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Demirci S, Khan MBN, Hinojosa G, Le A, Leonard A, Essawi K, Gudmundsdottir B, Liu X, Zeng J, Inam Z, Chu R, Uchida N, Araki D, London E, Butt H, Maitland SA, Bauer DE, Wolfe SA, Larochelle A, Tisdale JF. Ex vivo culture resting time impacts transplantation outcomes of genome-edited human hematopoietic stem and progenitor cells in xenograft mouse models. Cytotherapy 2024; 26:641-648. [PMID: 38506770 PMCID: PMC11127784 DOI: 10.1016/j.jcyt.2024.02.011] [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: 10/28/2023] [Revised: 01/30/2024] [Accepted: 02/13/2024] [Indexed: 03/21/2024]
Abstract
Ex vivo resting culture is a standard procedure following genome editing in hematopoietic stem and progenitor cells (HSPCs). However, prolonged culture may critically affect cell viability and stem cell function. We investigated whether varying durations of culture resting times impact the engraftment efficiency of human CD34+ HSPCs edited at the BCL11A enhancer, a key regulator in the expression of fetal hemoglobin. We employed electroporation to introduce CRISPR-Cas9 components for BCL11A enhancer editing and compared outcomes with nonelectroporated (NEP) and electroporated-only (EP) control groups. Post-electroporation, we monitored cell viability, death rates, and the frequency of enriched hematopoietic stem cell (HSC) fractions (CD34+CD90+CD45RA- cells) over a 48-hour period. Our findings reveal that while the NEP group showed an increase in cell numbers 24 hours post-electroporation, both EP and BCL11A-edited groups experienced significant cell loss. Although CD34+ cell frequency remained high in all groups for up to 48 hours post-electroporation, the frequency of the HSC-enriched fraction was significantly lower in the EP and edited groups compared to the NEP group. In NBSGW xenograft mouse models, both conditioned with busulfan and nonconditioned, we found that immediate transplantation post-electroporation led to enhanced engraftment without compromising editing efficiency. Human glycophorin A+ (GPA+) red blood cells (RBCs) sorted from bone marrow of all BCL11A edited mice exhibited similar levels of γ-globin expression, regardless of infusion time. Our findings underscore the critical importance of optimizing the culture duration between genome editing and transplantation. Minimizing this interval may significantly enhance engraftment success and minimize cell loss without compromising editing efficiency. These insights offer a pathway to improve the success rates of genome editing in HSPCs, particularly for conditions like sickle cell disease.
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Affiliation(s)
- Selami Demirci
- Cellular and Molecular Therapeutics Branch (CMTB), National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, Maryland, USA..
| | | | - Gabriela Hinojosa
- Cellular and Molecular Therapeutics Branch (CMTB), National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Anh Le
- Cellular and Molecular Therapeutics Branch (CMTB), National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Alexis Leonard
- Cellular and Molecular Therapeutics Branch (CMTB), National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, Maryland, USA.; St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Khaled Essawi
- College of Applied Medical Sciences, Jazan University, Gizan, Saudi Arabia
| | - Bjorg Gudmundsdottir
- Cellular and Molecular Therapeutics Branch (CMTB), National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Xiong Liu
- Cellular and Molecular Therapeutics Branch (CMTB), National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Jing Zeng
- Department of Pediatrics, Harvard Stem Cell Institute, Broad Institute of MIT and Harvard, Harvard Medical School, Boston, Massachusetts, USA
| | - Zaina Inam
- Cellular and Molecular Therapeutics Branch (CMTB), National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Rebecca Chu
- Cellular and Molecular Therapeutics Branch (CMTB), National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Naoya Uchida
- Cellular and Molecular Therapeutics Branch (CMTB), National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Daisuke Araki
- CMTB, NHLBI/Regenerative Therapies for Inherited Blood Disorders, NIH, Bethesda, Maryland, USA
| | - Evan London
- Cellular and Molecular Therapeutics Branch (CMTB), National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Henna Butt
- Cellular and Molecular Therapeutics Branch (CMTB), National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Stacy A Maitland
- Department of Molecular, Cell and Cancer Biology, Li Weibo Institute for Rare Diseases Research, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Daniel E Bauer
- Department of Pediatrics, Harvard Stem Cell Institute, Broad Institute of MIT and Harvard, Harvard Medical School, Boston, Massachusetts, USA
| | - Scot A Wolfe
- Department of Molecular, Cell and Cancer Biology, Li Weibo Institute for Rare Diseases Research, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Andre Larochelle
- CMTB, NHLBI/Regenerative Therapies for Inherited Blood Disorders, NIH, Bethesda, Maryland, USA
| | - John F Tisdale
- Cellular and Molecular Therapeutics Branch (CMTB), National Heart Lung and Blood Institutes (NHLBI)/National Institute of Diabetes, and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, Maryland, USA..
