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Naik S, Li Y, Talleur AC, Selukar S, Ashcraft E, Cheng C, Madden RM, Mamcarz E, Qudeimat A, Sharma A, Srinivasan A, Suliman AY, Epperly R, Obeng EA, Velasquez MP, Langfitt D, Schell S, Métais JY, Arnold PY, Hijano DR, Maron G, Merchant TE, Akel S, Leung W, Gottschalk S, Triplett BM. Memory T-cell enriched haploidentical transplantation with NK cell addback results in promising long-term outcomes: a phase II trial. J Hematol Oncol 2024; 17:50. [PMID: 38937803 PMCID: PMC11212178 DOI: 10.1186/s13045-024-01567-0] [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: 05/06/2024] [Accepted: 06/13/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Relapse remains a challenge after transplantation in pediatric patients with hematological malignancies. Myeloablative regimens used for disease control are associated with acute and long-term adverse effects. We used a CD45RA-depleted haploidentical graft for adoptive transfer of memory T cells combined with NK-cell addback and hypothesized that maximizing the graft-versus-leukemia (GVL) effect might allow for reduction in intensity of conditioning regimen. METHODS In this phase II clinical trial (NCT01807611), 72 patients with hematological malignancies (complete remission (CR)1: 25, ≥ CR2: 28, refractory disease: 19) received haploidentical CD34 + enriched and CD45RA-depleted hematopoietic progenitor cell grafts followed by NK-cell infusion. Conditioning included fludarabine, thiotepa, melphalan, cyclophosphamide, total lymphoid irradiation, and graft-versus-host disease (GVHD) prophylaxis consisted of a short-course sirolimus or mycophenolate mofetil without serotherapy. RESULTS The 3-year overall survival (OS) and event-free-survival (EFS) for patients in CR1 were 92% (95% CI:72-98) and 88% (95% CI: 67-96); ≥ CR2 were 81% (95% CI: 61-92) and 68% (95% CI: 47-82) and refractory disease were 32% (95% CI: 11-54) and 20% (95% CI: 6-40). The 3-year EFS for all patients in morphological CR was 77% (95% CI: 64-87) with no difference amongst recipients with or without minimal residual disease (P = 0.2992). Immune reconstitution was rapid, with mean CD3 and CD4 T-cell counts of 410/μL and 140/μL at day + 30. Cumulative incidence of acute GVHD and chronic GVHD was 36% and 26% but most patients with acute GVHD recovered rapidly with therapy. Lower rates of grade III-IV acute GVHD were observed with NK-cell alloreactive donors (P = 0.004), and higher rates of moderate/severe chronic GVHD occurred with maternal donors (P = 0.035). CONCLUSION The combination of a CD45RA-depleted graft and NK-cell addback led to robust immune reconstitution maximizing the GVL effect and allowed for use of a submyeloablative, TBI-free conditioning regimen that was associated with excellent EFS resulting in promising long-term outcomes in this high-risk population. The trial is registered at ClinicalTrials.gov (NCT01807611).
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Affiliation(s)
- Swati Naik
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA.
| | - Ying Li
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Aimee C Talleur
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Subodh Selukar
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Emily Ashcraft
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Cheng Cheng
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Renee M Madden
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ewelina Mamcarz
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Amr Qudeimat
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Akshay Sharma
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ashok Srinivasan
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ali Y Suliman
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Rebecca Epperly
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Esther A Obeng
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - M Paulina Velasquez
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Deanna Langfitt
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Sarah Schell
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Jean-Yves Métais
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Paula Y Arnold
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Diego R Hijano
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Gabriela Maron
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Salem Akel
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Wing Leung
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Stephen Gottschalk
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Brandon M Triplett
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA.
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2
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Miyamoto S, Niizato D, Tomomasa D, Nishimura A, Hoshino A, Kamiya T, Isoda T, Takagi M, Kajiwara M, Azumi S, Hirabayashi S, Sakamoto K, Kishimoto K, Miyamura T, Umeda K, Hirose A, Keino D, Yanagimachi M, Kanda K, Sakai Y, Ikawa Y, Watanabe K, Tanaka K, Mori T, Ichinohe T, Sakaguchi H, Morio T, Kanegane H. Allogeneic Hematopoietic cell Transplantation Using Alemtuzumab in Asian Patients with Inborn Errors of Immunity. J Clin Immunol 2024; 44:126. [PMID: 38773000 DOI: 10.1007/s10875-024-01734-5] [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: 02/01/2024] [Accepted: 05/09/2024] [Indexed: 05/23/2024]
Abstract
Alemtuzumab is used with reduced-toxicity conditioning (RTC) in allogeneic hematopoietic cell transplantation (HCT), demonstrating efficacy and feasibility for patients with inborn errors of immunity (IEI) in Western countries; however, the clinical experience in Asian patients with IEI is limited. We retrospectively analyzed patients with IEI who underwent the first allogeneic HCT with alemtuzumab combined with RTC regimens in Japan. A total of 19 patients were included and followed up for a median of 18 months. The donors were haploidentical parents (n = 10), matched siblings (n = 2), and unrelated bone marrow donors (n = 7). Most patients received RTC regimens containing fludarabine and busulfan and were treated with 0.8 mg/kg alemtuzumab with intermediate timing. Eighteen patients survived and achieved stable engraftment, and no grade 3-4 acute graft-versus-host disease was observed. Viral infections were observed in 11 patients (58%) and 6 of them presented symptomatic. The median CD4+ T cell count was low at 6 months (241/µL) but improved at 1 year (577/µL) after HCT. Whole blood cells continued to exhibit > 80% donor type in most cases; however, 3/10 patients exhibited poor donor chimerism only among T cells and also showed undetectable levels of T-cell receptor recombination excision circles (TRECs) at 1 year post-HCT. This study demonstrated the efficacy and safety of alemtuzumab; however, patients frequently developed viral infections and slow reconstitution or low donor chimerism in T cells, emphasizing the importance of monitoring viral status and T-cell-specific chimerism. (238 < 250 words).
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Affiliation(s)
- Satoshi Miyamoto
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Daiki Niizato
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Dan Tomomasa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Akira Nishimura
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Akihiro Hoshino
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Takahiro Kamiya
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Takeshi Isoda
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Masatoshi Takagi
- Department of Community Pediatrics, Perinatal and Maternal Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Michiko Kajiwara
- Center for Transfusion Medicine and Cell Therapy, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Shohei Azumi
- Department of Hematology and Oncology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Shinsuke Hirabayashi
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Kenichi Sakamoto
- Department of Pediatrics, Shiga University of Medical Science, Shiga, Japan
| | - Kenji Kishimoto
- Department of Hematology and Oncology, Kobe Children's Hospital, Hyogo, Japan
| | - Takako Miyamura
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Katsutsugu Umeda
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ayana Hirose
- Division of Hematology/Oncology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Dai Keino
- Division of Hematology/Oncology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Masakatsu Yanagimachi
- Division of Hematology/Oncology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Kaori Kanda
- Department of Pediatrics, Gifu Municipal Hospital, Gifu, Japan
| | - Yuta Sakai
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Yasuhiro Ikawa
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Kenichiro Watanabe
- Department of Hematology and Oncology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Keisuke Tanaka
- Department of Hematology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Takehiko Mori
- Department of Hematology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Hirotoshi Sakaguchi
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Hirokazu Kanegane
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
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Vasseur L, Cuffel A, Pondarré C, Dalle JH, Chevillon F, Fourmont AM, Flamarion E, Yakouben K, Guérin-El Khourouj V, Morin F, Ibanez C, Peffault de Latour R, Boissel N, Arlet JB, Moins-Teisserenc H, Caillat-Zucman S, Dhédin N. Early lymphocyte reconstitution and viral infections in adolescents and adults transplanted for sickle cell disease. Bone Marrow Transplant 2024; 59:708-710. [PMID: 38413822 DOI: 10.1038/s41409-024-02224-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Loïc Vasseur
- Hematology Adolescent and Young Adult Unit, St-Louis University Hospital, AP-HP, Paris, France
| | - Alexis Cuffel
- Immunology laboratory, St-Louis University Hospital, AP-HP, Paris, France
| | - Corinne Pondarré
- Referral Center for Sickle Cell Disease, Pediatrics, CHIC Hospital, Créteil, France
- Inserm U955, Paris XII University, Créteil, France
| | - Jean-Hugues Dalle
- Pediatric immuno-hematology, Robert Debré University Hospital, AP-HP, Paris, France
| | - Florian Chevillon
- Hematology Adolescent and Young Adult Unit, St-Louis University Hospital, AP-HP, Paris, France
| | - Aude-Marie Fourmont
- Hematology Adolescent and Young Adult Unit, St-Louis University Hospital, AP-HP, Paris, France
| | - Edouard Flamarion
- French Sickle Cell Referral Centre, Department of Internal Medicine, Georges Pompidou European Hospital, Université de Paris Cité, AP-HP, Paris, France
| | - Karima Yakouben
- Pediatric immuno-hematology, Robert Debré University Hospital, AP-HP, Paris, France
| | | | - Florence Morin
- Immunology laboratory, St-Louis University Hospital, AP-HP, Paris, France
| | - Clara Ibanez
- Immunology laboratory, St-Louis University Hospital, AP-HP, Paris, France
| | | | - Nicolas Boissel
- Hematology Adolescent and Young Adult Unit, St-Louis University Hospital, AP-HP, Paris, France
- URP-3518, Saint-Louis Research Institute, Université de Paris Cité, Paris, France
| | - Jean-Benoit Arlet
- French Sickle Cell Referral Centre, Department of Internal Medicine, Georges Pompidou European Hospital, Université de Paris Cité, AP-HP, Paris, France
| | | | | | - Nathalie Dhédin
- Hematology Adolescent and Young Adult Unit, St-Louis University Hospital, AP-HP, Paris, France.
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4
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Pandrowala A, Khan S, Kataria D, Kakunje M, Mishra V, Mamtora D, Mudaliar S, Bodhanwala M, Agarwal B, Hiwarkar P. The role of graft T-cell size in patients receiving alemtuzumab serotherapy for non-malignant disorders: results of an institutional protocol. Sci Rep 2024; 14:988. [PMID: 38200046 PMCID: PMC10781954 DOI: 10.1038/s41598-023-50416-6] [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: 07/18/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
Although graft T cells assist in engraftment, mediate antiviral immune-reconstitution, and cause graft-versus-host disease, graft size is not determined by T-cell content of the graft. The conventional method of graft size determination based on CD34+ cells with alemtuzumab serotherapy is associated with delayed immune reconstitution, contributing to an increased risk of viral infections and graft failure. Alemtuzumab, a long half-life anti-CD52 monoclonal antibody is a robust T-cell depleting serotherapy, and relatively spares memory-effector T cells compared to naïve T cells. We therefore hypothesized that graft size based on T-cell content in patients receiving peripheral blood stem cell graft with alemtuzumab serotherapy would facilitate immune-reconstitution without increasing the risk of graft-versus-host disease. We retrospectively analysed twenty-six consecutive patients with non-malignant disorders grafted using alemtuzumab serotherapy and capping of graft T cells to a maximum of 600 million/kg. The graft T-cell capping protocol resulted in early immune-reconstitution without increasing the risk of severe graft-versus-host disease. Graft T-cell content correlated with CD4+ T-cell reconstitution and acute graft-versus-host disease. The course of CMV viraemia was predictable without recurrence and associated with early T-cell recovery. No patient developed chronic graft-versus-host disease. Overall survival at one year was 100% and disease-free survival was 96% at a median of 899 days (range: 243-1562). Graft size determined by peripheral blood stem cell graft T-cell content in patients receiving alemtuzumab serotherapy for non-malignant disorders is safe and leads to early T-cell immune-reconstitution with excellent survival outcomes.
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Affiliation(s)
- Ambreen Pandrowala
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India
| | - Sanna Khan
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India
| | - Darshan Kataria
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India
| | - Manasa Kakunje
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India
| | - Varsha Mishra
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India
| | - Dhruv Mamtora
- Department of Pathology, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Sangeeta Mudaliar
- Department of Paediatric Haematology, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Minnie Bodhanwala
- Department of Paediatrics, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Bharat Agarwal
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India
- Department of Paediatric Haematology, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Prashant Hiwarkar
- Department of Blood and Marrow Transplantation, Bai Jerbai Wadia Hospital for Children, Mumbai, 400012, India.
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5
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Cuvelier GDE, Paulson K, Bow EJ. Updates in hematopoietic cell transplant and cellular therapies that enhance the risk for opportunistic infections. Transpl Infect Dis 2023; 25 Suppl 1:e14101. [PMID: 37461887 DOI: 10.1111/tid.14101] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Infectious disease physicians may be asked to evaluate and manage a variety of infections in immunocompromised hosts undergoing hematopoietic cell transplant (HCT) and cellular therapies. Over the last decade, several advances in cellular therapy have occurred, with implications for the types of infectious complications that may be seen. AIMS The purpose of this review is to update the infectious disease physician on newer advances in HCT and cellular therapy, including haploidentical transplant, expanding indications for transplant in older individuals and children, and chimeric antigen receptor T-cells. We will review how these advances might influence infectious disease complications following HCT. We will also provide a perspective that infectious disease physicians can use to evaluate the degree of immune suppression in an individual patient to help determine the type of infections that may be encountered.
