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Pan M, Wu Y, Yang L, Zhu P, Shi J, Lai X, Liu L, Zhao Y, Yu J, Huang H, Luo Y. Reduced intensity conditioning regimen of fludarabine, busulfan, ATG based haploidentical stem cell transplantation for older or unfit patients. Ann Hematol 2024; 103:3105-3119. [PMID: 38829409 DOI: 10.1007/s00277-024-05819-4] [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: 01/02/2024] [Accepted: 05/26/2024] [Indexed: 06/05/2024]
Abstract
Reduced-intensity conditioning (RIC) regimens allogeneic hematopoietic stem cell transplantation (HSCT) was developed for older patients or those with poor functional status. Haploidentical donor was appropriate alternative donor for patients without matched donors or patients with emergency disease state. However, there was few studies report the outcomes of RIC regimen of anti-thymocyte globulin (ATG) based haploidentical HSCT. The selection of the appropriate RIC regimen based on age and comorbidities in ATG-based haploidentical HSCT remains poorly described. To investigate the safety and efficacy of RIC regimen ATG-based haploidentical HSCT in older or unfit patients. Additionally, to explore the potential factors that impact the prognosis of RIC regimen of ATG-based haploidentical HSCT. We included a retrospective cohort of 63 patients with hematologic malignant diseases who underwent their first RIC haploidentical HSCT from November 2016 to June 2022 at our institutions. The conditioning regimen involved fludarabine (Flu) 30 mg/m²/kg 6 days combined with busulfan 3.2 mg/kg 2 days (Bu2) or 3 days (Bu3). ATG-Fresenius (ATG-F) was administered 10 mg/kg in total, ATG-thymoglobulin (ATG-T) was administered 6 mg/kg in total. The median age of patients in the entire cohort was 60 (32-67) years with a median follow-up of 496 (83-2182) days. There were 29 patients with AML, 20 patients with MDS, and 14 patients with ALL. A total of 32 patients underwent Bu2 RIC haplo-HSCT and 31 patients were treated with Bu3 RIC haplo-HSCT. The 2-year overall survival (OS) and 2-year disease-free survival (DFS) in whole cohort were 67.7% (95% confidence interval [CI], 53.8 - 85.1%) and 61.4% (95% CI, 48.8 - 77.3%) respectively. The cumulative incidence rates of grades II to IV and grades III to IV acute graft-versus-host disease (aGVHD) in whole cohort were 15.8% (95% CI, 4.8 - 19.6%) and 9.7% (95% CI, 0.0 - 11.8%) respectively. The 2-year cumulative incidence of chronic GVHD was 34.0% (95% CI, 18.9 - 46.3%). The 2-year cumulative incidence rates of relapse (IR) and non-relapse mortality (NRM) rates in whole cohort were 27.5% (95% CI, 14.5 - 33.7%) and 11.6% (95% CI, 2.2 - 21.9%) respectively. The probability of 2-year OS were 60.2% (95% CI:42.5-85.3%) in Bu2 and 85.5%(95% CI:73.0-100%) in Bu3 group respectively(P = 0.150). The probability of 2-year DFS were 49.7% (95% CI:33.0-74.8%) in Bu2 and 72.6% (95% CI:55.5-95.5%) in Bu3 group respectively (P = 0.045). The 2-year IR of Bu2 group was significantly higher than Bu3 group (P = 0.045). However, the 2-year NRM were not significantly different between Bu2 and Bu3 group(P > 0.05). In multivariable analysis, RIC regimen of Bu3 had superior OS and DFS than Bu2 group respectively [HR 0.42, 95% CI 0.18-0.98; P = 0.044; HR 0.34, 95% CI 0.14-0.86; P = 0.022]. Besides, RIC regimen of Bu3 had lower IR than Bu2 group [HR 0.34, 95% CI 0.13-0.89; P = 0.029]. The RIC regimen of ATG-based haploidentical HSCT is a safe and effective treatment option for patients who are older or have poor functional status. In particular, a relatively high-intensity pre-treatment regimen consisting of Bu achieves significant improvements in OS and DFS, thus providing more favorable post-transplantation clinical outcomes.
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Affiliation(s)
- Mingyue Pan
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yibo Wu
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Luxin Yang
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Panpan Zhu
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Jimin Shi
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Xiaoyu Lai
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Lizhen Liu
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yanmin Zhao
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Jian Yu
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - He Huang
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China.
