Tregs.159
Studies of Tregs in the setting of cGVHD have
shown reduced frequency of circulating Tregs
compared with patients without cGVHD and nor-
mal controls; however, the function of the cells
remains normal.154,160,161 The first in-human use
of adoptive transfer of ex vivo-expanded Tregs was
performed in two patients; one with SR-aGVHD
and the other with SR-cGVHD.162 The patient
with cGVHD had significant improvement in
GVHD symptoms and was able to reduce the
amount of immunosuppressive therapy required.
Theil and colleagues evaluated use of adoptive
Treg transfer in five patients with SR-cGVHD;
two patients had clinical improvement in GVHD
symptoms while the other three had stable disease
as the best response.163 No significant toxicity or
GVHD exacerbations were observed.
One potential limiting factor of widespread use of
adoptive Treg therapy is the need to manufacture
sufficient numbers of Tregs for infusion without
contaminating the product with other T-cell subsets,
such as effector T cells, which could affect the
response. This requires laboratory expertise to per-
form complex methods for both cell purification and
expansion.164 Larger prospective randomized stud-
ies are still needed to determine the benefit and long-
term outcomes. See Table 4 for ongoing clinical
trials.
Mesenchymal stromal cells
Response rates in treatment of SR-cGVHD have
been less robust,86,165,166 except notably in patients
with sclerodermatous GVHD. The best reported
response rate was seen in four patients with exten-
sive skin scleroderma and ulceration who had sig-
nificant improvement after four to eight treatments
with MSCs.167 Lack of clear benefit in cGVHD
Therapeutic Advances in Hematology 9(1)
may be due to significant heterogeneity in multi-
ple aspects between studies.81 Well-designed ran-
domized studies with standardized methods of
source procurement, expansion techniques, and
dosing schedules are needed to further clarify the
role of MSCs in the treatment of GVHD. There
are currently three trials underway evaluating
MSCs for treatment of cGVHD (Table 5).
Conclusion
As the number of allogeneic HSCT continues to
increase each year, the importance and need for
effective therapies to treat aGVHD and cGVHD
and thereby improve outcomes for this potentially
curative therapy cannot be over-emphasized.
Responses to primary therapy with corticoster-
oids are often suboptimal and treatment can be
complicated by significant side effects, including
diabetes, hypertension, osteoporosis, myopathy,
and avascular necrosis. Available second-line
treatments have even lower response rates, lead-
ing to poor outcomes in acute GVHD, and pro-
longed morbidity with delayed immune recovery
with chronic GVHD. Currently, there is a desper-
ate need for new treatment options for this mor-
bid complication of transplant. It would be ideal
to identify targeted therapies that are not as
broadly immunosuppressive, which can be used
prior to the development of severe and irreversi-
ble tissue damage, and can provide durable
responses without impacting graft versus tumor
(GVT) effects. Continued understanding of the
underlying immune mechanisms and pathways
that are involved in the pathophysiology of
GVHD should yield development of more effec-
tive therapeutics.
While these novel therapies have been tested in
preclinical models and have shown promising
results in early phase studies, larger multicenter
studies are needed to determine true efficacy,
preferably in comparison with current available
therapies and long-term outcomes. Many of these
agents are also being studied for prevention of
GVHD, which would be ideal as long as GVT is
not compromised. These therapies should help to
improve symptoms and prevent progression of
GVHD, to enhance patient quality of life and
ultimately improve OS.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
38 journals.sagepub.com/home/tah
Conflict of interest statement
The authors declare that there is no conflict of
interest.
References
   1. Wingard JR, Majhail NS, Brazauskas R,
et al. Long-term survival and late deaths after
allogeneic hematopoietic cell transplantation.
J Clin Oncol 2011; 29: 2230–2239.
   2. Pidala J and Anasetti C. Glucocorticoid-
refractory acute graft-versus-host disease. Biol
Blood Marrow Transplant 2010; 16:
1504–1518.
   3. Horwitz ME and Sullivan KM. Chronic graft-
versus-host disease. Blood Rev 2006; 20:
15–27.
   4. Bhushan V and Collins RH Jr. Chronic graft-
versus-host disease. JAMA 2003; 290:
2599–603.
   5. Lee SJ, Vogelsang G and Flowers ME. Chronic
graft-versus-host disease. Biol Blood Marrow
Transplant 2003; 9: 215–233.
   6. Khoury HJ, Wang T, Hemmer MT, et al.
Improved survival after acute graft-
versus-host disease diagnosis in the
modern era. Haematologica 2017; 102:
958–966.
   7. Hahn T, McCarthy PL, Hassebroek A, et al.
Significant improvement in survival after
allogeneic hematopoietic cell transplantation
during a period of significantly increased use,
older recipient age, and use of unrelated donors.
J Clin Oncol 2013; 31: 2437–2449.
   8. El-Jawahri A, Li S, Antin JH, et al. Improved
treatment-related mortality and overall survival
of patients with grade IV acute GVHD in the
modern years. Biol Blood Marrow Transplant
2016; 22: 910–918.
   9. Matte CC, Liu J, Cormier J, et al. Donor APCs
are required for maximal GVHD but not for
GVL. Nat Med 2004; 10: 987–992.
  10. Koyama M, Kuns RD, Olver SD, et al. Recipient
nonhematopoietic antigen-presenting cells are
sufficient to induce lethal acute graft-versus-host
disease. Nat Med 2011; 18: 135–142.
  11. Paczesny S, Hanauer D, Sun Y, et al. New
perspectives on the biology of acute GVHD.
Bone Marrow Transplant 2010; 45: 1–11.
  12. Magenau J, Runaas L and Reddy P. Advances
in understanding the pathogenesis of graft-
versus-host disease. Br J Haematol 2016; 173:
190–205.