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2
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Zhang L, Wang L, Long J, Yin Y, Patil S. Nutritional and Body Composition Changes in Paediatric β-Thalassemia Patients Undergoing Hematopoietic Stem Cell Transplantation: A Retrospective Study Using Bioelectrical Impedance Analysis. J Multidiscip Healthc 2024; 17:2203-2214. [PMID: 38751668 PMCID: PMC11094366 DOI: 10.2147/jmdh.s463796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024] Open
Abstract
Objective This retrospective study evaluated nutritional status and body composition changes in paediatric β-thalassemia (β-TM) patients before and after hematopoietic stem cell transplantation (HSCT), using bioelectrical impedance analysis (BIA), and explored their relationship with HSCT outcomes. Methods A cohort of 40 paediatric β-TM patients undergoing allogeneic HSCT was assessed for their nutritional status, anthropometric parameters, including body mass index (BMI), weight, and height, and body composition parameters pre-and post-HSCT, focusing on BIA measurements, including intracellular water (ICW), extracellular water (ECW), fat mass (FAT), fat-free mass (FFM), Skeletal Muscle Mass (SMM), soft Lean Mass (SLM), percent body fat (PBF), Body Cell Mass (BCM), Phase angle (PA) and muscle balance pre- and post-HSCT. Post-HSCT clinical outcomes, including acute graft-vs-host disease (aGVHD), engraftment time, oral mucositis (OM), sinusoidal obstruction syndrome (SOS), and diarrhoea in relation to nutrition status after HSCT were analysed. Results After HSCT, 28.21% experienced diminished nutritional status, with 71.43% of those who were wasting before HSCT showing diminished nutritional status, significantly higher than the normal group (18.75%, P = 0.012). Anthropometric changes included significant weight reduction (87.5%, 22.15 ± 7.46 vs 20.74 ± 6.57, P < 0.001) and BMI decrease (90%, 15.19 ± 1.70 vs 14.05 ± 1.48, P < 0.001). Body composition parameters, which are FFM, SMM, SLM, ICW, ECW, BCM, and PA (18.26 ± 5.71 vs 17.27 ± 5.19, 8.68 ± 3.30 vs 7.93 ± 3.02, 17.11 ± 5.28 vs 16.06 ± 4.84, 8.19 ± 2.54 vs 7.62 ± 2.31, 5.15 ± 1.58 vs 4.94 ± 1.47, 11.74 ± 3.63 vs 10.92 ± 3.32, 4.42 ± 0.50 vs 3.90 ± 0.57, respectively, P < 0.001) analysis revealed significant decreases. No significant differences in clinical outcomes were observed based on nutritional status. Conclusion Paediatric β-TM patients undergoing HSCT exhibit significant changes in nutrition status and body composition, emphasizing the need for focused attention on malnourished children who are more prone to diminished nutritional status. Comprehensive BIA aids in understanding the impact, urging consideration for extended follow-up and larger cohorts in future research.
