Large-volume leukapheresis using femoral venous access for harvesting peripheral blood stem cells with the Fenwal CS 3000 Plus from normal healthy donors: predictors of CD34+ cell yield and collection efficiency

Personalized autologous stem cell harvesting improves patient collection outcomes

OBJECTIVES

This study aims to demonstrate that utilizing a personalized approach to apheresis stem cell collection, can safely optimize the collection outcomes, especially in the context of poor mobilizers and high cell targets.

BACKGROUND

The optimal mobilization and harvesting of peripheral blood stem cells is critical to the success of the stem cell transplant. The ideal strategy that promotes better cell yields, with sustainable use of resources and assuring patient safety, should be pursued.

METHODS

PBSC collections for autologous stem cell transplant data according to a fixed-processed volume strategy (One Size Fits All) or individualized to patients CD34+ peripheral blood content and target approach (Custom-Tailored or CT) were retrospectively compared.

RESULTS

A total of 263 collections from 142 patients were assessed. The majority of patients were male, had multiple myeloma and were mobilized with isolated G-CSF. The CT strategy promoted a significantly higher CD34+ cell yield when the pre-collection CD34 was lower than 20/µl (1.02 ± 0.16 versus 1.36 ± 0.23, p < 0.001) and also a decrease in the proportion of mobilization cycles that needed 3 apheresis (31% versus 14%, p = 0.02). There was no difference in apheresis-related adverse events between the groups.

CONCLUSION

Tailoring the apheresis procedures to the patient-specific characteristics and objectives, can effectively promote better patient outcome.

Collection of Peripheral Blood Progenitor Cells in 1 Day Is Associated with Decreased Donor Toxicity Compared to 2 Days in Unrelated Donors

Peripheral blood stem cells (PBSCs) have been increasingly used for allogeneic hematopoietic cell transplantation instead of bone marrow stem cells. Current National Marrow Donor Program policy recommends 5 days of daily filgrastim, followed by either 1 or 2 days of apheresis for unrelated donors, depending on collection center choice. To date, there are no published studies comparing the differences in donor experience between 1 day and 2 days of apheresis. We examined 22,348 adult unrelated donor collections in 184 centers between 2006 and 2016. Of these 22,348 donors, 20,004 (89.5%) had collection on 1 day, and the other 2344 (9.5%) had collection over 2 days. Information on why donors underwent apheresis in 1 day or 2 days was not available. Donors who underwent apheresis in 1 day were more likely to be male (67% versus 46%; P < .001), younger (age <30 years, 48% versus 36%; P < .001), and have a higher body weight (83.0 kg versus 75.9 kg; P< .001) and body mass index (BMI; >30, 30% versus 22%; P < .001). Successful collection of the requested CD34+ cell count was achieved on the first day in 82% of 1-day collections and in 16% of 2-day collections. Despite not administering filgrastim the evening after the first day of collection in patients who underwent 2 days of apheresis, the median concentration of CD34+ cells/L in the product was higher on the second day of apheresis compared with the first day (23.8 × 106 CD34+/L on day 1 versus 28.7 × 106 CD34+/L on day 2; P< .001). Donors who underwent collection in 1 day were less likely to experience citrate toxicity (36% versus 52%; P< .001), hospitalization (1% versus 6%; P< .001), and other side effects related to apheresis (Modified Toxicity Criteria incidence: 20% versus 26%; P < .001). Female sex, older age, collection via central lines, and higher BMI were factors associated with greater likelihood for the development of toxicity, whereas less toxicity was noted in those with higher CD34+ counts and more blood processed on the first day of collection. We conclude that although unrelated donors can be successfully collected in 1 day or 2 days, 1-day apheresis procedures were associated with less overall toxicity, and thus we recommend single-day collections, especially if the requested number of cells have been collected in 1 day.

Trends in peripheral stem/progenitor cell manipulation and clinical application

Transplants using peripheral blood hemopoietic stem/progenitor (PBHS) cells are widely performed for the treatment of patients with hematologic disorders in routine practice and clinical trials. Although the process from mobilization to infusion of PBHS cells has been mostly established, optimal conditions for each process remain undetermined. Adverse reactions caused by PBHS cell infusions have not been systematically recorded. In transplants using PBHS cells, a number of problems still exist. In this section, the current status of and future perspectives regarding PBHS cells are described.

Performance and safety of femoral central venous catheters in pediatric autologous peripheral blood stem cell collection

INTRODUCTION

Autologous peripheral blood hematopoietic progenitor cell collection (A-HPCC) in children typically requires placement of a central venous catheter (CVC) for venous access. There is scant published data regarding the performance and safety of femoral CVCs in pediatric A-HPCC.

