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Sánchez LM, Morrone K, Frei-Jones M, Fasipe TA. Clinical Practice Patterns in Sickle Cell Disease Treatment: Disease-modifying and Potentially Curative Therapies. J Pediatr Hematol Oncol 2024; 46:e277-e283. [PMID: 38718300 DOI: 10.1097/mph.0000000000002869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 04/02/2024] [Indexed: 06/25/2024]
Abstract
Therapeutic options for sickle cell disease (SCD) have increased recently as well as the development of updated national guidelines. It is not known how these options are being offered or to what degree guidelines are incorporated into clinical practice. This study aimed to describe practice patterns for pediatric hematologists regarding the use of disease-modifying and potentially curative therapies for SCD. A 9-section, cross-sectional electronic survey was disseminated during a 3-month period via SurveyMonkey, to members of the American Society of Pediatric Hematology/Oncology Hemoglobinopathy Special Interest Group (ASPHO HSIG). A total of 88 physician members of the ASPHO HSIG were surveyed. Ninety percent of respondents (72/80) start hydroxyurea routinely in patients with HbSS and HbSβ 0 thalassemia, regardless of disease severity. Laboratory monitoring was recommended every 3 months for stable dosing in 63.8% (51/80). New therapies were recommended for patients on hydroxyurea who were still experiencing SCD complications: L-glutamine 68.5% (37/54) or crizanlizumab 93.1% (54/58). Voxelotor was recommended for patients on hydroxyurea with low hemoglobin in 65.1% (43/66) of cases. Matched sibling transplant was considered for any disease severity by 55.1% (38/69). Gene therapy trials are offered on-site by 29% (20/69). Our study demonstrated the enhanced utilization of hydroxyurea while revealing the unexplored potential of other disease-modifying therapies in SCD. These findings underscore the importance of continued knowledge acquisition about the long-term efficacy of new medical therapies and addressing barriers to the use of proven therapies and guide the development of future studies of optimal SCD management.
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Affiliation(s)
| | - Kerry Morrone
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | - Melissa Frei-Jones
- Department of Pediatrics, Division of Hematology/Oncology, UTHealth Joe R. and Teresa Lozano Long School of Medicine-San Antonio, San Antonio
| | - Titilope A Fasipe
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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BinAmir HA, AlAhmari A, AlQahtani A, Mohamed G, Alotaibi F, AlShamrani M, AlSaeed A, AlGhanmi S, Heji A, Alreshaid A, AlKawi A, AlHazzani A, AlZawahmah M, Shuaib A, Al-Ajlan F, AlMohareb F. Posterior reversible encephalopathy syndrome post stem cell transplantation in sickle cell disease: case series and literature review. Front Med (Lausanne) 2024; 11:1330688. [PMID: 38751974 PMCID: PMC11094324 DOI: 10.3389/fmed.2024.1330688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction Posterior reversible encephalopathy syndrome (PRES) is a serious neurological syndrome that may develop following immunosuppressive therapy for stem cell transplantation (SCT). We report 8 patients with sickle cell disease (SCD) who developed PRES, which is likely to be related to immunosuppression. Methods This is retrospective cohort analysis of the SCD registry at the King Faisal Specialist Hospital and Research Center (KFSHRC) in Riyadh, Saudi Arabia. Inclusion criteria included all adults SCD patients who underwent SCT from 2011 until 2022. We explored all cases of PRES in patients with SCT. PRES was diagnosed with MRI imaging showing reversible vasogenic cerebral edema associated with neurological symptoms including severe headache, seizures, encephalopathy, delirium, and visual disturbances. Results During ten years follow-up (2011-2022) we found 8 patients with PRES (age range between 14 to 37 years at diagnosis) PRES occurred 8 to 124 days following SCT in 7 cases and one patient developed PRES 8 months prior to SCT. All patients were on immunosuppressive medications, including tacrolimus, cyclosporine, sirolimus and or mycophenolate mofetil. Headache, seizures, visual hallucinations, confusion, and drowsiness were the most common presenting symptoms. MRI showed abnormalities in the occipital, parietal and frontal lobes in most cases. Recovery was complete in all patients and no recurrences were noted. Two patients had graft versus host disease (GVHD). We compared risk factors for PRES among the 8 cases and 136 SCT in SCD patients who did not develop PRES. There was a significant association between PRES and imaging abnormalities, including previous bi-hemispheric infarctions (p = 0.001), and cerebral microbleeds (CBMs). PRES was strongly associated with presence (p = 0.006), size (p = 0.016) and number (p = 0.005) of CMBs. Conclusion PRES can develop days to weeks following SCT in patients with SCD, and is associated with immunosuppressive therapy, previous bi-hemispheric infarctions and CMB. Prompt recognition and intervention leads to good recovery.
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Affiliation(s)
- Hussain A. BinAmir
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ali AlAhmari
- Hematology, Stem Cell Transplant and Cellular Therapy Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - AlWaleed AlQahtani
- Radiology Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gamal Mohamed
- Department of Biostatistics, Epidemiology, and Scientific Computing, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fawaz Alotaibi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohamed AlShamrani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ali AlSaeed
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Suwaidi AlGhanmi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Alaa Heji
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulrahman Alreshaid
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Department of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Ammar AlKawi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Department of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Adel AlHazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Department of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Mohamed AlZawahmah
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ashfaq Shuaib
- Department of Medicine University of Alberta, Edmonton, AB, Canada
| | - Fahad Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Department of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Fahad AlMohareb
- Hematology, Stem Cell Transplant and Cellular Therapy Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Krishnamurti L, Liang J, He Z, Deng Y, Nallagatla VR, Hamidi R, Flagg A, Shah N. Incidence and risk factors of pain crisis after hematopoietic cell transplantation for sickle cell disease. Blood Adv 2024; 8:1908-1919. [PMID: 38324722 PMCID: PMC11021890 DOI: 10.1182/bloodadvances.2023010749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 01/09/2024] [Accepted: 01/14/2024] [Indexed: 02/09/2024] Open
Abstract
ABSTRACT Vaso-occlusive episodes (VOC) or pain crises are the most common indications for hematopoietic cell transplantation (HCT) for sickle cell disease (SCD). Elimination of pain crisis after HCT is an important patient-centered outcome and may improve understanding of the natural history of pain syndromes in SCD. We examined deidentified records of 763 patients followed-up for a median of 36.7 months (range, 0.3-168.6 months), with 69.6% patient's age <18 years at HCT, 83.3% patient's Karnofsky-Lansky performance score (KPS) ≥90, overall survival 92.9%, event-free survival 72.4%, graft failure (GF) 22.4%, AGVHD 21.4%, CGVHD 27%, and pain crisis 8.65%. On unadjusted logistic regression, increased risk of pain crisis after HCT was observed in patient's aged >10 years at HCT (range, 11-17 years; OR, 9.43; 95% CI, 3.20-27.79; P < .0001), in age ≥18 years (OR, 16.62; 95% CI, 5.85-47.16; P < .0001), in those with history of pain crisis 2 years before HCT (OR, 13.16; 95% CI, 4.08-42.42; P < .0001), alternate donors (haploidentical [OR, 4.80; 95% CI, 2.48-9.31; P < .0001], unrelated matched [OR, 2.71; 95% CI, 1.23-5.97; P = .0132], and mismatched unrelated [OR, 3.19; 95% CI, 1.44-7.05; P = .0041], and those with GF (n = 41 [5.37%]; OR, 7.15; 95% CI, 4.20-12.18; P < .0001). Pain crisis was less frequent with KPS of ≥90 (OR, 0.31; 95% CI, 0.18-0.55; P < .0001). Multivariable logistic regression models confirmed age at HCT, KPS, graft type, donor type, history of VOC 2 years before HCT, and GF as independent predictors of pain crisis after HCT and generated predictive models and nomograms for pain crisis after HCT for SCD, which can support shared decision making.
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Affiliation(s)
- Lakshmanan Krishnamurti
- Section of Pediatric Hematology-Oncology and Stem Cell Transplantation, Yale School of Medicine, New Haven, CT
| | - Jingchen Liang
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Zili He
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Vineetha R. Nallagatla
- Section of Pediatric Hematology-Oncology and Stem Cell Transplantation, Yale School of Medicine, New Haven, CT
| | | | - Aron Flagg
- Section of Pediatric Hematology-Oncology and Stem Cell Transplantation, Yale School of Medicine, New Haven, CT
| | - Niketa Shah
- Section of Pediatric Hematology-Oncology and Stem Cell Transplantation, Yale School of Medicine, New Haven, CT
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Rostami T, Rad S, Rostami MR, Mirhosseini SA, Alemi H, Khavandgar N, Janbabai G, Kiumarsi A, Kasaeian A, Mousavi SA. Hematopoietic Stem Cell Transplantation in Sickle Cell Disease: A Multidimentional Review. Cell Transplant 2024; 33:9636897241246351. [PMID: 38680015 PMCID: PMC11057353 DOI: 10.1177/09636897241246351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/06/2024] [Accepted: 03/17/2024] [Indexed: 05/01/2024] Open
Abstract
While exagamglogene autotemcel (Casgevy) and lovotibeglogene autotemcel (Lyfgenia) have been approved by the US Food and Drug Administration (FDA) as the first cell-based gene therapies for the treatment of patients 12 years of age and older with sickle cell disease (SCD), this treatment is not universally accessible. Allogeneic hematopoietic stem cell transplant (HSCT) has the potential to eradicate the symptoms of patients with SCD, but a significant obstacle in HSCT for SCD is the availability of suitable donors, particularly human leukocyte antigen (HLA)-matched related donors. Furthermore, individuals with SCD face an elevated risk of complications during stem cell transplantation due to SCD-related tissue damage, endothelial activation, and inflammation. Therefore, it is imperative to consider optimal conditioning regimens and investigate HSCT from alternative donors. This review encompasses information on the use of HSCT in patients with SCD, including the indications for HSCT, conditioning regimens, alternative donors, and posttransplant outcomes.
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Affiliation(s)
- Tahereh Rostami
- Hematologic Malignancies Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Soroush Rad
- Hematology, Oncology and Stem Cell Transplantation Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Rostami
- Hematologic Malignancies Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seied Amirhossein Mirhosseini
- Department of Internal Medicine, School of Medicine, Imam Ali Hospital, Alborz University of Medical Sciences, Tehran, Iran
| | - Hediyeh Alemi
- Hematology, Oncology and Stem Cell Transplantation Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Digestive Oncology Research Center, Digestive Diseases Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Naghmeh Khavandgar
- Hematology, Oncology and Stem Cell Transplantation Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Digestive Oncology Research Center, Digestive Diseases Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghasem Janbabai
- Hematologic Malignancies Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Azadeh Kiumarsi
- Department of Pediatrics, School of Medicine, Childrens Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Kasaeian
- Hematology, Oncology and Stem Cell Transplantation Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Digestive Oncology Research Center, Digestive Diseases Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Clinical Research Development Unit, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seied Asadollah Mousavi
- Hematology, Oncology and Stem Cell Transplantation Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Cseh A, Galimard JE, de la Fuente J, Isgro A, Zecca M, Garwer B, Biffi A, Aljurf M, Sundin M, Belendez C, Locatelli F, Balduzzi A, Lawson S, Sengeloev H, Ifversen M, Saccardi R, Wynn R, Lankester AC, Corbacioglu S, Peters C. Busulfan-fludarabine- or treosulfan-fludarabine-based conditioning before allogeneic HSCT from matched sibling donors in paediatric patients with sickle cell disease: A study on behalf of the EBMT Paediatric Diseases and Inborn Errors Working Parties. Br J Haematol 2024; 204:e1-e5. [PMID: 37795523 DOI: 10.1111/bjh.19122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 09/07/2023] [Accepted: 09/12/2023] [Indexed: 10/06/2023]
Abstract
How important is choice of conditioning regimen in allogeneic haematopoietic stem cell transplantation (HSCT) for sickle cell disease (SCD)? We compared HSCT outcomes by conditioning regimen in paediatric patients with SCD from the EBMT registry. In 2010-2020, 251 patients aged <18 years underwent a first matched sibling donor (MSD) HSCT with conditioning based on busulfan-fludarabine (bu-flu; n = 89) or treosulfan-fludarabine (treo-flu; n = 162). In the bu-flu and treo-flu groups, 51.7% and 99.4% of patients, respectively, received thiotepa. Median follow-up was 2.7 years. Two-year overall survival (OS) was 98.7% (95% confidence interval [CI]: 90.9-99.8) with bu-flu and 99.3% (95% CI: 95.2-99.9) with treo-flu (p = 0.63). Grade III-IV acute graft-versus-host disease (GVHD) at 100 days was 2.4% (95% CI: 0.4-7.5) and 0.6% (0.1%-3.2%) for bu-flu and treo-flu respectively (p = 0.25). The 2-year incidence of extensive chronic GVHD was 1.5% (95% CI: 0.1-7.3) with bu-flu and 8.0% (95% CI: 4.1-13.3) with treo-flu (p = 0.057). These multinational data confirm the excellent curative capacity of MSD HSCT with myeloablative conditioning. Both conditioning regimens yielded excellent OS, low rates of acute and chronic GVHD, and low rates of graft failure.