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Affiliation(s)
- Geoffrey D E Cuvelier
- Department of Paediatrics and Child Health, Section of Paediatric Haematology/Oncology-BMT, Max Rady College of Medicine, the University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Paediatric Haematology/Oncology-BMT, CancerCare Manitoba, Winnipeg, Manitoba, Canada
- Manitoba Blood and Marrow Transplant Programme, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Kristjan Paulson
- Manitoba Blood and Marrow Transplant Programme, CancerCare Manitoba, Winnipeg, Manitoba, Canada
- Section of Haematology/Oncology, Department of Internal Medicine, Max Rady College of Medicine, the University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Manitoba, Winnipeg, Manitoba, Canada
| | - Eric J Bow
- Manitoba Blood and Marrow Transplant Programme, CancerCare Manitoba, Winnipeg, Manitoba, Canada
- Section of Haematology/Oncology, Department of Internal Medicine, Max Rady College of Medicine, the University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Manitoba, Winnipeg, Manitoba, Canada
- Section of Infectious Diseases, Department of Internal Medicine, Max Rady College of Medicine, The University of Manitoba, Winnipeg, Manitoba, Canada
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Achini-Gutzwiller FR, Schilham MW, von Asmuth EGJ, Jansen-Hoogendijk AM, Jol-van der Zijde CM, van Tol MJD, Bredius RGM, Güngör T, Lankester AC, Moes DJAR. Exposure-response analysis of alemtuzumab in pediatric allogeneic HSCT for nonmalignant diseases: the ARTIC study. Blood Adv 2023; 7:4462-4474. [PMID: 37285798 PMCID: PMC10440472 DOI: 10.1182/bloodadvances.2022009051] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 05/19/2023] [Accepted: 05/20/2023] [Indexed: 06/09/2023] Open
Abstract
Alemtuzumab (anti-CD52 antibody) is frequently prescribed to children with nonmalignant diseases undergoing allogeneic hematopoietic stem cell transplantation (HSCT) to prevent graft failure (GF) and acute graft-versus-host disease (aGVHD). The aim of this multicenter study was the characterization of alemtuzumab population pharmacokinetics to perform a novel model-based exposure-response analysis in 53 children with nonmalignant immunological or hematological disease and a median age of 4.4 years (interquartile range [IQR], 0.8-8.7). The median cumulative alemtuzumab dose was 0.6 mg/kg (IQR, 0.6-1) administered over 2 to 7 days. A 2-compartment population pharmacokinetics model with parallel linear and nonlinear elimination including allometrically scaled bodyweight (median, 17.50 kg; IQR, 8.76-33.00) and lymphocyte count at baseline (mean, 2.24 × 109/L; standard deviation ± 1.87) as significant pharmacokinetic predictors was developed using nonlinear mixed effects modeling. Based on the model-estimated median concentration at day of HSCT (0.77 μg/mL; IQR, 0.33-1.82), patients were grouped into a low- (≤0.77 μg/mL) or high- (>0.77 μg/mL) exposure groups. High alemtuzumab exposure at day of HSCT correlated with delayed CD4+ and CD8+ T-cell reconstitution (P value < .0001) and increased risk of GF (P value = .043). In contrast, alemtuzumab exposure did not significantly influence the incidence of aGVHD grade ≥2, mortality, chimerism at 1 year, viral reactivations, and autoimmunity at a median follow-up of 3.3 years (IQR, 2.5-8.0). In conclusion, this novel population pharmacokinetics model is suitable for individualized intravenous precision dosing to predict alemtuzumab exposure in pediatric allogeneic HSCT for nonmalignant diseases, aiming at the achievement of early T-cell reconstitution and prevention of GF in future prospective studies.
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Affiliation(s)
- Federica R. Achini-Gutzwiller
- Department of Pediatric Stem Cell Transplantation and Hematology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Laboratory for Pediatric Immunology, Willem Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatric Stem Cell Transplantation, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Marco W. Schilham
- Laboratory for Pediatric Immunology, Willem Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik G. J. von Asmuth
- Laboratory for Pediatric Immunology, Willem Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Anja M. Jansen-Hoogendijk
- Laboratory for Pediatric Immunology, Willem Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Cornelia M. Jol-van der Zijde
- Laboratory for Pediatric Immunology, Willem Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten J. D. van Tol
- Laboratory for Pediatric Immunology, Willem Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Robbert G. M. Bredius
- Department of Pediatric Stem Cell Transplantation, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Tayfun Güngör
- Department of Pediatric Stem Cell Transplantation and Hematology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Arjan C. Lankester
- Department of Pediatric Stem Cell Transplantation, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Dirk Jan A. R. Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
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7
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Slatter MA, Maschan MA, Gennery AR. T-lymphocyte depleted transplants for inborn errors of immunity. Expert Rev Clin Immunol 2023; 19:1315-1324. [PMID: 37554030 DOI: 10.1080/1744666x.2023.2245146] [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: 04/13/2023] [Accepted: 08/02/2023] [Indexed: 08/10/2023]
Abstract
INTRODUCTION Hematopoietic stem cell transplantation is a curative treatment for many inborn errors of immunity (IEI). Incremental improvements and advances in care have led to high rates of >85% survival and cure in many of these diseases. Improvements in HLA-classification and matching have led to increased survival using HLA-matched donors, but survival using T-lymphocyte-depleted mismatched grafts remained significantly worse until fairly recently. Advances in T-lymphocyte depletion methods and graft engineering, although not specific to IEI, have been widely adopted and instrumental in changing the landscape of donor selection, such that a donor should now be possible for every patient. AREAS COVERED A literature review focusing on T-lymphocyte depletion methodologies and treatment results was performed. The importance of early T-lymphocyte immunoreconstitution to protect against viral infection is reviewed. Two main platforms now dominate the field - immune-magnetic selection of specific cell types and post-transplant chemotherapeutic targeting of rapidly proliferating allo-reactive T-lymphocytes - the emerging literature on these reports, focusing on IEI, is explored, as well as the impact of serotherapy on early immunoreconstitution. EXPERT OPINION Pharmacokinetic monitoring of serotherapy agents, and use of co-stimulatory molecule blockade are likely to become more widespread. Post-transplant cyclophosphamide or TCR depletion strategies are likely to become the dominant methods of transplantation for nonmalignant diseases.
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Affiliation(s)
- M A Slatter
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Paediatric Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - M A Maschan
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
- Department of Hematology, Oncology and Radiation Therapy, Pirogov Russian National Research Medical University, Moscow, Russia
| | - A R Gennery
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Paediatric Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle Upon Tyne, UK
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8
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Chen YF, Li J, Xu LL, Găman MA, Zou ZY. Allogeneic stem cell transplantation in the treatment of acute myeloid leukemia: An overview of obstacles and opportunities. World J Clin Cases 2023; 11:268-291. [PMID: 36686358 PMCID: PMC9850970 DOI: 10.12998/wjcc.v11.i2.268] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/02/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
As an important treatment for acute myeloid leukemia, allogeneic hematopoietic stem cell transplantation (allo-HSCT) plays an important role in reducing relapse and improving long-term survival. With rapid advancements in basic research in molecular biology and immunology and with deepening understanding of the biological characteristics of hematopoietic stem cells, allo-HSCT has been widely applied in clinical practice. During allo-HSCT, preconditioning, the donor, and the source of stem cells can be tailored to the patient’s conditions, greatly broadening the indications for HSCT, with clear survival benefits. However, the risks associated with allo-HSCT remain high, i.e. hematopoietic reconstitution failure, delayed immune reconstitution, graft-versus-host disease, and post-transplant relapse, which are bottlenecks for further improvements in allo-HSCT efficacy and have become hot topics in the field of HSCT. Other bottlenecks recognized in the current treatment of individuals diagnosed with acute myeloid leukemia and subjected to allo-HSCT include the selection of the most appropriate conditioning regimen and post-transplantation management. In this paper, we reviewed the progress of relevant research regarding these aspects.
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Affiliation(s)
- Yong-Feng Chen
- Department of Basic Medical Sciences, School of Medicine of Taizhou University, Taizhou University, Taizhou 318000, Zhejiang Province, China
| | - Jing Li
- Department of Histology and Embryology, North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Ling-Long Xu
- Department of Hematology, Taizhou Central Hospital, Taizhou 318000, Zhejiang Province, China
| | - Mihnea-Alexandru Găman
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest 050474, Romania
| | - Zhen-You Zou
- Department of Scientific Research,Brain Hospital of Guangxi Zhuang Autonomous Region, Liuzhou 545005, Guangxi Zhuang Autonomous Region, China
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9
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Peggs KS, Albon SJ, Oporto Espuelas M, Irving C, Richardson R, Casanovas-Company J, Wallace R, Guvenel A, Ghorashian S, Collura A, Subramaniyam M, Flutter B, Popova B, Castro F, Lopes A, Champion K, Schofield O, Clifton-Hadley L, Taylor T, Farrell M, Adams S, Gilmour KC, Mackinnon S, Tholouli E, Amrolia PJ. Immunotherapy with CD25/CD71-allodepleted T cells to improve T-cell reconstitution after matched unrelated donor hematopoietic stem cell transplant: a randomized trial. Cytotherapy 2023; 25:82-93. [PMID: 36220712 DOI: 10.1016/j.jcyt.2022.08.010] [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: 04/21/2022] [Revised: 07/21/2022] [Accepted: 08/27/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND AIMS Delayed immune reconstitution is a major challenge after matched unrelated donor (MUD) stem cell transplant (SCT). In this randomized phase 2 multi-center trial, Adoptive Immunotherapy with CD25/71 allodepleted donor T cells to improve immunity after unrelated donor stem cell transplant (NCT01827579), the authors tested whether allodepleted donor T cells (ADTs) can safely be used to improve immune reconstitution after alemtuzumab-based MUD SCT for hematological malignancies. METHODS Patients received standard of care or up to three escalating doses of ADTs generated through CD25+/CD71+ immunomagnetic depletion. The primary endpoint of the study was circulating CD3+ T-cell count at 4 months post-SCT. Twenty-one patients were treated, 13 in the ADT arm and eight in the control arm. RESULTS The authors observed a trend toward improved CD3+ T-cell count at 4 months in the ADT arm versus the control arm (230/µL versus 145/µL, P = 0.18), and three ADT patients achieved normal CD3+ T-cell count at 4 months (>700/µL). The rates of significant graft-versus-host disease (GVHD) were comparable in both cohorts, with grade ≥2 acute GVHD in seven of 13 and four of eight patients and chronic GVHD in three of 13 and three of eight patients in the ADT and control arms, respectively. CONCLUSIONS These data suggest that adoptive transfer of ADTs is safe, but that in the MUD setting the benefit in terms of T-cell reconstitution is limited. This approach may be of more use in the context of more rigorous T-cell depletion.
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Affiliation(s)
- Karl S Peggs
- Department of Hematology, University College London Hospital, London, UK
| | - Sarah J Albon
- Molecular and Cellular Immunology Section, University College London Great Ormond Street Institute of Child Health, London, UK; Gene and Cell Therapy, Great Ormond Street Hospital for Children, London, UK
| | - Macarena Oporto Espuelas
- Molecular and Cellular Immunology Section, University College London Great Ormond Street Institute of Child Health, London, UK.
| | - Catherine Irving
- Molecular and Cellular Immunology Section, University College London Great Ormond Street Institute of Child Health, London, UK; Gene and Cell Therapy, Great Ormond Street Hospital for Children, London, UK
| | - Rachel Richardson
- Molecular and Cellular Immunology Section, University College London Great Ormond Street Institute of Child Health, London, UK; Gene and Cell Therapy, Great Ormond Street Hospital for Children, London, UK
| | - Joan Casanovas-Company
- Molecular and Cellular Immunology Section, University College London Great Ormond Street Institute of Child Health, London, UK; Gene and Cell Therapy, Great Ormond Street Hospital for Children, London, UK
| | - Rebecca Wallace
- Gene and Cell Therapy, Great Ormond Street Hospital for Children, London, UK; Molecular Hematology Section, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Aleks Guvenel
- Molecular and Cellular Immunology Section, University College London Great Ormond Street Institute of Child Health, London, UK; Gene and Cell Therapy, Great Ormond Street Hospital for Children, London, UK
| | - Sara Ghorashian
- Molecular Hematology Section, University College London Great Ormond Street Institute of Child Health, London, UK; Department of Hematology, Great Ormond Street Hospital for Children, London, UK
| | - Angela Collura
- Molecular and Cellular Immunology Section, University College London Great Ormond Street Institute of Child Health, London, UK; Gene and Cell Therapy, Great Ormond Street Hospital for Children, London, UK
| | - Meera Subramaniyam
- Molecular and Cellular Immunology Section, University College London Great Ormond Street Institute of Child Health, London, UK; Gene and Cell Therapy, Great Ormond Street Hospital for Children, London, UK
| | - Barry Flutter
- Gene and Cell Therapy, Great Ormond Street Hospital for Children, London, UK; Molecular Hematology Section, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Bilyana Popova
- Cancer Research UK and University College London Cancer Trials Center, London, UK
| | - Fernanda Castro
- Cancer Research UK and University College London Cancer Trials Center, London, UK
| | - Andre Lopes
- Cancer Research UK and University College London Cancer Trials Center, London, UK
| | - Kim Champion
- Cancer Research UK and University College London Cancer Trials Center, London, UK
| | - Oliver Schofield
- Cancer Research UK and University College London Cancer Trials Center, London, UK
| | - Laura Clifton-Hadley
- Cancer Research UK and University College London Cancer Trials Center, London, UK
| | - Thomas Taylor
- Department of Hematology, University College London Hospital, London, UK
| | - Maria Farrell
- Department of Hematology, Manchester Royal Infirmary, Manchester, UK
| | - Stuart Adams
- Department of Hematology, Great Ormond Street Hospital for Children, London, UK
| | - Kimberly C Gilmour
- Cell Therapy and Immunology, Camelia Botnar Laboratories, Great Ormond Street Hospital for Children, London, UK
| | - Stephen Mackinnon
- Department of Hematology, University College London Hospital, London, UK
| | - Eleni Tholouli
- Department of Hematology, Manchester Royal Infirmary, Manchester, UK
| | - Persis J Amrolia
- Molecular and Cellular Immunology Section, University College London Great Ormond Street Institute of Child Health, London, UK; Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, UK.
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10
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van Vugt LK, Schagen MR, de Weerd A, Reinders ME, de Winter BC, Hesselink DA. Investigational drugs for the treatment of kidney transplant rejection. Expert Opin Investig Drugs 2022; 31:1087-1100. [PMID: 36175360 DOI: 10.1080/13543784.2022.2130751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Kidney transplant rejection remains an important clinical problem despite the development of effective immunosuppressive drug combination therapy. Two major types of rejection are recognized, namely T-cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR), which have a different pathophysiology and are treated differently. Unfortunately, long-term outcomes of both TCMR and ABMR remain unsatisfactory despite current therapy. Hence, alternative therapeutic drugs are urgently needed. AREAS COVERED This review covers novel and investigational drugs for the pharmacological treatment of kidney transplant rejection. Potential therapeutic strategies and future directions are discussed. EXPERT OPINION The development of alternative pharmacologic treatment of rejection has focused mostly on ABMR, since this is the leading cause of kidney allograft loss and currently lacks an effective, evidence-based therapy. At present, there is insufficient high-quality evidence for any of the covered investigational drugs to support their use in ABMR. However, with the emergence of targeted therapies, this potential arises for individualized treatment strategies. In order to generate more high-quality evidence for such strategies and overcome the obstacles of classic, randomized, controlled trials, we advocate the implementation of adaptive trial designs and surrogate clinical endpoints. We believe such adaptive trial designs could help to understand the risks and benefits of promising drugs such as tocilizumab, clazakizumab, belimumab, and imlifidase.
