【Abstract】 Objective To explore the effective methods for the treatment of intestinal acute graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (Allo-HSCT). Methods Fifteen patients with acute intestinal GVHD (aGVHD) of degree II-IV were given cyclophosphamide, intravenously, once every 7-8 d until the disappearance/remission of GVHD symptoms, and the effect of cyclophosphamide and its toxicity and side effects were judged. RESULTS All 15 patients with intestinal GVHD achieved improvement with disappearance/remission of symptoms, and the toxic side effects associated with cyclophosphamide were tolerated. This treatment may reduce the dosage of other immunosuppressants. Conclusion Small-dose, short-term application of cyclophosphamide can be a safe and effective treatment for II-IV degree intestinal aGVHD after Allo-HSCT. Wei Xudong, Department of Hematology, Henan Cancer Hospital 【Keywords】 Hematopoietic stem cell transplantation; intestinal graft-versus-host disease; cyclophosphamide The efficacy of refractory intestinal GVHD treated with CTX 【Abstract】 Purpose To investigate the efficacy of refractory GVHD treated by CTX after allogenenic hematopoitic stem cell Method The 15 cases patients with refractory GVHD were treated with CTX at dose 02.~0.4g,every 5~7days until the symptom of GVHD was controlled. The side effect was observed.Results 10 cases of the patients achieved CR and 6 cases PR.The success rate is 80%.The side effect of CTX were The side effect of CTX were tolerable.Conclusion:small dose CTX is an effective way to treat patients with refractory GVHD. 【Key words】 Hematopoitic stem cell transplantation; GVHD; CTX Graft-versus-host disease (GVHD) is a major complication after allogeneic hematopoietic stem cell transplantation (Allo-HSCT), and is an important factor affecting the efficacy of treatment. Acute GVHD (aGVHD) occurring on the basis of a short course of methotrexate + cyclosporine as a prophylactic regimen is treated with glucocorticoids as the treatment of choice. The therapeutic efficiency of glucocorticoids is 50-70%. If hormone therapy is ineffective, the case is refractory GVHD.Other second-line drug treatments for GVHD, such as anti-thymocyte globulin (ATG), monoclonal antibodies, etc., are mostly monoclonal antibody preparations, which are expensive but have limited efficacy. Cyclophosphamide is an immunosuppressant, which we used to achieve better efficacy in the treatment of 15 cases of intestinal refractory GVHD, which is now reported as follows: Objects and methods 1.Case selection:From July 2004 to August 2008, 15 patients clinically diagnosed as intestinal a-GVHD after HSCT at the Hematology Institute of Henan Cancer Hospital received cyclophosphamide treatment. There were 5 cases in the group with degree II intestinal aGVHD, 5 cases in the group with degree III intestinal GVHD, and 5 cases in the group with degree IV intestinal GVHD.Of the 15 patients, 7 had a cutaneous type with mossy papules prior to the diagnosis of intestinal aGVHD, 4 combined with hepatic GVHD, which manifested itself as abnormalities of hepatic enzymology (2 of which were accompanied by bilirubin elevation), and 9 cases had thrombocytopenia.There were 8 males and 7 females among the 15 patients with the median age of 35 years old (28-45 years old). There were 8 cases of chronic granulocytic leukemia (CML), 1 case of chronic granulomonocytic leukemia, 3 cases of acute myeloid leukemia, and 3 cases of acute lymphoblastic leukemia. There were 2 cases of haploidentical hematopoietic stem cell transplantation, 3 cases of peripheral blood hematopoietic stem cell transplantation, 11 cases of sibling all-compatible hematopoietic stem cell transplantation, 10 cases of ABO blood group compatible transplantation, and 5 cases of blood group incompatible transplantation. 