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Goklemez S, Hasni S, Hakim FT, Muraro PA, Pirsl F, Rose J, Memon S, Fowler DF, Steinberg SM, Baker EH, Panch SR, Gress R, Illei GG, Lipsky PE, Pavletic SZ. Long-term follow-up after lymphodepleting autologous hematopoietic cell transplantation for treatment-resistant systemic lupus erythematosus. Rheumatology (Oxford) 2021; 61:3317-3328. [PMID: 34875023 DOI: 10.1093/rheumatology/keab877] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/15/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Autologous hematopoietic cell transplantation (AHSCT) improves immunologic dysfunction in patients with Systemic Lupus Erythematosus (SLE). However, the curative potential of this therapy remains uncertain. This study reports outcomes in SLE patients receiving a lymphodepleting reduced intensity regimen for AHSCT in SLE. METHODS Eight patients with SLE refractory to treatment, including intravenous cyclophosphamide, were enrolled. Five had lupus nephritis and three central nervous system involvement as primary indications for transplant. Hematopoietic cell mobilization with cyclophosphamide, G-CSF and rituximab was followed by collection of CD34+ positively selected cells. The conditioning regimen consisted of concurrent administration of cyclophosphamide, fludarabine, and rituximab. All immunosuppressive medications were discontinued at the start of mobilization and corticosteroids were rapidly tapered after the transplant. RESULTS Five of eight patients achieved a complete response, including a decline in the SLEDAI to zero, which was sustained in four patients for a median of 165 months (range 138-191). One patient achieved a partial response, which was followed by relapse at month 18. Two patients with nephritis and most underlying organ comorbidities had early deaths from infection and multiorgan failure. AHSCT resulted in profound lymphodepletion, followed by expansion of Treg cells and repopulation of naive T and B cells. Patients with CR showed a sustained suppression of the SLE-associated interferon-induced gene signature, marked depletion of memory and plasmablast B cells, and resultant sustained elimination of anti-dsDNA antibody. CONCLUSION Durable clinical and serologic remissions with suppression in the interferon gene signature can be achieved in refractory SLE following lymphodepleting AHSCT. TRIAL REGISTRATION ClinicalTrials.gov, https://clinicaltrials.gov, NCT00076752.
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Affiliation(s)
- Sencer Goklemez
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Sarfaraz Hasni
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Frances T Hakim
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Paolo A Muraro
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, United Kingdom
| | - Filip Pirsl
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jeremy Rose
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Sarfraz Memon
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Seth M Steinberg
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Eva H Baker
- Department of Radiology and Imaging Services; Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Sandya R Panch
- Center for Cellular Engineering, National Institutes of Health, USA
| | - Ronald Gress
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Peter E Lipsky
- AMPEL Bio Solutions and the RILITE Research Institute, Charlottesville, Virginia, USA
| | - Steven Z Pavletic
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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Griffith LM, VanRaden M, Barrett AJ, Childs RW, Fowler DH, Kang EM, Tisdale JF, Klein HG, Stroncek DF. Transfusion support for matched sibling allogeneic hematopoietic stem cell transplantation (1993-2010): factors that predict intensity and time to transfusion independence. Transfusion 2019; 59:303-315. [PMID: 30362577 PMCID: PMC6322947 DOI: 10.1111/trf.14966] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 08/23/2018] [Accepted: 08/28/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Patients undergoing allogeneic hematopoietic stem cell transplant require variable, often extensive transfusion support. Identification of factors that predict urgent, intensive, or special needs should improve management of these patients. STUDY DESIGN AND METHODS This is a retrospective study of red blood cell (RBC) and platelet transfusion support provided for sequential matched sibling donor allogeneic transplants conducted at the Clinical Center, National Institutes of Health, from 1993 through 2010. Factors potentially important for predicting quantity of RBC and platelet transfusions, and time to transfusion independence through Day 200 following hematopoietic stem cell transplantation were evaluated. RESULTS Subjects (n = 800) received 10,591 RBC and 10,199 platelet transfusions. Multivariable analysis demonstrated that the need for RBC pretransplant, CD34+ dose, transplant year, diagnostic category, and ABO match were significantly independently associated with quantity of RBC transfusions during Days 0 through 30. Only pretransplant need for RBCs, CD34+ dose, and transplant year had significance during Days 0 through 100. Similar analyses for quantity of platelet transfusions demonstrated that for both Days 0 through 30 and 0 through 100 significant factors were need for platelet support before transplant, CD34+ dose, transplant year, and transplant regimen. Of note, long term, during Days 101 through 200, only CD34+ dose remained significant for quantity of RBC and platelet transfusions. Analysis of time to transfusion independence demonstrated that patients with ABO major mismatches required longer to achieve freedom from RBC transfusion support compared to identical matches or those with minor mismatches. CONCLUSION Patient-specific factors including CD34+ dose and ABO match of the graft should be given particular consideration by transfusion services when planning support of patients receiving allogeneic hematopoietic stem cell transplant.