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Affiliation(s)
- Annamária Cseh
- St. Anna Children's Cancer Research Institute, Vienna, Austria
| | | | - Josu de la Fuente
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, England
| | | | - Marco Zecca
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Padua University and Hospital, Padova, Italy
| | - Birgit Garwer
- Bone Marrow Transplantation Centre, University Hospital Eppendorf, Hamburg, Germany
| | - Alexandra Biffi
- Dipartimento di Pediatria, Clinica di Oncoematologia Pediatrica, Padova, Italy
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mikael Sundin
- Paediatric Haematology, Karolinska University Hospital Children's Hospital, Stockholm, Sweden
| | - Cristina Belendez
- Oncohematologia Pediatrica, Hospital Universitario Materno Infantil Gregorio Marañon, Madrid, Spain
| | | | - Adriana Balduzzi
- Centro Trapianti di Midollo Osseo Clinica Pediatrica, Università di Milano Bicocca Ospedale San Gerardo Monza, Monza, Italy
| | - Sarah Lawson
- Department of Haematology, Birmingham Children's Hospital, Birmingham, UK
| | | | | | | | - Robert Wynn
- Department of Paediatric Haematology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Arjan C Lankester
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Regensburg, Germany
| | - Christina Peters
- St. Anna Children's Cancer Research Institute, Vienna, Austria
- St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
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6
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Rotin LE, Viswabandya A, Kumar R, Patriquin CJ, Kuo KHM. A systematic review comparing allogeneic hematopoietic stem cell transplant to gene therapy in sickle cell disease. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2023; 28:2163357. [PMID: 36728286 DOI: 10.1080/16078454.2022.2163357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Allogeneic hematopoietic stem cell transplant (HSCT) and gene therapy (GT) are two potentially curative approaches for sickle cell disease (SCD), but they have never been compared in clinical trials. OBJECTIVE To compare the safety and efficacy of HSCT and GT to assist clinicians and patients in making informed treatment decisions. METHODS Phase I-III clinical trials and case reports/series were included. Regimens included HSCT from all stem cell sources, lentiviral gene therapy, and gene editing, with any conditioning regimen. We searched Medline and EMBASE databases as of 1st June 2020 for studies reporting HSCT and GT outcomes in SCD. The Newcastle-Ottawa scale was used to assess the risk of bias. Descriptive statistics and post-hoc imputation for standard deviations of mean change in FEV1 and FVC were performed. RESULTS In total, 56 studies (HSCT, n = 53; GT, n = 3) representing 1,198 patients met inclusion criteria (HSCT, n = 1,158; GT, n = 40). Length of follow-up was 3,881.5 and 58.7 patient-years for HSCT and GT, respectively. Overall quality of evidence was low, with no randomized controlled trials identified. Two-year overall survival for HSCT was 91%; mortality was 2.5% for GT. Acute chest syndrome and vaso-occlusive episodes were reduced post-HSCT and GT. Meta-analysis was not possible due to lack of comparator and heterogeneity in outcome measures reporting. Very few studies reported post-transplant end-organ function. Six secondary malignancies (5 post-HSCT, 1 post-GT) were reported. DISCUSSION Reporting of SCD-related complications and patient-important outcomes is lacking for both strategies. We advocate for standardized reporting to better compare outcomes within and between treatment groups.
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Affiliation(s)
- Lianne E Rotin
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Canada.,Division of Hematology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Auro Viswabandya
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, Canada.,Messner Allogeneic Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Rajat Kumar
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, Canada.,Messner Allogeneic Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Christopher J Patriquin
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, Canada.,Division of Medical Oncology and Hematology, Department of Medicine, University Health Network, Toronto, Canada
| | - Kevin H M Kuo
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, Canada.,Division of Medical Oncology and Hematology, Department of Medicine, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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7
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Vallée T, Schmid I, Gloning L, Bacova M, Ahrens J, Feuchtinger T, Klein C, Gaertner VD, Albert MH. Excellent outcome of stem cell transplantation for sickle cell disease. Ann Hematol 2023; 102:3217-3227. [PMID: 37726493 PMCID: PMC10567813 DOI: 10.1007/s00277-023-05447-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
Many sickle cell disease (SCD) patients lack matched family donors (MFD) or matched unrelated donors (MUD), implying haploidentical donors (MMFD) as a logical donor choice. We used a reduced toxicity protocol for all donor types. We included 31 patients (2-22 years) with MFD (n = 15), MMFD (10), or MUD (6) HSCT and conditioning with alemtuzumab/ATG, thiotepa, fludarabine and treosulfan, and post-transplant cyclophosphamide for MMFD. After the initial six patients, treosulfan was replaced by targeted busulfan (AUC 65-75 ng*h/ml). After a median follow-up of 26 months (6-123), all patients are alive and off immunosuppression. Two MMFD patients experienced secondary graft failure with recurrence of SCD, both after treosulfan conditioning. Neither acute GVHD ≥ °III nor moderate/severe chronic GVHD was observed. The disease-free, severe GVHD-free survival was 100%, 100%, and 80% in the MFD, MUD, and MMFD groups, respectively (p = 0.106). There was a higher rate of virus reactivation in MMFD (100%) and MUD (83%) compared to MFD (40%; p = 0.005), but not of viral disease (20% vs 33% vs 13%; p = 0.576). Six patients had treosulfan-based conditioning, two of whom experienced graft failure (33%), compared to 0/25 (0%) after busulfan-based conditioning (p = 0.032). Donor chimerism was ≥ 80% in 28/31 patients (90%) at last follow-up. Reduced toxicity myeloablative conditioning resulted in excellent overall survival, negligible GVHD, and low toxicity among all donor groups in pediatric and young adult patients with SCD.
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Affiliation(s)
- Tanja Vallée
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Irene Schmid
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Lisa Gloning
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Martina Bacova
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Jutta Ahrens
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Tobias Feuchtinger
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Christoph Klein
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Vincent D Gaertner
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Michael H Albert
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany.
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8
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Shah NC, Rangarajan HG, Ngwube A, Shenoy S. Mixed donor chimerism following stem cell transplantation for sickle cell disease. Curr Opin Hematol 2023; 30:187-193. [PMID: 37694765 DOI: 10.1097/moh.0000000000000786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Sickle cell disease is a debilitating hemoglobinopathy with high morbidity and mortality. Hematopoietic stem cell transplantation (HCT) is curative, but the presence of mixed donor/recipient chimerism post-HCT raises concerns about disease control long-term. Mixed donor/recipient chimerism is reported in significant numbers even after aggressive HCT conditioning regimens. Post-HCT, adequacy of donor erythropoiesis is crucial for disease control. This review explores the relationship between mixed donor/recipient chimerism and outcomes post-HCT. Serial chimerism analysis in lineage specific manner in erythroid or myeloid cells post-HCT predicts for disease control and HCT success. Adequate and stable donor-derived erythropoiesis is essential for reversing SCD manifestations. Myeloid lineage chimerism mirrors erythropoiesis is commercially available, and a reliable indicator of adequacy. Using this tool, the minimum threshold of donor chimerism is required to prevent SCD-related complications and maintain sickle hemoglobin less than 50% is approximately 20-25% even when a donor has Hb S trait. Curative interventions should, at a minimum, meet this goal long-term. Achieving a balance between successful engraftment while minimizing toxicity is important in patients vulnerable because of age or preexisting morbidity and is the objective of recent clinical trials. As HCT and gene therapies evolve, efficient long-term follow-up that includes durability assessment of mixed donor/recipient chimerism will be crucial.
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Affiliation(s)
- Niketa C Shah
- Section of Pediatric Hematology/Oncology and Stem cell Transplant, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Hemalatha G Rangarajan
- Division of Pediatric Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
| | - Alexander Ngwube
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona
| | - Shalini Shenoy
- Division of Pediatric Hematology Oncology, Washington University, St. Louis, Missouri. USA
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9
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Bakshi N, Liu Z, Gillespie S, Keesari R, Leake D, Khemani K, Kumari P, Rees CA, Dampier C, Morris CR. Patient-reported outcomes in children with sickle cell disease at presentation for an acute pain episode. Blood Adv 2023; 7:5103-5107. [PMID: 36322873 PMCID: PMC10477437 DOI: 10.1182/bloodadvances.2021006794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 09/14/2022] [Accepted: 09/19/2022] [Indexed: 06/16/2023] Open
Affiliation(s)
- Nitya Bakshi
- Division of Pediatric Hematology-Oncology-Blood and Marrow Transplant, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Aflac Cancer and Blood Disorders, Children's Healthcare of Atlanta, Atlanta, GA
| | - Zihao Liu
- Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - Rohali Keesari
- Pediatric Biostatistics Core, Emory University, Atlanta, GA
| | | | - Kirshma Khemani
- Division of Pediatric Hematology-Oncology-Blood and Marrow Transplant, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Aflac Cancer and Blood Disorders, Children's Healthcare of Atlanta, Atlanta, GA
| | - Polly Kumari
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Chris A. Rees
- Children’s Healthcare of Atlanta, Atlanta, GA
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Carlton Dampier
- Division of Pediatric Hematology-Oncology-Blood and Marrow Transplant, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Aflac Cancer and Blood Disorders, Children's Healthcare of Atlanta, Atlanta, GA
| | - Claudia R. Morris
- Children’s Healthcare of Atlanta, Atlanta, GA
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
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10
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Inam Z, Tisdale JF, Leonard A. Outcomes and long-term effects of hematopoietic stem cell transplant in sickle cell disease. Expert Rev Hematol 2023; 16:879-903. [PMID: 37800996 DOI: 10.1080/17474086.2023.2268271] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Hematopoietic stem cell transplant (HSCT) is the only readily available curative option for sickle cell disease (SCD). Cure rates following human leukocyte antigen (HLA)-matched related donor HSCT with myeloablative or non-myeloablative conditioning are >90%. Alternative donor sources, including haploidentical donor and autologous with gene therapy, expand donor options but are limited by inferior outcomes, limited data, and/or shorter follow-up and therefore remain experimental. AREAS COVERED Outcomes are improving with time, with donor type and conditioning regimens having the greatest impact on long-term complications. Patients with stable donor engraftment do not experience SCD-related symptoms and have stabilization or improvement of end-organ pathology; however, the long-term effects of curative strategies remain to be fully established and have significant implications in a patient's decision to seek therapy. This review covers currently published literature on HSCT outcomes, including organ-specific outcomes implicated in SCD, as well as long-term effects. EXPERT OPINION HSCT, both allogeneic and autologous gene therapy, in the SCD population reverses the sickle phenotype, prevents further organ damage, can resolve prior organ dysfunction in both pediatric and adult patients. Data support greater success with HSCT at a younger age, thus, curative therapies should be discussed early in the patient's life.
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Affiliation(s)
- Zaina Inam
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
- Center for Cancer and Blood Disorders, Children's National Hospital, Washington, DC, USA
| | - John F Tisdale
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alexis Leonard
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, USA
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11
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Hussain MS, Chaturvedi V. The Present Condition of Sickle Cell Disease: An Overview of Stem Cell Transplantation as a Cure. PHARMACEUTICAL FRONTS 2023; 05:e57-e63. [DOI: 10.1055/s-0043-1768918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024] Open
Abstract
AbstractTreatment of sickle cell disease (SCD) remains largely palliative. While it can enhance living standards, persons having SCD still suffer from extreme sickling crises, end-organ destruction, and reduced life expectancy. Increasing research has resulted in the recognition and advancement of stem cell transplantation and gene therapy as possible solutions for SCDs. However, there have been various factors that have hindered their clinical application. The more advantageous of the two, stem cell transplantation, is constrained by a small donor pool, transplant difficulties, and eligibility requirements. The current article reviewed the literature on SCDs, current treatment options, and more particularly the progress of stem cell transplants. It outlined various challenges of stem cell transplant and proposed ways to increase the donor pool using alternative strategies and modifications of regimen conditioning with minimal transplant-related toxicities and associated complications.