2. Methods: Pretreatment program: Bu (leucovorin)/Cy (cyclophosphamide)-based program was adopted, and drugs such as Ara-C, BCNU or VP-16 were added according to the disease type and pre-transplantation status, and Gleevec was added to 3 cases of CML-BP patients. Prophylaxis of aGVHD: Sibling HLA-matched allografts were performed with cyclosporine A (CsA) + short course methotrexate (MTX). Unrelated transplants add primaquine (MMF) and CD25 monoclonal antibody. Haploid type transplantation plus primaquine (MMF) and anti-thymocyte immunoglobulin (ATG). Diagnosis and grading of intestinal GVHD: The diagnosis of aGVHD is described in the literature [1]. For concomitant cutaneous or hepatic a-GVHD (which often occurs first), the diagnosis is made on the basis of typical clinical manifestations such as nausea, vomiting, anorexia, diarrhea, cramping abdominal pain, abdominal distension, paralytic intestinal obstruction or intestinal bleeding. Gastrointestinal endoscopy was performed in patients with only intestinal a-GVHD manifestations, and biopsy tissues were sent to pathology to exclude enteritis caused by other factors, especially CMV enteritis. Fred Hutchinson grading of aGVHD was used: diarrhea volume >500 ml/day was grade I; >1000 ml/day was grade II; >1500 ml/day was grade III; abdominal pain/intestinal obstruction was grade IV. Medication before cyclophosphamide treatment: 15 patients were those who were ineffective with methylprednisolone 2mg/(Kg・d) for at least 5d. 15 patients were those who were ineffective with prednisone 2mg/Kg + cyclosporine 1~2 mg/Kg or those who occurred under the above medication (among them, 10 cases were concomitantly taking mycophenolate mofetil 0.5~1g/d, and 2 cases were concomitantly taking mycophenolate mofetil 1g/d after After the effect was not obvious in 3~5d, CD25 monoclonal antibody about 1g/Kg was added, which was dissolved in 100 ml saline on the 1st, 4th, 8th, 15th and 22nd day for sedation, and methotrexate was applied simultaneously in 3 cases, which was taken as 5 or 10 mg every 5~7 d for intravenous drip). Cyclophosphamide treatment: according to the patient’s blood routine, cyclophosphamide 0.2 or 0.4 g added to 20 ml of saline every 7~8 d, intravenous injection, until the disappearance of symptoms/relief. Those with more frequent use of the drug can be appropriately given mesylate sodium relief to prevent hemorrhagic cystitis. Determine the efficacy of cyclophosphamide therapy or cyclophosphamide toxicity. At the initial stage of cyclophosphamide treatment, maintain the original immunosuppressant treatment, when cyclophosphamide gained efficacy, gradually reduce the patient’s corticosteroid dosage, cyclosporine CD25 monoclonal antibody or mycophenolate mofetil and other immunosuppressant dosage. The efficacy and toxic side effects of cyclophosphamide were evaluated as follows: (1) Efficacy evaluation: the criteria for judging the efficacy were referred to in the literature [2]: the efficacy was categorized into CR, PR and NR, which were defined as follows: complete remission was the complete disappearance of the relevant symptoms or the return to normal of objective parameters; partial remission was the improvement of more than 50% in the above indexes of all the affected organs, but did not reach complete remission; ineffective was the patients who were treated with a total amount of more than 2g of cyclophosphamide and observed for at least 7d, and the above mentioned indexes were not improved. Ineffective means that the patient has been treated with more than 2g of cyclophosphamide in total and observed for at least 7d, and there is no change or progress in the above indexes. (2) Evaluation of toxic side effects: graded according to the National Cancer Institute (NCI)/National Institutes of Health (NIH) toxicity criteria. Data analysis: SPSS 10.0 statistical software was applied for data analysis. The number of cases, age and time were expressed as X+ -S. RESULTS 1. Efficacy: 15 patients achieved remission or disappearance of intestinal GVHD. Most patients were given 3 doses of CTX, which was added on d 1-28 after hormone resistance, with a mean duration of 7.5 days. 3 patients achieved complete remission after 2 applications, including 2 patients with grade IV GVHD who were given up to 8 applications. Ten patients achieved complete remission (complete remission rate of 66.67%), while the remaining three cases achieved partial remission, one of which was not in remission, and one of which gave up further treatment due to economic reasons. 2. Toxic side effects: Adverse effects were mild in all 15 patients, only 4 patients experienced mild nausea and vomiting, which could be tolerated after symptomatic treatment. 3. Follow-up: Median follow-up was 20 months (5-54). 