Study On Risk Indices To Assess Asparaginase-related Adverse Reaction From Children With Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia(ALL)is a malignant proliferative disease caused by abnormal proliferation and differentiation of hematopoietic stem cells.It has a high degree of malignancy,easy to relapse and poor prognosis,therefore seriously threatening human health.With about half of cases occurring in children and teenagers ALL becomes the most common cause of child mortality.With the refinement of clinical classification and the continuous standardization and improvement of treatment prescription,the 5-year overall survival rate(OS)of children with ALL has reached more than 90%,and the disease-free survival rate(DFS)has reached more than 80%.As one of the most important chemotherapy medicines,the application of asparaginase(ASP)can improve the complete response rate and cure rate for children with ALL,and is one of the most important chemotherapy drugs for children with ALL.Complete exhaustion of asparagine(ASN)is considered a crucial factor in achieving optimal therapeutic effects.Tumor cells cannot produce ASN on their own,therefore need to intake ASN from the host plasma for protein synthesis.Through hydrolyzing asparagine to aspartic acid and ammonia,ASP consume asparagine in plasma,inhibiting the synthesis of protein,ribonucleic acid and DNA,eventually inducing the apoptosis of leukemia cells and playing a role in the treatment of leukemia.However,ASP chemotherapy can cause a variety of adverse reactions,and serious adverse reactions may be life-threatening.Adverse reactions can be divided into anaphylactic and non-anaphylactic reactions.Allergic reactions are divided into clinical hypersensitivity reactions and non-clinical subclinical hypersensitivity reactions(i.e,silent inactivation)according to the presence or absence of clinical symptoms.Non-allergic adverse reactions include:acute pancreatitis,coagulation functional abnormality,temporary increase in blood glucose,liver and kidney function damage,etc.Those adverse reactions limit the clinical application of ASP,lessen the treatment effect of children with ALL,and pose serious complications which endanger life of children.Therefore,it is critical to look for some new bio-indices to assess asparaginase-related adverse reactions from children with ALL,which likely improve the overall treatment effects.Children with ALL behavior distinctly from one another and from adults in clinical symptoms and biological characteristics.Many aspects including clinical features,genetic biology,response to treatment and prognosis are all likely related to the adverse reactions from children with ALL.This study,collects clinical data and the occurrence of adverse reactions from children with ALL,analyzes the relationship between clinical characteristics and ASP adverse reactions,evaluates the risk of adverse reactions in children,therefore provide preventive treatment and benefit children with ALL by improving the response and survival rate.At present,foreign clinical studies often assess the activity of drugs and the correlation of adverse reactions by measuring the activity of L-asp enzyme and anti-L-asp antibody,which is found that closely related to clinical efficacy.However,there are few relevant studies in China.The study detects L-Asp activity and anti-L-Asp antibodies in the peripheral blood of children with ALL receiving PEG-Asp-containing therapy aiming at exploring their value in assessing the risk of asparaginase-related allergic and non-allergic adverse reactions.Besides,this study detects and encodes the relevant gene loci of the gene GRIA1rs4958351 of glutamate receptor,and study the relationship with the adverse reactions such as clinical features,allergic reactions,silent inactivation,and non-allergic reactions.Aiming at predicting the possible drug resistance,adverse reactions drug resistance and prognostic adverse events.The study can provide a theoretical basis for standardizing chemotherapy regimens and clinical rational drug use,and reduce the risk of adverse reactions and poor prognosis through early intervention if necessary.Part One Analysis of the correlation between clinical features of ALL and adverse reaction to asparaginase chemotherapy in childrenObjective:The correlation between asparaginase-related adverse reactions and clinical features in children with ALL was analyzed,and the risk of asparaginase-related adverse reactions in children was evaluated,and prevention treatment options were further determined.Method:From July 2019 to May 2022,170 hospitalized children aged 1 to 18 years old,hospitalized in Handan Central Hospital of Hebei Province were diagnosed with ALL by Morphology-ImmunologyCytogenetics-Molecular Biology(MICM)and given PEG-Asp chemotherapy.General clinical data of 170 children were collected and adverse reactions were recorded.After evaluation,It was independently attributed to asparaginase-related adverse effects.Asparaginase-related adverse reactions were further divided into allergic reactions(rash,dyspnea,anaphylactic shock,laryngeal edema,etc.)and non-allergic adverse reactions(nausea and vomiting,pancreatitis,diarrhea,elevated aminotransferases,headaches,etc.).In addition,measures to respond to adverse reactions were recorded.The child’s disease status(new or relapse),immunotyping,risk stratification,and allergy history were analyzed.Analyze data with SPSS 26.0.The Fisher’s exact test was used to precisely compare the incidence of adverse reactions in patients with different disease characteristics.Independent factors for asparaginase adverse reactions were assessed by logistic regression analysis.Results:1.Correlation between clinical features and asparaginase-related allergic reactions.De novo(vs relapse)disease status(P=0.135),higher risk stratification(P=0.087),and presence of allergic history(P=0.103)seemed to correlate with higher asparaginase-related anaphylaxis rates,but without statical significance,while T-ALL(vs B-ALL)(P=0.106)was similar between childhood ALL patients with or without asparaginase-related anaphylaxis.The difference was without statical significance,and the difference between T-ALL and B-ALL was not statistically significant.2.Correlation between clinical factors and asparaginase non-allergic adverse reactionsDisease status,immunophenotype,risk stratification,or allergy history were not associated with the incidence of asparaginase related non-allergic adverse reaction.