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Affiliation(s)
- Luyang Zhang
- Department of Haematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong Province, 518000, People’s Republic of China
| | - Li Wang
- Department of Clinical Nutrition, Shenzhen Children’s Hospital, Shenzhen, Guangdong Province, 518000, People’s Republic of China
| | - Jiewen Long
- Department of Haematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong Province, 518000, People’s Republic of China
| | - Yan Yin
- Department of Haematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong Province, 518000, People’s Republic of China
| | - Sandip Patil
- Department of Haematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong Province, 518000, People’s Republic of China
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3
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Hu J, Zhong Y, Xu P, Xin L, Zhu X, Jiang X, Gao W, Yang B, Chen Y. β-Thalassemia gene editing therapy: Advancements and difficulties. Medicine (Baltimore) 2024; 103:e38036. [PMID: 38701251 PMCID: PMC11062644 DOI: 10.1097/md.0000000000038036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/05/2024] [Indexed: 05/05/2024] Open
Abstract
β-Thalassemia is the world's number 1 single-gene genetic disorder and is characterized by suppressed or impaired production of β-pearl protein chains. This results in intramedullary destruction and premature lysis of red blood cells in peripheral blood. Among them, patients with transfusion-dependent β-thalassemia face the problem of long-term transfusion and iron chelation therapy, which leads to clinical complications and great economic stress. As gene editing technology improves, we are seeing the dawn of a cure for the disease, with its reduction of ineffective erythropoiesis and effective prolongation of survival in critically ill patients. Here, we provide an overview of β-thalassemia distribution and pathophysiology. In addition, we focus on gene therapy and gene editing advances. Nucleic acid endonuclease tools currently available for gene editing fall into 3 categories: zinc finger nucleases, transcription activator-like effector nucleases, and regularly interspaced short palindromic repeats (CRISPR-Cas9) nucleases. This paper reviews the exploratory applications and exploration of emerging therapeutic tools based on 3 classes of nucleic acid endonucleases in the treatment of β-thalassemia diseases.
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Affiliation(s)
- Jing Hu
- The First Clinical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Yebing Zhong
- The First Clinical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Pengxiang Xu
- The First Clinical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Liuyan Xin
- Hematology Department, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Xiaodan Zhu
- The First Clinical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Xinghui Jiang
- The First Clinical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Weifang Gao
- The First Clinical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Bin Yang
- The First Clinical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Yijian Chen
- The First Clinical College, Gannan Medical University, Ganzhou, Jiangxi, China
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Sánchez LM, George A, Friend BD, Bhar S, Sasa G, Doherty EE, Craddock J, Steffin D, Salem B, Yassine K, Omer B, Martinez C, Leung K, Krance RA, John TD. Hematopoietic stem cell transplantation for B-thalassemia major with alemtuzumab. Pediatr Hematol Oncol 2024; 41:260-272. [PMID: 38131101 DOI: 10.1080/08880018.2023.2296933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023]
Abstract
While matched related donor (MRD) allogeneic hematopoietic stem cell transplantation (HSCT) is a curative option for transfusion-dependent beta-thalassemia (TDT), the use of alternative sources has increased, resulting in the exploration of novel transplant-conditioning regimens to reduce the contribution of graft-versus-host disease (GVHD) and graft failure (GF) to transplant-related morbidity and mortality. Alemtuzumab is a CD52 monoclonal antibody that has been successfully incorporated into myeloablative conditioning regimens for other hematologic conditions, yet there have been limited studies regarding the use of alemtuzumab in HSCT for TDT. The purpose of this study was to evaluate engraftment, incidence of GVHD, and transplant related morbidity and mortality in patients with TDT who received alemtuzumab in addition to standard busulfan-based conditioning. The primary endpoint was severe GVHD-free, event-free survival (GEFS). Our cohort included 24 patients with a median age of 6.8 years (range 1.5-14.9). Eleven patients received a 10/10 MRD HSCT, eleven 10/10 unrelated donor (UD), and two mismatched UD. All patients achieved primary engraftment. For all patients, 5-year GEFS was 77.4% and 5-year overall survival (OS) was 91%. The 5-year cumulative incidence of GF (attributed to poor graft function) without loss of donor chimerism was 13.8% (95% CI: 4.5, 35.3). We report low rates of significant acute GVHD grade II-IV (12.5%) and chronic GVHD (4.4%). Younger age and MRD were associated with significantly improved GEFS, OS and EFS. Our results show that the use of alemtuzumab promotes stable engraftment, may reduce rates of severe GVHD, and results in acceptable GEFS, OS, and EFS.
