Filgrastim enhances T-cell clearance by antithymocyte globulin exposure after unrelated cord blood transplantation

Residual antithymocyte globulin (ATG; Thymoglobulin) exposure after allogeneic hematopoietic (stem) cell transplantation (HCT) delays CD4(+) T-cell immune reconstitution (CD4(+) IR), subsequently increasing morbidity and mortality. This effect seems particularly present after cord blood transplantation (CBT) compared to bone marrow transplantation (BMT). The reason for this is currently unknown. We investigated the effect of active-ATG exposure on CD4(+) IR after BMT and CBT in 275 patients (CBT n = 155, BMT n = 120; median age, 7.8 years; range, 0.16-19.2 years) receiving their first allogeneic HCT between January 2008 and September 2016. Multivariate log-rank tests (with correction for covariates) revealed that CD4(+) IR was faster after CBT than after BMT with <10 active-ATG x day/mL (P=.018) residual exposure. In contrast, >10 active-ATG x day/mL exposure severely impaired CD4(+) IR after CBT (P<.001), but not after BMT (P=.74). To decipher these differences, we performed ATG-binding and ATG-cytotoxicity experiments using cord blood and bone marrow graft derived T-cell subsets, B cells, natural killer cells, and monocytes. No differences were observed. Nevertheless, a major covariate in our cohort was Filgrastim treatment (only given after CBT). We found that Filgrastim (granulocyte colony-stimulating factor [G-CSF]) exposure highly increased neutrophil-mediated ATG cytotoxicity (by 40-fold [0.5 vs 20%; P=.002]), which explained the enhanced T-cell clearance after CBT. These findings imply revision of the use (and/or timing) of G-CSF in patients with residual ATG exposure.