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Affiliation(s)
- Md. Sadique Hussain
- School of Pharmaceutical Sciences, Jaipur National University, Jaipur, Rajasthan, India
| | - Varunesh Chaturvedi
- School of Pharmaceutical Sciences, Jaipur National University, Jaipur, Rajasthan, India
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12
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Dovern E, Nijland SJAM, van Muilekom MM, Suijk LMJ, Hoogendoorn GM, Mekelenkamp H, Biemond BJ, Haverman L, Nur E. Physical, Mental, and Social Health of Adult Patients with Sickle Cell Disease after Allogeneic Hematopoietic Stem Cell Transplantation: A Mixed-Methods Study. Transplant Cell Ther 2023; 29:283.e1-283.e9. [PMID: 36634737 DOI: 10.1016/j.jtct.2023.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/02/2023] [Accepted: 01/02/2023] [Indexed: 01/11/2023]
Abstract
Patients with sickle cell disease (SCD) experience a considerable physical and psychosocial disease burden. In recent years, the application of allogeneic hematopoietic stem cell transplantation (HSCT) to treat adults with SCD has increased. A thorough understanding of patients' physical, mental, and social health before and after cure is needed to meet the needs of this growing group of patients. We aimed to explore the perspectives of adult SCD patients on the changes in their experienced health and personal life goals after being cured. A mixed-methods approach was used, comprising a semistructured interview and a set of 9 Patient Reported Outcomes Measurement Information System (PROMIS) measures. Adult SCD patients who underwent HSCT at least 1 year earlier were eligible to participate in the study. Interviews were thematically analyzed using MAXQDA software. PROMIS T scores were compared with reference scores of the general population using SPSS Statistics. Ten patients participated in the study; their median age was 29.5 years (range, 19 to 49 years), and their median time since HSCT was 2.7 years (range, 1.0 to 3.5 years). Themes from the interviews were (1) pain/living pain free, (2) physical well-being, (3) mental well-being, (4) perspective/ outlook, (5) education/work, (6) family/friends, and (7) activities/participation. Following the PROMIS framework, we described these themes in a narrative synthesis according to health domain and categorized in 4 chronological time phases: before HSCT, first year post-transplantation, current situation, and future expectations. Physical health improved greatly, but transplantation-related toxicity, ongoing pain from avascular osteonecrosis, and fatigue negatively impacted quality of life in some patients. Furthermore, emotional struggles during the post-transplantation period were common, and patients expressed a need for psychological help. Patients reported improvements in social health and the ability to pursue personal life goals. The mean T scores of all PROMIS measures fell within the normal symptom limits compared with reference data of the general population, although, large variations were observed among the participants, matching our qualitative findings. In general, adult SCD patients experienced improved physical, mental, and social health after cure by HSCT and were able to pursue personal life goals. Yet they found themselves confronted with a new and unfamiliar reality that brought different challenges. Pain due to irreversible avascular osteonecrosis continued to have a negative impact. Clinicians should aim to help patients have realistic expectations before transplantation and offer timely psychological care.
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Affiliation(s)
- Elisabeth Dovern
- Department of Hematology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.
| | - Sterre J A M Nijland
- Department of Hematology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Maud M van Muilekom
- Department of Child and Adolescent Psychiatry & Psychosocial Care, Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Mental Health and Personalized Medicine, Amsterdam Public Health, Amsterdam, The Netherlands; Child Development, Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Liesbeth M J Suijk
- Department of Hematology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Gerianne M Hoogendoorn
- Department of Hematology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Hilda Mekelenkamp
- Division of Stem Cell Transplantation, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart J Biemond
- Department of Hematology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Lotte Haverman
- Department of Child and Adolescent Psychiatry & Psychosocial Care, Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Mental Health and Personalized Medicine, Amsterdam Public Health, Amsterdam, The Netherlands; Child Development, Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Erfan Nur
- Department of Hematology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands
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13
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Krishnamurti L, Neuberg D, Sullivan KM, Smith S, Eapen M, Walters MC. Enrollment Lessons from a Biological Assignment Study of Marrow Transplantation versus Standard Care for Adolescents and Young Adults with Sickle Cell Disease: Considerations for Future Gene and Cellular Therapy Trials. Transplant Cell Ther 2023; 29:217-221. [PMID: 36270432 PMCID: PMC10539686 DOI: 10.1016/j.jtct.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/19/2022] [Accepted: 10/10/2022] [Indexed: 11/12/2022]
Abstract
We previously conducted a single-arm feasibility study (STRIDE1) of myeloablative bone marrow transplantation (BMT) in adolescents and young adults with sickle cell disease (SCD). The trial identified donors before entry, enrolled well, and found no unexpected regimen-related toxicity. Although many single-arm studies have been published, there are no controlled trials of either BMT or gene therapy in SCD. Therefore, we designed a comparative trial by biological assignment (available donor versus no donor). This multicenter National Institutes of Health-funded study (Blood and Marrow Transplant Clinical Trials Network 1503; STRIDE2) enrolled patients between 2016 and 2021 at 35 sites. Lagging recruitment led to study closure, and here we report the impediments to accrual. The BMT regimen and entry criteria were from STRIDE1, and 2-year survival was the primary endpoint. To minimize selection bias from prior HLA typing, STRIDE2 excluded individuals with previously identified donors. Accrual was stopped at 69% of target (138 enrolled; assigned 28 with donor, 96 with no donor). Barriers to enrollment included lower than expected frequency of HLA-matched related and unrelated donors; loss of enrollees owing to previously identified donors; conventional care arm dissuading some seeking BMT; challenging short-term endpoints in SCD, including incomplete documentation of sickle pain episodes; state Medicaid (primary insurers of SCD) denial of BMT coverage for adult SCD despite the study having secured Coverage with Evidence Development from the Center for Medicare & Medicaid Services; slowed accrual in 2019 to 2021 during the Coronavirus disease 2019 pandemic; and restriction of BMT resourcing for nonmalignant diseases by academic medical (cancer) centers. Social obstacles and access to BMT centers also limited entry, as did practitioner and participant concerns over suitability, cost, and toxicity. Planning for future controlled trials of curative therapy in SCD and other nonmalignant diseases likely will meet these enrollment challenges. Lessons from this trial may aid the development of future comparative studies.
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Affiliation(s)
- Lakshmanan Krishnamurti
- Section of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut; Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.
| | | | | | - Shannon Smith
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Mary Eapen
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mark C Walters
- Department of Pediatrics, UCSF Benioff Children's Hospital, Oakland, California
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14
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Bakshi N, Astles R, Chou E, Hurreh A, Sil S, Sinha CB, Sanders KA, Peddineni M, Gillespie SE, Keesari R, Krishnamurti L. Multimodal phenotyping and correlates of pain following hematopoietic cell transplant in children with sickle cell disease. Pediatr Blood Cancer 2023; 70:e30046. [PMID: 36322607 PMCID: PMC9820671 DOI: 10.1002/pbc.30046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/24/2022] [Accepted: 09/19/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION There is limited understanding of pain, patient-reported outcomes (PROs) of health-related quality of life (HRQoL), psychological factors, and experimental pain sensitivity before and following hematopoietic cell transplant (HCT) in children with sickle cell disease (SCD). METHODS Individuals aged 8 years and older, English speaking, and scheduled for a HCT were invited to participate in an observational study where they completed assessments of pain, PROs, psychological factors, and qualitative interviews before and around 3 months, 6 months, 1 year, and 2 years post-HCT. An optional substudy of experimental pain sensitivity before and around 6 month, 1 year, and 2 years post-HCT was also offered. RESULTS Data from eight participants (median age 13.5 years, 25% female) with sickle cell anemia (SCA) or similarly severe genotype, and successful donor-derived erythropoiesis post-HCT are reported. We found that collection of pain, PROs, psychological factors, and qualitative data were feasible in the context of HCT. We found moderate to large differences in pain and some PROs between baseline to 1 year and baseline to 2 year post-HCT based on effect sizes, but only some differences were statistically significant. We found moderate to large differences in pressure pain threshold and moderate differences in cold pain threshold between baseline to 1 year and baseline to 2 year post-HCT based on effect sizes, but these differences were not statistically significant. Qualitative data indicated an improvement in pain and HRQoL post-HCT. CONCLUSION This study provides a framework for the conduct of multimodal pain assessments before and after HCT, which is feasible but faced with unique barriers.
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Affiliation(s)
- Nitya Bakshi
- Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Rachel Astles
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Eric Chou
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Asha Hurreh
- James T. Laney School of Graduate Studies, Emory University, Atlanta, Georgia, USA
| | - Soumitri Sil
- Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Cynthia B Sinha
- Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kolanda Ackey Sanders
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Manasa Peddineni
- Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida, USA
| | - Scott E Gillespie
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Rohali Keesari
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Lakshmanan Krishnamurti
- Division of Pediatric Hematology-Oncology-BMT, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
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15
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Light J, Boucher M, Baskin-Miller J, Winstead M. Managing the Cerebrovascular Complications of Sickle Cell Disease: Current Perspectives. J Blood Med 2023; 14:279-293. [PMID: 37082003 PMCID: PMC10112470 DOI: 10.2147/jbm.s383472] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/31/2023] [Indexed: 04/22/2023] Open
Abstract
The importance of protecting brain function for people with sickle cell disease (SCD) cannot be overstated. SCD is associated with multiple cerebrovascular complications that threaten neurocognitive function and life. Without screening and preventive management, 11% of children at 24% of adults with SCD have ischemic or hemorrhagic strokes. Stroke screening in children with SCD is well-established using transcranial Doppler ultrasound (TCD). TCD velocities above 200 cm/s significantly increase the risk of stroke, which can be prevented using chronic red blood cell (RBC) transfusion. RBC transfusion is also the cornerstone of acute stroke management and secondary stroke prevention. Chronic transfusion requires long-term management of complications like iron overload. Hydroxyurea can replace chronic transfusions for primary stroke prevention in a select group of patients or in populations where chronic transfusions are not feasible. Silent cerebral infarction (SCI) is even more common than stroke, affecting 39% of children and more than 50% of adults with SCD; management of SCI is individualized and includes careful neurocognitive evaluation. Hematopoietic stem cell transplant prevents cerebrovascular complications, despite the short- and long-term risks. Newer disease-modifying agents like voxelotor and crizanlizumab, as well as gene therapy, may treat cerebrovascular complications, but these approaches are investigational.
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Affiliation(s)
- Jennifer Light
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria Boucher
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jacquelyn Baskin-Miller
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mike Winstead
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Correspondence: Mike Winstead, Division of Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC, USA, Tel +1 919-966-1178, Fax +1 919-966-7629, Email
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16
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Hulbert ML, King AA, Shenoy S. Organ function indications and potential improvements following curative therapy for sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:277-282. [PMID: 36485131 PMCID: PMC9820741 DOI: 10.1182/hematology.2022000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Curative therapies for sickle cell disease include allogeneic hematopoietic stem cell transplantation (HSCT) and gene-modified autologous stem cell transplantation. HSCT has been used for 30 years with success measured by engraftment, symptom control, graft-vs-host disease (GVHD) risk, organ toxicity, and immune reconstitution. While human leukocyte antigen-matched sibling donor (MSD) transplants have excellent outcomes, alternate donor transplants (unrelated/haploidentical) are just beginning to overcome GVHD and engraftment hurdles to match MSD. Gene therapy, a newly developed treatment, is undergoing careful evaluation in many trials with varying approaches. The risk/benefit ratio to the patient in relation to outcomes, toxicities, and mortality risk drives eligibility for curative interventions. Consequently, eligibility criteria for MSD transplants can be less stringent, especially in the young. Posttransplant outcome analysis after the "cure" with respect to organ function recovery is essential. While established damage such as stroke is irreversible, transplant can help stabilize (pulmonary function), prevent further deterioration (stroke), improve (neurocognition), and protect unaffected organs. Tracking organ functions postintervention uniformly between clinical trials and for adequate duration is essential to answer safety and efficacy questions related to curative therapies. Age-appropriate application/outcome analyses of such therapies will be the ultimate goal in overcoming this disease.
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17
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Lawal RA, Walters MC, Fitzhugh CD. Allogeneic Transplant and Gene Therapy: Evolving Toward a Cure. Hematol Oncol Clin North Am 2022; 36:1313-1335. [PMID: 36400545 PMCID: PMC9681017 DOI: 10.1016/j.hoc.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Curative therapies for sickle cell disease (SCD) include allogeneic human leukocyte antigen (HLA)- matched sibling and haploidentical hematopoietic cell transplant (HCT), gene therapy, and gene editing. However, comparative trial data that might facilitate selecting one curative therapy over another are unavailable. New strategies to decrease graft rejection and graft-versus-host disease (GVHD) risks are needed to expand haploidentical HCT. Myeloablative gene therapy and gene editing also has limitations. Herein, we review recent studies on curative therapies for SCD in the past 5 years.
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Affiliation(s)
- R AdeBisi Lawal
- Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room 4-5140, Bethesda, MD 20892, USA; Hematology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark C Walters
- University of California San Francisco Benioff Children's Hospital, 747 52nd Street, Oakland CA 94609, USA
| | - Courtney D Fitzhugh
- Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room 6N240A, Bethesda, MD 20892, USA.