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Affiliation(s)
- Lukas K van Vugt
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maaike R Schagen
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Annelies de Weerd
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marlies Ej Reinders
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Brenda Cm de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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11
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Achini-Gutzwiller FR, Snowden JA, Corbacioglu S, Greco R. Haematopoietic stem cell transplantation for severe autoimmune diseases in children: A review of current literature, registry activity and future directions on behalf of the autoimmune diseases and paediatric diseases working parties of the European Society for Blood and Marrow Transplantation. Br J Haematol 2022; 198:24-45. [PMID: 37655707 DOI: 10.1111/bjh.18176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 11/27/2022]
Abstract
Although modern clinical management strategies have improved the outcome of paediatric patients with severe autoimmune and inflammatory diseases over recent decades, a proportion will experience ongoing or recurrent/relapsing disease activity despite multiple therapies often leading to irreversible organ damage, and compromised quality of life, growth/development and long-term survival. Autologous and allogeneic haematopoietic stem cell transplantation (HSCT) have been used successfully to induce disease control and often apparent cure of severe treatment-refractory autoimmune diseases (ADs) in children. However, transplant-related outcomes are disease-dependent and long-term outcome data are limited in respect to efficacy and safety. Moreover, balancing risks of HSCT against AD prognosis with continually evolving non-transplant options is challenging. This review appraises published literature on HSCT strategies and outcomes in individual paediatric ADs. We also provide a summary of the European Society for Blood and Marrow Transplantation (EBMT) Registry, where 343 HSCT procedures (176 autologous and 167 allogeneic) have been reported in 326 children (<18 years) for a range of AD indications. HSCT is a promising treatment modality, with potential long-term disease control or cure, but therapy-related morbidity and mortality need to be reduced. Further research is warranted to establish the position of HSCT in paediatric ADs via registries and prospective clinical studies to support evidence-based interspeciality guidelines and recommendations.
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Affiliation(s)
- Federica R Achini-Gutzwiller
- Division of Paediatric Stem Cell Transplantation and Haematology, Children's Research Centre (CRC), University Children's Hospital of Zurich, Zurich, Switzerland
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Selim Corbacioglu
- Department of Paediatric Oncology, Haematology and Stem Cell Transplantation, University Children's Hospital Regensburg, Regensburg, Germany
| | - Raffaella Greco
- Unit of Haematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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12
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Ru Y, Zhu J, Song T, Ding Y, Zhu Z, Fan Y, Xu Y, Sun A, Qiu H, Jin Z, Tang X, Han Y, Fu C, Chen S, Ma X, Chen F, Chen J, Wu D. Features of Epstein–Barr Virus and Cytomegalovirus Reactivation in Acute Leukemia Patients After Haplo-HCT With Myeloablative ATG-Containing Conditioning Regimen. Front Cell Infect Microbiol 2022; 12:865170. [PMID: 35651756 PMCID: PMC9149257 DOI: 10.3389/fcimb.2022.865170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/18/2022] [Indexed: 01/24/2023] Open
Abstract
Background Haploidentical donor hematopoietic cell transplantation (haplo-HCT) has become a preferred option for patients without HLA-matched donors, but it increases the risk of viral reactivations. Epstein–Barr virus (EBV) and cytomegalovirus (CMV) are common viruses post-HCT, but limited data have been reported in the setting of haplo-HCT. Methods We conducted a retrospective study enrolling acute leukemia patients who received haplo-HCT with myeloablative conditioning regimen employing ATG in our center from July 2014 to July 2017. All the patients enrolled were EBV-IgM and EBV-DNA negative but EBV-IgG positive, and so were their donors. The same went for CMV as well. Results In total, 602 patients were recruited consisting of 331 with acute myeloid leukemia (AML) and 271 with acute lymphoblastic leukemia (ALL). One-year cumulative incidences of EBV (22.9% ± 2.4% vs. 27.4% ± 2.8%, P = 0.169) and CMV (24.7% ± 2.4% vs. 29.4% ± 2.8%, P = 0.190) reactivation were comparable between AML and ALL. EBV and CMV were independent risk factors for each other. In the AML group, male recipients [HR = 1.275, 95% CI (1.001–1.624), P = 0.049] and acute graft-versus-host disease [HR = 1.592, 95% CI (1.001–2.533), P = 0.049] were independent risk factors for EBV reactivation and CMV reactivation, respectively. CMV rather than EBV reactivation was related to a trend of worsened treatment-related mortality (TRM) (15.6% ± 0.1% vs. 10.2% ± 0.0%, P = 0.067) and progression-free survival (PFS) (60.6% ± 4.1% vs. 70.3% ± 2.3%, P = 0.073), while significant impacts were revealed only in the subgroup analysis. CMV reactivation resulted in a remarkable inferior 2-year overall survival (OS) (64.2% ± 5.7% vs. 77.6% ± 3.2%, P = 0.038) and PFS (55.0% ± 5.9% vs. 71.9% ± 3.4%, P = 0.042) in ALL patients. On the other hand, in the EBV+/CMV− subgroup, relapse was lower in ALL patients (8.2% ± 0.2% vs. 32.4% ± 0.8%, P = 0.010) compared with AML patients, which led to a superior 2-year OS (82.0% ± 6.2% vs. 60.3% ± 8.8%, P = 0.016) and PFS (74.5% ± 7.0% vs. 57.5% ± 8.4%, P = 0.036). Conclusion We concluded that EBV and CMV reactivations were frequent in acute leukemia patients after haplo-HCT, with possibly distinctive risk factors from HLA-matched HCT. There could be a potential interaction between EBV and CMV, but impacts on transplant outcomes remained complex.
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Affiliation(s)
- Yuhua Ru
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Jinjin Zhu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Tiemei Song
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Yiyang Ding
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Ziling Zhu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Yi Fan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Yang Xu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Aining Sun
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Huiying Qiu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Zhengming Jin
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Xiaowen Tang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Yue Han
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Chengcheng Fu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Suning Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Xiao Ma
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Feng Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Jia Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
- *Correspondence: Depei Wu, ; Jia Chen,
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
- *Correspondence: Depei Wu, ; Jia Chen,
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13
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Impact of in vivo T-cell depletion in patients with myelodysplastic syndromes undergoing allogeneic hematopoietic stem cell transplant: a registry study from the Chronic Malignancies Working Party of the EBMT. Bone Marrow Transplant 2022; 57:768-774. [DOI: 10.1038/s41409-022-01620-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 03/18/2021] [Accepted: 02/14/2022] [Indexed: 11/08/2022]
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14
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Zelikson V, Simmons G, Raman N, Krieger E, Rebiero A, Hawks K, Aziz M, Roberts C, Chesney A, Reed J, Gress R, Toor A. Dynamical Systems Modeling of Early-Term Immune Reconstitution with Different Antithymocyte Globulin Administration Schedules in Allogeneic Stem Cell Transplantation. Transplant Cell Ther 2022; 28:85.e1-85.e9. [PMID: 34688968 PMCID: PMC8820845 DOI: 10.1016/j.jtct.2021.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/06/2021] [Accepted: 10/12/2021] [Indexed: 02/03/2023]
Abstract
Alloreactivity forms the basis of allogeneic hematopoietic cell transplantation (HCT), with donor-derived T cell response to recipient antigens mediating clinical responses either in part or entirely. These encompass the different manifestations of graft-versus-host disease (GVHD), infection risk, and disease response. While the latter is contingent on disease biology and thus may be less predictable, the former 2 manifestations are more likely to be directly proportional to the magnitude of donor-derived T cell recovery. Herein we explore the quantitative aspects of immune cell recovery following allogeneic HCT and clinical outcomes in 2 cohorts of HLA-matched allograft recipients who received rabbit antithymocyte globulin (ATG) on different schedules (days -9 to -7 versus days -3 to -1). Monocyte as well as donor-derived T cell (ddCD3) recovery was superior in those given ATG early in the course of disease (days -9/-7). This difference was related to a more rapid rate of ddCD3 recovery, driven largely by CD3+/CD8+ cells in the first month post-transplantation. Early monocyte recovery was associated with later T cell recovery and improved survival. In contrast, rapid and early ddCD3 expansion out of proportion to monocyte recovery was associated with a high likelihood of acute GVHD and poor survival. This analytic methodology demonstrates that modeling "early-term immune reconstitution" following HCT yields insights that may be useful in the management of post-transplantation immunosuppression and adaptive cellular therapy to optimize clinical outcomes. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Viktoriya Zelikson
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Gary Simmons
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Natasha Raman
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Elizabeth Krieger
- Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
| | - Anatevka Rebiero
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Kelly Hawks
- Massey Cancer Center, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - May Aziz
- Massey Cancer Center, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Catherine Roberts
- Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
| | - Alden Chesney
- Department of Physics, Department of Pathology, Virginia Commonwealth University, Richmond, Virginia
| | - Jason Reed
- Experimental Transplant and Immunology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | | | - Amir Toor
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
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15
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Hematopoietic stem cell transplantation for Wiskott-Aldrich syndrome: an EBMT inborn errors working party analysis. Blood 2022; 139:2066-2079. [PMID: 35100336 DOI: 10.1182/blood.2021014687] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/17/2022] [Indexed: 11/20/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is a potentially curative treatment for patients affected by Wiskott-Aldrich syndrome (WAS). Reported HSCT outcomes have improved over time with respect to overall survival, but some studies have identified older age and HSCT from alternative donors as risk factors predicting poorer outcome. We analyzed 197 patients transplanted at EBMT centers between 2006 and 2017, who received conditioning as recommended by the inborn errors working party (IEWP): either busulfan (n=103) or treosulfan (n=94) combined with fludarabine ± thiotepa. After a median follow-up after HSCT of 44.9 months, 176 patients were alive, resulting in a 3-year overall survival of 88.7%, and chronic GVHD-free survival (CRFS; events: death, graft failure, severe chronic GVHD) of 81.7%. Overall survival and CRFS were not significantly impacted by conditioning regimen (busulfan- versus treosulfan-based), donor type (MSD/MFD vs MUD/MMUD vs. MMFD), and period of HSCT (2006-2013 vs. 2014-2017). Patients younger than 5 years at HSCT had a significantly better overall survival. The overall cumulative incidences of grade III-IV acute GVHD and extensive/moderate/severe chronic GVHD were 6.6% and 2.1%, respectively. Patients receiving treosulfan-based conditioning had a higher incidence of graft failure, mixed donor chimerism and more frequently received secondary procedures (2nd HSCT, unconditioned stem cell boost, donor lymphocyte infusion, or splenectomy). In summary, HSCT for WAS with conditioning regimens currently recommended by IEWP results in excellent survival and low rates of GVHD, regardless of donor or stem cell source, but age ≥5 years remains a risk factor for overall survival.
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16
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Kania SP, Silva JMF, Charles OJ, Booth J, Cheung SYA, Yates JWT, Worth A, Breuer J, Klein N, Amrolia PJ, Veys P, Standing JF. Epstein-Barr Virus Reactivation After Paediatric Haematopoietic Stem Cell Transplantation: Risk Factors and Sensitivity Analysis of Mathematical Model. Front Immunol 2022; 13:903063. [PMID: 35903096 PMCID: PMC9314642 DOI: 10.3389/fimmu.2022.903063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/15/2022] [Indexed: 11/22/2022] Open
Abstract
Epstein-Barr virus (EBV) establishes a lifelong latent infection in healthy humans, kept under immune control by cytotoxic T cells (CTLs). Following paediatric haematopoetic stem cell transplantation (HSCT), a loss of immune surveillance leads to opportunistic outgrowth of EBV-infected cells, resulting in EBV reactivation, which can ultimately progress to post-transplant lymphoproliferative disorder (PTLD). The aims of this study were to identify risk factors for EBV reactivation in children in the first 100 days post-HSCT and to assess the suitability of a previously reported mathematical model to mechanistically model EBV reactivation kinetics in this cohort. Retrospective electronic data were collected from 56 children who underwent HSCT at Great Ormond Street Hospital (GOSH) between 2005 and 2016. Using EBV viral load (VL) measurements from weekly quantitative PCR (qPCR) monitoring post-HSCT, a multivariable Cox proportional hazards (Cox-PH) model was developed to assess time to first EBV reactivation event in the first 100 days post-HSCT. Sensitivity analysis of a previously reported mathematical model was performed to identify key parameters affecting EBV VL. Cox-PH modelling revealed EBV seropositivity of the HSCT recipient and administration of anti-thymocyte globulin (ATG) pre-HSCT to be significantly associated with an increased risk of EBV reactivation in the first 100 days post-HSCT (adjusted hazard ratio (AHR) = 2.32, P = 0.02; AHR = 2.55, P = 0.04). Five parameters were found to affect EBV VL in sensitivity analysis of the previously reported mathematical model. In conclusion, we have assessed the effect of multiple covariates on EBV reactivation in the first 100 days post-HSCT in children and have identified key parameters in a previously reported mechanistic mathematical model that affect EBV VL. Future work will aim to fit this model to patient EBV VLs, develop the model to account for interindividual variability and model the effect of clinically relevant covariates such as rituximab therapy and ATG on EBV VL.
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Affiliation(s)
- Soumya P Kania
- Infection, Immunity and Inflammation Research & Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Juliana M F Silva
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Oscar J Charles
- Infection, Immunity and Inflammation Research & Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - John Booth
- Digital Research, Informatics and Virtual Environment Unit, National Institute for Health and Care Research (NIHR) Great Ormond Street Hospital Biomedical Research Centre, London, United Kingdom
| | - S Y Amy Cheung
- Integrated Drug Development, Certara, Princeton, NJ, United States
| | - James W T Yates
- Drug Metabolism and Pharmacokinetics (DMPK) Modelling, In-Vitro In-Vivo Translation, GlaxoSmithKline, Stevenage, United Kingdom
| | - Austen Worth
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Judith Breuer
- Infection, Immunity and Inflammation Research & Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Nigel Klein
- Infection, Immunity and Inflammation Research & Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Persis J Amrolia
- Infection, Immunity and Inflammation Research & Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, University College London, London, United Kingdom.,Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Paul Veys
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Joseph F Standing
- Infection, Immunity and Inflammation Research & Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, University College London, London, United Kingdom.,Department of Pharmacy, Great Ormond Street Hospital for Children, London, United Kingdom
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17
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Zaidman I, Shaziri T, Averbuch D, Even-Or E, Dinur-Schejter Y, NaserEddin A, Brooks R, Shadur B, Gefen A, Stepensky P. Neurological complications following pediatric allogeneic hematopoietic stem cell transplantation: Risk factors and outcome. Front Pediatr 2022; 10:1064038. [PMID: 36533248 PMCID: PMC9755488 DOI: 10.3389/fped.2022.1064038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/01/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (HSCT) is an efficient treatment for numerous malignant and nonmalignant conditions affecting children. This procedure can result in infectious and noninfectious neurological complications (NCs). OBJECTIVE The objective of the study is to examine the incidence, risk factors, and outcomes of NCs in pediatric patients following allogeneic HSCT. METHODS We performed a retrospective study of 746 children who underwent 943 allogeneic HSCTs in two large pediatric hospitals in Israel from January 2000 to December 2019. RESULTS Of the pediatric patients 107 (14.3%) experienced 150 NCs. The median follow-up was 55 months. Noninfectious NCs were more common than infectious NCs (81.3% vs. 18.7%). Factors significantly associated with type of NC (infectious vs. noninfectious) were underlying disease (immunodeficiency vs. malignant and metabolic/hematologic disease) (p-value = 0.000), and use of immunosuppressive agent, either Campath or ATG (p-value = 0.041). Factors with a significant impact on developing neurological sequelae post-NC were number of HSCT >1 (p-value = 0.028), the use of alemtuzumab as an immunosuppressive agent (p-value = 0.003), and infectious type of NC (p-value = 0.046). The overall survival rate of whole NC-cohort was 44%; one-third of all mortality cases were attributed to the NC. The strongest prognostic factors associated with mortality were older age at HSCT (p-value = 0.000), the use of alemtuzumab as an immunosuppressive agent (p-value = 0.004), and the existence of neurological sequelae (p-value = 0.000). Abnormal central nervous system imaging (p-value = 0.013), the use of alemtuzumab as an immunosuppressive agent (p-value = 0.019), and neurological sequelae (p-value = 0.000) had statistically significant effects on neurological cause of death. CONCLUSION Infectious and noninfectious NCs are a significant cause of morbidity and mortality following allogeneic HSCT in children. Further research is required to better understand the risk factors for different NCs and their outcomes regarding sequelae and survival.