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Affiliation(s)
- Linda M. Griffith
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Mark VanRaden
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - A. John Barrett
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Richard W. Childs
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Daniel H. Fowler
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Elizabeth M. Kang
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - John F. Tisdale
- Molecular and Clinical Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Harvey G. Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | - David F. Stroncek
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
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Optimal Outcomes in Young Class 3 Patients With Thalassemia Undergoing HLA-Identical Sibling Bone Marrow Transplantation. Transplantation 2016; 100:925-32. [PMID: 26457600 DOI: 10.1097/tp.0000000000000928] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Bone marrow transplantation (BMT) for class 3 patients with thalassemia is challenging due to high rates of graft rejection and transplant-related mortality. Since the first studies of BMT in the late 1980s, a number of conditioning regimens have been designed to improve outcomes, but with suboptimal results. Here we report the outcome of transplantation in class 3 patients using a modified protocol. METHODS Sixty-three patients between 5 and 16.7 years of age with class 3 thalassemia received HLA-matched sibling BMT following either the original protocol (26 patients) or the modified protocol (37 patients). Both regimens comprised preconditioning cytoreduction with hydroxyurea and azathioprine starting at -45 days pretransplant, and fludarabine from days -16 to -12. Conditioning was performed with busulfan and cyclophosphamide (original protocol) or with busulfan, thiotepa, and cyclophosphamide (modified protocol). RESULTS The 2 groups showed similar patient demographics. At day 0, the degree of cytoreduction (lymphopenia, neuthropenia, and thrombocytopenia) achieved by the modified protocol was greater than the original protocol. The incidence of graft failure/rejection was significantly higher in the original group (15%; 95% confidence interval [95% CI], 5-32%) compared with the modified group (0%) (P = 0.014). The respective 5-year thalassemia-free survival rates were 73% (95% CI, 51-86%) and 92% (95% CI, 77-97%) (P = 0.047). Both groups showed similar incidences of grades II to IV acute graft-versus host disease. Modified protocol did not increase nonhematological toxicity or infectious complications. CONCLUSIONS The modified treatment protocol effectively and safely prevented graft failure/rejection and significantly increased thalassemia-free survival of class 3 patients with thalassemia.
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Population pharmacokinetic/dynamic model of lymphosuppression after fludarabine administration. Cancer Chemother Pharmacol 2014; 75:67-75. [PMID: 25374408 DOI: 10.1007/s00280-014-2618-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 10/24/2014] [Indexed: 12/20/2022]
Abstract
PURPOSE Quantitative relationships between 9-β-D-arabinofuranosyl-2-fluoroadenine (F-ara-A) concentrations and lymphosuppression have not been reported, but would be useful for regimen design. A population pharmacokinetic/pharmacodynamic model was constructed in this study using data from 41 hematopoietic cell transplant (HCT) recipients conditioned with busulfan in combination with fludarabine (total dose 120 mg/m², Protocol 1519) or with fludarabine (total dose 250 mg/m²) with rabbit antithymocyte globulin (rATG, Protocol 2041). METHODS Individual pharmacokinetic parameters were fixed to post hoc Bayesian estimates, and circulating absolute lymphocyte counts (ALC) were obtained during the 3 weeks prior to graft infusion. A semi-physiological cell-kill model with three lymphocyte transit compartments was applied and aptly characterized the time course of suppression of circulating ALC by fludarabine administration. Drug- and system-specific parameters were estimated using a maximum likelihood expectation maximization algorithm, and the final model was qualified using an internal visual predictive check. RESULTS The final model successfully characterized the time course and variability in ALC. Pharmacodynamic parameters exhibited considerable between subject variability (38.9-211 %). The HCT protocol was the only covariate associated with the pharmacodynamic parameters, specifically the lymphocyte kill rate, the transit rate between lymphocyte compartments, and the baseline ALC. CONCLUSIONS This model can be used to simulate the degree of lymphosuppression for design of future fludarabine-based conditioning regimens.
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