  13. Zeiser R, Socie G and Blazar BR. Pathogenesis  
of acute graft-versus-host disease: From
intestinal microbiota alterations to donor T cell
activation. Br J Haematol 2016; 175: 191–207.
  14. Weisdorf D, Haake R, Blazar B, et al. Treatment  
of moderate/severe acute graft-versus-host disease
after allogeneic bone marrow transplantation:
an analysis of clinical risk features and outcome.
Blood 1990; 75: 1024–1030.  
  15. MacMillan ML, Weisdorf DJ, Wagner JE, et al.
Response of 443 patients to steroids as primary
therapy for acute graft-versus-host disease:
comparison of grading systems. Biol Blood
Marrow Transplant 2002; 8: 387–394.  
  16. MacMillan ML, Robin M, Harris AC, et al. A
refined risk score for acute graft-versus-host
disease that predicts response to initial therapy,
survival, and transplant-related mortality. Biol
Blood Marrow Transplant 2015; 21: 761–767.  
  17. Levine JE, Logan B, Wu J, et al. Graft-versus-
host disease treatment: predictors of survival.  
Biol Blood Marrow Transplant 2010; 16:
1693–1699.
  18. Deeg HJ. How I treat refractory acute GVHD.
Blood 2007; 109: 4119–4126.  
  19. Castilla-Llorente C, Martin PJ, McDonald
GB, et al. Prognostic factors and outcomes of
severe gastrointestinal GVHD after allogeneic  
hematopoietic cell transplantation. Bone Marrow
Transplant 2014; 49: 966–971.
  20. Martin PJ, Rizzo JD, Wingard JR, et al. First-
and second-line systemic treatment of acute  
graft-versus-host disease: recommendations of
the American Society of Blood and Marrow
Transplantation. Biol Blood Marrow Transplant  
2012; 18: 1150–1163.
  21. MacMillan ML, DeFor TE and Weisdorf DJ.
What predicts high risk acute graft-versus-host
disease (GVHD) at onset?: identification of  
those at highest risk by a novel acute GVHD
risk score. Br J Haematol 2012; 157: 732–741.
  22. Levine JE, Braun TM, Harris AC, et al. A
prognostic score for acute graft-versus-host
disease based on biomarkers: a multicentre
study. Lancet Haematol 2015; 2: e21–e29.  
  23. Kirken RA and Wang YL. Molecular actions of
sirolimus: sirolimus and mTor. Transplant Proc
2003; 35(Suppl. 3): 227S–230S.
 
  24. Couriel DR, Saliba R, Escalon MP, et al.
Sirolimus in combination with tacrolimus and
corticosteroids for the treatment of resistant
chronic graft-versus-host disease. Br J Haematol  
2005; 130: 409–417.
journals.sagepub.com/home/tah 39
L Hill, A Alousi et al.
25. Johnston LJ, Brown J, Shizuru JA, et al.
Rapamycin (sirolimus) for treatment of chronic
graft-versus-host disease. Biol Blood Marrow
Transplant 2005; 11: 47–55.
26. Benito AI, Furlong T, Martin PJ, et al.
Sirolimus (rapamycin) for the treatment of
steroid-refractory acute graft-versus-host
disease. Transplantation 2001; 72: 1924–1929.
27. Lutz M and Mielke S. New perspectives on
the use of mTOR inhibitors in allogeneic
haematopoietic stem cell transplantation and
graft-versus-host disease. Br J Clin Pharmacol
2016; 82: 1171–1179.
28. Pidala J, Tomblyn M, Nishihori T, et al.
Sirolimus demonstrates activity in the primary
therapy of acute graft-versus-host disease
without systemic glucocorticoids. Haematologica
2011; 96: 1351–1356.
29. Yamaoka K, Saharinen P, Pesu M, et al. The
Janus kinases (Jaks). Genome Biol 2004; 5: 253.
30. Spoerl S, Mathew NR, Bscheider M, et al.
Activity of therapeutic JAK 1/2 blockade in
graft-versus-host disease. Blood 2014;123:
3832–3842.
31. O’Shea JJ and Murray PJ. Cytokine signaling
modules in inflammatory responses. Immunity
2008; 28: 477–487.
32. Perner F, Schnoder TM, Ranjan S, et al.
Specificity of JAK-kinase inhibition determines
impact on human and murine T-cell function.
Leukemia 2016; 30: 991–995.
33. Murray PJ. The JAK-STAT signaling pathway:
input and output integration. J Immunol 2007;
178: 2623–2639.
34. Heine A, Held SA, Daecke SN, et al. The
JAK-inhibitor ruxolitinib impairs dendritic cell
function in vitro and in vivo. Blood 2013; 122:
1192–1202.
35. Betts BC, Abdel-Wahab O, Curran SA, et al.
Janus kinase-2 inhibition induces durable
tolerance to alloantigen by human
dendritic cell-stimulated T cells yet preserves
immunity to recall antigen. Blood 2011; 118:
5330–5339.
36. Hechinger AK, Smith BA, Flynn R, et al.
Therapeutic activity of multiple common
gamma-chain cytokine inhibition in acute and
chronic GVHD. Blood 2015; 125: 570–580.
37. Choi J, Ziga ED, Ritchey J, et al. IFNγR
signaling mediates alloreactive T-cell trafficking
and GVHD. Blood 2012; 120: 4093–4103.
38. Choi J, Cooper ML, Alahmari B, et al.
Pharmacologic blockade of JAK1/JAK2 reduces
Therapeutic Advances in Hematology 9(1)
GVHD and preserves the graft-versus-leukemia
effect. PloS One 2014; 9: e109799.
  39. Zeiser R, Burchert A, Lengerke C, et al.  
Ruxolitinib in corticosteroid-refractory graft-
versus-host disease after allogeneic stem cell
transplantation: a multicenter survey. Leukemia
2015; 29: 2062–2068.
  40. Schroeder MA, Khoury HJ, Jagasia M, et al. A  
phase I trial of Janus Kinase (JAK) inhibition
with INCB039110 in acute graft-versus-host
disease (aGVHD). Blood 2016; 128: abstract
390.
  41. Im A, Hakim FT and Pavletic SZ. Novel targets  
in the treatment of chronic graft-versus-host
disease. Leukemia 2017; 31: 543–554.
  42. Moreau P, Richardson PG, Cavo M, et al.
Proteasome inhibitors in multiple myeloma: 10  
years later. Blood 2012; 120: 947–959.
  43. Finn PW, Stone JR, Boothby MR, et al.
Inhibition of NF-κB-dependent T cell activation  
abrogates acute allograft rejection. J Immunol
2001; 167: 5994–6001.
  44. Sun K, Welniak LA, Panoskaltsis-Mortari
A, et al. Inhibition of acute graft-versus-host
disease with retention of graft-versus-tumor  
effects by the proteasome inhibitor bortezomib.
Proc Natl Acad Sci U S A 2004; 101: 8120–
8125.
  45. Sun K, Wilkins DE, Anver MR, et al.
Differential effects of proteasome inhibition  
by bortezomib on murine acute graft-versus-
host disease (GVHD): delayed administration
of bortezomib results in increased GVHD-
dependent gastrointestinal toxicity. Blood 2005;
106: 3293–3299.
 