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18
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Flor-Park MV, Ozahata MC, Moura ICG, Blatyta P, Kelly S, Oliveira CDL, Capuani L, Belisário AR, Carneiro-Proietti ABF, Araujo AS, Loureiro P, Maximo C, Rodrigues DOW, Mota RA, Sabino E, Custer B, Rocha V. Is Severity Score Associated With Indication for Hematopoietic Stem Cell Transplantation in Individuals With Sickle Cell Anemia? Transplant Cell Ther 2022; 28:708.e1-708.e8. [PMID: 35788087 PMCID: PMC10979754 DOI: 10.1016/j.jtct.2022.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/08/2022] [Accepted: 06/26/2022] [Indexed: 10/16/2022]
Abstract
Manifestations of sickle cell disease (SCD) begin early in childhood and cause morbidity and decreased life expectancy. Hematopoietic stem cell transplantation (HSCT) is curative but associated with risk of mortality attributable to the transplant. This risk should be counterbalanced with SCD morbidity and mortality. A severity score using a Bayesian network model was previously validated to predict the risk of death in adult individuals with SCD. The objective of this study is to calculate the severity scores of participants in a multicenter cohort of Brazilians with SCD, using a previously published Bayesian network-derived score, associated with risk of death and then compare the severity scores between participants with and without an indication for HSCT as defined by the Brazilian Ministry of Health (MoH) criteria. This is an observational, retrospective study. We analyzed 2063 individuals with sickle cell anemia from the Recipient Epidemiology and Donor Evaluation Study-III Brazil SCD cohort and applied a Bayesian network-derived score to compare candidates and non-candidates for HSCT according to the Brazilian MoH transplant criteria. Classical statistical methods were used to analyze data and make comparisons. We compared severity scores between cohort members with (n = 431) and without (n = 1632) HSCT indications according to Brazilian MoH. Scores were not different in adult participants with ≥1 HSCT indication when compared to those with no indication (mean 0.342 versus 0.292; median 0.194 versus 0.183, P = .354) and receiver operating characteristic curves did not demonstrate an obvious threshold to differentiate participants with or without HSCT indications. Severity score may predict risk of death but does not differentiate HSCT candidates. Current indications should be evaluated to ensure that patients with more severe disease who might benefit from HSCT are appropriately identified.
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Affiliation(s)
- Miriam V Flor-Park
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Instituto da Criança, São Paulo, Brazil.
| | | | | | | | - Shannon Kelly
- Vitalant Research Institute, Epidemiology, San Francisco, California; University of California San Francisco Benioff Children's Hospital, Oakland, California
| | | | - Ligia Capuani
- Departamento de Moléstias Infecciosas e Parasitárias da Faculdade de medicina da Universidade de São Paulo, Brazil
| | | | | | - Aderson S Araujo
- Department of Hematology, Fundação de Hematologia e Hemoterapia de Pernambuco, HEMOPE, Pernambuco, Brazil
| | - Paula Loureiro
- Research Department, Fundação de Hematologia e Hemoterapia de Pernambuco, HEMOPE, Pernambuco, Brazil; Research Department, Universidade de Pernambuco, Pernambuco, Brazil
| | - Claudia Maximo
- Department of Hematology, Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti-HEMORIO, Rio de Janeiro, Brazil
| | | | - Rosimere A Mota
- Department of Hematology, Hemocentro Regional de Montes Claros, Fundação HEMOMINAS, Montes Claros, Brazil
| | - Ester Sabino
- Instituto de Medicina Tropical and Departamento de Moléstias Infecciosas e Parasitárias da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Brian Custer
- Vitalant Research Institute, Epidemiology, San Francisco, California; Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Vanderson Rocha
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Serviço de Hematologia, Hemoterapia e Terapia Celular, São Paulo, Brazil; Laboratory of Medical Investigation (LIM 31) in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Department of Haematology, University of Oxford, Churchill Hospital, Oxford, United Kingdom
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19
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Treadwell MJ, Du L, Bhasin N, Marsh AM, Wun T, Bender MA, Wong TE, Crook N, Chung JH, Norman S, Camilo N, Cavazos J, Nugent D. Barriers to hydroxyurea use from the perspectives of providers, individuals with sickle cell disease, and families: Report from a U.S. regional collaborative. Front Genet 2022; 13:921432. [PMID: 36092883 PMCID: PMC9461276 DOI: 10.3389/fgene.2022.921432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Sickle cell disease (SCD) is an inherited blood disorder that affects about 100,000 people in the U.S., primarily Blacks/African-Americans. A multitude of complications negatively impacts quality of life. Hydroxyurea has been FDA approved since 1998 as a disease-modifying therapy for SCD, but is underutilized. Negative and uninformed perceptions of hydroxyurea and barriers to its use hinder adherence and promotion of the medication. As the largest real-world study to date that assessed hydroxyurea use for children and adults with SCD, we gathered and analyzed perspectives of providers, individuals with SCD, and families. Participants provided information about socio-demographics, hospital and emergency admissions for pain, number of severe pain episodes interfering with daily activities, medication adherence, and barriers to hydroxyurea. Providers reported on indications for hydroxyurea, reasons not prescribed, and current laboratory values. We found that hydroxyurea use was reported in over half of eligible patients from this large geographic region in the U.S., representing a range of sickle cell specialty clinical settings and practices. Provider and patient/caregiver reports about hydroxyurea use were consistent with one another; adults 26 years and older were least likely to be on hydroxyurea; and the likelihood of being on hydroxyurea decreased with one or more barriers. Using the intentional and unintentional medication nonadherence framework, we found that, even for patients on hydroxyurea, challenges to taking the medicine at the right time and forgetting were crucial unintentional barriers to adherence. Intentional barriers such as worry about side effects and “tried and it did not work” were important barriers for young adults and adults. For providers, diagnoses other than HgbSS or HgbS-β0 thalassemia were associated with lower odds of prescribing, consistent with evidence-based guidelines. Our results support strengthening provider understanding and confidence in implementing existing SCD guidelines, and the importance of shared decision making. Our findings can assist providers in understanding choices and decisions of families; guide individualized clinical discussions regarding hydroxyurea therapy; and help with developing tailored interventions to address barriers. Addressing barriers to hydroxyurea use can inform strategies to minimize similar barriers in the use of emerging and combination therapies for SCD.
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Affiliation(s)
- Marsha J. Treadwell
- Division of Hematology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA, United States
- *Correspondence: Marsha J. Treadwell,
| | - Lisa Du
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA, United States
| | - Neha Bhasin
- Division of Hematology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA, United States
| | - Anne M. Marsh
- Division of Hematology/Oncology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Theodore Wun
- Division of Hematology and Oncology, Department of Internal Medicine, University of California, Davis, Davis, CA, United States
| | - M. A. Bender
- Odessa Brown Children’s Clinic, Seattle Children’s Hospital, Seattle, WA, United States
| | - Trisha E. Wong
- Division of Pediatric Hematology and Oncology and Department of Pathology, Oregon Health and Sciences University, Portland, OR, United States
| | - Nicole Crook
- Center for Inherited Blood Disorders, Orange, CA, United States
| | - Jong H. Chung
- Hematology-Oncology, Department of Pediatrics, University of California, Davis, Davis, CA, United States
| | - Shannon Norman
- Alaska Bleeding Disorders Clinic, Anchorage, AK, United States
| | - Nicolas Camilo
- St. Luke’s Children’s Cancer Institute, Boise, ID, United States
| | - Judith Cavazos
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA, United States
| | - Diane Nugent
- Center for Inherited Blood Disorders, Orange, CA, United States
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20
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Ezenwa MO, Yao Y, Mandernach MW, Fedele DA, Lucero RJ, Corless I, Dyal BW, Belkin MH, Rohatgi A, Wilkie DJ. A Stress and Pain Self-management mHealth App for Adult Outpatients With Sickle Cell Disease: Protocol for a Randomized Controlled Study. JMIR Res Protoc 2022; 11:e33818. [PMID: 35904878 PMCID: PMC9377464 DOI: 10.2196/33818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 03/16/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This paper describes the research protocol for a randomized controlled trial of a self-management intervention for adults diagnosed with sickle cell disease (SCD). People living with SCD experience lifelong recurrent episodes of acute and chronic pain, which are exacerbated by stress. OBJECTIVE This study aims to decrease stress and improve SCD pain control with reduced opioid use through an intervention with self-management relaxation exercises, named You Cope, We Support (YCWS). Building on our previous findings from formative studies, this study is designed to test the efficacy of YCWS on stress intensity, pain intensity, and opioid use in adults with SCD. METHODS A randomized controlled trial of the short-term (8 weeks) and long-term (6 months) effects of YCWS on stress, pain, and opioid use will be conducted with 170 adults with SCD. Patients will be randomized based on 1:1 ratio (stratified on pain intensity [≤5 or >5]) to be either in the experimental (self-monitoring of outcomes, alerts or reminders, and use of YCWS [relaxation and distraction exercises and support]) or control (self-monitoring of outcomes and alerts or reminders) group. Patients will be asked to report outcomes daily. During weeks 1 to 8, patients in both groups will receive system-generated alerts or reminders via phone call, text, or email to facilitate data entry (both groups) and intervention use support (experimental). If the participant does not enter data after 24 hours, the study support staff will contact them for data entry troubleshooting (both groups) and YCWS use (experimental). We will time stamp and track patients' web-based activities to understand the study context and conduct exit interviews on the acceptability of system-generated and staff support. This study was approved by our institutional review board. RESULTS This study was funded by the National Institute of Nursing Research of the National Institutes of Health in 2020. The study began in March 2021 and will be completed in June 2025. As of April 2022, we have enrolled 45.9% (78/170) of patients. We will analyze the data using mixed effects regression models (short term and long term) to account for the repeated measurements over time and use machine learning to construct and evaluate prediction models. Owing to the COVID-19 pandemic, the study was modified to allow for mail-in consent process, internet-based consent process via email or Zoom videoconference, devices delivered by FedEx, and training via Zoom videoconference. CONCLUSIONS We expect the intervention group to report reductions in pain intensity (primary outcome; 0-10 scale) and in stress intensity (0-10 scale) and opioid use (Wisepill event medication monitoring system), which are secondary outcomes. Our study will contribute to advancing the use of nonopioid therapy such as guided relaxation and distraction techniques for managing SCD pain. TRIAL REGISTRATION ClinicalTrials.gov NCT04484272; https://clinicaltrials.gov/ct2/show/NCT04484272. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/33818.
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Affiliation(s)
- Miriam O Ezenwa
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, FL, United States
| | - Yingwei Yao
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, FL, United States
| | - Molly W Mandernach
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL, United States
| | - David A Fedele
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States
| | - Robert J Lucero
- Diversity, Equity, and Inclusion, UCLA School of Nursing, Los Angeles, CA, United States
- Department of Family, Community, and Health System Science, University of Florida College of Nursing, Gainesville, FL, United States
| | - Inge Corless
- School of Nursing, MGH Institute of Health Profressions, Boston, MA, United States
| | - Brenda W Dyal
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, FL, United States
| | - Mary H Belkin
- College of Medicine, University of Florida-Jacksonville, Jacksonville, FL, United States
| | - Abhinav Rohatgi
- College of Medicine, University of Florida-Jacksonville, Jacksonville, FL, United States
| | - Diana J Wilkie
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, FL, United States
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21
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Across the Myeloablative Spectrum: Hematopoietic Cell Transplant Conditioning Regimens for Pediatric Patients with Sickle Cell Disease. J Clin Med 2022; 11:jcm11133856. [PMID: 35807140 PMCID: PMC9267729 DOI: 10.3390/jcm11133856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 11/16/2022] Open
Abstract
One out of every five hundred African American children in the United States has sickle cell disease (SCD). While multiple disease-modifying therapies are available, hematopoietic cell transplantation (HCT) remains the only curative option for children with SCD. HLA-matched sibling HCT has demonstrated excellent efficacy, but its availability remains limited; alternative donor strategies are increasingly explored. While Busulfan-Cyclophosphamide has become the most widespread conditioning regimen employed in HCT for pediatric SCD, many other regimens have been examined. This review explores different conditioning regimens across the intensity spectrum: from myeloablative to non-myeloablative. We describe survival and organ function outcomes in pediatric SCD patients who have received HCT and discuss the strengths and weaknesses of the various conditioning intensities. Finally, we posit novel directions in allogeneic HCT for SCD.