- Institute of Hematology, Zhejiang University, Hangzhou, China.
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China.
| | - Yi Luo
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China.
- Institute of Hematology, Zhejiang University, Hangzhou, China.
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China.
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Teramoto M, Takahashi T, Matsumoto K, Jaber M, Kaida K, Tamaki H, Ikegame K, Yoshihara S. Individualized rabbit anti-thymocyte globulin dosing in adult haploidentical hematopoietic cell transplantation with high-risk hematologic malignancy: Exposure-response analysis and population pharmacokinetics simulations. Am J Hematol 2024; 99:387-395. [PMID: 38165019 DOI: 10.1002/ajh.27195] [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: 06/29/2023] [Revised: 12/09/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Abstract
Hematopoietic cell transplantation (HCT) for hematologic malignancies with non-remission disease and/or prior post-transplant relapse have poor relapse-free survival. We previously demonstrated the efficacy of haploidentical reduced-intensity HCT regimen with glucocorticoid-based graft-versus-host disease (GVHD) prophylaxis. We recently showed a possible association between rabbit antithymocyte globulin (rATG) exposure and acute GVHD (aGVHD) risk, leading to hypothesize that optimization of rATG exposure may further improve this regimen. We retrospectively examined the exposure-response association of rATG and key clinical outcomes post haploidentical HCT. We subsequently developed an individualized rATG dosing that optimizes rATG exposure using a previously developed population pharmacokinetic model. Of the 103 patients analyzed, the median age was 47 years (range: 17-70) and majority had a non-remission disease prior to HCT (88%). rATG concentration on day 0 of HCT (Cday_0 ) was the strongest predictor of Grade 2-4 aGVHD through day +100. Patients with Cday_0 ≥ 20 μg/mL had an approximately 3-fold lower risk of Grade 2-4 aGVHD (hazard ratio [HR]: 0.32, 95% confidence interval [CI]: 0.16, 0.62) and Grade 3-4 aGVHD (HR: 0.33, 95% CI: 0.16, 0.68) as well as an approximately 2-fold lower risk of overall mortality (HR: 0.47, 95% CI: 0.28, 0.77) and relapse (HR: 0.50, 95% CI: 0.26, 0.94). In conclusion, this reduced-intensity haploidentical HCT regimen with exposure-optimized rATG may provide a promising option to patients undergoing high-risk HCT for hematologic malignancy. The developed rATG dosing warrant prospective validation.
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Affiliation(s)
- Masahiro Teramoto
- Department of Hematology, Hyogo Medical University Hospital, Hyogo, Japan
| | - Takuto Takahashi
- Pediatric Stem Cell Transplantation, Boston Children's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
| | - Kana Matsumoto
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Kyoto, Japan
| | - Mutaz Jaber
- Pediatric Stem Cell Transplantation, Boston Children's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Katsuji Kaida
- Department of Hematology, Hyogo Medical University Hospital, Hyogo, Japan
| | - Hiroya Tamaki
- Department of Hematology, Hyogo Medical University Hospital, Hyogo, Japan
| | - Kazuhiro Ikegame
- Department of Hematology, Hyogo Medical University Hospital, Hyogo, Japan
| | - Satoshi Yoshihara
- Department of Hematology, Hyogo Medical University Hospital, Hyogo, Japan
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Takahashi T, Teramoto M, Matsumoto K, Jaber MM, Tamaki H, Ikegame K, Yoshihara S, Kaida K. Population Pharmacokinetics of Total Rabbit Anti-thymocyte Globulin in Non-obese Adult Patients Undergoing Hematopoietic Cell Transplantation for Hematologic Malignancy. Clin Pharmacokinet 2023; 62:1081-1091. [PMID: 37284975 DOI: 10.1007/s40262-023-01252-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Rabbit anti-thymocyte globulin (rATG), a therapeutic polyclonal antibody against human T cells, is commonly used in conditioning therapy prior to allogeneic hematopoietic cell transplantation (HCT). Previous studies successfully developed an individualized rATG dosing regimen based on "active" rATG population PK (popPK) analysis, while "total" rATG can be a more logistically favorable alternative for early HCT outcomes. We conducted a novel popPK analysis of total rATG. METHODS Total rATG concentration was measured in adult human-leukocyte antigen (HLA) mismatched HCT patients who received a low-dose rATG regimen (total 2.5-3 mg/kg) within 3 days prior to HCT. PopPK modeling and simulation was performed using nonlinear mixed effect modeling approach. RESULTS A total of 504 rATG concentrations were available from 105 non-obese patients with hematologic malignancy (median age 47 years) treated in Japan. The majority had acute leukemia or malignant lymphoma (94%). Total rATG PK was described by a two-compartment linear model. Influential covariate relations include ideal body weight [positively on both clearance (CL) and central volume of distribution], baseline serum albumin (negatively on CL), CD4+ T cell dose (positively on CL), and baseline serum IgG (positively on CL). Simulated covariate effects predicted that early total rATG exposures were affected by ideal body weight. CONCLUSIONS This novel popPK model described the PK of total rATG in the adult HCT patients who received a low-dose rATG conditioning regimen. This model can be used for model-informed precision dosing in the settings with minimal baseline rATG targets (T cells), and early clinical outcomes are of interest.