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Affiliation(s)
- Irina Zaidman
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Tamar Shaziri
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dina Averbuch
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ehud Even-Or
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yael Dinur-Schejter
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Adeeb NaserEddin
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Rebecca Brooks
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Pediatric Intensive Care Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Bella Shadur
- Immunology Division, Garvan Institute of Medical Research, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Aharon Gefen
- Division of Pediatric Hematology Oncology and Bone Marrow Transplantation, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel.,Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Polina Stepensky
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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18
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Clofarabine-fludarabine-busulfan in HCT for pediatric leukemia: an effective, low toxicity, TBI-free conditioning regimen. Blood Adv 2021; 6:1719-1730. [PMID: 34781362 PMCID: PMC8941455 DOI: 10.1182/bloodadvances.2021005224] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/10/2021] [Indexed: 11/20/2022] Open
Abstract
CloFluBu-conditioning results in encouraging EFS for ALL and AML, with low TRM, limited incidence of aGvHD and GF, and no cases of VOD. Minimal residual disease status prior to transplantation impacted outcome due to increased relapse risk in both AML and ALL patients.
We prospectively studied clofarabine-fludarabine-busulfan (CloFluBu)-conditioning in allogeneic hematopoietic cell therapy (HCT) for lymphoid and myeloid malignancies and hypothesized that CloFluBu provides a less toxic alternative to conventional conditioning regimens, with adequate antileukemic activity. All patients receiving their first HCT, from 2011-2019, were included and received CloFluBu. The primary endpoint was event-free survival (EFS). Secondary endpoints were overall survival (OS), graft-versus-host disease (GvHD)-relapse-free survival (GRFS), treatment-related mortality (TRM), cumulative incidence of relapse (CIR), acute and chronic GvHD (aGvHD and cGvHD), and veno-occlusive disease (VOD). Cox proportional hazard and Fine and Gray competing-risk models were used for data analysis. One hundred fifty-five children were included: 60 acute lymphoid leukemia (ALL), 69 acute myeloid leukemia (AML), and 26 other malignancies (mostly MDS-EB). The median age was 9.7 (0.5 to 18.6) years. Estimated 2-year EFS was 72.0% ± 6.0 in ALL patients, and 62.4% ± 6.0 in AML patients. TRM in the whole cohort was 11.0% ± 2.6, incidence of aGvHD 3 to 4 at 6 months was 12.3% ± 2.7, extensive cGvHD at 2 years was 6.4% ± 2.1. Minimal residual disease-positivity prior to HCT was associated with higher CIR, both in ALL and AML. CloFluBu showed limited toxicity and encouraging EFS. CloFluBu is a potentially less toxic alternative to conventional conditioning regimens. Randomized prospective studies are needed.
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19
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Successful mismatched hematopoietic stem cell transplantation for pediatric hemoglobinopathy by using ATG and post-transplant cyclophosphamide. Bone Marrow Transplant 2021; 56:2203-2211. [PMID: 33941871 DOI: 10.1038/s41409-021-01302-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 03/26/2021] [Accepted: 04/09/2021] [Indexed: 02/05/2023]
Abstract
The use of HLA-mismatched (un)related donors is historically associated with a higher incidence of transplant-related complications and mortality. However, the use of such donors may overcome the limited availability of HLA-matched donors for patients with β-thalassemia major (TM) and sickle cell disease (SCD). We investigated hematopoietic stem cell transplantation (HSCT) outcomes of pediatric TM and SCD patients treated with a mismatched donor using a treosulfan-based conditioning in combination with ATG and post-transplant cyclophosphamide (PT-CY) and compared these results to the clinical outcome of patients treated by matched donor HSCT without PT-CY. Thirty-eight children (n = 24 HLA-identical or 10/10-matched donors; n = 14 HLA-mismatched donors), who received a non-depleted bone marrow graft were included. Event-free survival (EFS) and GvHD were not higher in the mismatched PT-Cy group as compared to the matched group. Moreover, despite delayed neutrophil engraftment (day +22 vs. +26, p = 0.002) and immune recovery in the mismatched PT-Cy group, this did not result in more infectious complications. Therefore, we conclude that in the absence of an HLA-identical or a matched unrelated donor, HSCT with a mismatched unrelated or haploidentical donor in combination with ATG plus PT-CY can be considered a safe and effective treatment option for pediatric hemoglobinopathy patients.
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20
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Ottaviano G, Achini-Gutzwiller F, Kalwak K, Lanino E, Faraci M, Rao K, Chiesa R, Amrolia P, Bonanomi S, Rovelli A, Veys P, Lankester A, Balduzzi A, Lucchini G. Impact of in Vivo Lymphodepletion on Outcome in Children with Nonmalignant Disorders Receiving Peripheral Blood Stem Cell Transplantation. Transplant Cell Ther 2021; 27:1020.e1-1020.e5. [PMID: 34450334 DOI: 10.1016/j.jtct.2021.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/22/2021] [Accepted: 08/18/2021] [Indexed: 10/20/2022]
Abstract
Peripheral blood stem cell transplantation (PBSCT) with in vivo lymphodepletion can provide faster neutrophil recovery with limited risk of severe graft-versus-host disease (GVHD) in children with nonmalignant disorders (NMDs). We aimed to provide an historical comparison of these 2 strategies regarding the prevalence of GVHD, viral reactivation, timing of immune reconstitution, and final outcomes. Data on 98 children undergoing PBSCT were collected from 5 European pediatric transplantation centers. Only patients with NMDs receiving treosulfan or myeloablative busulfan conditioning and 9-10/10 HLA-matched transplant were included. The patients were divided into 2 groups according to in vivo lymphodepletion with antithymocyte globulin (ATG) or with alemtuzumab. We compared rates of acute and chronic GVHD; Epstein-Barr virus, cytomegalovirus, and adenovirus reactivation; chimerism; lymphocyte recovery; overall survival (OS) and event-free survival (EFS) between the 2 groups. The rate of severe acute GVHD (grade III-IV) was significantly higher in patients receiving ATG (26% vs 10% in alemtuzumab recipients; P < .05), whereas viral reactivations occurred with a similar rate in the 2 groups (alemtuzumab, 56%; ATG, 57%). Alemtuzumab was the major risk factor for delayed T cell immune reconstitution in the first 3 months after transplantation (odds ratio [OR], 6.0; 95% confidence interval [CI], 1.8 to 19; P < .005). Extended chronic GVHD, ADV reactivation, slower CD3+ cell recovery, and HLA-mismatch reduced the probability of survival. Infections were the main cause of mortality in our cohort, and delayed T cell recovery was significantly associated with mortality in multivariate analysis (OR, 12; 95% CI, 1.2 to 114; P < .05). Ultimately, no differences in OS and EFS survival were seen between the ATG and alemtuzumab groups. ATG and alemtuzumab showed similar impacts on outcomes of children undergoing PBSCT for NMDs. The 2 strategies of in vivo lymphodepletion showed specific drawbacks that were counterbalanced by benefits that ultimately led to a comparable survival rate. A patient-centered lymphodepletion strategy can be advised in children undergoing PBSCT for NMDs, by favoring T cell recovery in the presence of invasive infection or GVHD prevention in high-risk mismatched donor transplantation.
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Affiliation(s)
- Giorgio Ottaviano
- Bone Marrow Transplant Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.
| | - Federica Achini-Gutzwiller
- Department of Pediatrics, Stem Cell Transplantation Program, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands; Division of Pediatric Stem Cell Transplantation and Children's Research Center (CRC), University Children's Hospital of Zurich, Zurich, Switzerland
| | - Krzysztof Kalwak
- Department and Clinic of Pediatric Hematology, Oncology and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Edoardo Lanino
- Istituto G. Gaslini, Hematopoietic Stem Cell Transplantation Unit- Hematology-Oncology, Genova, Italy
| | - Maura Faraci
- Istituto G. Gaslini, Hematopoietic Stem Cell Transplantation Unit- Hematology-Oncology, Genova, Italy
| | - Kanchan Rao
- Bone Marrow Transplant Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Robert Chiesa
- Bone Marrow Transplant Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Persis Amrolia
- Bone Marrow Transplant Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Sonia Bonanomi
- Clinica Pediatrica, Università degli studi di Milano-Bicocca, Ospedale San Gerardo/Fondazione MBBM, Monza, Italy
| | - Attilio Rovelli
- Clinica Pediatrica, Università degli studi di Milano-Bicocca, Ospedale San Gerardo/Fondazione MBBM, Monza, Italy
| | - Paul Veys
- Bone Marrow Transplant Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Arjan Lankester
- Department of Pediatrics, Stem Cell Transplantation Program, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands
| | - Adriana Balduzzi
- Clinica Pediatrica, Università degli studi di Milano-Bicocca, Ospedale San Gerardo/Fondazione MBBM, Monza, Italy
| | - Giovanna Lucchini
- Bone Marrow Transplant Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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21
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Monlish DA, Beezhold KJ, Chiaranunt P, Paz K, Moore NJ, Dobbs AK, Brown RA, Ozolek JA, Blazar BR, Byersdorfer CA. Deletion of AMPK minimizes graft-versus-host disease through an early impact on effector donor T cells. JCI Insight 2021; 6:e143811. [PMID: 34291733 PMCID: PMC8410053 DOI: 10.1172/jci.insight.143811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 06/10/2021] [Indexed: 12/25/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation is a viable treatment for multiple hematologic diseases, but its application is often limited by graft-versus-host disease (GVHD), where donor T cells attack host tissues in the skin, liver, and gastrointestinal tract. Here, we examined the role of the cellular energy sensor AMP kinase (AMPK) in alloreactive T cells during GVHD development. Early posttransplant, AMPK activity increased more than 15-fold in allogeneic T cells, and transplantation of T cells deficient in both AMPKα1 and AMPKα2 decreased GVHD severity in multiple disease models. Importantly, a lack of AMPK lessened GVHD without compromising antileukemia responses or impairing lymphopenia-driven immune reconstitution. Mechanistically, absence of AMPK decreased both CD4+ and CD8+ effector T cell numbers as early as day 3 posttransplant, while simultaneously increasing regulatory T cell (Treg) percentages. Improvements in GVHD resulted from cell-intrinsic perturbations in conventional effector T cells as depletion of donor Tregs had minimal impact on AMPK-related improvements. Together, these results highlight a specific role for AMPK in allogeneic effector T cells early posttransplant and suggest that AMPK inhibition may be an innovative approach to mitigate GVHD while preserving graft-versus-leukemia responses and maintaining robust immune reconstitution.
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Affiliation(s)
- Darlene A Monlish
- Division of Blood and Marrow Transplantation and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kevin J Beezhold
- Division of Blood and Marrow Transplantation and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Pailin Chiaranunt
- Division of Blood and Marrow Transplantation and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Katelyn Paz
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nathan J Moore
- Division of Blood and Marrow Transplantation and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Andrea K Dobbs
- Division of Blood and Marrow Transplantation and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rebecca A Brown
- Division of Blood and Marrow Transplantation and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John A Ozolek
- Department of Pathology, Anatomy and Laboratory Medicine, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Bruce R Blazar
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Craig A Byersdorfer
- Division of Blood and Marrow Transplantation and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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22
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John TD, Friend B, Yassine K, Sasa G, Bhar S, Salem B, Omer B, Craddock J, Doherty E, Martinez C, Heslop HE, Krance RA, Leung K. Matched related hematopoietic cell transplant for sickle cell disease with alemtuzumab: the Texas Children's Hospital experience. Bone Marrow Transplant 2021; 56:2797-2803. [PMID: 34274957 DOI: 10.1038/s41409-021-01415-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 11/09/2022]
Abstract
Serotherapeutic agents facilitate engraftment and prevent graft-versus-host disease (GVHD) following hematopoietic stem cell transplant. Anti-thymocyte globulin is generally added to conditioning chemotherapy for matched related donor transplant (MRD-HCT) for sickle cell disease (SCD). Alemtuzumab, however, is appealing due to its broad lymphocyte killing that may achieve very low rejection and GVHD rates. To assess the impact of alemtuzumab in MRD-HCT for SCD, we retrospectively reviewed transplant-related outcomes and markers of immunity in 38 consecutive patients at Texas Children's Hospital having received myeloablative conditioning with alemtuzumab. Median follow-up was 4.8 years (range: 0.2-17). All patients engrafted. Donor chimerism was mixed in 47.1% of patients at ≥2-years. Donor chimerism <50% was uncommon (n = 2). One patient with low myeloid chimerism (19%) had sickle-related hemolysis at 10-years. Incidence of acute GVHD grade II-IV (5.3%) and extensive chronic GVHD (2.8%) was very low. Five-year event-free survival (EFS) and composite chronic GVHD-EFS were excellent at 94.7% (95% CI: 80.3, 98.6) and 89.2% (95% CI: 73.7, 95.8), respectively. Infections did not contribute to mortality although cytomegalovirus reactivation occurred commonly in the first 3 months after transplant. Our data suggest potential for alemtuzumab in myeloablative transplant for children with SCD although further evaluation in older patients and with unrelated donors is warranted.