METHODS

Seven-year, retrospective study of A-HPCC in pediatric patients collected between 2009 and January 2017. Inclusion criteria were an age ≤ 21 years and A-HPCC using a femoral CVC for venous access. Femoral CVC performance was examined by CD34 collection rate, inlet rate, collection efficiency (MNC-FE, CD34-FE), bleeding, flow-related adverse events (AE), CVC removal, and product sterility testing. Statistical analysis and graphing were performed with commercial software.

RESULTS

A total of 75/119 (63%) pediatric patients (median age 3 years) met study criteria. Only 16% of children required a CVC for ≥ 3 days. The CD34 collect rate and CD34-FE was stable over time whereas MNC-FE decreased after day 4 in 80% of patients. CD34-FE and MNC-FE showed inter- and intra-patient variability over time and appeared sensitive to plerixafor administration. Femoral CVC showed fewer flow-related AE compared to thoracic CVC, especially in pediatric patients (6.7% vs. 37%, P = 0.0005; OR = 0.12 (95%CI: 0.03-0.45). CVC removal was uneventful in 73/75 (97%) patients with hemostasis achieved after 20-30 min of pressure. In a 10-year period, there were no instances of product contamination associated with femoral CVC colonization.

CONCLUSION

Femoral CVC are safe and effective for A-HPCC in young pediatric patients. Femoral CVC performance was maintained over several days with few flow-related alarms when compared to thoracic CVCs.

Female donors and donors who are lighter than their recipient are less likely to meet the CD34+ cell dose requested for peripheral blood stem cell transplantation

BACKGROUND

It is of clinical relevance to recognize donors who are unlikely to meet the requested stem cell dose for transplantation, as this group may benefit from an alternative mobilization regimen. This study was performed to evaluate the frequency of unrelated donor peripheral blood stem cell (PBSC) collections that meet the target yield and the impact of donor factors on this.

STUDY DESIGN AND METHODS

All sequential PBSC collections facilitated by the national registry (n = 323) from January through December 2011 were analyzed. Donor factors analyzed included age, sex, weight, and presence of a central line.

RESULTS

In univariate analyses, we found that reaching the target yield was significantly associated with a higher donor weight (85.6 kg vs. 75.3 kg, p < 0.001), male donor sex (55% vs. 19%, p < 0.001), a positive difference in weight between donor and recipient (4.3 kg vs. -8 kg, p < 0.001), and a higher volume of blood processed (13.8 L vs. 11.9 L, p < 0.001). After stepwise binary logistic regression, sex (p < 0.001) and difference between donor and recipient weight (p < 0.005) remained significantly associated with target yield being met after 1 day of collection.

CONCLUSIONS

This study shows than women and donors who are lighter than their recipient have a decreased likelihood of meeting the transplant physician's requested dose. New strategies to improve mobilization in such donors are needed. These findings may also impact future donor recruitment strategies.

Central venous catheter insertion in peripheral blood hematopoietic stem cell sibling donors: the SIdEM (Italian Society of Hemapheresis and Cell Manipulation) point of view

Collection of peripheral blood hematopoietic stem cells (PBSC) is the practice of choice for graft procurement in both autologous and allogeneic setting. The success of this procedure depends on the use of adequate vascular accesses. Well-sized peripheral veins are the first option in autologous and allogeneic donations. In autologous setting, in case of lack of adequate veins, central venous catheters (CVC) may be used for collection. In the allogeneic setting, although available data have shown the safety of the use of CVC, there are still some controversies about the possible insertion of a CVC in donors. A specific policy from competent registries is usually applied in the different countries to regulate the use of CVC in unrelated donors. In siblings, the question is still undefined due both to the lack of shared guidelines and to the specific characteristics of this donation. In fact, in not so rare cases, larger stem cell doses for specific cell manipulations (e.g., T/B cell depletion in the haploidentical setting) are needed. The lack of international rules or standard that forbid the use of a CVC in siblings and published data that document the safety of this procedure, allowed the Società Italiana di Emaferesi e Manipolazione Cellulare (SIdEM) national Board to identify a possible, shared, operational approach to address this issue by a case-specific risk-benefit assessment.