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Affiliation(s)
- Luisanna M Sánchez
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Anil George
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Brian D Friend
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Saleh Bhar
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Ghadir Sasa
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Erin E Doherty
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - John Craddock
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - David Steffin
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Baheyeldin Salem
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Khaled Yassine
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Bilal Omer
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Caridad Martinez
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kathryn Leung
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert A Krance
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Tami D John
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Center for Cell and Gene Therapy, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
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Liu D, Nong X, Lai F, Nong C, Wang T, Tang Y. Noninvasive Prenatal Diagnosis of SEA-Thalassemia by Combining 1000 Genomes Database and Relative Haplotype Dosage. Hemoglobin 2024:1-8. [PMID: 38632980 DOI: 10.1080/03630269.2024.2327830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 02/29/2024] [Indexed: 04/19/2024]
Abstract
To explore a noninvasive method for diagnosis of SEA-thalassemia and to investigate whether the regional factors affect the accuracy of this method. The method involved using a public database and bioinformatics software to construct parental haplotypes for proband and predicting fetal genotypes using relative haplotype dosage. We screened and downloaded sequencing data of couples who were both SEA-thalassemia carriers from the China National Genebank public data platform, and matched the sequencing data format with that of the reference panel using Ubuntu system tools. We then used Beagle software to construct parental haplotypes, predicted fetal haplotypes by relative haplotype dosage. Finally, we used Hidden Markov Model and Viterbi algorithm to determine fetal pathogenic haplotypes. All noninvasive fetal genotype diagnosis results were compared with gold standard gap-PCR electrophoresis results. Our method was successful in diagnosing 13 families with SEA-thalassemia carriers. The best diagnostic results were obtained when Southern Chinese Han was used as the reference panel, and 10 families showed full agreement between our noninvasive diagnostic results and the gap-PCR electrophoresis results. The accuracy of our method was higher when using a Chinese Han as the reference panel for haplotype construction in the Southern Chinese Han region as opposed to Beijing Chinese region. The combined use of public databases and relative haplotype dosage for diagnosing SEA-thalassemia is a feasible approach. Our method produces the best noninvasive diagnostic results when the test samples and population reference panel are closely matched in both ethnicity and geography. When constructing parental haplotypes with our method, it is important to consider the effect of region in addition to population background alone.
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Affiliation(s)
- Dewen Liu
- Graduate School, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Xuejuan Nong
- Center for Medical Laboratory Science, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Fengming Lai
- Graduate School, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Chen Nong
- Graduate School, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Taizhong Wang
- School of Medical Laboratory, Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Yulian Tang
- School of Medical Laboratory, Youjiang Medical University for Nationalities, Baise, Guangxi, China
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6
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Corbacioglu S, Frangoul H, Locatelli F, Hobbs W, Walters M. Defining curative endpoints for transfusion-dependent β-thalassemia in the era of gene therapy and gene editing. Am J Hematol 2024; 99:422-429. [PMID: 38100154 DOI: 10.1002/ajh.27166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/16/2023] [Accepted: 11/06/2023] [Indexed: 02/15/2024]
Abstract
β-thalassemia is a monogenic disease that results in varying degrees of anemia. In the most severe form, known as transfusion-dependent β-thalassemia (TDT), the clinical hallmarks are ineffective erythropoiesis and a requirement of regular, life-long red blood cell transfusions, with the development of secondary clinical complications such as iron overload, end-organ damage, and a risk of early mortality. With the exception of allogeneic hematopoietic cell transplantation, current treatments for TDT address disease symptoms and not the underlying cause of disease. Recently, a growing number of gene addition and gene editing-based treatments for patients with TDT with the potential to provide a one-time functional cure have entered clinical trials. A key challenge in the design and evaluation of these trials is selecting endpoints to evaluate if these novel genetic therapies have a curative versus an ameliorative effect. Here, we present an overview of the pathophysiology of TDT, review emerging gene addition or gene editing therapeutic approaches for TDT currently in clinical trials, and identify a series of endpoints that can quantify therapeutic effects, including a curative outcome.