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Affiliation(s)
- Tami D John
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Brian Friend
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Khaled Yassine
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Ghadir Sasa
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Saleh Bhar
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Baheyeldin Salem
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Bilal Omer
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - John Craddock
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Erin Doherty
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Caridad Martinez
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Helen E Heslop
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Robert A Krance
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Kathryn Leung
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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23
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CD4+ T-cell reconstitution predicts survival outcomes after acute graft-versus-host-disease: a dual-center validation. Blood 2021; 137:848-855. [PMID: 33150379 DOI: 10.1182/blood.2020007905] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/04/2020] [Indexed: 11/20/2022] Open
Abstract
Acute graft-versus-host-Disease (aGVHD) is a major cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT). We previously showed that early CD4+ T-cell immune reconstitution (IR; CD4+ IR) predicts survival after HCT. Here, we studied the relation between CD4+ IR and survival in patients developing aGVHD. Pediatric patients undergoing first allogeneic HCT at University Medical Center Utrecht (UMC)/Princess Máxima Center (PMC) or Memorial Sloan Kettering Cancer Center (MSK) were included. Primary outcomes were nonrelapse mortality (NRM) and overall survival (OS), stratified for aGVHD and CD4+ IR, defined as ≥50 CD4+ T cells per μL within 100 days after HCT or before aGVHD onset. Multivariate and time-to-event Cox proportional hazards models were applied, and 591 patients (UMC/PMC, n = 276; MSK, n = 315) were included. NRM in patients with grade 3 to 4 aGVHD with or without CD4+ IR within 100 days after HCT was 30% vs 80% (P = .02) at UMC/PMC and 5% vs 67% (P = .02) at MSK. This was associated with lower OS without CD4+ IR (UMC/PMC, 61% vs 20%; P = .04; MSK, 75% vs 33%; P = .12). Inadequate CD4+ IR before aGVHD onset was associated with significantly higher NRM (74% vs 12%; P < .001) and inferior OS (24% vs 78%; P < .001). In this retrospective analysis, we demonstrate that early CD4+ IR, a simple and robust marker predictive of outcomes after HCT, is associated with survival after moderate to severe aGVHD. This association must be confirmed prospectively but suggests strategies to improve T-cell recovery after HCT may influence survival in patients developing aGVHD.
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How I Treat: Allogeneic HSCT for adults with Inborn Errors of Immunity. Blood 2021; 138:1666-1676. [PMID: 34077952 DOI: 10.1182/blood.2020008187] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 05/10/2021] [Indexed: 11/20/2022] Open
Abstract
Inborn Errors of Immunity (IEI) are rare inherited disorders arising from monogenic germline mutations in genes that regulate the immune system. The majority of IEI are Primary Immunodeficiencies characterised by severe infection often associated with autoimmunity, autoinflammation and/or malignancy. Allogeneic hematopoietic stem cell transplant (HSCT) has been the corrective treatment of choice for many IEI presenting with severe disease in early childhood and experience has made this a successful and comparatively safe treatment in affected children. Early HSCT outcomes in adults were poor, resulting in extremely limited use worldwide. This is changing due to a combination of improved IEI diagnosis to inform patient selection, better understanding of the natural history of specific IEI and improvements in transplant practice. Recently published HSCT outcomes for adults with IEI have been comparable with pediatric data, making HSCT an important option for correction of clinically severe IEI in adulthood. Here we discuss our practice for patient selection, timing of HSCT, donor selection and conditioning, peri- and post HSCT management and our approach to long term follow up. We stress the importance of multidisciplinary involvement in the complex decision-making process that we believe is required for successful outcomes in this rapidly emerging area.
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Penna S, Villa A, Capo V. Autosomal recessive osteopetrosis: mechanisms and treatments. Dis Model Mech 2021; 14:261835. [PMID: 33970241 PMCID: PMC8188884 DOI: 10.1242/dmm.048940] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Autosomal recessive osteopetrosis (ARO) is a severe inherited bone disease characterized by defective osteoclast resorption or differentiation. Clinical manifestations include dense and brittle bones, anemia and progressive nerve compression, which hamper the quality of patients' lives and cause death in the first 10 years of age. This Review describes the pathogenesis of ARO and highlights the strengths and weaknesses of the current standard of care, namely hematopoietic stem cell transplantation (HSCT). Despite an improvement in the overall survival and outcomes of HSCT, transplant-related morbidity and the pre-existence of neurological symptoms significantly limit the success of HSCT, while the availability of human leukocyte antigen (HLA)-matched donors still remains an open issue. Novel therapeutic approaches are needed for ARO patients, especially for those that cannot benefit from HSCT. Here, we review preclinical and proof-of-concept studies, such as gene therapy, systematic administration of deficient protein, in utero HSCT and gene editing. Summary: Autosomal recessive osteopetrosis is a heterogeneous and rare bone disease for which effective treatments are still lacking for many patients. Here, we review the literature on clinical, preclinical and proof-of-concept studies.
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Affiliation(s)
- Sara Penna
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan 20132, Italy.,Translational and Molecular Medicine (DIMET), University of Milano-Bicocca, Monza 20900, Italy
| | - Anna Villa
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan 20132, Italy.,Institute of Genetic and Biomedical Research, Milan Unit, National Research Council, Milan 20090, Italy
| | - Valentina Capo
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan 20132, Italy.,Institute of Genetic and Biomedical Research, Milan Unit, National Research Council, Milan 20090, Italy
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26
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Sipe CJ, Claudio Vázquez PN, Skeate JG, McIvor RS, Moriarity BS. Targeted genome editing for the correction or alleviation of primary Immunodeficiencies. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2021; 182:111-151. [PMID: 34175040 DOI: 10.1016/bs.pmbts.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Primary immunodeficiencies (PID) are a growing list of unique disorders that result in a failure of the innate/adaptive immune systems to fully respond to disease or infection. PIDs are classified into five broad categories; B cell disorders, combined B and T cell disorders, phagocytic disorders, complement disorders, and disorders with recurrent fevers and inflammation. Many of these disorders, such as X-SCID, WAS, and CGD lead to early death in children if intervention is not implemented. At present, the predominant method of curative therapy remains an allogeneic transplant from a healthy donor, however many complications and limitations exist with his therapy such as availability of donors, graft vs host disease, graft rejection, and infection. More recently, gene therapy using viral based complementation vectors have successfully been implemented to functionally correct patient cells in an autologous transplant, but these methods carry significant risks, including insertional mutagenesis, and provide non-physiological gene expression. For these reasons, gene-editing reagents such as targeted nucleases, base editors (BE), and prime editors (PE) are being explored. The BE and PE tools, sometimes referred to as digital editors, are of very high interest as they provide both enhanced molecular specificity and do not rely on DNA repair pathways after DSBs to change individual base pairs or directly replace DNA sequences responsible for pathogenic phenotypes. With this in mind the purpose of this chapter is to highlight some of the most common PIDs found within the human population, discuss successes and shortcomings of previous intervention strategies, and highlight how the next generation of gene-editing tools may be deployed to directly repair the underlying genetic causes of this class of disease.
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Affiliation(s)
- Christopher J Sipe
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States; Center for Genome Engineering, University of Minnesota, Minneapolis, MN, United States; Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States; Department of Genetics, Cell Biology and Development, University of Minnesota, Minneapolis, MN, United States
| | - Patricia N Claudio Vázquez
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States; Center for Genome Engineering, University of Minnesota, Minneapolis, MN, United States; Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States; Department of Genetics, Cell Biology and Development, University of Minnesota, Minneapolis, MN, United States
| | - Joseph G Skeate
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States; Center for Genome Engineering, University of Minnesota, Minneapolis, MN, United States; Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States
| | - R Scott McIvor
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States; Center for Genome Engineering, University of Minnesota, Minneapolis, MN, United States; Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States; Department of Genetics, Cell Biology and Development, University of Minnesota, Minneapolis, MN, United States
| | - Branden S Moriarity
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States; Center for Genome Engineering, University of Minnesota, Minneapolis, MN, United States; Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States; Department of Genetics, Cell Biology and Development, University of Minnesota, Minneapolis, MN, United States.
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27
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Hu Z, Dalal J. Challenges in HLH transplant: Tricks to prevent menace of mixed chimerism. Pediatr Blood Cancer 2021; 68:e28602. [PMID: 32893946 DOI: 10.1002/pbc.28602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/05/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Zhongbo Hu
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Jignesh Dalal
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
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28
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EBMT/ESID inborn errors working party guidelines for hematopoietic stem cell transplantation for inborn errors of immunity. Bone Marrow Transplant 2021; 56:2052-2062. [PMID: 34226669 PMCID: PMC8410590 DOI: 10.1038/s41409-021-01378-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/26/2021] [Accepted: 06/09/2021] [Indexed: 02/05/2023]
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29
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Wustrau K, Greil J, Sykora KW, Albert MH, Burkhardt B, Lang P, Meisel R, Wössmann W, Beier R, Schulz A, Bader P, Chada M, Kühl JS, Schlegel PG, Speckmann C, Gruhn B, Seidel M, Wawer A, Ozga AK, Janka G, Ehl S, Müller I, Lehmberg K. Risk factors for mixed chimerism in children with hemophagocytic lymphohistiocytosis after reduced toxicity conditioning. Pediatr Blood Cancer 2020; 67:e28523. [PMID: 32618429 DOI: 10.1002/pbc.28523] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Reduced toxicity conditioning for hematopoietic stem cell transplantation of patients with hemophagocyticlymphohistiocytosis (HLH) results in favorable survival, however at the expense of relevant rates of mixed chimerism. Factors predisposing to mixed chimerism remain to be determined. PROCEDURE Patients with primary HLH transplanted 2009-2016 after treosulfan- or melphalan-based conditioning regimens were analyzed in a retrospective multicenter study for survival, engraftment, chimerism, and adverse events. Mixed chimerism was considered substantial if < 25% donor chimerism occurred and/or if secondary cell therapy was administered. Donor type, graft source, type of alkylating agent, type of serotherapy, and remission status were analyzed as potential risk factors in a multivariable logistic regression model. RESULTS Among 60 patients, engraftment was achieved in 95%, and the five-year estimated overall survival rate was 75%. Prevalence of any recipient chimerism was 48%. Substantial recipient chimerism was recorded in 32% of patients. Secondary post-HSCT cell therapy was administered in 30% of patients. A human leukocyte antigen (HLA)-mismatched donor (< 10/10) was the only significant risk factor for the occurrence of substantial recipient chimerism (P = 0.01; odds ratio, 5.8; CI 95%, 1.5-26.3). CONCLUSION The use of an HLA-matched donor is the most important factor to avoid substantial recipient chimerism following treosulfan -or melphalan-based conditioning in primary HLH.
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Affiliation(s)
- Katharina Wustrau
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg, Hamburg, Germany
| | - Johann Greil
- Pediatric Hematology and Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Karl-Walter Sykora
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Michael H Albert
- Pediatric Hematology and Oncology, Dr. von Hauner University Children's Hospital, Munich, Germany
| | - Birgit Burkhardt
- Pediatric Hematology and Oncology, University Hospital Münster, Münster, Germany
| | - Peter Lang
- Pediatric Hematology and Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Roland Meisel
- Division of Pediatric Stem Cell Therapy, Clinic for Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Wilhelm Wössmann
- Pediatric Hematology and Oncology, University Hospital Gießen, Gießen, Germany
| | - Rita Beier
- Pediatric Hematology and Oncology, University Hospital Essen, Essen, Germany
| | - Ansgar Schulz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Peter Bader
- Division for Stem Cell Transplantation and Immunology, University Hospital for Children and Adolescent Medicine, Frankfurt am Main, Germany
| | - Martin Chada
- Pediatric Hematology and Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Jörn-Sven Kühl
- Pediatric Oncology, Hematology and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Paul-Gerhardt Schlegel
- Pediatric Oncology, Hematology and Stem Cell Transplantation, University Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Carsten Speckmann
- Center of Chronic Immunodeficiency, Faculty of Medicine, Institute for Immunodeficiency, University Medical Center, University of Freiburg, University of Freiburg, Freiburg, Germany.,Center for Pediatrics and Adolescent Medicine, Faculty of Medicine, University Medical Center, University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Bernd Gruhn
- Department of Pediatrics, Jena University Hospital, Jena, Germany
| | - Markus Seidel
- Division of Pediatric-Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Angela Wawer
- Pediatric Hematology and Oncology, University Hospital Munich, Munich, Germany
| | - Ann-Kathrin Ozga
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg, Hamburg, Germany
| | - Gritta Janka
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg, Hamburg, Germany
| | - Stephan Ehl
- Center of Chronic Immunodeficiency, Faculty of Medicine, Institute for Immunodeficiency, University Medical Center, University of Freiburg, University of Freiburg, Freiburg, Germany.,Center for Pediatrics and Adolescent Medicine, Faculty of Medicine, University Medical Center, University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Ingo Müller
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg, Hamburg, Germany
| | - Kai Lehmberg
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg, Hamburg, Germany
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30
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Devine K, Ranganathan S, Mazariegos G, Bond G, Soltys K, Ganoza A, Sun Q, Sindhi R. Induction regimens and post-transplantation lymphoproliferative disorder after pediatric intestinal transplantation: Single-center experience. Pediatr Transplant 2020; 24:e13723. [PMID: 32424963 DOI: 10.1111/petr.13723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 02/05/2020] [Accepted: 04/05/2020] [Indexed: 10/24/2022]
Abstract
Pediatric recipients of intestinal transplants have a high incidence of PTLD, but the impact of specific induction immunosuppression agents is unclear. In this single-center retrospective review from 2000 to 2017, we describe the incidence, characteristics, and outcomes of PTLD after primary intestinal transplantation in 173 children with or without liver, after induction with rATG, alemtuzumab, or anti-IL-2R agents. Thirty cases of PTLD occurred among 28 children, 28 EBV+ and 2 EBV-. Although not statistically significant, the PTLD incidence was higher after isolated intestinal transplant compared with liver-inclusive allograft (19.3% vs 13.3%, P = .393) and after induction with anti-IL-2R antibody and alemtuzumab compared with rATG (28.6% and 27.3% vs 13.3%, P = .076). The 30 PTLD cases included 13 monomorphic PTLD, 13 polymorphic PTLD, one spindle cell, one Burkitt lymphoma, and two cases too necrotic to classify. After reduction of immunosuppression, management was based on disease histology and extent. Resection with or without rituximab was used for polymorphic tumors and limited disease extent, whereas chemotherapy was used for diffuse disease. Of the 28 patients, 11 recovered with functioning allografts (39.3%), 10 recovered after enterectomy (35.7%), and seven patients died (25%), three due to PTLD and four due to other causes. All who died of progressive PTLD had received chemotherapy, highlighting the mortality of PTLD, toxicity of treatment and need for novel agents. Alemtuzumab is no longer used for induction at our center.