Predictors of the yield of mobilized peripheral blood CD34+ cells in HLA-matched sibling donor

We examined the donor factors that may affect the yield of peripheral blood stem cell (PBSC) mobilized from healthy donors. Pre-apheresis PB-CD34(+) cell count was the only factor that correlated with PBSC yield. Leukocyte count (LC) and monocyte count (MC) correlated with PB-CD34(+) cell. Male gender and PB-CD34(+) cell count of at least 87.1/μL and 69.8/μL on day-4 and -5 of G-CSF were associated with the ability to harvest at least 5×10(6)/kg CD34(+) cells after one apheresis. We concluded that gender and PB-CD34(+) cell count are important predictors of PBSC yield. LC and MC may serve as surrogate markers for estimating the PB-CD34(+) cell count.

The choice of vascular access for therapeutic apheresis

Therapeutic apheresis (TA) is performed using either centrifugation-based or filter-based systems. The blood flow rate (BFR) used for TA using centrifugation-based systems is less than 100 mL/min. Because of this low BFR requirement, even peripheral veins can be considered as an option for TA, especially for less-frequent treatments and those performed for short periods. Other options for vascular access (VA) include central venous catheters (temporary or tunneled), totally implantable ports, and arteriovenous fistulae (AVF) or grafts (AVG). Nontunneled catheters should be considered as the choice of VA for relatively short-term treatments mainly in the inpatient settings. For long-term treatments, ports and tunneled catheters should be considered because of lower rates of infections compared to nontunneled catheters. However, studies in hemodialysis (HD) patients have demonstrated significantly higher morbidity and mortality rates associated with the use of tunneled catheters as compared to AVF. Therefore, if TA is being considered for several years, AVG and AVF would be the preferred options of VA. Studies in HD population indicate far better outcomes with the use of AVF as compared to AVG. This article, as presented at the Therapeutic Apheresis Academy in September 2011, is an overview of the available VA options for TA based on indication and duration of treatment. Pros and cons of each option are mentioned briefly. Finally, for those considered for AVF placement for chronic TA, specific recommendations are made for the care of AVF based on our own experience at University of Virginia.

Collection of peripheral blood CD34+ progenitor cells from healthy dogs and dogs diagnosed with lymphoproliferative diseases using a Baxter-Fenwal CS-3000 Plus blood cell separator

BACKGROUND

Canine peripheral blood mononuclear cell (PBMC) apheresis using a Baxter-Fenwal CS-3000 Plus automated blood cell separator has not been reported.

OBJECTIVE

To determine the feasibility and safety of using a CS-3000 Plus blood cell separator with a small volume separation container holder (SVSCH) and small volume collection chamber (SVCC) to harvest canine PBMCs from dogs weighing <50 kg.

ANIMALS

Eight healthy mongrel dogs and 11 client-owned dogs in clinical remission for lymphoproliferative diseases (LPD).

METHODS

In this prospective study, aphereses were performed using a Baxter-Fenwal CS-3000 Plus blood cell separator, with or without recombinant human granulocyte colony-stimulating factor (rhG-CSF) treatment.

RESULTS

Aphereses from 6 healthy dogs given rhG-CSF yielded an average of 1.1 × 10(7) ± 8.2 × 10(6) CD34+ cells/kg. Aphereses from LPD dogs given rhG-CSF yielded an average of 5.4 × 10(6) ± 3.25 × 10(6) CD34+ cells/kg (P = .17). Higher hematocrit in both groups of dogs receiving rhG-CSF correlated with an increased number of CD34+ cells/kg harvested (healthy, P = .04; LPD, P = .05). Apheresis was well tolerated by all dogs.

CONCLUSIONS AND CLINICAL IMPORTANCE

Canine PBMC apheresis using the Baxter-Fenwal CS-3000 Plus cell separator with an SVSCH and SVCC is a feasible and safe option for harvesting an adequate number of CD34+ peripheral blood progenitor cells from dogs weighing ≥17 kg for hematopoietic cell transplantation.

Adverse events and safety issues in blood donation--a comprehensive review

Although blood donation is generally safe, a variety of risks and complications exist, the most common being iron deficiency, vasovagal reactions and citrate-related events. In the last decades, extensive efforts have significantly improved recipient and product safety, but there is still great potential to optimise donor care. Many therapies in modern medicine depend on the prompt availability of blood products, therefore it is crucial to maintain a motivated and healthy donor pool in view of a limited number of healthy volunteers willing and able to give blood or blood components. We present a comprehensive review on adverse events addressing all types of blood donation including whole blood, plasma, platelet, peripheral blood stem cell, leucocyte and bone marrow donation. In addition, we outline strategies for the prevention and treatment of these events and give a blueprint for future research in this field.