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22
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Reduction in Prevalence of Thrombotic Events in Sickle Cell Disease after Allogeneic Hematopoietic Transplantation. Transplant Cell Ther 2022; 28:277.e1-277.e6. [PMID: 35181561 DOI: 10.1016/j.jtct.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 11/21/2022]
Abstract
Thrombosis is a recognized complication in sickle cell disease (SCD). Allogeneic hematopoietic cell transplantation (allo-HCT) remains the only curative options for patients with severe SCD phenotypes. There is limited data describing the effects of allo-HCT on recurrent thrombotic events (venous and arterial events). We evaluated 31 patients with SCD who have undergone allo-HCT with a median follow up of 34.5 months (range:13-115) post-transplant. No patient continued anticoagulation or anti-platelets after allo-HCT. There was an absolute difference of 32% [95% CI=12.3-32.2, p=0.002] in the prevalence of venous thromboembolic (VTE) events before and after allo-HSCT. In addition, there was an absolute 38.5% [95% CI=10.63-45.96, p=0.006] difference in the number of ischemic cerebrovascular accidents (CVA) before and after allo-HSCT. Patients with severe SCD who undergo allo-HCT are less likely to develop recurrent thrombotic events OR 0.22 [95% CI=0.058 - 0.83, p=0.025] when compared to a control cohort of patients matched for age and genotype. Following curative therapy with allo-HCT, there is a reduction in recurrent arterial and venous thrombosis in patients with severe SCD phenotypes.
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23
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Shah NC, Bhoopatiraju S, Abraham A, Anderson E, Andreansky M, Bhatia M, Chaudhury S, Cuvelier GDE, Godder K, Grimley M, Hale G, Kamani N, Jacobsohn D, Ngwube A, Gilman AL, Skiles J, Yu LC, Shenoy S. Granulocyte Colony-Stimulating Factor is Safe and Well Tolerated following Allogeneic Transplantation in Patients with Sickle Cell Disease. Transplant Cell Ther 2021; 28:174.e1-174.e5. [PMID: 34958973 DOI: 10.1016/j.jtct.2021.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 10/19/2022]
Abstract
Granulocyte colony-stimulating factor (G-CSF) used after hematopoietic stem cell transplantation (HSCT) can enhance neutrophil recovery in patients rendered neutropenic by the preparative regimen. G-CSF is contraindicated in patients with sickle cell disease (SCD) as life-threatening complications can ensue in the presence of sickle vasculopathy. However, the safety profile of G-CSF after HSCT for SCD has not been previously described. We report clinical outcomes in the first 100 days post-HSCT in patients supported with G-CSF until neutrophil recovery on a clinical trial of reduced intensity transplantation for SCD. Patients (n=62) received G-CSF for a median of 9 days (range, 5-33) following transplant from the best available stem cell source. Preparation for transplant included a target hemoglobin S level of ≤45%. Neutrophil engraftment (ANC >0.5 × 103/mL) was achieved at a median of 13 days (range,10-34) and platelet engraftment (>50 × 103/mL) at a median of 19 days (range, 12-71). The median duration of inpatient hospitalization following stem cell infusion (day 0) was 21.5 days (range 11-33). No patient developed SCD related complications following G-CSF use. The most common organ toxicities encountered between G-CSF commencement (on day +7) and day +100 were anorexia (14), hypertension (11) and electrolyte imbalance requiring correction (9). Central nervous system related events were noted in 5 patients, all with pre-existing cerebral vasculopathy/moyamoya disease and attributed to reversible posterior leukoencephalopathy syndrome (RPLS) in the presence of calcineurin inhibitor therapy and hypertension. We conclude that G-CSF does not adversely impact SCD transplant recipients and can be safely used post-HSCT to enhance neutrophil recovery.
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Affiliation(s)
| | | | | | | | | | | | | | - Geoff D E Cuvelier
- Manitoba Blood and Marrow Transplant Program, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | | | | | | | | | | | | | | | | | - Lolie C Yu
- Children's Hospital/LSUHSC, New Orleans, LA
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24
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Shah N, Krishnamurti L. Evidence-Based Minireview: In young children with severe sickle cell disease, do the benefits of HLA-identical sibling donor HCT outweigh the risks? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:190-195. [PMID: 34889371 PMCID: PMC8791135 DOI: 10.1182/hematology.2021000322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
In case 1, a 14-month-old male child with sickle cell disease (SCD) was referred for evaluation for an allogeneic hematopoietic stem cell transplant (HCT). The patient had a history of dactylitis 3 times in his first year of life and febrile episodes twice at the consult. His 4-year-old sister was found to be human leukocyte antigen (HLA) identical. The patient was started on hydroxyurea (HU) at 2.5 years of age. His parents again sought consultation when he was 5 years old because of concerns about his medical condition. At the time, the patient had experienced 2 vaso-occlusive pain episodes (VOEs) requiring hospitalization during the previous 2 years. He had also experienced intermittent pain crises requiring rest at home for 2 to 3 days. The child has not attended school in person due to the COVID-19 pandemic. The family is considering HCT but is ambivalent about it because of potential toxicity. In case 2, an 8-year-old female child is 3 years out from HCT for SCD from her HLA-identical sibling. Before HCT, despite receiving HU, she had experienced >5 VOEs requiring hospitalization and 2 episodes of acute chest syndromes in the previous 3 years. She had also been missing almost 50 days of school days each year. After HCT, she is now attending school regularly and participating in all normal age-appropriate activities. The parents believe that HCT has been transformative in their child's life.
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Affiliation(s)
- Niketa Shah
- Section of Pediatric Hematology/Oncology/BMT, Yale School of Medicine, New Haven, CT
| | - Lakshmanan Krishnamurti
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
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25
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Krishnamurti L. Hematopoietic cell transplantation for sickle cell disease: updates and future directions. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:181-189. [PMID: 34889368 PMCID: PMC8791142 DOI: 10.1182/hematology.2021000251] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Excellent outcomes in hematopoietic cell transplantation (HCT) from HLA-identical siblings, improvements in conditioning regimens, novel graft-versus-host disease prophylaxis, and the availability of alternative donors have all contributed to the increased applicability and acceptability of HCT for sickle cell disease (SCD). In young children with symptomatic SCD with an available HLA-identical related donor, HCT should be carefully considered. HCT from alternative donors is typically undertaken only in patients with severe symptoms, causing or likely to cause organ damage, and in the context of clinical trials. Patients undergoing HCT for SCD require careful counseling and preparation. They require careful monitoring of unique organ toxicities and complications during HCT. Patients must be prospectively followed for a prolonged time to determine the long-term outcomes and late effects of HCT for SCD. Thus, there is a need for a universal, longitudinal clinical registry to follow patients after HCT for SCD in conjunction with individuals who do not receive HCT to compare outcomes. Antibody-based conditioning and ex-vivo umbilical cord blood expansion are likely to improve the availability and acceptability of HCT. In addition, new disease-modifying drugs and the emerging option of the autologous transplantation of gene-modified hematopoietic progenitor cells are likely to expand the available therapeutic options and make decision-making by patients, physicians, and caregivers even more complicated. Future efforts must also focus on determining the impact of socioeconomic status on access to and outcomes of HCT and the long-term impact of HCT on patients, families, and society.
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Affiliation(s)
- Lakshmanan Krishnamurti
- Correspondence Lakshmanan Krishnamurti, Children's Healthcare of Atlanta-Egleston, 1405 Clifton Road NE, Atlanta, GA 30322; e-mail:
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26
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Leonard A, Bertaina A, Bonfim C, Cohen S, Prockop S, Purtill D, Russell A, Boelens JJ, Wynn R, Ruggeri A, Abraham A. Curative therapy for hemoglobinopathies: an International Society for Cell & Gene Therapy Stem Cell Engineering Committee review comparing outcomes, accessibility and cost of ex vivo stem cell gene therapy versus allogeneic hematopoietic stem cell transplantation. Cytotherapy 2021; 24:249-261. [PMID: 34879990 DOI: 10.1016/j.jcyt.2021.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/23/2021] [Accepted: 09/04/2021] [Indexed: 12/17/2022]
Abstract
Thalassemia and sickle cell disease (SCD) are the most common monogenic diseases in the world and represent a growing global health burden. Management is limited by a paucity of disease-modifying therapies; however, allogeneic hematopoietic stem cell transplantation (HSCT) and autologous HSCT after genetic modification offer patients a curative option. Allogeneic HSCT is limited by donor selection, morbidity and mortality from transplant conditioning, graft-versus-host disease and graft rejection, whereas significant concerns regarding long-term safety, efficacy and cost limit the broad applicability of gene therapy. Here the authors review current outcomes in allogeneic and autologous HSCT for transfusion-dependent thalassemia and SCD and provide our perspective on issues surrounding accessibility and costs as barriers to offering curative therapy to patients with hereditary hemoglobinopathies.
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Affiliation(s)
- Alexis Leonard
- Division of Hematology, Children's National Hospital, Washington, DC, USA
| | - Alice Bertaina
- Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Carmem Bonfim
- Pediatric Bone Marrow Transplantation Division, Hospital Pequeno Principe, Curitiba, Brazil
| | - Sandra Cohen
- Université de Montréal and Maisonneuve Rosemont Hospital, Montréal, Canada
| | - Susan Prockop
- Stem Cell Transplantation and Cellular Therapies, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Duncan Purtill
- Department of Haematology, Fiona Stanley Hospital, Perth, Australia
| | - Athena Russell
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Robert Wynn
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Annalisa Ruggeri
- Department of Hematology and bone marrow transplantation, IRCCS Ospedale San Raffaele, Segrate, Milan, Italy
| | - Allistair Abraham
- Center for Cancer and Immunology Research, CETI, Children's National Hospital, Washington, DC, USA.
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27
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Karkoska K, McGann PT. How I approach disease-modifying therapy in children with sickle cell disease in an era of novel therapies. Pediatr Blood Cancer 2021; 68:e29363. [PMID: 34550643 DOI: 10.1002/pbc.29363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/19/2021] [Accepted: 09/06/2021] [Indexed: 11/06/2022]
Abstract
Finally,after decades of stagnation, the therapeutic landscape for sickle cell disease (SCD) is changing with an increasing number of novel therapeutics. Hydroxyurea remains the primary disease-modifying therapy and, when started early in life with maintenance of an optimal dose, can reduce many SCD-related complications. To complement hydroxyurea, there are a growing number of pharmacologic options with additional efforts focused on the development and optimization of curative therapies. Here, we review current treatment options and provide recommendations as to how to approach the treatment of children and adolescents within this evolving therapeutic landscape to allow for full and healthy lives.
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Affiliation(s)
- Kristine Karkoska
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick T McGann
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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28
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Veludhandi A, Ross D, Sinha CB, McCracken C, Bakshi N, Krishnamurti L. A Decision Support Tool for Allogeneic Hematopoietic Stem Cell Transplantation for Children With Sickle Cell Disease: Acceptability and Usability Study. JMIR Form Res 2021; 5:e30093. [PMID: 34709190 PMCID: PMC8587189 DOI: 10.2196/30093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/26/2021] [Accepted: 07/27/2021] [Indexed: 01/16/2023] Open
Abstract
Background Individuals living with sickle cell disease (SCD) may benefit from a variety of disease-modifying therapies, including hydroxyurea, voxelotor, crizanlizumab, L-glutamine, and chronic blood transfusions. However, allogeneic hematopoietic stem cell transplantation (HCT) remains the only nonexperimental treatment with curative intent. As HCT outcomes can be influenced by the complex interaction of several risk factors, HCT can be a difficult decision for health care providers to make for their patients with SCD. Objective The aim of this study is to determine the acceptability and usability of a prototype decision support tool for health care providers in decision-making about HCT for SCD, together with patients and their families. Methods On the basis of published transplant registry data, we developed the Sickle Options Decision Support Tool for Children, which provides health care providers with personalized transplant survival and risk estimates for their patients to help them make informed decisions regarding their patients’ management of SCD. To evaluate the tool for its acceptability and usability, we conducted beta tests of the tool and surveys with physicians using the Ottawa Decision Support Framework and mobile health app usability questionnaire, respectively. Results According to the mobile health app usability questionnaire survey findings, the overall usability of the tool was high (mean 6.15, SD 0.79; range 4.2-7). According to the Ottawa Decision Support Framework survey findings, acceptability of the presentation of information on the decision support tool was also high (mean 2.94, SD 0.63; range 2-4), but the acceptability regarding the amount of information was mixed (mean 2.59, SD 0.5; range 2-3). Most participants expressed that they would use the tool in their own patient consults (13/15, 87%) and suggested that the tool would ease the decision-making process regarding HCT (8/9, 89%). The 4 major emergent themes from the qualitative analysis of participant beta tests include user interface, data content, usefulness during a patient consult, and potential for a patient-focused decision aid. Most participants supported the idea of a patient-focused decision aid but recommended that it should include more background on HCT and a simplification of medical terminology. Conclusions We report the development, acceptability, and usability of a prototype decision support tool app to provide individualized risk and survival estimates to patients interested in HCT in a patient consultation setting. We propose to finalize the tool by validating predictive analytics using a large data set of patients with SCD who have undergone HCT. Such a tool may be useful in promoting physician-patient collaboration in making shared decisions regarding HCT for SCD. Further incorporation of patient-specific measures, including the HCT comorbidity index and the quality of life after transplant, may improve the applicability of the decision support tool in a health care setting.