  46. Vodanovic-Jankovic S, Hari P, Jacobs P, et al.
NF-κB as a target for the prevention of graft-
versus-host disease: comparative efficacy of
bortezomib and PS-1145. Blood 2006; 107:
827–834.  
  47. Koreth J, Stevenson KE, Kim HT, et al.
Bortezomib, tacrolimus, and methotrexate for
prophylaxis of graft-versus-host disease after  
reduced-intensity conditioning allogeneic stem
cell transplantation from HLA-mismatched
unrelated donors. Blood 2009; 114: 3956–3959.
  48. Wagner JL, Mookerjee B, Filicko-O’Hara JE,
et al. Bortezomib for steroid refractory acute
graft versus host disease (GVHD). Biol Blood  
Marrow Transplant 18: S370.
  49. Marcondes AM, Li X, Tabellini L, et al.
Inhibition of IL-32 activation by alpha-1
antitrypsin suppresses alloreactivity and  
increases survival in an allogeneic murine
40 journals.sagepub.com/home/tah
marrow transplantation model. Blood 2011;
118: 5031–5039.
50. Marcondes AM, Karoopongse E, Lesnikova M,
et al. alpha-1-antitrypsin (AAT)-modified donor
cells suppress GVHD but enhance the GVL
effect: a role for mitochondrial bioenergetics.
Blood 2014; 124: 2881–2891.
51. Tawara I, Sun Y, Lewis EC, et al. Alpha-1-
antitrypsin monotherapy reduces graft-versus-
host disease after experimental allogeneic bone
marrow transplantation. Proc Natl Acad Sci U S
A 2012; 109: 564–569.
52. Marcondes AM, Hockenbery D, Lesnikova
M, et al. Response of steroid-refractory acute
GVHD to alpha1-antitrypsin. Biol Blood Marrow
Transplant 2016; 22: 1596–601.
53. Rutz S, Eidenschenk C and Ouyang W. IL-22,
not simply a Th17 cytokine. Immunol Rev 2013;
252: 116–132.
54. Lamarthee B, Malard F, Gamonet C, et al.
Donor interleukin-22 and host type I interferon
signaling pathway participate in intestinal graft-
versus-host disease via STAT1 activation and
CXCL10. Mucosal Immunol 2016; 9: 309–321.
55. Hanash AM, Dudakov JA, Hua G, et al.
Interleukin-22 protects intestinal stem cells
from immune-mediated tissue damage and
regulates sensitivity to graft versus host disease.
Immunity 2012; 37: 339–350.
56. Couturier M, Lamarthee B, Arbez J, et al.
IL-22 deficiency in donor T cells attenuates
murine acute graft-versus-host disease mortality
while sparing the graft-versus-leukemia effect.
Leukemia 2013; 27: 1527–1537.
57. Lindemans CA, Calafiore M, Mertelsmann
AM, et al. Interleukin-22 promotes intestinal-
stem-cell-mediated epithelial regeneration.
Nature 2015; 528: 560–564.
58. Sabat R, Ouyang W and Wolk K. Therapeutic
opportunities of the IL-22-IL-22R1 system. Nat
Rev Drug Discov 2014; 13: 21–38.
59. Wolk K, Witte E, Wallace E, et al. IL-22
regulates the expression of genes responsible for
antimicrobial defense, cellular differentiation,
and mobility in keratinocytes: a potential role in
psoriasis. Eur J Immunol 2006; 36:
1309–1323.
60. Beniwal-Patel P and Saha S. The role of
integrin antagonists in the treatment of
inflammatory bowel disease. Expert Opin Biol
Ther 2014; 14: 1815–1823.
61. Danese S, Semeraro S, Marini M, et al.
Adhesion molecules in inflammatory bowel

disease: therapeutic implications for gut
inflammation. Dig Liver Dis 2005; 37: 811–818.
  62. Rommer PS, Dudesek A, Stuve O, et al.  
Monoclonal antibodies in treatment of multiple
sclerosis. Clin Exp Immunol 2014; 175: 373–
384.
  63. Schwab N, Schneider-Hohendorf T, Melzer N,  
et al. Natalizumab-associated PML: challenges
with incidence, resulting risk, and risk
stratification. Neurology 2017; 88:
1197–1205.
 