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Affiliation(s)
- Kaitlin Devine
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - George Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Geoffrey Bond
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Armando Ganoza
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Qing Sun
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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31
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Children with WAS: prefer early transplant! Blood 2020; 135:2018-2020. [PMID: 32497225 DOI: 10.1182/blood.2020006079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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32
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Lum SH, Selvarajah S, Deya-Martinez A, McNaughton P, Sobh A, Waugh S, Burton-Fanning S, Newton L, Gandy J, Nademi Z, Owens S, Williams E, Emonts M, Flood T, Cant A, Abinun M, Hambleton S, Gennery AR, Slatter M. Outcome of autoimmune cytopenia after hematopoietic cell transplantation in primary immunodeficiency. J Allergy Clin Immunol 2020; 146:406-416. [PMID: 32442647 DOI: 10.1016/j.jaci.2020.04.053] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 04/02/2020] [Accepted: 04/09/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Post hematopoietic cell transplantation (HCT) autoimmune cytopenia (AIC) is a potentially life-threatening complication, but studies focusing on large cohorts of patients transplanted for primary immunodeficiency are lacking. OBJECTIVES This study sought to determine the incidence, risk factors, and outcomes of post-HCT AIC and B-lymphocyte function following rituximab. METHODS We retrospectively studied 502 children with primary immunodeficiency who were transplanted at our center between 1987 and 2018. RESULTS Thirty-six patients (9%) developed post-HCT AIC, with a median onset of 6.5 months post-HCT. On univariate analysis, pre-HCT AIC, mismatched donor, alemtuzumab, anti-thymocyte antiglobulin, and acute and chronic graft versus host disease were significantly associated with post-HCT AIC. After multivariate analysis, alemtuzumab (subdistribution hazard ratio, 9.0; 95% CI, 1.50-54.0; P = .02) was independently associated with post-HCT AIC. Corticosteroid and high-dose intravenous immunoglobulin achieved remission in 50% (n = 18), additional rituximab led to remission in 25% (n = 9), and the remaining 25% were treated with a combination of various modalities including sirolimus (n = 5), bortezomib (n = 3), mycophenolate mofetil (n = 2), splenectomy (n = 2), and second HCT (n = 3). The mortality of post-HCT AIC reduced from 25% (4 of 16) prior to 2011 to 5% (1 of 20) after 2011. The median follow-up of 5.8 years (range, 0.4 to 29.1 years) showed that 26 of 30 survivors (87%) were in complete remission, and 4 were in remission with ongoing sirolimus and low-dose steroids. Of the 17 who received rituximab, 7 had B-lymphocyte recovery, 5 had persistent low B-lymphocyte count and remained on intravenous immunoglobulin replacement, 2 had second HCT, and 3 died. CONCLUSIONS The frequency of post HCT AIC in our cohort was 9%, and the most significant risk factors for its occurrence were the presence of graft versus host disease and the use of alemtuzumab.
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Affiliation(s)
- Su Han Lum
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Sabeena Selvarajah
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Angela Deya-Martinez
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Peter McNaughton
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ali Sobh
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Sheila Waugh
- Microbiology and Virology, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Lisa Newton
- Microbiology and Virology, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Julie Gandy
- Microbiology and Virology, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Zohreh Nademi
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Stephen Owens
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Eleri Williams
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Marieke Emonts
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Terry Flood
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew Cant
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Mario Abinun
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Microbiology and Virology, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Sophie Hambleton
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew R Gennery
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Mary Slatter
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
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GRFS and CRFS in alternative donor hematopoietic cell transplantation for pediatric patients with acute leukemia. Blood Adv 2020; 3:1441-1449. [PMID: 31053571 DOI: 10.1182/bloodadvances.2018030171] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/07/2019] [Indexed: 12/22/2022] Open
Abstract
We report graft-versus-host disease (GVHD)-free relapse-free survival (GRFS) (a composite end point of survival without grade III-IV acute GVHD [aGVHD], systemic therapy-requiring chronic GVHD [cGVHD], or relapse) and cGVHD-free relapse-free survival (CRFS) among pediatric patients with acute leukemia (n = 1613) who underwent transplantation with 1 antigen-mismatched (7/8) bone marrow (BM; n = 172) or umbilical cord blood (UCB; n = 1441). Multivariate analysis was performed using Cox proportional hazards models. To account for multiple testing, P < .01 for the donor/graft variable was considered statistically significant. Clinical characteristics were similar between UCB and 7/8 BM recipients, because most had acute lymphoblastic leukemia (62%), 64% received total body irradiation-based conditioning, and 60% received anti-thymocyte globulin or alemtuzumab. Methotrexate-based GVHD prophylaxis was more common with 7/8 BM (79%) than with UCB (15%), in which mycophenolate mofetil was commonly used. The univariate estimates of GRFS and CRFS were 22% (95% confidence interval [CI], 16-29) and 27% (95% CI, 20-34), respectively, with 7/8 BM and 33% (95% CI, 31-36) and 38% (95% CI, 35-40), respectively, with UCB (P < .001). In multivariate analysis, 7/8 BM vs UCB had similar GRFS (hazard ratio [HR], 1.12; 95% CI, 0.87-1.45; P = .39), CRFS (HR, 1.06; 95% CI, 0.82-1.38; P = .66), overall survival (HR, 1.07; 95% CI, 0.80-1.44; P = .66), and relapse (HR, 1.44; 95% CI, 1.03-2.02; P = .03). However, the 7/8 BM group had a significantly higher risk for grade III-IV aGVHD (HR, 1.70; 95% CI, 1.16-2.48; P = .006) compared with the UCB group. UCB and 7/8 BM groups had similar outcomes, as measured by GRFS and CRFS. However, given the higher risk for grade III-IV aGVHD, UCB might be preferred for patients lacking matched donors.
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34
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Admiraal R, Jol-van der Zijde CM, Furtado Silva JM, Knibbe CAJ, Lankester AC, Boelens JJ, Hale G, Etuk A, Wilson M, Adams S, Veys P, van Kesteren C, Bredius RGM. Population Pharmacokinetics of Alemtuzumab (Campath) in Pediatric Hematopoietic Cell Transplantation: Towards Individualized Dosing to Improve Outcome. Clin Pharmacokinet 2019; 58:1609-1620. [PMID: 31131436 PMCID: PMC6885503 DOI: 10.1007/s40262-019-00782-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVE Alemtuzumab (Campath®) is used to prevent graft-versus-host disease and graft failure following pediatric allogeneic hematopoietic cell transplantation. The main toxicity includes delayed immune reconstitution, subsequent viral reactivations, and leukemia relapse. Exposure to alemtuzumab is highly variable upon empirical milligram/kilogram dosing. METHODS A population pharmacokinetic (PK) model for alemtuzumab was developed based on a total of 1146 concentration samples from 206 patients, aged 0.2-19 years, receiving a cumulative intravenous dose of 0.2-1.5 mg/kg, and treated between 2003 and 2015 in two centers. RESULTS Alemtuzumab PK were best described using a two-compartment model with a parallel saturable and linear elimination pathway. The linear clearance pathway, central volume of distribution, and intercompartmental distribution increased with body weight. Blood lymphocyte counts, a potential substrate for alemtuzumab, did not impact clearance. CONCLUSION The current practice with uniform milligram/kilogram doses leads to highly variable exposures in children due to the non-linear relationship between body weight and alemtuzumab PK. This model may be used for individualized dosing of alemtuzumab.
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Affiliation(s)
- Rick Admiraal
- Division of Stem Cell Transplantation, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, University of Leiden, Leiden, The Netherlands
- Pediatric Blood and Marrow Transplantation Program, Prinses Maxima Center, Utrecht, The Netherlands
| | - Cornelia M Jol-van der Zijde
- Division of Stem Cell Transplantation, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Catherijne A J Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, University of Leiden, Leiden, The Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Arjan C Lankester
- Division of Stem Cell Transplantation, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap Jan Boelens
- Pediatric Blood and Marrow Transplantation Program, Prinses Maxima Center, Utrecht, The Netherlands
- Stem Cell Transplant and Cellular Therapies, Memorial Sloane Kettering Cancer Center, New York, NY, USA
| | | | - Aniekan Etuk
- Department of Haematology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
| | - Melanie Wilson
- Department of Haematology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
| | - Stuart Adams
- Department of Haematology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
| | - Paul Veys
- Bone Marrow Transplantation Department, Great Ormond Street Hospital, London, UK
| | - Charlotte van Kesteren
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, University of Leiden, Leiden, The Netherlands
- Pediatric Blood and Marrow Transplantation Program, Prinses Maxima Center, Utrecht, The Netherlands
| | - Robbert G M Bredius
- Division of Stem Cell Transplantation, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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Sheth V, Kennedy V, de Lavallade H, Mclornan D, Potter V, Engelhardt BG, Savani B, Chinratanalab W, Goodman S, Greer J, Kassim A, York S, Kenyon M, Gandhi S, Kulasekararaj A, Marsh J, Mufti G, Pagliuca A, Jagasia M, Raj K. Differential Interaction of Peripheral Blood Lymphocyte Counts (ALC) With Different in vivo Depletion Strategies in Predicting Outcomes of Allogeneic Transplant: An International 2 Center Experience. Front Oncol 2019; 9:623. [PMID: 31355140 PMCID: PMC6636242 DOI: 10.3389/fonc.2019.00623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/24/2019] [Indexed: 11/17/2022] Open
Abstract
Dosing regimens for antithymocyte globulin (ATG) and anti-CD52 antibody (alemtuzumab) for graft vs. host disease prophylaxis (GVHD) are empiric or weight-based, and do not account for individual patient factors. Recently, it has been shown that recipient peripheral blood absolute lymphocyte count (ALC) on the day of ATG administration interacts with the dose of ATG administered to predict transplantation outcome. Similarly, we wanted to analyze if the recipient ALC interacts with alemtuzumab dosing to predict outcomes. We retrospectively compared 364 patients, 124 patients receiving ATG (anti-thymocyte globulin) for GVHD prophylaxis, and undergoing unrelated first allogeneic transplant for myeloid and lymphoid malignancies (group 1) to 240 patients receiving alemtuzumab (group 2), in similar time period. There was no difference in survival or acute and chronic GVHD between 60 and 100 mg of alemtuzumab dosing. Unlike ATG (where the pre-transplant recipient ALC interacted with ATG dose on day of its administration (day 1) to predict OS and DFS (p = 0.05), within alemtuzumab group, the recipient ALC on second day of alemtuzumab administration (day 2) and its interaction with alemtuzumab dose strongly predicted OS, DFS and relapse (p = 0.05, HR-1.81, 1.1–3.3; p = 0.002, HR-2.41, CI, 1.3–4.2; and p = 0.003, HR-2.78, CI, 1.4–5.2), respectively. ALC (day 2) of 0.08 × 109/lit or higher, had a specificity of 96% in predicting inferior DFS. Like ATG, there is definite but differential interaction between the recipient peripheral blood ALC and alemtuzumab dose to predict OS, DFS, and relapses.
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Affiliation(s)
- Vipul Sheth
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Vanessa Kennedy
- Department of Haematology and Stem Cell Transplant, Stanford University, Stanford, CA, United States
| | - Hugues de Lavallade
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Donal Mclornan
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Victoria Potter
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Brian G Engelhardt
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Bipin Savani
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Wichai Chinratanalab
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Stacey Goodman
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - John Greer
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Adetola Kassim
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Sally York
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Michelle Kenyon
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Shreyans Gandhi
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Austin Kulasekararaj
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Judith Marsh
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Ghulam Mufti
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Antonio Pagliuca
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
| | - Madan Jagasia
- Department of Haematology and Stem Cell Transplant, Vanderbilt University, Nashville, TN, United States
| | - Kavita Raj
- Department of Haematology and Stem Cell Transplantation, Kings College Hospital, London, United Kingdom
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36
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Elfeky R, Lazareva A, Qasim W, Veys P. Immune reconstitution following hematopoietic stem cell transplantation using different stem cell sources. Expert Rev Clin Immunol 2019; 15:735-751. [PMID: 31070946 DOI: 10.1080/1744666x.2019.1612746] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Adequate immune reconstitution post-HSCT is crucial for the success of transplantation, and can be affected by both patient- and transplant-related factors. Areas covered: A systematic literature search in PubMed, Scopus, and abstracts of international congresses is performed to investigate immune recovery posttransplant. In this review, we discuss the pattern of immune recovery in the post-transplant period focusing on the impact of stem cell source (bone marrow, peripheral blood stem cells, and cord blood) on immune recovery and HSCT outcome. We examine the impact of serotherapy on immune reconstitution and the need to tailor dosing of serotherapy agents when using different stem cell sources. We discuss new techniques being used particularly with cord blood and haploidentical grafts to improve immune recovery in each scenario. Expert opinion: Cord blood T cells provide a unique CD4+ biased immune reconstitution. Initial studies using targeted serotherapy with cord grafts showed improved immune recovery with limited alloreactivity. Two competing haploidentical approaches have developed in recent years including TCRαβ/CD19 depleted grafts and post-cyclophosphamide haplo-HSCT. Both approaches have comparable survival rates with limited alloreactivity. However, delayed immune reconstitution is still an ongoing problem and could be improved by modified donor lymphocyte infusions from the same haploidentical donor.
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Affiliation(s)
- Reem Elfeky
- a Blood and bone marrow transplant unit , Great Ormond Street hospital , London , UK
| | - Arina Lazareva
- a Blood and bone marrow transplant unit , Great Ormond Street hospital , London , UK
| | - Waseem Qasim
- a Blood and bone marrow transplant unit , Great Ormond Street hospital , London , UK
| | - Paul Veys
- a Blood and bone marrow transplant unit , Great Ormond Street hospital , London , UK
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37
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van der Maas NG, Berghuis D, van der Burg M, Lankester AC. B Cell Reconstitution and Influencing Factors After Hematopoietic Stem Cell Transplantation in Children. Front Immunol 2019; 10:782. [PMID: 31031769 PMCID: PMC6473193 DOI: 10.3389/fimmu.2019.00782] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/25/2019] [Indexed: 12/20/2022] Open
Abstract
B cell reconstitution after hematopoietic stem cell transplantation (HSCT) is variable and influenced by different patient, donor, and treatment related factors. In this review we describe B cell reconstitution after pediatric allogeneic HST, including the kinetics of reconstitution of the different B cell subsets and the development of the B cell repertoire, and discuss the influencing factors. Observational studies show important roles for stem cell source, conditioning regimen, and graft vs. host disease in B cell reconstitution. In addition, B cell recovery can play an important role in post-transplant infections and vaccine responses to encapsulated bacteria, such as pneumococcus. A substantial number of patients experience impaired B cell function and/or dependency on Ig substitution after allogeneic HSCT. The underlying mechanisms are largely unresolved. The integrated aspects of B cell recovery after HSCT, especially BCR repertoire reconstitution, are awaiting further investigation using modern techniques in order to gain more insight into B cell reconstitution and to develop strategies to improve humoral immunity after allogeneic HSCT.