BCL2 gene polymorphism could predict the treatment outcomes in acute myeloid leukemia patients

The Bcl-2 protein inhibits apoptosis (programmed cell death) of hematopoietic stem cells induced by a variety of noxious stimuli, thus mediating chemoresistance and decreasing chemosensitivity. Higher Bcl-2 expression correlates to an adverse outcome following therapy for acute myeloid leukemia (AML). The current study determined whether a BCL2 gene single nucleotide polymorphism (SNP) could affect treatment outcomes in 99 AML patients excluding acute promyelocytic leukemia. Two genotypes were tested, including BCL2 -938 C>A (rs2279115) and +21 A>G (rs1801018). Neither the -938 C>A nor the +21 A>G BLC2 genotype was associated with complete remission (CR) rates following chemotherapy. The -938 A>C BCL2 genotype did not affect leukemia-free survival (LFS), event-free survival (EFS) or overall survival (OS). However, of interest, the BCL2 +21 A>G genotype correlated with LFS, EFS and OS: The group with the +21 AA genotype had a significantly longer median LFS (p<0.001) or EFS (p=0.004), and OS (p=0.04). The multivariate analyses confirmed that this BCL2 gene SNP is an independent prognostic factor for LFS (p=0.05, HR 1.83, 95% C.I. [1.02-3.45]) and EFS (p=0.02, HR 3.13 [1.34-6.43]), but not for OS (p=0.1). This data suggests the involvement of a Bcl-2-mediated mechanism in the development of chemoresistance in AML.

Multiple myeloma patients receiving large volume leukapheresis efficiently yield enough CD34+ cells to allow double transplants

Current protocols for myeloma patients require more than one autologous transplant. We performed a retrospective study to determine the cost-effectiveness of large volume leukapheresis (LVL) compared with standard volume leukapheresis (SVL) collection when two transplants are required. We evaluated 87 patients who underwent a cumulative total of 260 LVL and SVL collections. The median product volume per collection was 356 ml for LVL, and this was significantly higher than the median product volume per collection for SVL (median 149.5 ml, P < 0.001). The median total CD34+ cell yield/kg was 6.4 x 10(6) for LVL and 5.2 x 10(6) for SVL. This difference was statistically significant (P = 0.005). Because the target CD34+ cell dose for a single transplant was 3 x 10(6)/kg at our institution, overall the LVL yields enough CD34+ cells that could allow for two transplants. Therefore, more patients in the LVL group were able to undergo a potential second transplant. Because of the reserved cells for a second transplant, LVL patients received significantly less CD34+ cell/kg per transplant than the patients in SVL group (P = <0.001). As a result, LVL group had statistically significant but clinically insignificant delay in neutrophil (P = <0.001) and platelet (P = 0.02) engraftments. Additionally, using LVL instead of SVL to collect >or=6 x 10(6)/kg CD34+ cells may potentially save $7,497 per patient. We therefore conclude that LVL is the method of choice for collection of multiple myeloma patients when two transplants are anticipated.

Non-CD34+ cells, especially CD8+ cytotoxic T cells and CD56+ natural killer cells, rather than CD34 cells, predict early engraftment and better transplantation outcomes in patients with hematologic malignancies after allogeneic peripheral stem cell transplantation

The effect of the transplant dose of each cell subset on engraftment kinetics and transplantation outcomes was evaluated in HLA-identical allogeneic peripheral blood stem cell transplantation (PBSCT). Sixty-nine patients were included in this retrospective study. Engraftment kinetics, transplantation outcomes, and immune reconstitution up to 1 year after transplantation were analyzed according to the transplant dose of CD34+ and non-CD34+ cells, including natural killer (NK) cells and CD8+ cytotoxic T (Tc) cells. An accelerated neutrophil engraftment was strongly associated with a higher transplant dose of NK cells (12 versus 16 days, P < .001) and Tc cells (13 versus 16 days, P < .001) but not CD34+ cells (P = .442). Survival analyses revealed a favorable prognosis for patients who received a higher dose of non-CD34+ cell subsets, rather than CD34+ cells, in terms of overall survival (OS; P = .024 for NK cells and .050 for Tc cells) and nonrelapse mortality (NRM; P = .005 for NK cells, .060 for Tc cells). In addition, a higher transplant dose of NK and Tc cells was correlated with a faster lymphoid reconstitution. In multivariate analyses, rapid neutrophil engraftment was correlated with a higher transplant dose of NK cells (P = .001) and Tc cells (P = .004). Moreover, an increased OS was associated with the NK cell dose (P = .007) and chronic graft-versus-host disease (P = .009), whereas a decreased NRM was associated with the NK dose (P = .024). In conclusion, in a PBSCT setting, a higher transplant dose of NK and Tc cells accelerated neutrophil engraftment, improved the immune reconstitution, and decreased NRM, thereby increasing OS after allogeneic PBSCT.