  64. TYSABRI (natalizumab) US prescribing
information. Cambridge, MA: Biogen Inc.,
2016.
 
  65. Lam MC and Bressler B. Vedolizumab
for ulcerative colitis and Crohn’s disease:
results and implications of GEMINI studies.
 
Immunotherapy 2014; 6: 963–971.
  66. Neurath MF. Current and emerging therapeutic
targets for IBD. Nat Rev Gastroenterol Hepatol
2017; 14: 269–278.
 
  67. Dutt S, Ermann J, Tseng D, et al. L-selectin
and beta7 integrin on donor CD4 T cells
are required for the early migration to host
mesenteric lymph nodes and acute colitis of
 
graft-versus-host disease. Blood 2005; 106:
4009–4015.
  68. Petrovic A, Alpdogan O, Willis LM, et al.
LPAM (alpha 4 beta 7 integrin) is an important
homing integrin on alloreactive T cells in the
 
development of intestinal graft-versus-host
disease. Blood 2004; 103: 1542–1547.
  69. Li B, New JY, Yap EH, et al. Blocking
L-selectin and alpha4-integrin changes donor
cell homing pattern and ameliorates murine
 
acute graft versus host disease. Eur J Immunol
2001; 31: 617–624.
  70. Fløisand Y, Lundin KE, Lazarevic V, et al.
Targeting integrin α4β7 in steroid-refractory
 
intestinal graft-versus-host disease. Biol Blood
Marrow Transplant 2017; 23: 172–175.
  71. Francisco JA, Cerveny CG, Meyer DL, et al.
cAC10-vcMMAE, an anti-CD30-monomethyl
auristatin E conjugate with potent and selective
 
antitumor activity. Blood 2003; 102:
1458–1465.
  72. Gerli R, Pitzalis C, Bistoni O, et al. CD30+
T cells in rheumatoid synovitis: mechanisms
of recruitment and functional role. J Immunol
 
2000; 164: 4399–4407.
  73. Ihn H, Yazawa N, Kubo M, et al. Circulating
levels of soluble CD30 are increased in patients
with localized scleroderma and correlated with
journals.sagepub.com/home/tah 41
L Hill, A Alousi et al.
serological and clinical features of the disease.
J Rheumatol 2000; 27: 698–702.
74. Chen YB, McDonough S, Hasserjian R, et al.
Expression of CD30 in patients with acute
graft-versus-host disease. Blood 2012; 120:
691–696.
75. Chen YB, Perales MA, Li S, et al. Phase 1
multicenter trial of brentuximab vedotin for
steroid-refractory acute graft-versus-host
disease. Blood 2017; 129: 3256–3261.
76. Kekre N and Antin JH. Emerging drugs for
graft-versus-host disease. Expert Opin Emerg
Drugs 2016; 21: 209–218.
77. Kebriaei P and Robinson S. Treatment of graft-
versus-host-disease with mesenchymal stromal
cells. Cytotherapy 2011; 13: 262–268.
78. Aggarwal S and Pittenger MF. Human
mesenchymal stem cells modulate allogeneic
immune cell responses. Blood 2005; 105:
1815–1822.
79. Jiang Y, Jahagirdar BN, Reinhardt RL, et al.
Pluripotency of mesenchymal stem cells derived
from adult marrow. Nature 2002; 418:
41–49.
80. Di Nicola M, Carlo-Stella C, Magni M, et al.
Human bone marrow stromal cells suppress
T-lymphocyte proliferation induced by cellular
or nonspecific mitogenic stimuli. Blood 2002;
99: 3838–3843.
81. Rizk M, Monaghan M, Shorr R, et al.
Heterogeneity in studies of mesenchymal
stromal cells to treat or prevent graft-versus-host
disease: a scoping review of the evidence. Biol
Blood Marrow Transplant 2016; 22: 1416–1423.
82. Kebriaei P and Robinson S. Mesenchymal
stem cell therapy in the treatment of acute and
chronic graft versus host disease. Front Oncol
2011; 1: 16.
83. Le Blanc K, Rasmusson I, Sundberg B,
et al. Treatment of severe acute graft-versus-
host disease with third party haploidentical
mesenchymal stem cells. Lancet 2004; 363:
1439–1441.
84. Le Blanc K, Frassoni F, Ball L, et al.
Mesenchymal stem cells for treatment of
steroid-resistant, severe, acute graft-versus-host
disease: a phase II study. Lancet 2008; 371:
1579–1586.
85. Von Bonin M, Stolzel F, Goedecke A, et al.
Treatment of refractory acute GVHD with
third-party MSC expanded in platelet lysate-
containing medium. Bone Marrow Transplant
2009; 43: 245–251.
Therapeutic Advances in Hematology 9(1)
  86. Ringden O, Uzunel M, Rasmusson I, et al.
Mesenchymal stem cells for treatment of
therapy-resistant graft-versus-host disease.
 