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Affiliation(s)
- Nicolaas G van der Maas
- Willem-Alexander Children's Hospital, Department of Pediatrics and Laboratory for Pediatric Immunology, Leiden University Medical Center, Leiden, Netherlands
| | - Dagmar Berghuis
- Willem-Alexander Children's Hospital, Department of Pediatrics and Laboratory for Pediatric Immunology, Leiden University Medical Center, Leiden, Netherlands
| | - Mirjam van der Burg
- Willem-Alexander Children's Hospital, Department of Pediatrics and Laboratory for Pediatric Immunology, Leiden University Medical Center, Leiden, Netherlands
| | - Arjan C Lankester
- Willem-Alexander Children's Hospital, Department of Pediatrics and Laboratory for Pediatric Immunology, Leiden University Medical Center, Leiden, Netherlands
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38
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Neven B, Diana JS, Castelle M, Magnani A, Rosain J, Touzot F, Moreira B, Fremond ML, Briand C, Bendavid M, Levy R, Morelle G, Vincent M, Magrin E, Bourget P, Chatenoud L, Picard C, Fischer A, Moshous D, Blanche S. Haploidentical Hematopoietic Stem Cell Transplantation with Post-Transplant Cyclophosphamide for Primary Immunodeficiencies and Inherited Disorders in Children. Biol Blood Marrow Transplant 2019; 25:1363-1373. [PMID: 30876929 DOI: 10.1016/j.bbmt.2019.03.009] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/08/2019] [Indexed: 01/25/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is a potentially curative treatment for some inherited disorders, including selected primary immunodeficiencies (PIDs). In the absence of a well-matched donor, HSCT from a haploidentical family donor (HIFD) may be considered. In adult recipients high-dose post-transplant cyclophosphamide (PTCY) is increasingly used to mitigate the risks of graft failure and graft-versus-host disease (GVHD). However, data on the use of PTCY in children (and especially those with inherited disorders) are scarce. We reviewed the outcomes of 27 children transplanted with an HIFD and PTCY for a PID (n = 22) or osteopetrosis (n = 5) in a single center. The median age was 1.5 years (range, .2 to 17). HSCT with PTCY was a primary procedure (n = 21) or a rescue procedure after graft failure (n = 6). The conditioning regimen was myeloablative in most primary HSCTs and nonmyeloablative in rescue procedures. After a median follow-up of 25.6 months, 24 of 27 patients had engrafted. Twenty-one patients are alive and have been cured of the underlying disease. The 2-year overall survival rate was 77.7%. The cumulative incidences of acute GVHD grade ≥ II, chronic GVHD, and autoimmune disease were 45.8%, 24.2%, and 29.6%, respectively. There were 2 cases of grade III acute GVHD and no extensive cGVHD. The cumulative incidences of blood viral replication and life-threatening viral events were 58% and 15.6%, respectively. There was evidence of early T cell immune reconstitution. In the absence of an HLA-identical donor, HIFD HSCT with PTCY is a viable option for patients with life-threatening inherited disorders.
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Affiliation(s)
- Bénédicte Neven
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM U1163 and Institut Imagine, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France.
| | - Jean-Sébastien Diana
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France; Biotherapy Department, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Martin Castelle
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alessandra Magnani
- INSERM U1163 and Institut Imagine, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France; Biotherapy Department, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jérémie Rosain
- INSERM U1163 and Institut Imagine, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France; Study Center for Primary Immunodeficiencies, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Fabien Touzot
- INSERM U1163 and Institut Imagine, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France; Biotherapy Department, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Baptiste Moreira
- Immunology Laboratory, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie-Louise Fremond
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM U1163 and Institut Imagine, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France
| | - Coralie Briand
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France
| | - Matthieu Bendavid
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France
| | - Romain Levy
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France
| | - Guillaume Morelle
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France
| | - Marc Vincent
- INSERM U1163 and Institut Imagine, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France
| | - Elsa Magrin
- INSERM U1163 and Institut Imagine, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France; Biotherapy Department, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Philippe Bourget
- Functional explorations Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lucienne Chatenoud
- Immunology Laboratory, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Capucine Picard
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM U1163 and Institut Imagine, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France; Study Center for Primary Immunodeficiencies, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alain Fischer
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM U1163 and Institut Imagine, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France; College de France, Paris, France
| | - Despina Moshous
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM U1163 and Institut Imagine, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France
| | - Stéphane Blanche
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Paris-Descartes University, Sorbonne Paris Cité, Paris, France
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39
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Oostenbrink LVE, Jol-van der Zijde CM, Kielsen K, Jansen-Hoogendijk AM, Ifversen M, Müller KG, Lankester AC, van Halteren AGS, Bredius RGM, Schilham MW, van Tol MJD. Differential Elimination of Anti-Thymocyte Globulin of Fresenius and Genzyme Impacts T-Cell Reconstitution After Hematopoietic Stem Cell Transplantation. Front Immunol 2019; 10:315. [PMID: 30894854 PMCID: PMC6414431 DOI: 10.3389/fimmu.2019.00315] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/06/2019] [Indexed: 01/11/2023] Open
Abstract
Anti-thymocyte globulin (ATG) is a lymphocyte depleting agent applied in hematopoietic stem cell transplantation (HSCT) to prevent rejection and Graft-vs.-Host Disease (GvHD). In this study, we compared two rabbit ATG products, ATG-Genzyme (ATG-GENZ), and ATG-Fresenius (ATG-FRES), with respect to dosing, clearance of the active lymphocyte binding component, post-HSCT immune reconstitution and clinical outcome. Fifty-eigth pediatric acute leukemia patients (n = 42 ATG-GENZ, n = 16 ATG-FRES), who received a non-depleted bone marrow or peripheral blood stem cell graft from an unrelated donor were included. ATG-GENZ was given at a dosage of 6-10 mg/kg; ATG-FRES at 45-60 mg/kg. The active component of ATG from both products was cleared at different rates. Within the ATG-FRES dose range no differences were found in clearance of active ATG or T-cell re-appearance. However, the high dosage of ATG-GENZ (10 mg/kg), in contrast to the low dosage (6-8 mg/kg), correlated with prolonged persistence of active ATG and delayed T-cell reconstitution. Occurrence of serious acute GvHD (grade III-IV) was highest in the ATG-GENZ-low dosage group. These results imply that dosing of ATG-GENZ is more critical than dosing of ATG-FRES due to the difference in clearance of active ATG. This should be taken into account when designing clinical protocols.
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Affiliation(s)
| | | | - Katrine Kielsen
- Institute for Inflammation Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Marianne Ifversen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Klaus G Müller
- Institute for Inflammation Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Arjan C Lankester
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | | | - Robbert G M Bredius
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Marco W Schilham
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Maarten J D van Tol
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
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40
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Adoptive T Cell Therapy Strategies for Viral Infections in Patients Receiving Haematopoietic Stem Cell Transplantation. Cells 2019; 8:cells8010047. [PMID: 30646564 PMCID: PMC6356262 DOI: 10.3390/cells8010047] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/08/2019] [Accepted: 01/11/2019] [Indexed: 01/18/2023] Open
Abstract
Adverse outcomes following virus-associated disease in patients receiving allogeneic haematopoietic stem cell transplantation (HSCT) have encouraged strategies to control viral reactivation in immunosuppressed patients. However, despite timely treatment with antiviral medication, some viral infections remain refractory to treatment, which hampers outcomes after HSCT, and are responsible for a high proportion of transplant-related morbidity and mortality. Adoptive transfer of donor-derived lymphocytes aims to improve cellular immunity and to prevent or treat viral diseases after HSCT. Early reports described the feasibility of transferring nonspecific lymphocytes from donors, which led to the development of cell therapy approaches based on virus-specific T cells, allowing a targeted treatment of infections, while limiting adverse events such as graft versus host disease (GvHD). Both expansion and direct selection techniques have yielded comparable results in terms of efficacy (around 70–80%), but efficacy is difficult to predict for individual cases. Generating bespoke products for each donor–recipient pair can be expensive, and there remains the major obstacle of generating products from seronegative or poorly responsive donors. More recent studies have focused on the feasibility of collecting and infusing partially matched third-party virus-specific T cells, reporting response rates of 60–70%. Future development of this approach will involve the broadening of applicability to multiple viruses, the optimization and cost-control of manufacturing, larger multicentred efficacy trials, and finally the creation of cell banks that can provide prompt access to virus-specific cellular product. The aim of this review is to summarise present knowledge on adoptive T cell manufacturing, efficacy and potential future developments.
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41
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Shaw P, Shizuru J, Hoenig M, Veys P. Conditioning Perspectives for Primary Immunodeficiency Stem Cell Transplants. Front Pediatr 2019; 7:434. [PMID: 31781522 PMCID: PMC6851055 DOI: 10.3389/fped.2019.00434] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/07/2019] [Indexed: 01/10/2023] Open
Abstract
The majority of children undergoing Hematopoietic Stem cell Transplantation (HSCT) require conditioning therapy to make space and prevent rejection of the donor stem cells. The exception is certain children with Severe Combined immune deficiency, who have limited or no ability to reject the donor graft. Transplant conditioning is associated with significant morbidity and mortality from both direct toxic effects of chemotherapy as well as opportunistic infections associated with profound immunosuppression. The ultimate goal of transplant practice is to achieve sufficient engraftment of donor cells to correct the underlying disease with minimal short- and long-term toxicity to the recipient. Traditional combinations, such as busulfan and cyclophosphamide, achieve a high rate of full donor engraftment, but are associated with significant acute transplant-related-mortality and late effects such as infertility. Less "intensive" approaches, such as combinations of treosulfan or melphalan with fludarabine, are less toxic, but may be associated with rejection or low level chimerism requiring the need for re-transplantation. The major benefit of these novel approaches, however, which we hope will be realized in the decades to come, may be the preservation of fertility. Future approaches look to replace chemotherapy with non-toxic antibody conditioning. The lessons learnt in refining conditioning for HSCT are likely to be equally applicable to gene therapy protocols for the same diseases.
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Affiliation(s)
- Peter Shaw
- Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Judith Shizuru
- Departments of Medicine and Pediatrics, Stanford University, Stanford, CA, United States
| | - Manfred Hoenig
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Ulm, Ulm, Germany
| | - Paul Veys
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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42
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Admiraal R, Boelens JJ. Pharmacotherapy in Pediatric Hematopoietic Cell Transplantation. Handb Exp Pharmacol 2019; 261:471-489. [PMID: 31375921 DOI: 10.1007/164_2019_247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hematopoietic cell transplantation (HCT) is a curative treatment option for both malignant and nonmalignant diseases. Success of the procedure mainly depends on disease control and treatment-related complications. Pharmacotherapy plays a major role in HCT and significantly impacts the outcomes. Main drug use within HCT includes conditioning, GvHD prophylaxis, and prevention/treatment of infections.Increasing evidence suggests individualized dosing in (pediatric) HCT may improve outcome. Dose individualization may result in a better predictable drug treatment in terms of safety and efficacy, including timely immune reconstitution after HCT and optimal tumor or disease control, which may result in improved survival chances.
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Affiliation(s)
- R Admiraal
- Blood and Marrow Transplantation Program, Prinses Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - J J Boelens
- Stem Cell Transplantation and Cellular Therapies Pediatrics, New York, NY, USA. .,Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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43
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Robin M, Raj K, Chevret S, Gauthier J, de Lavallade H, Michonneau D, McLornan D, Peffault de Latour R, Potter V, Kulasekararaj A, Sicre de Fontbrune F, Pagliuca A, Yakoub-Agha I, Socié G, Mufti GJ. Alemtuzumab vs anti-thymocyte globulin in patients transplanted from an unrelated donor after a reduced intensity conditioning. Eur J Haematol 2018; 101:466-474. [PMID: 29714032 DOI: 10.1111/ejh.13085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Relapse and graft-vs-host disease (GVHD) are still the main complications after allogeneic hematopoietic stem cell transplantation, especially in the setting of reduced intensity regimen (RIC) and unrelated donor. We compared here anti-thymocyte globulin (ATG) or alemtuzumab as GVHD prophylaxis in patients with myeloid disease transplanted after RIC and from an unrelated donor. METHOD ATG and alemtuzumab patients have been matched by age, gender, HLA matching, comorbidities and cytogenetics risk (119 patients in each group). RESULTS After matching, we found that ATG decreased the risk of relapse (HR: 0.55, P = .0049) and improved relapse-free survival (RFS, HR: 0.70, P = .042). The improved RFS with ATG was more pronounced in CMV-positive patients but was not influenced by disease risk. Regarding overall survival, GVHD-free relapse-free survival and transplant-related mortality, the risk was similar using ATG or alemtuzumab. CONCLUSION Even if GVHD risk is lowered by alemtuzumab use, it does not translate in better outcome due to higher risk of relapse.
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Affiliation(s)
- Marie Robin
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1131 Université Paris 7, Paris, France
| | - Kavita Raj
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Sylvie Chevret
- Service de biostatistique, Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | - Jordan Gauthier
- CHU de Lille, LIRIC INSERM U955, Université Lille2, Paris, France
| | - Hugues de Lavallade
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - David Michonneau
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1160 Université Paris 7, Paris, France
| | - Donal McLornan
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | | | - Victoria Potter
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Austin Kulasekararaj
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | | | - Antonio Pagliuca
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Ibrahim Yakoub-Agha
- Service de biostatistique, Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | - Gérard Socié
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1160 Université Paris 7, Paris, France
| | - Ghulam J Mufti
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
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Groth C, van Groningen LFJ, Matos TR, Bremmers ME, Preijers FWMB, Dolstra H, Reicherts C, Schaap NPM, van Hooren EHG, IntHout J, Masereeuw R, Netea MG, Levine JE, Morales G, Ferrara JL, Blijlevens NMA, van Oosterhout YVJM, Stelljes M, van der Velden WJFM. Phase I/II Trial of a Combination of Anti-CD3/CD7 Immunotoxins for Steroid-Refractory Acute Graft-versus-Host Disease. Biol Blood Marrow Transplant 2018; 25:712-719. [PMID: 30399420 DOI: 10.1016/j.bbmt.2018.10.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 10/25/2018] [Indexed: 01/01/2023]
Abstract
Effective therapies for treating patients with steroid-refractory acute graft-versus-host-disease (SR-aGVHD), particularly strategies that reduce the duration of immunosuppression following remission, are urgently needed. The investigated immunotoxin combination consists of a mixture of anti-CD3 and anti-CD7 antibodies separately conjugated to recombinant ricin A (CD3/CD7-IT), which induces in vivo depletion of T cells and natural killer (NK) cells and suppresses T cell receptor activation. We conducted a phase I/II trial to examine the safety and efficacy of CD3/CD7-IT in 20 patients with SR-aGVHD; 17 of these patients (85%) had severe SR-aGVHD, and all 20 patients had visceral organ involvement, including 18 (90%) with gastrointestinal (GI) involvement and 5 (25%) with liver involvement. A validated 2-biomarker algorithm classified the majority of patients (11 of 20) as high risk. On day 28 after the start of CD3/CD7-IT therapy, the overall response rate was 60% (12 of 20), with 10 patients (50%) achieving a complete response. The 6-month overall survival rate was 60% (12 of 20), including 64% (7 of 11) classified as high risk by biomarkers. The 1-week course of treatment with CD3/CD7-IT caused profound but transient depletion of T cells and NK cells, followed by rapid recovery of the immune system with a diverse TCR Vβ repertoire, and preservation of Epstein-Barr virus- and cytomegalovirus-specific T cell clones. Furthermore, our results indicate that CD3/CD7-IT appeared to be safe and well tolerated, with a relatively low prevalence of manageable and reversible adverse events, primarily worsening of hypoalbuminemia, microangiopathy, and thrombocytopenia. These encouraging results suggest that CD3/CD7-IT may improve patient outcomes in patients with SR-aGVHD.