1 out of 15 patients died of multi-organ failure and interstitial pneumonia, 1 patient died of grade IV GVHD due to economic reasons forgoing further treatment. the rest of the patients survived disease-free. DISCUSSION The incidence of aGVHD after Allo-HSCT is 40% to 60%, and the lethality of degree III-IV aGVHD can be as high as 50% or more [2-3]. At present, corticosteroid is still the first choice and the first line of treatment for aGVHD, about 50% of aGVHD patients are effective for hormone therapy, and those who are ineffective for hormone therapy are treated with second-line drugs such as ATG, FK506, MMF, interleukin receptor monoclonal antibody CD25, etc. The literature has reported that the results are not satisfactory, and only 10%-30% of the patients can obtain CR [2-4]. We have not yet seen any report on CTX for GVHD. Our institute applied CTX to treat refractory intestinal aGVHD, and 80% of the patients achieved complete remission or partial remission, which is a satisfactory result. Intestinal aGVHD was more pronounced in these 15 patients, and skin and liver GVHD also gradually recovered during treatment, so it seems that CTX is equally effective for GVHD with multi-organ involvement. Currently, ATG and CD25 monoclonal antibody are commonly used as second-line drugs for the treatment of GVHD, etc. ATG is highly immunosuppressive, poorly selective, and can easily be fatal due to severe infections after use. CD25 monoclonal antibody can specifically bind to the α chain of IL-2 receptor on the surface of activated T lymphocytes, blocking IL-2-mediated activation and proliferation of T lymphocytes, so as to achieve the purpose of treating GVHD, and because of its strong selectivity, it has relatively fewer concurrent infections, but its price is expensive, and its therapeutic efficacy is also very limited. Huang et al [5] reported that the application of low-dose methotrexate for the treatment of GVHD after allogeneic hematopoietic stem cells achieved good results, and we were inspired by this to apply CTX for the treatment of GVHD, which also achieved good results. CTX is a powerful immunosuppressant, the main mechanism of action is to inhibit the number and function of T and B cells at the same time, and it acts directly on the immune cells with a long-lasting effect. Glucocorticosteroids, on the other hand, can act directly on effector cells, and therefore have a rapid onset of action and a short-lived effect. Therefore, it is believed that there may be a certain synergistic effect when the two are applied together. In this study, the acute adverse reactions after the application of CTX treatment were mild, only a few occurred nausea, fatigue, alopecia, and no case of serious hepatic and renal function damage, hemorrhagic cystitis, and there was no obvious bone marrow suppression. Recent animal studies [6] found that small doses of CTX monotherapy given at the right time after transplantation can effectively prevent aGVHD.The role of CTX in the prevention and treatment of GVHD needs to be further investigated. As patients with refractory GVHD spend a lot of money on treatment, this drug is inexpensive and therefore eases the economic burden of patients without serious adverse effects, and is indeed worth promoting. References 1 Thomas ED, Storb R, Clift RA, et al. Bone marrow transplantation .New Engl J Med,1975,292:832-843, 895-902. 2 Koc ON, Gerson SL, Phillips GL, et a1. Autologous CD34+ cell transplantation for patients with advanced lymphoma: effect of overnight storage on peripheral blood progenitor cdl enrichment and engraftment [J]. Bone Marrow Transplant, 1998, 21:337-343. 3 Zubair A, ZahriehD, Daley H, et al, Early neutrophil engraftment following autologous BMT provides a functional predictor of long-term hematopoietic reconstitution [J].Transfusion, 2003, 43(5): 614-621. 4 Malphettes M, Carcelain G, Saint-Mezard P, et a1. evidence for naive T cell repopulation despite thymus irradiation after autologous transplantation in adults with multiple myeloma: role of ex vivo CD34+ selection and age [J].Blood, 2003, 101(5):1891-1897. 5 Huang XJ, Jiang Q, Chen H et al. Methotrexate for the treatment of graft-versus-host disease after allogeneic hematopoietic stem cell transplantation [J]. Chinese Medical Journal, 2005, 85(16):1097-1101. 6 PrigozhinaTB, Elkin G, khitrin S ,at al. Prevention of acute graft-vs-host disease by a single low-dose cyclophosphamide injection following allogeneic bone marrow transplantation.[J].Exp Hematol.2008 Dec;36(12):1750-9.