(P>0.05).3.Correlation between clinical factors and total asparaginase-related adverse reactionsDisease status,immunophenotype,risk stratification,or allergy history were not associated with the incidence of total asparaginase-related adverse reaction(all P>0.05).Conclusions:1.De novo,higher risk stratification,and allergy history showed a higher incidence of anaphylaxis.2.Disease status,immunophenotype,risk stratification,and allergy history were not associated with asparaginase-related non allergic adverse reactions or total adverse effects.Part Two A study of L-Asp activity and anti-L-Asp antibody to assess the risk of asparaginase-related adverse reactions in childhood acute lymphoblastic leukemiaObjective:This study aimed to investigate the relation of L-Asp activity and anti-L-asp antibody with allergic risk and non-allergic adverse reaction risk in children with acute lymphoblastic leukemia(ALL)patients who underwent PEG-asp contained therapy.Method:All patients were treated with PEG-Asp.On the 7th day after the start of treatment,peripheral venous blood samples were collected,plasma samples were centrifuged,and L-Asp activity was detected by high performance liquid image chromatography and anti-L-Asp antibody levels were detected by enzyme-linked immunosorbent assay.Results:There were 27(15.9%)patients who had PEG-Asp-related adverse reaction,17(10.0%)patients experienced PEG-Asp-related anaphylaxis and 14(8.2%)patients experienced PEG-Asp related non-anaphylaxis adverse reaction.Among them,4 children with ALL developed asparaginase-related allergic reactions and non-allergic adverse reactions at the same time.Moreover,L-asp activity was negatively related to anti-L-asp antibody in children with ALL(P<0.001).L-Asp activity was negatively correlated with ASP-related allergic reactions(P<0.001),and L-Asp activity was negatively correlated with ASP-related non-allergic adverse reactions(P=0.004),and L-Asp activity was negatively correlated with ASP-related adverse reactions(P<0.001).However,the anti-L-Asp antibodies show an opposite trend to L-Asp activity.Receiver operating characteristic(ROC)curve analyses exhibited L-Asp activity and anti-L-asp antibody exhibited superior predictive values in estimating PEG-Asp-related anaphylaxis risk with area under curve(AUC)of 0.955 and 0.905,respectively compared to PEG-Asp-related non-anaphylaxis adverse reaction risk with AUC of 0.730 and 0.675.Conclusions:1.L-Asp activity in children with ALL is negatively correlated with anti-L-Asp antibodies,and they are not only associated with the risk of anaphylaxis in children with ALL,but also with non-allergic adverse reactions.2.L-Asp activity and anti-L-ASP antibodies were superior to non-allergic adverse reactions in assessing the risk of anaphylactic reactions in children with ALL.3.Monitoring of L-Asp activity and anti-L-Asp antibodies may be helpful in the early evaluation and prevention of Asp-related adverse reactions in chemotherapy in children with ALL.Part Three A clinical study of GRIA1 gene polymorphisms to assess the risk of ASP-related adverse reactions in children with ALLObjective:To study the correlation between GRIAlrs4958351 gene polymorphisms and ASP-related adverse reactions after ASP chemotherapy in children with ALL.It provides a theoretical basis for preventing adverse reactions,further improving clinical efficacy and improving long-term prognosis.Method:A total of 170 children with ALL who were hospitalized for chemotherapy in the Handan Central Hospital from July 2019 to May 2022 were enrolled as study subjects.3ml of venous blood was extracted and the genotype of GRIAlrs4958351 was determined by mass spectrometry.The occurrence of adverse reactions after chemotherapy in children with ALL was recorded,and the correlation between the genotypes of the detection sites and allergic adverse reactions,silent inactivation and non-allergic adverse reactions was analyzed.Results:The probability of allergic reactions in children with GRIA4958351AA genotype ALL was 60%significantly higher than that of GG genotype by 6.6%,and the difference was statistically significant(P<0.001);It was slightly higher than the AG genotype by 28.6%,and there was no significant difference(P>0.05).The probability of silent inactivation in children with GRIA1 rs4958351 AA genotype ALL was 40%significantly higher than that of GG genotype 5.3%,and the difference was statistically significant(P=0.002);It was slightly higher than AG genotype by 28.6%,and the difference was not statistically significant(P>0.05).Conclusions:1.The risk allele for ASP-related allergic reactions in the GRIAlrs 4958351 genotype is the A allele.2.The AA allele in GRIAlrs4958351 allele is more prone to ASP-related allergic reactions and "silent inactivation" than the GG allele.3.GRIA1 rs4958351AA genotype can be used as a risk marker to evaluate ASP-related allergic reactions and "silent inactivation".