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Affiliation(s)
- Christoph Groth
- Department of Medicine A/Hematology and Oncology, University Hospital of Muenster, Muenster, Germany
| | - Lenneke F J van Groningen
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tiago R Matos
- Department of Dermatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Manita E Bremmers
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank W M B Preijers
- Department of Laboratory Medicine, Laboratory for Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harry Dolstra
- Department of Laboratory Medicine, Laboratory for Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christian Reicherts
- Department of Medicine A/Hematology and Oncology, University Hospital of Muenster, Muenster, Germany
| | - Nicolaas P M Schaap
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Joanna IntHout
- Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Section of Biostatistics, Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rosalinde Masereeuw
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Mihai G Netea
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - John E Levine
- Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - George Morales
- Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - James L Ferrara
- Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Matthias Stelljes
- Department of Medicine A/Hematology and Oncology, University Hospital of Muenster, Muenster, Germany
| | - Walter J F M van der Velden
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
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Bhatt ST, Bednarski JJ, Berg J, Trinkaus K, Murray L, Hayashi R, Schulz G, Hente M, Grimley M, Chan KW, Kamani N, Jacobsohn D, Nieder M, Hale G, Yu L, Adams R, Dalal J, Pulsipher MA, Haut P, Chaudhury S, Davis J, Jaroscak J, Andreansky M, Willert J, Shenoy S. Immune Reconstitution and Infection Patterns after Early Alemtuzumab and Reduced Intensity Transplantation for Nonmalignant Disorders in Pediatric Patients. Biol Blood Marrow Transplant 2018; 25:556-561. [PMID: 30321596 DOI: 10.1016/j.bbmt.2018.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/08/2018] [Indexed: 11/16/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is a therapeutic option for many nonmalignant disorders (NMD) and is curative or prevents disease progression. Reduced-intensity conditioning (RIC) in HSCT for NMD may reduce regimen-related acute toxicities and late complications. Myeloablation is often replaced by immune suppression in RIC regimens to support donor engraftment. The pace of immune reconstitution after immune suppression by RIC regimens is influenced by agents used, donor source, and graft-versus-host disease prophylaxis/treatment. In a multicenter trial (NCT 00920972) of HSCT for NMD, a RIC regimen consisting of alemtuzumab, fludarabine, and melphalan was substituted for myeloablation. Alemtuzumab was administered early (days -21 to -19) to mitigate major lymphodepletion of the incoming graft and the risk of graft rejection. Immune reconstitution and infectious complications were prospectively monitored for 1-year post-HSCT. Seventy-one patients met inclusion criteria for this report and received marrow or peripheral blood stem cell transplants. Immune reconstitution and infections are reported for related donor (RD) and unrelated donor (URD) transplants at 3 time-points (100days, 6 months, and 1 year post-HSCT). Natural killer cell recovery was rapid, and numbers normalized in both cohorts by day +100. Mean CD3, CD4, and CD8 T-lymphocyte numbers normalized by 6 months after RD HSCT and by 1 year in the URD group. CD4 and CD8 T-lymphocyte counts were significantly higher in patients who received RD HSCT at 6 months and at 1 year, respectively, post-HSCT compared with patients who received URD HSCT. The pace of CD19 B-cell recovery was markedly different between RD and URD cohorts. Mean B-cell numbers were normal by day 100 after RD HSCT but took 1 year post-HSCT to normalize in the URD cohort. Despite these differences in immune reconstitution, the timing and nature of infections did not differ between the groups, presumably because of comparable T-lymphocyte recovery. Immune reconstitution occurred at a faster pace than in prior reports using RIC with T-cell depletion. The incidence of infections was similar for both cohorts and occurred most frequently in the first 100days post-HSCT. Viral and fungal infections occurred at a lower incidence in this cohort, with "early" alemtuzumab compared with regimens administering serotherapy in the peritransplantation period. Patients were susceptible to bacterial infections primarily in the first 100days irrespective of donor source and had no increase in mortality from the same. The overall mortality rate from infections was 1.4% at 1 year. Close monitoring and prophylaxis against bacterial infections in the first 100days post-HSCT is necessary but is followed by robust immune reconstitution, especially in the T-cell compartment.
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Affiliation(s)
- Sima T Bhatt
- Washington University and Saint Louis Children's Hospital, St. Louis, Missouri
| | - Jeffrey J Bednarski
- Washington University and Saint Louis Children's Hospital, St. Louis, Missouri
| | - Julia Berg
- Washington University and Saint Louis Children's Hospital, St. Louis, Missouri
| | - Kathryn Trinkaus
- Siteman Cancer Center Biostatistics Shared Resource, St. Louis, Missouri
| | - Lisa Murray
- Washington University and Saint Louis Children's Hospital, St. Louis, Missouri
| | - Robert Hayashi
- Washington University and Saint Louis Children's Hospital, St. Louis, Missouri
| | - Ginny Schulz
- Washington University and Saint Louis Children's Hospital, St. Louis, Missouri
| | - Monica Hente
- Washington University and Saint Louis Children's Hospital, St. Louis, Missouri
| | | | - Ka Wah Chan
- Methodist Children's Hospital, San Antonio, Texas
| | - Naynesh Kamani
- Children's National Medical Center, Washington, District of Columbia
| | - David Jacobsohn
- Children's National Medical Center, Washington, District of Columbia
| | - Michael Nieder
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Gregory Hale
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Lolie Yu
- Louisiana State University, New Orleans, Louisiana
| | | | | | - Michael A Pulsipher
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | - Paul Haut
- Riley Children's Hospital, Indianapolis, Indiana
| | | | - Jeffrey Davis
- Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer Jaroscak
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | - Shalini Shenoy
- Washington University and Saint Louis Children's Hospital, St. Louis, Missouri.
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John TD, Naik S, Leung K, Sasa G, Martinez C, Krance RA. Allogeneic hematopoietic cell transplant following crizotinib monotherapy for relapsed/refractory anaplastic large cell lymphoma. Pediatr Transplant 2018; 22:e13210. [PMID: 29719098 DOI: 10.1111/petr.13210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2018] [Indexed: 12/26/2022]
Abstract
Relapsed ALK-positive ALCL often is responsive to CRZ monotherapy. The subsequent role of allogeneic HCT after achieving second remission is poorly understood. We report 6 children who underwent allogeneic HCT for relapsed ALCL after CRZ. Age at transplant ranged from 10.7 to 22.6 years. Follow-up ranged from 0.9 to 4.5 years. All patients engrafted. Three of 4 patients that received a reduced-toxicity conditioning regimen containing fludarabine, alemtuzumab, and low-dose irradiation showed progressive mixed chimerism. Five patients remain in remission. One patient developed isolated CNS relapse 3.6 years after HCT despite a lack of previous CNS involvement. No acute transplant-related complications were experienced. One patient developed chronic renal disease secondary to transplant-associated microangiopathy and one patient chronic GVHD secondary to DLI. Ultimately, allogeneic HCT appears safe and potentially curative after remission induction with CRZ. The role of conditioning therapy, ablative or reduced intensity, remains uncertain for patients' post-CRZ monotherapy, and further studies may be warranted.
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Affiliation(s)
- Tami D John
- Department of Pediatrics, Center for Cell and Gene Therapy, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX, USA
| | - Swati Naik
- Department of Pediatrics, Center for Cell and Gene Therapy, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX, USA
| | - Kathryn Leung
- Department of Pediatrics, Center for Cell and Gene Therapy, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Ghadir Sasa
- Department of Pediatrics, Center for Cell and Gene Therapy, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX, USA
| | - Caridad Martinez
- Department of Pediatrics, Center for Cell and Gene Therapy, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX, USA
| | - Robert A Krance
- Department of Pediatrics, Center for Cell and Gene Therapy, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX, USA
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Laberko A, Gennery AR. Clinical considerations in the hematopoietic stem cell transplant management of primary immunodeficiencies. Expert Rev Clin Immunol 2018; 14:297-306. [PMID: 29589971 DOI: 10.1080/1744666x.2018.1459189] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Primary immunodeficiencies (PID) are genetic immune disorders causing increased predisposition to infections and autoimmunity. The only curative procedure is hematopoietic stem cell transplantation (HSCT), results from which have improved dramatically since 2000. Complications remain a serious issue, especially in HLA non-identical transplantation. In PID patients, persistent infection and autoimmunity with end-organ damage cause particular problems with approach to transplantation. This article examines these, emphasising approach to management and consequences. Areas covered: It is challenging to know which patients should be offered HSCT. As new diseases are discovered, data are required to determine natural history, and HSCT outcomes. Treatment of adults can be challenging, although HSCT outcomes are encouraging. New methods of T-lymphocyte depletion show results comparable to those of matched sibling donor transplants. New cellular therapies to treat viral infections show promising results, and immunomodulatory methods are successful in treating acute graft-versus-host disease. Expert commentary: New T-lymphocyte depletion methods are a paradigm shift in approach to HSCT for PID. In combination with new cellular approaches to treating viral infection, immunomodulatory approaches to acute graft-versus-host disease and better understanding of endothelial activation syndromes, survival approaches 90%. Widespread introduction of newborn screening for severe combined immunodeficiencies will improve survival further.
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Affiliation(s)
- Alexandra Laberko
- a Immunology and Hematopoietic Stem Cell Transplantation Department , Dmitry Rogachev National Center for Pediatric Hematology, Oncology and Immunology , Moscow , Russia
| | - Andrew R Gennery
- b Primary Immunodeficiency Group, Institute of Cellular Medicine , Newcastle University , Newcastle upon Tyne , UK.,c Paediatric Immunology + HSCT , Great North Children's Hospital , Newcastle upon Tyne , UK
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Kruizinga MD, van Tol MJ, Bekker V, Netelenbos T, Smiers FJ, Bresters D, Jansen-Hoogendijk AM, van Ostaijen-ten Dam MM, Kollen WJ, Zwaginga JJ, Lankester AC, Bredius RG. Risk Factors, Treatment, and Immune Dysregulation in Autoimmune Cytopenia after Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Patients. Biol Blood Marrow Transplant 2018; 24:772-778. [DOI: 10.1016/j.bbmt.2017.12.782] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/09/2017] [Indexed: 10/18/2022]
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Guilcher GMT, Shah R, Shenoy S. Principles of alemtuzumab immunoablation in hematopoietic cell transplantation for non-malignant diseases in children: A review. Pediatr Transplant 2018; 22. [PMID: 29352515 DOI: 10.1111/petr.13142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2017] [Indexed: 12/19/2022]
Abstract
Alemtuzumab is a humanized mAb targeted to CD52. Alemtuzumab is highly immunosuppressive with the ability to deplete T and B cells (in addition to other immune cell lines). A growing understanding of the PKs, dosing, and timing of administration of alemtuzumab has allowed for the study of its use as a conditioning agent for allogeneic HCT. The highly immunosuppressive properties of the drug are particularly appealing in the setting of non-malignant HCT, where GVHD provides no clinical benefit and relapse of malignancy is not applicable. In addition, the degree of immune suppression achieved with alemtuzumab has allowed for a reduction in the intensity of myeloablative cytotoxic agents included in some HCT conditioning regimens, allowing for fewer acute and late toxicities. This review paper will provide a comprehensive summary of the mechanism of action, PKs, dosing, and timing of alemtuzumab, a brief description of its use in various allogeneic HCT protocols for non-malignant conditions and a summary of the data regarding its use for GVHD therapy. The goal of this review was to provide an understanding as to how alemtuzumab might be safely incorporated into HCT conditioning regimens for children with non-malignant disease, allowing for expanded access to curative HCT therapy.
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Affiliation(s)
- Gregory M T Guilcher
- Section of Paediatric Oncology/BMT, Departments of Oncology and Paediatrics, University of Calgary, Calgary, AB, Canada
| | - Ravi Shah
- Department of Paediatric Haematology/BMT, Great Ormond Street Hospital, NHS Foundation Trust, London, UK
| | - Shalini Shenoy
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, MO, USA
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Immune Reconstitution Following Autologous Stem Cell Transplantation in Patients with High-Risk Neuroblastoma at the Time of Immunotherapy. Biol Blood Marrow Transplant 2017; 24:452-459. [PMID: 29191664 DOI: 10.1016/j.bbmt.2017.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 11/11/2017] [Indexed: 12/25/2022]
Abstract
Outcomes for patients with high-risk neuroblastoma (HR-NBL) are significantly improved with the addition of immunotherapy (dinutuximab + cytokines) following autologous hematopoietic stem cell transplantation (auto-HSCT). We hypothesized that the immune system is not fully reconstituted at the initiation of immunotherapy. To test this hypothesis, we evaluated hematologic and immune subsets in 34 patients with HR-NBL before and after auto-HSCT. We found that absolute T, B, and NK cell counts at the time of immunotherapy were below normal in 80% of patients. Patients with residual disease at the time of transplantation had significantly lower absolute lymphocyte counts (ALC; P = .008), lower CD16+ cell counts (P = .009), and an abnormal ratio of cytokine-releasing to cytotoxic NK cells at the time of dinutuximab treatment. In addition, the preparative regimen used for auto-HSCT predicted immune recovery. Finally, higher total white blood cell count (P = .013) and ALC (P = .013) at 3 months after completion of therapy were measured in patients who remained in remission compared with those who relapsed. Our results indicate that most patients with HR-NBL do not have full immune reconstitution at the time of dinutuximab treatment after auto-HSCT, and that immune recovery may correlate with disease-related outcomes in patients with high-risk disease.
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