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Affiliation(s)
| | - Haydar Frangoul
- Sarah Cannon Research Institute and the Children's Hospital at TriStar Centennial, Nashville, Tennessee, USA
| | - Franco Locatelli
- IRCCS, Ospedale Pediatrico Bambino, Gesù Rome, Catholic University of the Sacred Heart, Rome, Italy
| | - William Hobbs
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | - Mark Walters
- Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
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7
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Sykora KW, Beier R, Schulz A, Cesaro S, Greil J, Gozdzik J, Sedlacek P, Bader P, Schulte J, Zecca M, Locatelli F, Gruhn B, Reinhardt D, Styczynski J, Piras S, Fagioli F, Bonanomi S, Caniglia M, Li X, Baumgart J, Kehne J, Mielcarek-Siedziuk M, Kalwak K. Treosulfan vs busulfan conditioning for allogeneic bmt in children with nonmalignant disease: a randomized phase 2 trial. Bone Marrow Transplant 2024; 59:107-116. [PMID: 37925531 PMCID: PMC10781637 DOI: 10.1038/s41409-023-02135-9] [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: 08/16/2023] [Revised: 10/12/2023] [Accepted: 10/17/2023] [Indexed: 11/06/2023]
Abstract
Optimal conditioning prior to allogeneic hematopoietic stem cell transplantation for children with non-malignant diseases is subject of ongoing research. This prospective, randomized, phase 2 trial compared safety and efficacy of busulfan with treosulfan based preparative regimens. Children with non-malignant diseases received fludarabine and either intravenous (IV) busulfan (4.8 to 3.2 mg/kg/day) or IV treosulfan (10, 12, or 14 g/m2/day). Thiotepa administration (2 × 5 mg/kg) was at the investigator's discretion. Primary endpoint was freedom from transplantation (treatment)-related mortality (freedom from TRM), defined as death between Days -7 and +100. Overall, 101 patients (busulfan 50, treosulfan 51) with at least 12 months follow-up were analyzed. Freedom from TRM was 90.0% (95% CI: 78.2%, 96.7%) after busulfan and 100.0% (95% CI: 93.0%, 100.0%) after treosulfan. Secondary outcomes (transplantation-related mortality [12.0% versus 3.9%]) and overall survival (88.0% versus 96.1%) favored treosulfan. Graft failure was more common after treosulfan (n = 11), than after busulfan (n = 2) while all patients were rescued by second procedures except one busulfan patient. CTCAE Grade III adverse events were similar in both groups. This study confirmed treosulfan to be an excellent alternative to busulfan and can be safely used for conditioning treatment in children with non-malignant disease.
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Affiliation(s)
- Karl-Walter Sykora
- Hannover Medical School, Ped. Haematology and Oncology, Hannover, Germany
| | - Rita Beier
- Hannover Medical School, Ped. Haematology and Oncology, Hannover, Germany.
| | - Ansgar Schulz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Jolanta Gozdzik
- Jagiellonian University Medical College, Center of Transplantation University Children's Hospital in Cracow, Cracow, Poland
| | | | - Peter Bader
- University Hospital Frankfurt, Frankfurt Main, Germany
| | | | - Marco Zecca
- Children's Hospital San Matteo, Pavia, Italy
| | | | - Bernd Gruhn
- Department of Pediatrics, Jena University Hospital, Jena, Germany
| | | | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, University Hospital, Collegium Medicum UMK, Bydgoszcz, Poland
| | - Simona Piras
- Children's Hospital Antonio Cao, Cagliari, Italy
| | | | | | | | | | | | | | | | - Krzysztof Kalwak
- Department of Pediatric Hematology, Oncology and BMT, Wroclaw Medical University, Wroclaw, Poland
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8
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DeZern AE, Brodsky RA. Combining PTCy and ATG for GvHD prophylaxis in non-malignant diseases. Blood Rev 2023; 62:101016. [PMID: 36244884 DOI: 10.1016/j.blre.2022.101016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 11/21/2022]
Abstract
Bone marrow transplantation for non-malignant diseases such as aplastic anemia and hemoglobinopathies is a burgeoning clinical area. The goal of these transplants is to correct the hematopoietic defect with as little toxicity as possible. This requires mitigation of transplant-specific toxicities such as graft versus host disease, given this is not needed in non-malignant disorders. This review details current clinical outcomes in the field with a focus on post-transplantation cyclophosphamide and anti-thymoglobulin as intensive graft versus host disease prophylaxis to achieve that goal.