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Affiliation(s)
- Takuto Takahashi
- Pediatric Stem Cell Transplantation, Boston Children's Hospital/Dana Farber Cancer Institute, Boston, MA, USA.
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, USA.
| | - Masahiro Teramoto
- Department of Hematology, Hyogo Medical University Hospital, Nishinomiya, Hyogo, Japan
| | - Kana Matsumoto
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Kyotanabe, Kyoto, Japan
| | - Mutaz M Jaber
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | - Hiroya Tamaki
- Department of Hematology, Hyogo Medical University Hospital, Nishinomiya, Hyogo, Japan
| | - Kazuhiro Ikegame
- Department of Hematology, Hyogo Medical University Hospital, Nishinomiya, Hyogo, Japan
| | - Satoshi Yoshihara
- Department of Hematology, Hyogo Medical University Hospital, Nishinomiya, Hyogo, Japan
| | - Katsuji Kaida
- Department of Hematology, Hyogo Medical University Hospital, Nishinomiya, Hyogo, Japan
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Takahashi T, Prockop SE. T-cell depleted haploidentical hematopoietic cell transplantation for pediatric malignancy. Front Pediatr 2022; 10:987220. [PMID: 36313879 PMCID: PMC9614427 DOI: 10.3389/fped.2022.987220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Access to allogenic hematopoietic cell transplantation (HCT), a potentially curative treatment for chemotherapy-resistant hematologic malignancies, can be limited if no human leukocyte antigen (HLA) identical related or unrelated donor is available. Alternative donors include Cord Blood as well as HLA-mismatched unrelated or related donors. If the goal is to minimize the number of HLA disparities, partially matched unrelated donors are more likely to share 8 or 9 of 10 HLA alleles with the recipient. However, over the last decade, there has been success with haploidentical HCT performed using the stem cells from HLA half-matched related donors. As the majority of patients have at least one eligible and motivated haploidentical donor, recruitment of haploidentical related donors is frequently more rapid than of unrelated donors. This advantage in the accessibility has historically been offset by the increased risks of graft rejection, graft-versus-host disease and delayed immune reconstitution. Various ex vivo T-cell depletion (TCD) methods have been investigated to overcome the immunological barrier and facilitate immune reconstitution after a haploidentical HCT. This review summarizes historical and contemporary clinical trials of haploidentical TCD-HCT, mainly in pediatric malignancy, and describes the evolution of these approaches with a focus on serial improvements in the kinetics of immune reconstitution. Methods of TCD discussed include in vivo as well as ex vivo positive and negative selection. In addition, haploidentical TCD as a platform for post-HCT cellular therapies is discussed. The present review highlights that, as a result of the remarkable progress over half a century, haploidentical TCD-HCT can now be considered as a preferred alternative donor option for children with hematological malignancy in need of allogeneic HCT.
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Affiliation(s)
- Takuto Takahashi
- Pediatric Stem Cell Transplantation, Boston Children's Hospital/Dana-Farber Cancer Institute, Boston, MA, United States.,Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, United States
| | - Susan E Prockop
- Pediatric Stem Cell Transplantation, Boston Children's Hospital/Dana-Farber Cancer Institute, Boston, MA, United States
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