Transplantation 2006; 81: 1390–1397.
  87. Martin BJ, Uberti J, Soiffer R, et al. Prochymal
improves response rates in patients with steroid-
refractory acute graft versus host disease
(SR-GVHD) involving the liver and gut: results
of a randomized, placebo-controlled, multicenter
phase III trial in GVHD. Orlando, FL: American  
Society of Bone Marrow Transplantation, 2010.
  88. Hashmi S, Ahmed M, Murad MH, et al.
Survival after mesenchymal stromal cell therapy
in steroid-refractory acute graft-versus-host
disease: systematic review and meta-analysis.  
Lancet Haematol 2016; 3: e45–e52.
  89. Taur Y, Xavier JB, Lipuma L, et al. Intestinal
domination and the risk of bacteremia in
patients undergoing allogeneic hematopoietic
stem cell transplantation. Clin Inf Dis 2012; 55:
905–914.
  90. Jenq RR, Ubeda C, Taur Y, et al. Regulation of
intestinal inflammation by microbiota following
allogeneic bone marrow transplantation. J Exp
Med 2012; 209: 903–911.
  91. Holler E, Butzhammer P, Schmid K, et al.
Metagenomic analysis of the stool microbiome
in patients receiving allogeneic stem cell
transplantation: loss of diversity is associated
with use of systemic antibiotics and more
pronounced in gastrointestinal graft-versus-host
disease. Biol Blood Marrow Transplant 2014; 20:
640–645.
  92. Shono Y, Docampo MD, Peled JU, et al.
Increased GVHD-related mortality with
broad-spectrum antibiotic use after allogeneic
hematopoietic stem cell transplantation in
human patients and mice. Sci Transl Med 2016;
8: 339ra71.
  93. Taur Y, Jenq RR, Perales MA, et al. The effects
of intestinal tract bacterial diversity on mortality
following allogeneic hematopoietic stem cell
transplantation. Blood 2014; 124: 1174–1182.
  94. Atarashi K, Tanoue T, Oshima K, et al. Treg
induction by a rationally selected mixture of
Clostridia strains from the human microbiota.
Nature 2013; 500: 232–236.
  95. Jenq RR, Taur Y, Devlin SM, et al. Intestinal
Blautia is associated with reduced death from
graft-versus-host disease. Biol Blood Marrow
Transplant 2015; 21: 1373–1383.
  96. Kakihana K, Fujioka Y, Suda W, et al. Fecal
microbiota transplantation for patients with
42 journals.sagepub.com/home/tah
steroid-resistant acute graft-versus-host disease
of the gut. Blood 2016; 128: 2083–2088.
97. Spindelboeck W, Schulz E, Uhl B, et al.
Repeated fecal microbiota transplantations
attenuate diarrhea and lead to sustained changes
in the fecal microbiota in acute, refractory
gastrointestinal graft-versus-host-disease.
Haematologica 2017; 102: e210–e213.
98. Thien M, Phan TG, Gardam S, et al. Excess
BAFF rescues self-reactive B cells from
peripheral deletion and allows them to enter
forbidden follicular and marginal zone niches.
Immunity 2004; 20: 785–798.
99. Sarantopoulos S and Ritz J. Aberrant B-cell
homeostasis in chronic GVHD. Blood 2015;
125: 1703–1707.
100. Allen JL, Fore MS, Wooten J, et al. B cells
from patients with chronic GVHD are activated
and primed for survival via BAFF-mediated
pathways. Blood 2012; 120: 2529–2536.
101. Mizoguchi A and Bhan AK. A case for
regulatory B cells. J Immunol 2006; 176:
705–710.
102. Khoder A, Sarvaria A, Alsuliman A, et al.
Regulatory B cells are enriched within the IgM
memory and transitional subsets in healthy
donors but are deficient in chronic GVHD.
Blood 2014; 124: 2034–2045.
103. Sarvaria A, Basar R, Mehta RS, et al. IL-
10+ regulatory B cells are enriched in cord
blood and may protect against cGVHD after
cord blood transplantation. Blood 2016; 128:
1346–1361.
104. Martin PJ, Inamoto Y, Carpenter PA, et al.
Treatment of chronic graft-versus-host disease:
past, present and future. Korean J Hematol
2011; 46: 153–163.
105. Wolff D, Bertz H, Greinix H, et al. The
treatment of chronic graft-versus-host disease:
consensus recommendations of experts from
Germany, Austria, and Switzerland. Dtsch
Arztebl Int 2011; 108: 732–740.
106. Hakim FT, Memon S, Jin P, et al. Upregulation
of IFN-inducible and damage-response
pathways in chronic graft-versus-host disease. J
Immunol 2016; 197: 3490–503.
107. Filipovich AH, Weisdorf D, Pavletic S, et al.
National Institutes of Health consensus
development project on criteria for clinical trials
in chronic graft-versus-host disease: I. Diagnosis
and staging working group report. Biol Blood
Marrow Transplant 2005; 11: 945–956.