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Affiliation(s)
- Amy E DeZern
- Division of Hematologic Malignancies, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD 21287-0013, United States of America.
| | - Robert A Brodsky
- Division of Hematology, The Johns Hopkins University School of Medicine, 720 Rutland Avenue | Ross 1025, Baltimore, MD 21205, United States of America.
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9
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Aygüneş U, Karagun BS, Ay Tuncel D, Sasmaz HI, Antmen B. Busulfan-Based and Treosulfan-Based Myeloablative Conditioning for Allogeneic Transplantation in Children with Thalassemia Major: a Single-Center Experience From Southern Turkey. EXP CLIN TRANSPLANT 2023; 21:883-892. [PMID: 38140932 DOI: 10.6002/ect.2023.0143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
OBJECTIVES Allogeneic hematopoietic stem cell transplant is the only curative treatment for patients with transfusion-dependent thalassemia major. In recent years, a number of novel approaches have improved patient outcomes and quality of life by minimizing the toxicity of conditioning regimens. The objective of this study was to compare the role of treosulfan- and busulfan-based conditioning in transfusion-dependent thalassemia. MATERIALS AND METHODS Data were collected retrospectively on 121 children with beta thalassemia major who underwent hematopoietic stem cell transplant using treosulfan-based (n = 37) or busulfan-based (n = 84) conditioning regimens between 2012 and 2022. RESULTS Two-year overall survival was 87.5% in the busulfan-based conditioning group and 91.1% in the treosulfan-based conditioning group.The group given the busulfan regimen compared with treosulfan regimen had significantly increased number of side effects (58.3% vs 21.6%, respectively; P < .001). When the busulfan-based regimen by level was evaluated, we observed no significant differences between the frequency of side effects according to drug serum levels. In addition, no significant differences were shown between the 2 regimen groups for cumulative incidence of acute and chronic graft-versus-host disease. CONCLUSIONS The safety and effectiveness of a treosulfan-based myeloablative conditioning regimen has been confirmed by ourretrospective investigation of pediatric patients with beta thalassemia.
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Affiliation(s)
- Utku Aygüneş
- From the Department of Pediatric Hematology, Oncology and Bone Marrow Transplantation, Acibadem Adana Hospital, Adana, Turkey
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10
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Christakopoulos GE, Telange R, Yen J, Weiss MJ. Gene Therapy and Gene Editing for β-Thalassemia. Hematol Oncol Clin North Am 2023; 37:433-447. [PMID: 36907613 PMCID: PMC10355137 DOI: 10.1016/j.hoc.2022.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
After many years of intensive research, emerging data from clinical trials indicate that gene therapy for transfusion-dependent β-thalassemia is now possible. Strategies for therapeutic manipulation of patient hematopoietic stem cells include lentiviral transduction of a functional erythroid-expressed β-globin gene and genome editing to activate fetal hemoglobin production in patient red blood cells. Gene therapy for β-thalassemia and other blood disorders will invariably improve as experience accumulates over time. The best overall approaches are not known and perhaps not yet established. Gene therapy comes at a high cost, and collaboration between multiple stakeholders is required to ensure that these new medicines are administered equitably.
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Affiliation(s)
- Georgios E Christakopoulos
- Department of Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS #355, Memphis, TN 38105, USA
| | - Raul Telange
- Department of Hematology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS #355, Memphis, TN 38105, USA
| | - Jonathan Yen
- Department of Hematology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS #355, Memphis, TN 38105, USA
| | - Mitchell J Weiss
- Department of Hematology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS #355, Memphis, TN 38105, USA.
