Common hereditary variants of the APOE gene and posttransplant outcome in acute myeloid leukemia

• Patients with acute myeloid leukemia who carry an APOE2 allele have inferior survival after allogeneic transplantation.

• The APOE2 allele is associated with an increased risk of acute and chronic GVHD when present in the host or transferred from the donor.

Apolipoprotein E (APOE) has multiple functions in metabolism and immunoregulation. Its common germ line variants APOE2, APOE3, and APOE4 give rise to 3 functionally distinct gene products. Previous studies reported yin-yang roles of APOE2 and APOE4 in immunological processes, but their effects in hematopoietic stem cell transplantation (HSCT) have never been studied. We performed APOE genotyping in 2 contemporary cohorts of 348 and 447 patients with acute myeloid leukemia who had received allogeneic HSCT and evaluated the associations of recipient and donor APOE genetic variations with posttransplant outcomes. Patients who carried at least 1 APOE2 allele had a higher risk of posttransplant death than APOE4 carriers in the discovery (hazard ratio [HR], 2.09; P = .024) and validation cohorts (HR, 1.96; P = .040). Detrimental APOE2 effects were driven by an increased risk of severe chronic graft-versus-host disease (GVHD; adjusted HR [HR_adj], 1.85; P = .034) and nonrelapse death (HR_adj, 1.72; P = .044). In non-APOE2 recipients, transplantation of an APOE2-positive allograft was associated with an increased incidence of grade 3 to 4 acute GVHD (HR_adj, 2.82; P = .012) and severe chronic GVHD (HR_adj, 2.54; P = .022) compared with APOE2-negative grafts. In summary, the APOE2 allele, typically considered a longevity gene in the general population, was associated with a higher risk of acute GVHD (HR_adj, 2.75; P = .002), chronic GVHD (HR_adj, 2.57; P = .001), and posttransplant mortality (HR_adj, 1.79; P = .004), when present in either the host or transplanted from the donor.