Poor mobilization is an independent prognostic factor in patients with malignant lymphomas treated by peripheral blood stem cell transplantation

Haemopoietic stem cell therapy is an increasingly adopted procedure in the treatment of patients with malignant lymphoma. In this retrospective analysis, we evaluated 262 patients, 57 (22%) with Hodgkin's and 205 (78%) with non-Hodgkin's lymphomas (NHL), and 665 harvesting procedures in order to assess the impact of poor mobilization on survival and to determine the factors that may be predictive of CD34(+) poor mobilization. The mobilization chemotherapy regimens consisted of high-dose cyclophosphamide in 92 patients (35.1%) and a high-dose cytarabine-containing regimen (DHAP in 87 patients -(33.2%), MAD in 83 (31.7%)). The incidence of poor mobilizers (<2 x 10(6) CD34(+) cells/kg) was 17.9% overall, with a 10% of very poor mobilizers (< or = 1 x 10(6)/kg). Refractory disease status and chemotherapeutic load (>3 regimens) before mobilization played a negative role and were associated with poor mobilization. Survival analysis of all harvested patients showed an overall survival at 3 years of 71% in good mobilizers vs 33% in poor mobilizers (P=0.002). The event-free survival at 3 years was 23% in poor mobilizers and 58% in good mobilizers (P=0.04). We conclude that in NHL patients, poor mobilization status is predictive of survival.

Rapid helper T-cell recovery above 200 × 106/l at 3 months correlates to successful transplant outcomes after allogeneic stem cell transplantation

The current study evaluates the role of quantitative measurement of peripheral lymphocyte subsets, especially CD4+ helper T-cell recovery, in predicting transplant outcomes including overall survival (OS) and non-relapse mortality (NRM) after allogeneic stem cell transplantation. A total of 69 allogeneic recipients were included with following diagnoses: acute myeloid leukemia 42, acute lymphoblastic leukemia 5, chronic myeloid leukemia 15, non-Hodgkin's lymphoma 5 and high-risk myelodysplastic syndrome 2. The peripheral lymphocyte subset counts (CD3+ T cells, CD3+4+ helper T cells, CD3+8+ cytotoxic T cells, CD19+ B cells, and CD56+ natural killer cells) were measured at 3, 6 and 12 months. The CD4+ helper T-cell reconstitution at 3 months was strongly correlated with OS (P<0.0001), NRM (P=0.0007), and opportunistic infections (P=0.0108) at the cutoff value of 200 x 10(6)/l CD4(+) helper T cells. Rapid CD4+ helper T-cell recovery was also associated with a higher CD4+ helper T-cell transplant dose (P=0.006) and donor type (P<0.001). An early CD4+ helper T-cell recovery at 3 months correlated with a subsequent faster helper T-cell recovery until 12 months, yet not with B-cell recovery. In a multivariate analysis, rapid recovery of CD4+ helper T cells at 3 months was a favorable prognostic factor together with higher CD34+ cell transplant dose in terms of OS (P=0.001) and NRM (P=0.005).

Multidrug resistance-1 gene polymorphisms associated with treatment outcomes in de novo acute myeloid leukemia

Multidrug resistance-1 (MDR-1) gene single nucleotide polymorphisms (SNPs) have been identified as associated with the treatment outcomes of acute myeloid leukemia (AML) in Caucasians; yet, similar evidence is lacking for Asian populations. A total of 101 AML patients were enrolled in the current study. Two MDR1 SNPs (C3435T and G2677T/A) were analyzed with PCR/RFLP assay. As regards C3435T polymorphism, C/C genotype was significantly correlated with lower functional P-glycoprotein (P-gp) activity in leukemic blasts (7.5%) compared with C/T (10.7%) or T/T genotype (19.9%, p = 0.029). In genotypic analyses, C/C at -3435 (p = 0.05) and G/G at -2677 (p = 0.04) were strongly associated with a higher probability of complete remission (CR). In addition, the 3-year event-free survival (EFS) was higher in G/G genotype at -2677 (60.6%) than nonG/G (21.9%; p = 0.0241), in C/C at -3435 was higher than nonC/C genotype (p = 0.0139), and was higher in GC haplotype homozygote (58.2%) than nonGC homozygote (22.6%; p = 0.0427). In a multivariate analysis, the group without GC haplotype showed worse EFS (p = 0.030), with unfavorable cytogenetic risk (p = 0.008). However, no differences were noted in overall survival according to the MDR1 SNPs (p = 0.491 for C3435T and p = 0.955 for G2677T/A).