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11
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Hu J, Gong S, Chen K, Yang R, Wang L, Yang K, Nie L, Zou L, Su T, Chen C, Xu Y, He X, Yang L, Xiao H, Fu B. Haploidentical transplant for paediatric patients with severe thalassaemia using post-transplant cyclophosphamide and methotrexate: A prospectively registered multicentre trial from the Bone Marrow Failure Working Group of Hunan Province, China. Br J Haematol 2023; 200:329-337. [PMID: 36254684 DOI: 10.1111/bjh.18520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/24/2022] [Accepted: 10/05/2022] [Indexed: 01/21/2023]
Abstract
Haploidentical transplantation strategies for patients with transfusion-dependent thalassaemia (TD-TM) remain to be investigated. In this study, 54 paediatric patients with TD-TM were treated with a novel approach using post-transplant cyclophosphamide (PTCy) and low-dose methotrexate (LD-MTX), following a myeloablative regimen. The incidence of neutrophil and platelet engraftment was 96.3% ± 2.6% and 94.4% ± 3.1% respectively. The cumulative incidence of grades II-III acute graft-versus-host disease (GVHD) was 13.8% ± 4.8% at 100 days. At three years, the cumulative incidence of chronic GVHD was 28.5% ± 8.5%. With a median follow-up of 520 days (132-1325 days), the overall survival (OS) and event-free survival (EFS) were 98.1% ± 1.8% and 90.7% ± 3.9% respectively. Compared with the low-dose cyclophosphamide (CTX) conditioning regimen (120 mg/kg), the high-CTX regimen (200 mg/kg) achieved a higher incidence of stable engraftment (100% vs 66.7% ± 15.7%, p = 0.003), a comparable incidence of grades II-III acute GVHD, a lower incidence of chronic GVHD (20.2% ± 8.3% vs 66.6% ± 19.2%, p = 0.011), and better overall survival (100% vs 88.9% ± 10.5%, p = 0.025) as well as EFS (95.6% ± 3.1% vs 66.7% ± 15.7%, p = 0.008). Our results using unmanipulated haploidentical grafts and PTCy with LD-MTX in TD-TM are encouraging. (chictr.org.cn ChiCTR1800017969).
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Affiliation(s)
- Jian Hu
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, China
| | - Susu Gong
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, China
| | - Keke Chen
- Department of Pediatric Hematology, Hunan Provincial People's Hospital, Changsha, China
| | - Rui Yang
- Department of Pediatric Hematology, First People's Hospital of Chenzhou, Chenzhou, China
| | - Leyuan Wang
- Department of Pediatric Hematology, Xiangya Hospital of Central South University, Changsha, China
| | - Kaitai Yang
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, China
| | - Lin Nie
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, China
| | - Lang Zou
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, China
| | - Tao Su
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, China
| | - Cong Chen
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, China
| | - Yajing Xu
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, China.,National Clinical Research Center for Geriatric Diseases, Changsha, China.,National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Hangzhou, China
| | - Xianglin He
- Department of Pediatric Hematology, Hunan Provincial People's Hospital, Changsha, China
| | - Liangchun Yang
- Department of Pediatric Hematology, Xiangya Hospital of Central South University, Changsha, China
| | - Hong Xiao
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, China
| | - Bin Fu
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, China.,National Clinical Research Center for Geriatric Diseases, Changsha, China.,National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Hangzhou, China
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12
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Levofloxacin prophylaxis and parenteral nutrition have a detrimental effect on intestinal microbial networks in pediatric patients undergoing HSCT. Commun Biol 2023; 6:36. [PMID: 36639555 PMCID: PMC9839701 DOI: 10.1038/s42003-023-04436-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
The gut microbiome (GM) has shown to influence hematopoietic stem cell transplantation (HSCT) outcome. Evidence on levofloxacin (LVX) prophylaxis usefulness before HSCT in pediatric patients is controversial and its impact on GM is poorly characterized. Post-HSCT parenteral nutrition (PN) is oftentimes the first-line nutritional support in the neutropenic phase, despite the emerging benefits of enteral nutrition (EN). In this exploratory work, we used a global-to-local networking approach to obtain a high-resolution longitudinal characterization of the GM in 30 pediatric HSCT patients receiving PN combined with LVX prophylaxis or PN alone or EN alone. By evaluating the network topology, we found that PN, especially preceded by LVX prophylaxis, resulted in a detrimental effect over the GM, with low modularity, poor cohesion, a shift in keystone species and the emergence of modules comprising several pathobionts, such as Klebsiella spp., [Ruminococcus] gnavus, Flavonifractor plautii and Enterococcus faecium. Our pilot findings on LVX prophylaxis and PN-related disruption of GM networks should be considered in patient management, to possibly facilitate prompt recovery/maintenance of a healthy and well-wired GM. However, the impact of LVX prophylaxis and nutritional support on short- to long-term post-HSCT clinical outcomes has yet to be elucidated.