108. Srinivasan M, Flynn R, Price A, et al.
Donor B-cell alloantibody deposition and
germinal center formation are required for
the development of murine chronic GVHD
and bronchiolitis obliterans. Blood 2012; 119:
1570–1580.
109. Kapur R, Ebeling S and Hagenbeek A. B-cell
involvement in chronic graft-versus-host
disease. Haematologica 2008; 93:
1702–1711.
110. Allen JL, Tata PV, Fore MS, et al. Increased
BCR responsiveness in B cells from patients
with chronic GVHD. Blood 2014; 123: 2108–
2115.
111. Dubovsky JA, Flynn R, Du J, et al. Ibrutinib
treatment ameliorates murine chronic
graft-versus-host disease. J Clin Invest 2014;
124: 4867–4876.
112. Schutt SD, Fu J, Nguyen H, et al. Inhibition of
BTK and ITK with Ibrutinib is effective in the
prevention of chronic graft-versus-host disease
in Mice. PLoS One 2015; 10: e0137641.
113. Miklos D, Cutler CS, Arora M, et al. Ibrutinib
for chronic graft-versus-host disease after
failure of prior therapy. Blood 2017, https://doi.
org/10.1182/blood-2017-07-793786 (accessed
18 September 2017).
114. Leonhardt F, Zirlik K, Buchner M, et al. Spleen
tyrosine kinase (Syk) is a potent target for
GvHD prevention at different cellular levels.
Leukemia 2012; 26: 1617–1629.
115. Flynn R, Allen JL, Luznik L, et al. Targeting
Syk-activated B cells in murine and human
chronic graft-versus-host disease. Blood 2015;
125: 4085–4094.
116. Deng GM, Liu L, Bahjat FR, et al. Suppression
of skin and kidney disease by inhibition of
spleen tyrosine kinase in lupus-prone mice.
Arthritis Rheum 2010; 62: 2086–2092.
117. Bahjat FR, Pine PR, Reitsma A, et al. An orally
bioavailable spleen tyrosine kinase inhibitor
delays disease progression and prolongs survival
in murine lupus. Arthritis Rheum 2008; 58:
1433–1444.
118. Braselmann S, Taylor V, Zhao H, et al. R406, an
orally available spleen tyrosine kinase inhibitor
blocks fc receptor signaling and reduces immune
complex-mediated inflammation. J Pharmacol
Exp Ther 2006; 319: 998–1008.
119. Smith J, McDaid JP, Bhangal G, et al. A spleen
tyrosine kinase inhibitor reduces the severity
of established glomerulonephritis. J Am Soc
Nephrol 2010; 21: 231–236.
journals.sagepub.com/home/tah 43
L Hill, A Alousi et al.
120. Kim MJ, McDaid JP, McAdoo SP, et al. Spleen
tyrosine kinase is important in the production of
proinflammatory cytokines and cell proliferation
in human mesangial cells following stimulation
with IgA1 isolated from IgA nephropathy
patients. J Immunol 2012; 189: 3751–3758.
121. Le Huu D, Kimura H, Date M, et al. Blockade
of Syk ameliorates the development of murine
sclerodermatous chronic graft-versus-host
disease. J Dermatol Sci 2014; 74: 214–221.
122. Riento K and Ridley AJ. Rocks: multifunctional
kinases in cell behaviour. Nat Rev Mol Cell Biol
2003; 4: 446–456.
123. Zanin-Zhorov A, Flynn R, Waksal SD, et al.
Isoform-specific targeting of ROCK proteins in
immune cells. Small GTPases 2016; 7: 173–177.
124. Biswas PS, Gupta S, Chang E, et al.
Phosphorylation of IRF4 by ROCK2
regulates IL-17 and IL-21 production and the
development of autoimmunity in mice. J Clin
Invest 2010; 120: 3280–3295.
125. Garrett-Sinha LA, John S and Gaffen SL.
IL-17 and the Th17 lineage in systemic lupus
erythematosus. Curr Opin Rheumatol 2008; 20:
519–525.
126. Ettinger R, Kuchen S and Lipsky PE. The role
of IL-21 in regulating B-cell function in health
and disease. Immunol Rev 2008; 223: 60–86.
127. Zanin-Zhorov A, Weiss JM, Nyuydzefe MS,
et al. Selective oral ROCK2 inhibitor down-
regulates IL-21 and IL-17 secretion in human
T cells via STAT3-dependent mechanism. Proc
Natl Acad Sci U S A 2014; 111: 16814–16819.
128. Korn T, Bettelli E, Oukka M, et al. IL-17
and Th17 Cells. Annu Rev Immunol 2009; 27:
485–517.
129. Chen Z, Laurence A and O’Shea JJ. Signal
transduction pathways and transcriptional
regulation in the control of Th17 differentiation.
Semin Immunol 2007; 19: 400–408.
130. Flynn R, Paz K, Du J, et al. Targeted Rho-
associated kinase 2 inhibition suppresses
murine and human chronic GVHD through a
Stat3-dependent mechanism. Blood 2016; 127:
2144–2154.
131. Buchbinder EI and Desai A. CTLA-4 and
PD-1 pathways: similarities, differences, and
implications of their inhibition. Am J Clin Oncol
2016; 39: 98–106.
132. Nahas MR, Soiffer RJ, Alyea EP, et al. Phase
1 clinical trial evaluating abatacept in patients
with steroid-refractory chronic graft versus host