Does mRNA level of microsomal carnitine palmitoyltransferase predict yield of peripheral blood stem cell apheresis?

Transplantation of autologous hematopoietic stem cells is a well established therapeutic procedure. Despite advances in efficacy of the stem cell mobilization and apheresis process until now a predictive factor for the expected stem cell yield before initiation of mobilization therapy could not be identified. The main objective of our study was to evaluate alterations in enzymes involved in fatty acid metabolism on the level of gene expression in mononuclear cells, as changes in relative mRNA levels of these enzymes could represent the hematopoietic regenerative potential. Data of 23 consecutive patients with different lymphoid malignancies undergoing stem cell mobilization were analyzed. Our results show that mRNA levels of microsomal carnitine palmitoyltransferase in peripheral blood mononuclear cells quantified before application of mobilization therapy correlate positively with the amount of CD34 positive cells in peripheral blood before first apheresis, in the first apheresis product and in the total harvest outcome. The association of enzymes involved in fatty acid metabolism with hematoopoiesis was further confirmed in healthy subjects on altitude-adaptation training and in proliferating or differentiating HL60 cells. This gives evidence for a possible predictive value of such analyzes though further data of a larger sample are to be collected to confirm our observations.

Clinical significance of platelet count at day +60 after allogeneic peripheral blood stem cell transplantation

Thrombocytopenia (TP) is a frequent complication after allogeneic stem cell transplantation (SCT) and regarded as a poor prognostic factor, especially in patients with chronic graft-versus-host disease (GVHD), although various factors were related to the development of TP after allogeneic SCT. Sixty-three patients receiving allogeneic peripheral blood stem cell transplantation (PBSCT) were stratified according to platelet count (PC) at day +60 and analyzed in terms of overall survival (OS) and the incidence of non-relapse mortality (NRM). Ten patients (15.9%) were stratified in group 1 (PC </= 29 x 10(9)/L), 23 patients (36.5%) in group 2 (PC 30-79 x 10(9)/L), and 30 patients in group 3 (PC >/= 80 x 10(9)/L). Group 3 was associated with lower incidence of extensive chronic GVHD (p=0.013), better 3-yr OS (p=0.0030), and lower NRM rate (p<0.0001). In multivariate analyses, the PC at day +60 was identified as an independent prognostic factor (p=0.003) together with CD34+ cell dose (p<0.001), disease risk (p=0.004), and acute GVHD (p=0.033) in terms of NRM, and the PC (p=0.047) and CD34+ cell dose (p=0.026) in terms of incidence of infectious events. Measuring the platelet count at day +60 is a simple method for predicting the risk of chronic GVHD development and prognosis after allogeneic PBSCT.

Survival Benefit of Asymptomatic Cytomegalovirus Reactivation after HLA-Identical Allogeneic Peripheral Blood Stem Cell Transplantation

BACKGROUND

Cytomegalovirus (CMV) reactivation (CMV-R) is associated with increased morbidity after allogeneic stem cell transplantation (SCT). However, after the introduction of ganciclovir preemptive therapy, CMV-R can be successfully controlled if the recipient's immunity recovers. Although many investigations have already focused on CMV-R as a risk factor, data related to the impact of asymptomatic CMV-R on transplant outcomes is scarce. Accordingly, the present study analyzed the differences in the transplant outcomes the immune reconstitution according to the CMV-R after allogeneic PBSCT.

METHODS

A total of 76 patients undergoing allogeneic peripheral blood stem cell transplantation (PBSCT) were included in the current study. The transplant outcomes and immune reconstitution after 3, 6, and 12 months were analyzed according to the occurrence of CMV-R in 33 patients.

RESULTS

The analysis revealed a favorable prognosis for the group with CMV-R compared to those without CMV-R: P = 0.0037 for OS, P = 0.0204 for NRM, and P = 0.05 for the risk of relapse. CMV-R was also found to correlate to the lymphoid reconstitution (P = 0.024). In multivariate analyses, CMV-R was found to be a favorable prognostic factor in terms of OS (P = 0.010, hazard ratio [HR] 2.948) and NRM (P = 0.05, HR 2.665), along with a higher transplant CD34 cell dose (P = 0.003 for OS, P = 0.002 for NRM), standard risk (P = 0.023 for OS), and acute GVHD grades 0-2 (P = 0.007 for NRM).