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Affiliation(s)
| | - Diana Ross
- School of Medicine, Emory University, Atlanta, GA, United States
| | - Cynthia B Sinha
- School of Medicine, Emory University, Atlanta, GA, United States
| | - Courtney McCracken
- Center for Research and Evaluation, Kaiser Permanente, Atlanta, GA, United States
| | - Nitya Bakshi
- School of Medicine, Emory University, Atlanta, GA, United States
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29
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AlJohani NI, Toor AA. What is the minimum adequate busulfan dose for patients with sickle cell disease undergoing reduced intensity conditioning with fludarabine, busulfan, and anti-thymocyte globulin? EJHAEM 2021; 2:471-474. [PMID: 35844726 PMCID: PMC9175827 DOI: 10.1002/jha2.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 11/17/2022]
Abstract
Fludarabine busulfan anti-thymocyte globulin is a common conditioning chemotherapy with reduced toxicity used for transplantation in sickle cell disease (SCD). The dose of busulfan used in this protocol is variable across studies and centers. The minimum dose that maintains long-term donor chimerism is not well established. We hypothesized that a lower, less-toxic dose could be used to maintain adequate long-lasting chimeras, which might allow for the inclusion of older or comorbid patients with this disease. In our retrospective study of 11 patients, 8-9.6 mg/kg was adequate to maintain chimerism in six patients. A 6 mg/kg dose resulted in transplant rejection in two patients. This suggests that 0.8 mg/kg IV busulfan every 6 h for 8-12 doses (total 8-9.6 mg/kg) is the minimum adequate busulfan dose required to maintain long-lasting chimeras, facilitating the successful withdrawal of immunosuppression in SCD patients who receive this protocol.
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Affiliation(s)
- Naif I. AlJohani
- Adult Hematology and Bone Marrow Transplant SectionOncology DepartmentKing Faisal Specialist Hospital and Research CentreJeddahSaudi Arabia
| | - Amir Ahmed Toor
- Department of Internal MedicineBMT programMassey Cancer CenterVirginia Commonwealth UniversityRichmondVirginiaUSA
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30
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Stroke and stroke prevention in sickle cell anemia in developed and selected developing countries. J Neurol Sci 2021; 427:117510. [PMID: 34077859 DOI: 10.1016/j.jns.2021.117510] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 02/02/2023]
Abstract
This comprehensive review provides an insight into the pathophysiology, epidemiology, evaluation, and treatment of sickle cell anemia (SCA)-related stroke in developed and developing countries. Vascular injury, hypercoagulability and vaso-occlusion play a role in the pathophysiology of stroke in SCA. Transcranial Doppler ultrasound (TCD) has lowered the incidence of ischemic stroke from 11% to 1% as TCD identifies children who are at risk for stroke, providing opportunities for interventions to reduce this risk. Whereas blood exchange is indicated in acute stroke, chronic transfusions (either simple or exchange on a monthly basis) are used for primary as well as secondary stroke prevention in developed countries. Children with abnormally high TCD velocities (≥ 200 cm/s) are at high risk of stroke and might benefit from hydroxyurea or hydroxycarbamide (HU) after a period of a successful transition from chronic transfusions. Hematopoietic stem cell transplant presents a cure for SCA. Gene therapy is currently investigated and may be offered to patients with SCA who had a stroke or who are at high risk of stroke if proven efficacious and safe. However, gene therapy is not likely to be implemented in low-income countries due to cost. Alternatively, HU is utilized for primary and secondary stroke prevention in developing countries. Further expansion of TCD implementation should be a priority in those settings.
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31
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A systematic review of quality of life in sickle cell disease and thalassemia after stem cell transplant or gene therapy. Blood Adv 2021; 5:570-583. [PMID: 33496753 DOI: 10.1182/bloodadvances.2020002948] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/07/2020] [Indexed: 01/19/2023] Open
Abstract
Patients with sickle cell disease (SCD) and thalassemia experience several complications across their lifespan that lead to impairment in different health-related quality of life (HRQOL) domains. There is increasing interest in curative therapies for patients with SCD and thalassemia, including hematopoietic stem cell transplant (HSCT) and gene therapy; however, the effect of these therapies on various HRQOL domains remains unclear. Our objective was to systematically evaluate the most recent evidence for the effect of HSCT and gene therapy on HRQOL in patients with SCD and thalassemia. A systematic search of medical literature databases was conducted. A total of 16 studies (thalassemia, n = 9; SCD, n = 6; both, n = 1) involving 517 participants met inclusion criteria (thalassemia, n = 416; SCD, n = 101). HSCT was associated with a small to large positive effects in most HRQOL domains (Cohen's d; mean = 0.47; median = 0.37; range, 0.27-2.05). In thalassemia, HSCT was frequently associated with large positive effects in physical and emotional HRQOL domains (median d = 0.79 and d = 0.57, respectively). In SCD, HSCT was associated with large positive effects in all HRQOL domains. Emerging data suggest improvement in HRQOL outcomes across different domains following gene therapy in thalassemia and SCD. The quality of evidence was moderate in 13 studies (81%). HSCT has a positive impact on several HRQOL domains in patients with SCD and thalassemia; however, more longitudinal studies are warranted to assess the sustainability of these effects. Reporting HRQOL outcomes from ongoing gene therapy or gene-editing trials in SCD and thalassemia is key to better understand the benefits of such therapies.
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Kharya G, Bakane AN, Rauthan AM. Pretransplant myeloid and immune suppression, reduced toxicity conditioning with posttransplant cyclophosphamide: Initial outcomes of novel approach for matched unrelated donor hematopoietic stem cell transplant for hemoglobinopathies. Pediatr Blood Cancer 2021; 68:e28909. [PMID: 33470527 DOI: 10.1002/pbc.28909] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 01/19/2023]
Abstract
Hematopoietic stem cell transplant (HSCT) is currently the only curative option for thalassemia major (TM) and sickle cell disease (SCD). We report our experience of using pretransplant immune suppression (PTIS), augmented Johns Hopkins conditioning, and posttransplant cyclophosphamide (PTCy) as graft-versus-host disease (GvHD) prophylaxis for matched unrelated donor (MUD) transplant in TM/SCD. At a median follow-up of 307.5 days (range 251-395), all patients (three TM, one SCD) are alive and disease free. MUD HSCT with PTIS, augmented Johns Hopkins conditioning, and PTCy as GvHD prophylaxis is a promising way of treating patients with hemoglobinopathies with low regimen-related toxicity (RRT), no risk of graft failure (GF) and minimal GvHD rates.
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Affiliation(s)
- Gaurav Kharya
- Center for Bone Marrow Transplant and Cellular Therapy, Indraprastha Apollo Hospital, New Delhi, India
| | - Atish N Bakane
- Center for Bone Marrow Transplant and Cellular Therapy, Indraprastha Apollo Hospital, New Delhi, India
| | - Archana M Rauthan
- Center for Bone Marrow Transplant and Cellular Therapy, Indraprastha Apollo Hospital, New Delhi, India
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Krishnamurti L. Hematopoietic Cell Transplantation for Sickle Cell Disease. Front Pediatr 2021; 8:551170. [PMID: 33469520 PMCID: PMC7813811 DOI: 10.3389/fped.2020.551170] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022] Open
Abstract
Sickle cell disease (SCD) is a severe autosomal recessively inherited disorder of the red blood cell characterized by erythrocyte deformation caused by the polymerization of the abnormal hemoglobin, which leads to erythrocyte deformation and triggers downstream pathological changes. These include abnormal rheology, vaso-occlusion, ischemic tissue damage, and hemolysis-associated endothelial dysfunction. These acute and chronic physiologic disturbances contribute to morbidity, organ dysfunction, and diminished survival. Hematopoietic cell transplantation (HCT) from HLA-matched or unrelated donors or haploidentical related donors or genetically modified autologous hematopoietic progenitor cells is performed with the intent of cure or long-term amelioration of disease manifestations. Excellent outcomes have been observed following HLA-identical matched related donor HCT. The majority of SCD patients do not have an available HLA-identical sibling donor. Increasingly, however, they have the option of undergoing HCT from unrelated HLA matched or related haploidentical donors. The preliminary results of transplantation of autologous hematopoietic progenitor cells genetically modified by adding a non-sickling gene or by genomic editing to increase expression of fetal hemoglobin are encouraging. These approaches are being evaluated in early-phase clinical trials. In performing HCT in patients with SCD, careful consideration must be given to patient and donor selection, conditioning and graft-vs.-host disease regimen, and pre-HCT evaluation and management during and after HCT. Sociodemographic factors may also impact awareness of and access to HCT. Further, there is a substantial decisional dilemma in HCT with complex tradeoffs between the possibility of amelioration of disease manifestations and early or late complications of HCT. The performance of HCT for SCD requires careful multidisciplinary collaboration and shared decision making between the physician and informed patients and caregivers.
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Affiliation(s)
- Lakshmanan Krishnamurti
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
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Iqbal M, Reljic T, Corbacioglu S, de la Fuente J, Gluckman E, Kumar A, Yassine F, Ayala E, El-Jawahri A, Murthy H, Almohareb F, Hashmi SK, Cappelli B, Alahmari A, Scigliuolo GM, Kassim A, Aljurf M, Kharfan-Dabaja MA. Systematic Review/Meta-Analysis on Efficacy of Allogeneic Hematopoietic Cell Transplantation in Sickle Cell Disease: An International Effort on Behalf of the Pediatric Diseases Working Party of European Society for Blood and Marrow Transplantation and the Sickle Cell Transplantation International Consortium. Transplant Cell Ther 2020; 27:167.e1-167.e12. [PMID: 33830027 DOI: 10.1016/j.jtct.2020.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/28/2020] [Accepted: 10/21/2020] [Indexed: 11/28/2022]
Abstract
Sickle cell disease (SCD) affects more than 300,000 children annually worldwide. Despite improved supportive care, long-term prognosis remains poor. Allogeneic hematopoietic cell transplantation (allo-HCT) is the sole validated curative option, resulting in sustained resolution of the clinical phenotype. The medical literature on allo-HCT for SCD is largely limited to children. Recent studies have evaluated allo-HCT efficacy in adults. Here, we conducted a systematic review/meta-analysis to assess the totality of evidence on the efficacy, or lack thereof, of allo-HCT in treating SCD. We performed a comprehensive literature search using PubMed/Medline, Embase, and Cochrane library databases on November 13, 2019. Four authors independently extracted data on clinical outcomes related to benefits (overall survival [OS] and disease-free survival [DFS]) and harms (acute graft-versus-host disease [aGVHD], chronic graft-versus-host disease [cGVHD], nonrelapse mortality [NRM], and graft failure [GF]). Our search identified a total of 1906 references. Only 33 studies (n= 2853 patients) met our inclusion criteria. We also performed a subset analysis by age. Analyses of all-age groups showed pooled rates of 96% for OS, 90% for DFS, 20% for aGVHD, 10% for cGVHD, 4% for NRM, and 5% for GF. In the pediatric population, pooled rates for OS, DFS, aGVHD, cGVHD, NRM, and GF were 97%, 91%, 26%, 11%, 5%, and 3%, respectively. In adults, pooled rates for OS, DFS, aGVHD, cGVHD, NRM, and GF were 98%, 90%, 7%, 1%, 0%, and 14%, respectively. Our data show that allo-HCT is safe and effective, yielding pooled OS rates exceeding 90%. The high GF rate of 14% in adults is concerning and emphasizes the need to evaluate new strategies.
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Affiliation(s)
- Madiha Iqbal
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Program, Mayo Clinic, Jacksonville, Florida
| | - Tea Reljic
- Program for Comparative Effectiveness Research, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Germany
| | - Josu de la Fuente
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Eliane Gluckman
- Eurocord, Paris-Diderot University Equipe d'Accueil 3518, Hospital Saint Louis, Paris, France; Monacord, Centre Scientifique de Monaco, Monaco
| | - Ambuj Kumar
- Program for Comparative Effectiveness Research, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Farah Yassine
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Program, Mayo Clinic, Jacksonville, Florida
| | - Ernesto Ayala
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Program, Mayo Clinic, Jacksonville, Florida
| | - Areej El-Jawahri
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Hemant Murthy
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Program, Mayo Clinic, Jacksonville, Florida
| | - Fahad Almohareb
- Adult Hematology/Bone Marrow Transplantation, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Shahrukh K Hashmi
- Adult Hematology/Bone Marrow Transplantation, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Department of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Barbara Cappelli
- Eurocord, Paris-Diderot University Equipe d'Accueil 3518, Hospital Saint Louis, Paris, France; Monacord, Centre Scientifique de Monaco, Monaco
| | - Ali Alahmari
- Adult Hematology/Bone Marrow Transplantation, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Graziana Maria Scigliuolo
- Eurocord, Paris-Diderot University Equipe d'Accueil 3518, Hospital Saint Louis, Paris, France; Monacord, Centre Scientifique de Monaco, Monaco
| | - Adetola Kassim
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Mahmoud Aljurf
- Adult Hematology/Bone Marrow Transplantation, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Program, Mayo Clinic, Jacksonville, Florida.