disease. Blood 2016; 128: abstract 387.
Therapeutic Advances in Hematology 9(1)
133. Malek TR and Bayer AL. Tolerance, not
immunity, crucially depends on IL-2. Nat Rev
Immunol 2004; 4: 665–674.
134. Nelson BH. IL-2, regulatory T cells, and
tolerance. J Immunol 2004; 172: 3983–3988.
135. Chinen T, Kannan AK, Levine AG, et al. An
essential role for the IL-2 receptor in Treg cell
function. Nat Immunol 2016; 17: 1322–1333.
136. Koreth J, Matsuoka K, Kim HT, et al.
Interleukin-2 and regulatory T cells in graft-
versus-host disease. N Engl J Med 2011; 365:
2055–2066.
137. Matsuoka K, Koreth J, Kim HT, et al. Low-
dose interleukin-2 therapy restores regulatory
T cell homeostasis in patients with chronic
graft-versus-host disease. Sci Transl Med 2013;
5: 179ra43.
138. Koreth J, Kim HT, Jones KT, et al. Efficacy,
durability, and response predictors of low-dose
interleukin-2 therapy for chronic graft-versus-
host disease. Blood 2016; 128: 130–137.
139. Herrera AF, Kim HT, Bindra B, et al. A phase
II study of bortezomib plus prednisone for
initial therapy of chronic graft-versus-host
disease. Biol Blood Marrow Transplant 2014; 20:
1737–1743.
140. Mulder A, Heidt S, Vergunst M, et al.
Proteasome inhibition profoundly affects
activated human B cells. Transplantation 2013;
95: 1331–1337.
141. Neubert K, Meister S, Moser K, et al. The
proteasome inhibitor bortezomib depletes
plasma cells and protects mice with lupus-like
disease from nephritis. Nat Med 2008; 14:
748–755.
142. El-Cheikh J, Michallet M, Nagler A, et al. High
response rate and improved graft-versus-host
disease following bortezomib as salvage therapy
after reduced intensity conditioning allogeneic
stem cell transplantation for multiple myeloma.
Haematologica 2008; 93: 455–458.
143. Mateos-Mazon J, Pérez-Simón JA, Lopez O,
et al. Use of bortezomib in the management
of chronic graft-versus-host disease among
multiple myeloma patients relapsing after
allogeneic transplantation. Haematologica 2007;
92: 1295–1296.
144. Todisco E, Sarina B, Castagna L, et al.
Inhibition of chronic graft-vs-host disease
with retention of anti-myeloma effects by
the proteasome inhibitor bortezomib. Leuk
Lymphoma 2007; 48:
1015–1018.
44 journals.sagepub.com/home/tah
145. Pai CC, Chen M, Mirsoian A, et al. Treatment
of chronic graft-versus-host disease with
bortezomib. Blood 2014; 124: 1677–1688.
146. Naymagon L and Abdul-Hay M. Novel agents
in the treatment of multiple myeloma: a review
about the future. J Hematol Oncol 2016; 9: 52.
147. Busca A. The use of monoclonal antibodies
for the treatment of graft-versus-host disease
following allogeneic stem cell transplantation.
Expert Opin Biol Ther 2011; 11: 687–697.
148. Cutler C, Kim HT, Bindra B, et al. Rituximab
prophylaxis prevents corticosteroid-requiring
chronic GVHD after allogeneic peripheral blood
stem cell transplantation: results of a phase 2
trial. Blood 2013; 122: 1510–1517.
149. Teeling JL, French RR, Cragg MS, et al.
Characterization of new human CD20
monoclonal antibodies with potent cytolytic
activity against non-Hodgkin lymphomas. Blood
2004; 104: 1793–1800.
150. Pidala J, Kim J, Betts BC, et al. Ofatumumab
in combination with glucocorticoids for
primary therapy of chronic graft-versus-host
disease: phase I trial results. Biol Blood Marrow
Transplant 2015; 21: 1074–1082.
151. Piccirillo CA and Shevach EM. Naturally-
occurring CD4+CD25+ immunoregulatory T
cells: central players in the arena of peripheral
tolerance. Semin Immunol 2004; 16: 81–88.
152. Baecher-Allan C, Brown JA, Freeman GJ,
et al. CD4+CD25high regulatory cells in
human peripheral blood. J Immunol 2001; 167:
1245–1253.
153. Stephens LA, Mottet C, Mason D, et al.
Human CD4(+)CD25(+) thymocytes and
peripheral T cells have immune suppressive
activity in vitro. Eur J Immunol 2001; 31:
1247–1254.
154. Sakaguchi S, Sakaguchi N, Asano M, et al.
Immunologic self-tolerance maintained by
activated T cells expressing IL-2 receptor
alpha-chains (CD25). Breakdown of a single
mechanism of self-tolerance causes various
autoimmune diseases. J Immunol 1995; 155:
1151–1164.
155. Rezvani K, Mielke S, Ahmadzadeh M, et al.
High donor FOXP3-positive regulatory T-cell
(Treg) content is associated with a low risk of
GVHD following HLA-matched allogeneic
SCT. Blood 2006; 108: 1291–1297.
156. Di Ianni M, Falzetti F, Carotti A, et al.
Tregs prevent GVHD and promote immune
reconstitution in HLA-haploidentical