CONCLUSION

In a PBSCT setting, CMV-R did not seem to be a poor prognostic factor in terms of OS and NRM, possibly due to the accelerated lymphoid immune reconstitution associated with CMV-R.

IL-10 promoter gene polymorphism associated with the occurrence of chronic GVHD and its clinical course during systemic immunosuppressive treatment for chronic GVHD after allogeneic peripheral blood stem cell transplantation

BACKGROUND

The current study attempted to evaluate the association between IL-10 promoter gene polymorphism and transplant outcomes including the occurrence of chronic graft-versus-host disease (GVHD) and its clinical course during systemic immunosuppressive treatment (IST) among 60 recipients of cytokine-mobilized peripheral blood stem cell (PBSC) from HLA-matched sibling donors.

METHODS

We analyzed 3 single-nucleotide polymorphisms in proximal region of IL-10 promoter gene (-1082/-819/-592).

RESULTS

In the current study, only two haplotypes (1082*A/819*T/592*A [ATA] and 1082*A/819*C/592*C [ACC]) were found. An increased occurrence of chronic GVHD was noted dependent on the IL-10 haplotypes (43% vs. 68% vs. 96% in ACC/ACC vs. ATA/ACC vs. ATA/ATA haplotype, P=0.003). In a logistic regression based on multinomial model, ATA/ATA homozygote had 7-fold increasing risk of the development of chronic GVHD compared with ACC/ACC homozygote. The incidence of chronic GVHD at 1 year was 46%+/-20%, 64%+/-10%, and 82%+/-5% in ACC/ACC, ATA/ACC and ATA/ATA group, respectively (P=0.0266). Plus, the duration of systemic IST was significantly shorter in recipients without ATA-haplotype comparing with those with ATA haplotype (339 days vs. 1,146 days, P=0.0091).

CONCLUSION

IL-10 promoter gene polymorphism was found to be apparently associated with chronic GVHD after allogeneic peripheral blood stem cell transplantation from HLA-matched sibling donors.

Safe And Efficient Collection of Cytokine-Mobilized Peripheral Blood Cells From Cynomolgus Monkeys (Macaca fascicularis) with Human Newborn-Equivalent Body Weights

Hematopoietic stem cells in bone marrow can be mobilized into peripheral blood by cytokine administration. Cytokine-mobilized peripheral blood stem cells are of great use in clinical applications. We previously established a modified procedure for the collection of cytokine-mobilized peripheral blood cells from rhesus monkeys (Macaca mulata) using a commercially available apparatus originally developed for human subjects. In this study, we examined the efficacy and safety of this method with even smaller macaques, cynomolgus monkeys (Macaca fascicularis), which are equivalent to human newborns in body weight (mean = 3.3 kg). Using the manufacturer's unmodified protocol (n=6), one monkey died of cardiac failure and three developed severe anemia. In contrast, using our modified procedure (n=6), no such complication was observed in any animal. In addition, the harvested nuclear cell, mononuclear cell and CD34(+) cell counts were significantly higher with the modified method. The modified method should allow safe and efficient collection of cytokine-mobilized peripheral blood cells from non-human primates as small as human newborns in a non-invasive manner.

Risk factors for late cytomegalovirus infection after allogeneic stem cell transplantation using HLA-matched sibling donor: donor lymphocyte infusion and previous history of early CMV infection

An increased incidence of late cytomegalovirus (CMV) infection has been reported during the last decade since the introduction of ganciclovir (GCV) prophylaxis or GCV pre-emptive therapy. Given that a donor lymphocyte infusion (DLI) can induce more severe GVHD, this may predispose a patient to late CMV infection. In all, 64 patients (median age 36, M/F 38/26) underwent allogeneic stem cell transplantation (SCT) using a matched sibling donor with bone marrow (n=9) or peripheral blood stem cells (n=55). The overall incidence of CMV infection, early and late CMV infection was 46.9 (30/64), 42.2 (27/64), and 16.4% (9/55), respectively. Early CMV infection was treated with GCV pre-emptive therapy that produced a 92.6% success rate. Among the 20 patients who received 35 DLIs, late CMV infection developed in eight (42.1%) of 19 evaluable cases with a median onset at 127 days post transplant. Risk factors for late CMV infection in a logistic regression analysis included DLIs (P=0.001) and a previous history of CMV infection (P=0.006). In conclusion, late CMV infection was strongly associated with DLIs and a previous history of early CMV infection. Accordingly, extended surveillance of CMV antigenemia is recommended for patients receiving DLIs or who have a previous history of CMV infection.

