Hematopoietic stem cell transplantation for severe combined immune deficiency

Stem Cell Transplantation in the Fetus

BACKGROUND

In utero transplantation (IUT) of hematopoietic stem cells has the potential to treat a large number of hematologic and metabolic diseases amenable to partial replacement of the hematopoietic system.

METHODS

A review of the literature was conducted that focused on the clinical and experimental experience with IUT and, in this context, the development of the hematopoietic and immune systems.

RESULTS

Successful application of IUT has been limited to the treatment of various types of immunodeficiencies that affect lymphocyte development and function. Other congenital defects such as the thalassemias have not resulted in clinically significant engraftment. Recent efforts at understanding and overcoming the barriers to engraftment in the fetus have focused on providing a selective advantage to donor stem cells and fostering immune tolerance toward the donor cells. The critical cellular components of the graft that promote engraftment and tolerance induction are being evaluated in animal models. Improvements in engraftment have resulted from the inclusion of T cells and/or dendritic cells in the graft, as well as a strategy of combined prenatal and postnatal transplantation.

CONCLUSIONS

The advantages, necessity, and benefits of early treatment will continue to encourage development of IUT as a means to treat hematopoietic and other types of birth defects.

Analysis of 120 pediatric patients with nonmalignant disorders transplanted using unrelated plasma-depleted or -reduced cord blood

BACKGROUND

Unrelated cord blood (CB) is an important stem cell source for unrelated hematopoietic cell transplantation (HCT) of patients with nonmalignant disorders. Processing methods to prepare red blood cell-reduced CB units incur significant nucleated cell loss. In contrast, plasma depletion or reduction (PDR) processing of CB units entails the removal of only a portion of the plasma with minimal nucleated cell loss. However, there are relatively limited data regarding outcomes of CB transplants using units processed by PDR.

STUDY DESIGN AND METHODS

A Center for International Blood and Marrow Transplant Research (CIBMTR)-audited analysis was performed on 120 pediatric patients with nonmalignant disorders transplanted between November 2001 and January 2008 at 29 US and 17 international centers using PDR CB units from two CB banks.

RESULTS

Transplant characteristics were as follows: median age, 3.5 years (range, 0.1-14 years); median patient weight, 15 kg (range, 4-61 kg); 58% male; HLA matches (intermediate-resolution HLA-A and HLA-B and high-resolution HLA-DRB1) of the units used in these patients six of six in 26, five of six in 48, four of six in 47, and three of six or two of six in 6; median prefreeze total nucleated cell dose, 10.5×10(7)/kg; median prefreeze CD34+ dose, 3.7×10(5)/kg; and nonmyeloablative regimen in 24%. The median times to myeloid and platelet engraftment were 21 and 49 days, respectively. The cumulative incidence of reported Grade II to IV acute graft-versus-host disease (aGVHD) was 38±5%, and 19±4% had Grade III to IV aGVHD. The Kaplan-Meier estimates of 3-year transplant-related mortality, overall survival, and disease-free survival were 20±4, 79±4, and 70±6%, respectively.

CONCLUSION

These data demonstrate the effectiveness of PDR CB units for HCT.

Prognostic potential of precise molecular diagnosis of Autosomal Recessive Osteopetrosis with respect to the outcome of bone marrow transplantation

Hematopoietic stem cell transplantation (HSCT) is often the only practical approach to fatal genetic defects. One of the first pathologies which HSCT was applied to was Autosomal Recessive Osteopetrosis (ARO), a rare genetic bone disease in which a deficit in bone resorption by osteoclasts leads to increased bone density and secondary defects. The disease is often lethal early in life unless treated with HSCT. In utero transplantation (IUT) of the oc/oc mouse, reproducing the clinical features of a subset of ARO, has demonstrated that the quality of life and the survival of transplanted animals are greatly improved, suggesting that a similar protocol could be applied to humans. However, recently the dissection of the molecular bases of the disease has shown that ARO is genetically heterogeneous and has revealed the presence of subsets of patients which do not benefit from HSCT. This observation highlights the importance of molecular diagnosing ARO to identify and establish the proper therapies for a better prognosis. In particular, on the basis of experimental results in murine models, efforts should be undertaken to develop approaches such as IUT and new pharmacological strategies.