transplantation. Blood 2011; 117:
3921–3928.
157. Brunstein CG, Miller JS, Cao Q, et al. Infusion
of ex vivo expanded T regulatory cells in adults
transplanted with umbilical cord blood: safety
profile and detection kinetics. Blood 2011; 117:
1061–1070.
158. Brunstein CG, Miller JS, McKenna DH, et al.
Umbilical cord blood-derived T regulatory cells
to prevent GVHD: kinetics, toxicity profile, and
clinical effect. Blood 2016; 127: 1044–1051.
159. Parmar S, Liu X, Najjar A, et al. Ex vivo
fucosylation of third-party human regulatory
T cells enhances anti-graft-versus-host disease
potency in vivo. Blood 2015; 125: 1502–1506.
160. Zorn E, Kim HT, Lee SJ, et al. Reduced
frequency of FOXP3+ CD4+CD25+
regulatory T cells in patients with chronic graft-
versus-host disease. Blood 2005; 106: 2903–
2911.
161. Jiang S, Lechler RI, He XS, et al. Regulatory
T cells and transplantation tolerance. Hum
Immunol 2006; 67: 765–776.
162. Trzonkowski P, Bieniaszewska M, Juscinska
J, et al. First-in-man clinical results of the
treatment of patients with graft versus
host disease with human ex vivo expanded
CD4+CD25+CD127- T regulatory cells. Clin
Immunol 2009; 133: 22–26.
163. Theil A, Tuve S, Oelschlagel U, et al. Adoptive
transfer of allogeneic regulatory T cells into
patients with chronic graft-versus-host disease.
Cytotherapy 2015; 17: 473–486.
164. Cutler CS, Koreth J and Ritz J. Mechanistic
approaches for the prevention and treatment
of chronic GVHD. Blood 2017; 129:
22–29.
165. Muller I, Kordowich S, Holzwarth C, et al.
Application of multipotent mesenchymal
stromal cells in pediatric patients following
allogeneic stem cell transplantation. Blood Cells
Mol Dis 2008; 40: 25–32.
166. Lucchini G, Introna M, Dander E, et al.
Platelet-lysate-expanded mesenchymal
stromal cells as a salvage therapy for severe
resistant graft-versus-host disease in a pediatric
population. Biol Blood Marrow Transplant 2010;
16: 1293–1301.
167. Zhou H, Guo M, Bian C, et al. Efficacy of bone
marrow-derived mesenchymal stem cells in the
treatment of sclerodermatous chronic graft-
versus-host disease: clinical report. Biol Blood
Marrow Transplant 2010; 16: 403–412.
journals.sagepub.com/home/tah 45
L Hill, A Alousi et al.
168. Gómez-Almaguer D, Ruiz-Argüelles GJ, del
Carmen Tarín-Arzaga L, et al. Alemtuzumab
for the treatment of steroid-refractory acute
graft-versus-host disease. Biol Blood Marrow
Transplant 2008; 14: 10–15.
169. Schnitzler M, Hasskarl J, Egger M, et al.
Successful treatment of severe acute intestinal
graft-versus-host resistant to systemic and
topical steroids with alemtuzumab. Biol Blood
Marrow Transplant 2009; 15: 910–918.
170. Martínez C, Solano C, Ferrá C, et al.
Alemtuzumab as treatment of steroid-refractory
acute graft-versus-host disease: results of a
phase II study. Biol Blood Marrow Transplant
2009; 15: 639–642.
171. Schub N, Günther A, Schrauder A, et al.
Therapy of steroid-refractory acute GVHD with
CD52 antibody alemtuzumab is effective. Bone
Marrow Transplant 2011; 46: 143–147.
172. Couriel D, Saliba R, Hicks K, et al. Tumor
necrosis factor-alpha blockade for the treatment
of acute GVHD. Blood 2004; 104: 649–654.
173. Patriarca F, Sperotto A, Damiani D, et al.
Infliximab treatment for steroid-refractory acute
graft-versus-host disease. Haematologica 2004;
89: 1352–1359.
174. Busca A, Locatelli F, Marmont F, et al.
Recombinant human soluble tumor necrosis
factor receptor fusion protein as treatment
for steroid refractory graft-versus-host disease
following allogeneic hematopoietic stem cell
transplantation. Am J Hematol 2007; 82: 45–52.
175. Chiang KY, Abhyankar S, Bridges K, et al.
Recombinant human tumor necrosis factor
receptor fusion protein as complementary
treatment for chronic graft-versus-host disease.
Transplantation 2002; 73: 665–667.
176. Kim JG, Sohn SK, Kim DH, et al. Different
efficacy of mycophenolate mofetil as salvage
treatment for acute and chronic GVHD after
allogeneic stem cell transplant. Eur J Haematol
2004; 73: 56–61.
177. Krejci M, Doubek M, Buchler T, et al.
Mycophenolate mofetil for the treatment of
acute and chronic steroid-refractory graft-
versus-host disease. Ann Hematol 2005; 84:
681–685.
178. Furlong T, Martin P, Flowers ME, et al.
Therapy with mycophenolate mofetil for
refractory acute and chronic GVHD. Bone
Marrow Transplant 2009; 44: 739–748.
179. Hoda D, Pidala J, Salgado-Vila N, et al.
Sirolimus for treatment of steroid-refractory
Therapeutic Advances in Hematology 9(1)
acute graft-versus-host disease. Bone Marrow
Transplant 2010; 45: 1347–1351.
180. Bolaños-Meade J, Jacobsohn DA, Margolis
J, et al. Pentostatin in steroid-refractory acute
graft-versus-host disease. J Clin Oncol 2005; 23:
2661–2668.
181. Pidala J, Kim J, Roman-Diaz J, et al. Pentostatin
as rescue therapy for glucocorticoid-refractory
acute and chronic graft-versus-host disease. Ann
Transplant 2010; 15: 21–29.
182. Jacobsohn DA, Chen AR, Zahurak M, et al.
Phase II study of pentostatin in patients with
corticosteroid-refractory chronic graft-versus-
Visit SAGE journals online
host disease. J Clin Oncol 2007; 25: 4255–4261.
journals.sagepub.com/
home/tah
183. Greinix HT, Volc-Platzer B, Kalhs P, et al.
SAGE journals Extracorporeal photochemotherapy in the
46 journals.sagepub.com/home/tah
treatment of severe steroid-refractory acute
graft-versus-host disease: a pilot study. Blood
2000; 96: 2426–2431.
184. Salvaneschi L, Perotti C, Zecca M, et al.
Extracorporeal photochemotherapy for
treatment of acute and chronic GVHD in
childhood. Transfusion 2001; 4110:
1299–1305.
185. Perfetti P, Carlier P, Strada P, et al.
Extracorporeal photopheresis for the treatment
of steroid refractory acute GVHD. Bone Marrow
Transplant 2008; 42: 609–617.
186. Couriel DR, Hosing C, Saliba R, et al.
Extracorporeal photochemotherapy for the
treatment of steroid-resistant chronic GVHD.
Blood 2006; 107: 3074–3080.