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Hayashi RJ. Considerations in Preparative Regimen Selection to Minimize Rejection in Pediatric Hematopoietic Transplantation in Non-Malignant Diseases. Front Immunol 2020; 11:567423. [PMID: 33193340 PMCID: PMC7604384 DOI: 10.3389/fimmu.2020.567423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/25/2020] [Indexed: 01/19/2023] Open
Abstract
The variables that influence the selection of a preparative regimen for a pediatric hematopoietic stem cell transplant procedure encompasses many issues. When one considers this procedure for non-malignant diseases, components in a preparative regimen that were historically developed to reduce malignant tumor burden may be unnecessary. The primary goal of the procedure in this instance becomes engraftment with the establishment of normal hematopoiesis and a normal immune system. Overcoming rejection becomes the primary priority, but pursuit of this goal cannot neglect organ toxicity, or post-transplant morbidity such as graft-versus-host disease or life threatening infections. With the improvements in supportive care, newborn screening techniques for early disease detection, and the expansion of viable donor sources, we have reached a stage where hematopoietic stem cell transplantation can be considered for virtually any patient with a hematopoietic based disease. Advancing preparative regiments that minimize rejection and transplant related toxicity will thus dictate to what extent this medical technology is fully utilized. This mini-review will provide an overview of the origins of conditioning regimens for transplantation and how agents and techniques have evolved to make hematopoietic stem cell transplantation a viable option for children with non-malignant diseases of the hematopoietic system. We will summarize the current state of this facet of the transplant procedure and describe the considerations that come into play in selecting a particular preparative regimen. Decisions within this realm must tailor the treatment to the primary disease condition to ideally achieve an optimal outcome. Finally, we will project forward where advances are needed to overcome the persistent engraftment obstacles that currently limit the utilization of transplantation for haematopoietically based diseases in children.
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Affiliation(s)
- Robert J Hayashi
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, MO, United States
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Stroke Treatment in the Setting of Systemic Disease. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00650-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Osunkwo I, Manwani D, Kanter J. Current and novel therapies for the prevention of vaso-occlusive crisis in sickle cell disease. Ther Adv Hematol 2020; 11:2040620720955000. [PMID: 33062233 PMCID: PMC7534097 DOI: 10.1177/2040620720955000] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 08/10/2020] [Indexed: 12/28/2022] Open
Abstract
Individuals with sickle cell disease (SCD) are living further into adulthood in high-resource countries. However, despite increased quantity of life, recurrent, acute painful episodes cause significant morbidity for affected individuals. These SCD-related painful episodes, also referred to as vaso-occlusive crises (VOCs), have multifactorial causes, and they often occur as a result of multicellular aggregation and vascular adherence of red blood cells, neutrophils, and platelets, leading to recurrent and unpredictable occlusion of the microcirculation. In addition to severe pain, long-term complications of vaso-occlusion may include damage to muscle and/or bone, in addition to vital organs such as the liver, spleen, kidneys, and brain. Severe pain associated with VOCs also has a substantial detrimental impact on quality of life for individuals with SCD, and is associated with increased health care utilization, financial hardship, and impairments in education and vocation attainment. Previous treatments have targeted primarily SCD symptom management, or were broad nontargeted therapies, and include oral or parenteral hydration, analgesics (including opioids), nonsteroidal anti-inflammatory agents, and various other types of nonpharmacologic pain management strategies to treat the pain associated with VOC. With increased understanding of the pathophysiology of VOCs, there are several new potential therapies that specifically target the pathologic process of vaso-occlusion. These new therapies may reduce cell adhesion and inflammation, leading to decreased incidence of VOCs and prevention of end-organ damage. In this review, we consider the benefits and limitations of current treatments to reduce the occurrence of VOCs in individuals with SCD and the potential impact of emerging treatments on future disease management.
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Affiliation(s)
- Ifeyinwa Osunkwo
- Non-Malignant Hematology Section, The Levine Cancer Institute and Atrium Health, Charlotte, NC, USA
| | - Deepa Manwani
- Division of Pediatric Hematology and Oncology, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, New York, NY, USA
| | - Julie Kanter
- Division of Hematology and Oncology, University of Alabama Birmingham, 1720 2nd Avenue S, NP 2510, Birmingham, AL 35294, USA
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Dhédin N, Paillard C, Dalle JH, Ouachée M, Buchbinder N, Brissot E, Beguin Y, Masouridi-Levrat S, Yakoub-Agha I, Bernit E, Pondarre C. [Allogeneic hematopoietic stem cell transplant in children and adults with sickle cell disease: Indications and modalities]. Bull Cancer 2020; 107:925-933. [PMID: 32921398 DOI: 10.1016/j.bulcan.2020.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/01/2020] [Accepted: 06/05/2020] [Indexed: 11/30/2022]
Abstract
Sickle cell disease is associated with severe complications and early mortality in adults. In children, hematopoietic stem cell transplant from HLA-identical sibling can stop the progression of the disease and leads to more than 95% long-term free survival without sickle cell disease. The aim of this workshop was to define indications and modalities of allogeneic hematopoietic stem cell transplant in children and adults with sickle cell disease. Patient and sibling HLA typing should be proposed, early in the course of the disease, when intensification therapies are required. Indications of transplant from HLA-identical sibling in children and adults are, cerebral vasculopathy, occurrence of vaso-occlusive events despite hydroxycarbamide, renal and hepatic diseases related to SCD, chronic anemia<7g/dL despite hydroxycarbamide, need to maintain transfusion programs longer than six months, and major transfusion difficulties related to red blood cell alloimmunization. In children with an HLA-identical sibling donor, we recommend a myeloablative conditioning regimen associating high dose busulfan, cyclophosphamide and ATG, considering the excellent results of this approach In patients over 15 years of age, we recommend the NIH approach consisting of a reduced intensity conditioning regimen by alemtuzumab, and 3Gy total body irradiation, followed by peripheral hematopoietic stem cells and post-transplant immunosuppression by sirolimus In the absence of HLA-identical sibling donor, there is no definitive data for preferring transplant from unrelated versus haplo-identical donors but we recommend to evaluate these approaches in prospective trials.
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Affiliation(s)
- Nathalie Dhédin
- Hôpital Saint-Louis, service d'hématologie adolescents jeunes adultes, Paris, France.
| | - Catherine Paillard
- CHU de Strasbourg, service d'onco-hématologie pédiatrique, Strasbourg, France.
| | - Jean-Hugues Dalle
- Hôpital Robert-Debré, université Paris 7 - Denis Diderot, service d'hémato-immunologie, Paris, France.
| | - Marie Ouachée
- Service de pédiatrie IHOP, 1, place Joseph-Renaut, 69373 Lyon cedex 08, France.
| | | | - Eolia Brissot
- Hôpital Saint-Antoine, Sorbonne université, service d'hématologie et thérapie cellulaire, 184, rue du Faubourg Saint-Antoine, Paris, France.
| | - Yves Beguin
- Université de Liège, CHU de liège, service d'hématologie, 1, avenue de l'Hôpital, 4000 Liège, Belgique.
| | | | - Ibrahim Yakoub-Agha
- Université de Lille, CHU de Lille, Inserm, Infinite, U1286, 59000 Lille, France.
| | - Emmanuelle Bernit
- Assistance publique-Hôpitaux de Marseille, service de médecine interne, Marseille, France.
| | - Corinne Pondarre
- Paris XII université, centre hospitalier intercommunal de Créteil, centre de référence de la drépanocytose, service de pédiatrie, Inserm unité 955, Créteil, France.
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Zimmerman C, Shenoy S. Chimerism in the Realm of Hematopoietic Stem Cell Transplantation for Non-malignant Disorders-A Perspective. Front Immunol 2020; 11:1791. [PMID: 32903736 PMCID: PMC7438804 DOI: 10.3389/fimmu.2020.01791] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/06/2020] [Indexed: 11/21/2022] Open
Abstract
Hematopoietic stem cell transplantation (HCT) is a curative intervention in non-malignant disorders (NMD) that benefit from donor-derived hematopoiesis, immunity, and establishment of vital cells or enzyme systems. Stability or reversal of disease symptoms depends on adequacy and long-term stability of donor cell engraftment in the compartment of interest. Unlike hematologic malignancies where complete replacement with donor derived hematopoiesis is desirable for a cure, NMD manifestations can often be controlled in the presence of mixed chimerism. This allows for exploration of reduced intensity conditioning regimens that can limit organ toxicity, late effects, and increase tolerability especially in young recipients or those with a large burden of disease related morbidity. However, the levels of donor chimerism conducive to disease control vary between NMD, need to focus on the hematopoietic lineage necessary to correct individual disorders, and need to be assessed for stability over time, i.e., a whole lifespan. An enhanced ability to reject grafts due to recipient immune competence, alloimmunization, and autoimmunity add to the complexity of this balance making NMD a highly diverse group of unrelated disorders. The addition of donor factors such as stem cell source and Human-Leukocyte-Antigen match extend the complexity such that 'one size does not fit all'. In this perspective, we will discuss current knowledge of the role of chimerism and goals, approach to HCT, and emerging methods of boosting engraftment and graft function, and monitoring recommendations. We draw attention to knowledge gaps and areas of necessity for further research and research support.
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Hematopoietic stem cell transplantation and cellular therapy in sickle cell disease: where are we now? Curr Opin Hematol 2020; 26:448-452. [PMID: 31483336 DOI: 10.1097/moh.0000000000000541] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Sickle cell disease (SCD) is a common monogenic disorder that is characterized by an A to T substitution in the β-globin gene that leads to the production of hemoglobin S (HbS). Polymerization of HbS leads to significant morbidity including vaso-occlusion, pain, hemolytic anemia, and end organ damage. Allogeneic hematopoietic cell transplantation (allo-HCT) is the only curative treatment; however, suitable donors are not always readily available. This study reviews the current status of allo-HCT and autologous cellular therapies for SCD. RECENT FINDINGS Alternative sources of allogeneic stem cells from unmatched donors such as cord blood and haploidentical donors are gaining traction. Early experience has shown that better conditioning regimens and graft-versus-host disease prophylaxis are needed before these donor sources can gain widespread use. Clinical trials are underway to determine the feasibility and efficacy of autologous transplantation with gene modified hematopoietic stem cells. Gene therapy strategies include HbS gene correction, gene addition, and hemoglobin F induction. Preliminary results are very encouraging. SUMMARY Matched sibling allo-HCT for patients with SCD results in more than 90% overall survival and more than 80% event-free survival. Because only 25-30% of patients have a matched sibling donor, alternative donor options such as matched unrelated donors, related haploidentical donors and unrelated umbilical cord blood donors are being considered. Clinical trials investigating various strategies for gene therapy followed by autologous transplantation are underway. One major challenge is obtaining sufficient hematopoietic stem cells for gene therapy. Studies are being conducted on the optimal mobilization regimen and collection strategy.
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Gluckman E, Fuente JDL, Cappelli B, Scigliuolo GM, Volt F, Tozatto-Maio K, Rocha V, Tommaso M, O’Boyle F, Smiers F, Cunha-Riehm CBD, Calore E, Bonanomi S, Graphakos S, Paisiou A, Albert MH, Ruggeri A, Zecca M, Lankester AC, Corbacioglu S. The role of HLA matching in unrelated donor hematopoietic stem cell transplantation for sickle cell disease in Europe. Bone Marrow Transplant 2020; 55:1946-1954. [DOI: 10.1038/s41409-020-0847-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 02/07/2023]
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Stenger EO, Shenoy S, Krishnamurti L. How I treat sickle cell disease with hematopoietic cell transplantation. Blood 2019; 134:2249-2260. [PMID: 31697818 PMCID: PMC6923666 DOI: 10.1182/blood.2019000821] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 10/28/2019] [Indexed: 12/14/2022] Open
Abstract
Sickle cell disease (SCD) leads to significant morbidity and early mortality, and hematopoietic cell transplantation (HCT) is the only widely available cure, with impacts seen on SCD-related organ dysfunction. Outcomes are excellent following matched-related donor (MRD) HCT, leading to significantly expanded application of this treatment over the past decade. The majority of SCD patients lack an MRD, but outcomes following alternative donor HCT continue to improve on clinical trials. Within this framework, we aim to provide our perspective on how to apply research findings to clinical practice, for an individual patient. We also emphasize that the preparation of SCD recipients for HCT and supporting them through HCT have special nuances that require awareness and close attention. Through the use of clinical vignettes, we provide our perpsective on the complex decision-making process in HCT for SCD as well as recommendations for the evaluation and support of these patients through HCT.