Transplantation outcome in allogeneic PBSCT patients according to a new chronic GVHD grading system, including extensive skin involvement, thrombocytopenia, and progressive-type onset

Patients who had suffered chronic GVHD after an allogeneic PBSCT were evaluated using a new chronic GVHD grading system. The study included 36 consecutive adult patients with hematological diseases, who survived at least until day 90 following allogeneic PBSCT and who could be evaluated for chronic GVHD. Extensive skin involvement was observed in five patients, thrombocytopenia in 14, and progressive-type onset in 10, while grade 1 chronic GVHD appeared in 21 patients, grade 2 in 10, and grade 3 in five. There was a significant difference in the probability of relapse between the groups with grade 1 and 2+3 chronic GVHD (55.3 vs 16.4%, P=0.0211). The difference was particularly marked in patients with high-risk hematological malignancies (grade 1 vs grade 2+3, 75 vs 0%, P=0.0115). With a median follow-up of 12 months (range, 4-52 months), 22 (66.1%) patients were still alive. The estimated 2-year survival rate for the whole population was 57.6%, while that for the group with chronic GVHD grade 1 and grade 2+3 was 53.5 and 56.3%, respectively (P=0.4387). Accordingly, there was a significant difference in the probability of relapse between the groups with grade 1 and grade 2+3 chronic GVHD.

Outcome of allogeneic peripheral blood stem cell transplantation using matched sibling donors in patients with high-risk hematological diseases

Although the use of peripheral blood stem cells instead of bone marrow is still a matter of debate in transplantation from HLA-identical sibling donors, allogeneic peripheral blood stem cell transplantation (PBSCT), with a stronger graft-versus-leukemia (GVL) effect, may be preferable as a source of stem cells, especially in the case of advanced hematologic diseases. As such, the current paper reports on the outcomes of 27 consecutive patients with high-risk hematologic diseases treated with allogeneic PBSCT. The median dose of CD34+, CD3+ cells, and MNC infused was 8.18 x 10(6)/kg (range: 2.78-14.93), 1.50 x 10(8)/kg (range: 0.06-4.25), and 7.17 x 10(8)/kg (range: 0.95-15.85), respectively. The median time taken for the ANC and platelets to reach 500 and 20,000 x 10(6)/microL was 15 (range: 9-25) and 16 d (range: 10-56), respectively. Three patients (11.1%) experienced transplant-related mortality within 90 d of transplantation, and 15 (62.5%) of 24 evaluated patients developed chronic graft-versus-host disease (GVHD; six limited, nine extensive). There was a significant difference in overall survival (OS) between the group with chronic GVHD and the group without chronic GVHD (P = 0.0253). The causes of death included relapse (six cases) and non-relapse mortality (infection: four cases, chronic GVHD-related death: three cases). The 4-yr OS rate and disease-free survival rate was 43.3 +/- 10.9% and 35.8 +/- 10.2%, respectively. Accordingly, chronic GVHD was found to have a positive role in patients with high-risk hematologic diseases that received allogeneic PBSCT.

Clinical impact of early absolute lymphocyte count after allogeneic stem cell transplantation

The role of repopulating lymphocytes after allogeneic stem cell transplantation (SCT) includes the prevention of serious infections and attacking residual tumour cells in the early post-transplant phase. Therefore, the current study analysed the role of the absolute lymphocyte count (ALC) on day 21 after SCT in predicting transplant outcomes of 82 patients in terms of the risk of opportunistic infections and recurrence of original disease. The median dose of CD34+, CD3+ and mononuclear cells (MNC) infused was 6.41 x 10(6)/kg, 1.96 x 10(8)/kg and 6.81 x 10(8)/kg respectively. The high ALC group (high ALC on day 21; > or =0.35 x 10(9)/l) was associated with the use of peripheral blood stem cells, matched sibling donors and higher cell doses of MNC, CD3+ and CD4+ cells. The high ALC group also exhibited a better overall survival (56.3% vs. 17.7%) and disease-free survival (50.1% vs. 15.9%) after 3 years and lower incidences of relapse (33.6% vs. 67.1%) and fungal infections (3.0% vs. 19.5%) after 1 year. The incidence of cytomegalovirus antigenaemia was lower in the high ALC group (47.7% vs. 73.7%). Accordingly, identifying the ALC on day 21 would appear to be a useful and simple measurement to predict those patients with a high risk of opportunistic infections and relapse after allogeneic SCT.