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Affiliation(s)
- Elizabeth O Stenger
- Division of Blood and Marrow Transplantation and Cellular Therapies, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Shalini Shenoy
- Division of Hematology/Oncology, Children's Hospital St. Louis, St. Louis, MO; and
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Choice of Donor Source and Conditioning Regimen for Hematopoietic Stem Cell Transplantation in Sickle Cell Disease. J Clin Med 2019; 8:jcm8111997. [PMID: 31731790 PMCID: PMC6912427 DOI: 10.3390/jcm8111997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/07/2019] [Accepted: 11/08/2019] [Indexed: 11/17/2022] Open
Abstract
In the United States, one out of every 500 African American children have sickle cell disease (SCD), and SCD affects approximately 100,000 Americans. Significant advances in the treatment of this monogenetic disorder have failed to substantially extend the life expectancy of adults with SCD over the past two decades. Hematopoietic stem cell transplantation (HSCT) remains the only curative option for patients with SCD. While human leukocyte antigen (HLA) matched sibling HSCT has been successful, its availability is extremely limited. This review summarizes various conditioning regimens that are currently available. We explore recent efforts to expand the availability of allogeneic HSCT, including matched unrelated, umbilical cord blood, and haploidentical stem cell sources. We consider the use of nonmyeloablative conditioning and haploidentical donor sources as emerging strategies to expand transplant availability, particularly for SCD patients with complications and comorbidities who can undergo neither matched related transplant nor myeloablative conditioning. Finally, we show that improved conditioning agents have improved success rates not only in the HLA-matched sibling setting but also alternative donor settings.
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Nickel RS, Horan JT, Abraham A, Qayed M, Haight A, Ngwube A, Liang H, Luban NLC, Hendrickson JE. Human leukocyte antigen (HLA) class I antibodies and transfusion support in paediatric HLA‐matched haematopoietic cell transplant for sickle cell disease. Br J Haematol 2019; 189:162-170. [DOI: 10.1111/bjh.16298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/19/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Robert S. Nickel
- Division of Hematology Children's National Hospital WashingtonDCUSA
- The George Washington University School of Medicine and Health Sciences Washington DCUSA
| | - John T. Horan
- Aflac Cancer and Blood Disorders Center Emory University Atlanta GAUSA
| | - Allistair Abraham
- Division of Hematology Children's National Hospital WashingtonDCUSA
- The George Washington University School of Medicine and Health Sciences Washington DCUSA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center Emory University Atlanta GAUSA
| | - Ann Haight
- Aflac Cancer and Blood Disorders Center Emory University Atlanta GAUSA
| | - Alexander Ngwube
- Center for Cancer and Blood Disorders Phoenix Children's Hospital Phoenix AZUSA
| | - Hua Liang
- Department of Statistics The George Washington University Washington DCUSA
| | - Naomi L. C. Luban
- Division of Hematology Children's National Hospital WashingtonDCUSA
- The George Washington University School of Medicine and Health Sciences Washington DCUSA
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Allogeneic Hematopoietic Stem Cell Transplantation for Adults with Sickle Cell Disease. J Clin Med 2019; 8:jcm8101565. [PMID: 31581479 PMCID: PMC6832368 DOI: 10.3390/jcm8101565] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 12/30/2022] Open
Abstract
Sickle cell disease (SCD) is an inherited red blood cell disorder that leads to substantial morbidity and early mortality. Acute and chronic SCD-related complications increase with older age, and therapies are urgently needed to treat adults. Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative therapy, but has been used less frequently in adults compared to children. This is, in part, due to (1) greater chronic organ damage, limiting tolerability to myeloablative conditioning regimens, (2) a higher rate of HSCT-related complications in adults versus children with SCD, and (3) limited coverage by public and private health insurance. Newer approaches using nonmyeloablative and reduced-intensity conditioning HSCT regimens have demonstrated better safety and tolerability, with high rates of stable engraftment in SCD adults. This review will focus on the impacts of HSCT, using more contemporary approaches to SCD-related complications in adults.
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Bernaudin F. Why, Who, When, and How? Rationale for Considering Allogeneic Stem Cell Transplantation in Children with Sickle Cell Disease. J Clin Med 2019; 8:jcm8101523. [PMID: 31546720 PMCID: PMC6833062 DOI: 10.3390/jcm8101523] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 09/14/2019] [Accepted: 09/19/2019] [Indexed: 02/07/2023] Open
Abstract
Considering the progress made in the management of sickle cell disease during the past 30 years, along with the excellent results obtained with hematopoietic stem cell transplantation (SCT), it is important to reexamine why, who, when and how to recommend allogeneic SCT in children with sickle cell disease. While sickle cell disease has a low risk of death in children and a high risk for morbidity during aging, SCT carries an early risk of death, graft-vs-host disease and infertility. Nevertheless, SCT offers at least 95% chance of cure with low risk of chronic graft-vs-host disease when a matched-sibling donor is available and the risks of infertility can be reduced by ovarian, sperm or testis cryopreservation. Thus, all available therapies such as hydroxyurea, transfusions and SCT should be presented to the parents, providers, and affected children and discussed with them from infancy. Furthermore, the use of these therapies should be adjusted to the severity of the disease and to local availabilities in order to choose the treatment offering the best benefit/risk ratio.
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Affiliation(s)
- Françoise Bernaudin
- French Referral Center for Sickle Cell Disease; SFGM-TC (Société Française de Greffe de Moelle et de Thérapie Cellulaire); DrepaGreffe Association 20 rue de Coulmiers, 94130 Nogent sur Marne, France.
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Magnani A, Pondarré C, Bouazza N, Magalon J, Miccio A, Six E, Roudaut C, Arnaud C, Kamdem A, Touzot F, Gabrion A, Magrin E, Couzin C, Fusaro M, André I, Vernant JP, Gluckman E, Bernaudin F, Bories D, Cavazzana M. Extensive multilineage analysis in patients with mixed chimerism after allogeneic transplantation for sickle cell disease: insight into hematopoiesis and engraftment thresholds for gene therapy. Haematologica 2019; 105:1240-1247. [PMID: 31537695 PMCID: PMC7193509 DOI: 10.3324/haematol.2019.227561] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/18/2019] [Indexed: 12/25/2022] Open
Abstract
Although studies of mixed chimerism following hematopoietic stem cell transplantation in patients with sickle cell disease (SCD) may provide insights into the engraftment needed to correct the disease and into immunological reconstitution, an extensive multilineage analysis is lacking. We analyzed chimerism simultaneously in peripheral erythroid and granulomonocytic precursors/progenitors, highly purified B and T lymphocytes, monocytes, granulocytes and red blood cells (RBC). Thirty-four patients with mixed chimerism and ≥12 months of follow-up were included. A selective advantage of donor RBC and their progenitors/precursors led to full chimerism in mature RBC (despite partial engraftment of other lineages), and resulted in the clinical control of the disease. Six patients with donor chimerism <50% had hemolysis (reticulocytosis) and higher HbS than their donor. Four of them had donor chimerism <30%, including a patient with AA donor (hemoglobin >10 g/dL) and three with AS donors (hemoglobin <10 g/dL). However, only one vaso-occlusive crisis occurred with 68.7% HbS. Except in the patients with the lowest chimerism, the donor engraftment was lower for T cells than for the other lineages. In a context of mixed chimerism after hematopoietic stem cell transplantation for SCD, myeloid (rather than T cell) engraftment was the key efficacy criterion. Results show that myeloid chimerism as low as 30% was sufficient to prevent a vaso-occlusive crisis in transplants from an AA donor but not constantly from an AS donor. However, the correction of hemolysis requires higher donor chimerism levels (i.e ≥50%) in both AA and AS recipients. In the future, this group of patients may need a different therapeutic approach.
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Affiliation(s)
- Alessandra Magnani
- Department of Biotherapy, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France .,Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest, Assistance Publique-Hôpitaux de Paris, INSERM CIC 1416, Paris, France
| | - Corinne Pondarré
- Centre de référence de drépanocytose, CHIC Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Inserm U955, Paris XII University, Créteil, France
| | - Naïm Bouazza
- Université Paris Descartes, EA7323, Sorbonne Paris Cité, CIC-1419 Inserm, Cochin-Necker, Paris, France
| | - Jeremy Magalon
- Cell Therapy Unit, Hôpital de la Conception, AP-HM, INSERM CIC BT 1409, Marseille, France
| | - Annarita Miccio
- Laboratory of Chromatin and gene regulation during development, Imagine Institute, Paris, France.,Paris Descartes-Sorbonne Paris Cité University, Imagine Institute, Paris
| | - Emmanuelle Six
- Paris Descartes-Sorbonne Paris Cité University, Imagine Institute, Paris.,Human Lymphohematopoiesis Laboratory, Inserm UMR 1163, Imagine Institute, University Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Cecile Roudaut
- Department of Biotherapy, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Cécile Arnaud
- Centre de référence de drépanocytose, CHIC Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Annie Kamdem
- Centre de référence de drépanocytose, CHIC Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Fabien Touzot
- Department of Immunology-Allergy-Rheumatology, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Aurélie Gabrion
- Department of Biotherapy, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Elisa Magrin
- Department of Biotherapy, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest, Assistance Publique-Hôpitaux de Paris, INSERM CIC 1416, Paris, France
| | - Chloé Couzin
- Department of Biotherapy, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mathieu Fusaro
- Study Center for Primary Immunodeficiencies, Assistance Publique-Hôpitaux de Paris (AP-HP), Necker-Enfants Malades University Hospital, Paris, France
| | - Isabelle André
- Paris Descartes-Sorbonne Paris Cité University, Imagine Institute, Paris.,Human Lymphohematopoiesis Laboratory, Inserm UMR 1163, Imagine Institute, University Paris Descartes Sorbonne Paris Cité, Paris, France
| | | | - Eliane Gluckman
- Monacord Hôpital Saint Louis Paris, Centre Scientifique de Monaco, Monaco and Eurocord, Hôpital Saint Louis, Université Paris Diderot, Paris, France
| | - Françoise Bernaudin
- Centre de référence de drépanocytose, CHIC Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Dominique Bories
- Hématologie Moléculaire, Hôpital Henri Mondor, Université Paris Est, Créteil, France
| | - Marina Cavazzana
- Department of Biotherapy, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Biotherapy Clinical Investigation Center, Groupe Hospitalier Universitaire Ouest, Assistance Publique-Hôpitaux de Paris, INSERM CIC 1416, Paris, France.,Paris Descartes-Sorbonne Paris Cité University, Imagine Institute, Paris.,Human Lymphohematopoiesis Laboratory, Inserm UMR 1163, Imagine Institute, University Paris Descartes Sorbonne Paris Cité, Paris, France
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Jordan LC, Juttukonda MR, Kassim AA, DeBaun MR, Davis LT, Pruthi S, Patel NJ, Lee CA, Waddle SL, Donahue MJ. Haploidentical bone marrow transplantation improves cerebral hemodynamics in adults with sickle cell disease. Am J Hematol 2019; 94:E155-E158. [PMID: 30838684 DOI: 10.1002/ajh.25455] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 02/27/2019] [Accepted: 03/03/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Lori C. Jordan
- Division of Pediatric Neurology, Department of PediatricsVanderbilt University Medical Center Nashville Tennessee
- Department of NeurologyVanderbilt University Medical Center Nashville Tennessee
| | - Meher R. Juttukonda
- Department of Radiology and Radiological SciencesVanderbilt University Medical Center Nashville Tennessee
| | - Adetola A. Kassim
- Division of Hematology, Department of MedicineVanderbilt University Medical Center Nashville Tennessee
| | - Michael R. DeBaun
- Division of Hematology/Oncology, Department of PediatricsVanderbilt University Medical Center Nashville Tennessee
| | - Larry T. Davis
- Department of Radiology and Radiological SciencesVanderbilt University Medical Center Nashville Tennessee
| | - Sumit Pruthi
- Department of Radiology and Radiological SciencesVanderbilt University Medical Center Nashville Tennessee
| | - Niral J. Patel
- Division of Pediatric Neurology, Department of PediatricsVanderbilt University Medical Center Nashville Tennessee
| | - Chelsea A. Lee
- Division of Pediatric Neurology, Department of PediatricsVanderbilt University Medical Center Nashville Tennessee
| | - Spencer L. Waddle
- Department of Radiology and Radiological SciencesVanderbilt University Medical Center Nashville Tennessee
| | - Manus J. Donahue
- Department of NeurologyVanderbilt University Medical Center Nashville Tennessee
- Department of Radiology and Radiological SciencesVanderbilt University Medical Center Nashville Tennessee
- Department of Psychiatry and Behavioral SciencesVanderbilt University Medical Center Nashville Tennessee
- Department of Physics and AstronomyVanderbilt University Nashville Tennessee
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