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13
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Liao J, Wu Y. Gene Editing in Hematopoietic Stem Cells. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1442:177-199. [PMID: 38228965 DOI: 10.1007/978-981-99-7471-9_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
Hematopoietic stem cells (HSCs) can be isolated and collected from the body, genetically modified, and expanded ex vivo. The invention of innovative and powerful gene editing tools has provided researchers with great convenience in genetically modifying a wide range of cells, including hematopoietic stem and progenitor cells (HSPCs). In addition to being used to modify genes to study the functional role that specific genes play in the hematopoietic system, the application of gene editing platforms in HSCs is largely focused on the development of cell-based gene editing therapies to treat diseases such as immune deficiency disorders and inherited blood disorders. Here, we review the application of gene editing tools in HSPCs. In particular, we provide a broad overview of the development of gene editing tools, multiple strategies for the application of gene editing tools in HSPCs, and exciting clinical advances in HSPC gene editing therapies. We also outline the various challenges integral to clinical translation of HSPC gene editing and provide the possible corresponding solutions.
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Affiliation(s)
- Jiaoyang Liao
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, China
| | - Yuxuan Wu
- Shanghai Frontiers Science Center of Genome Editing and Cell Therapy, Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, China.
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The Roles of Mitophagy and Autophagy in Ineffective Erythropoiesis in β-Thalassemia. Int J Mol Sci 2022; 23:ijms231810811. [PMID: 36142738 PMCID: PMC9502731 DOI: 10.3390/ijms231810811] [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: 07/27/2022] [Revised: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 01/19/2023] Open
Abstract
β-Thalassemia is one of the most common genetically inherited disorders worldwide, and it is characterized by defective β-globin chain synthesis leading to reduced or absent β-globin chains. The excess α-globin chains are the key factor leading to the death of differentiating erythroblasts in a process termed ineffective erythropoiesis, leading to anemia and associated complications in patients. The mechanism of ineffective erythropoiesis in β-thalassemia is complex and not fully understood. Autophagy is primarily known as a cell recycling mechanism in which old or dysfunctional proteins and organelles are digested to allow recycling of constituent elements. In late stage, erythropoiesis autophagy is involved in the removal of mitochondria as part of terminal differentiation. Several studies have shown that autophagy is increased in earlier erythropoiesis in β-thalassemia erythroblasts, as compared to normal erythroblasts. This review summarizes what is known about the role of autophagy in β-thalassemia erythropoiesis and shows that modulation of autophagy and its interplay with apoptosis may provide a new therapeutic route in the treatment of β-thalassemia. Literature was searched and relevant articles were collected from databases, including PubMed, Scopus, Prospero, Clinicaltrials.gov, Google Scholar, and the Google search engine. Search terms included: β-thalassemia, ineffective erythropoiesis, autophagy, novel treatment, and drugs during the initial search. Relevant titles and abstracts were screened to choose relevant articles. Further, selected full-text articles were retrieved, and then, relevant cross-references were scanned to collect further information for the present review.
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15
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YILDIRIM F, KOCA YOZGAT A, TATLI DOĞAN H, TURHAN N, YARALI HN, ÖZBEK NY. Is serum ferritin level or T2-sequence magnetic resonance imaging more effective in predicting liver iron in transfusion-dependent thalassemia cases? EGE TIP DERGISI 2022. [DOI: 10.19161/etd.1167238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim: Iron overload in transfusion-dependent thalassemia patients is a condition that requires continuous chelation therapy and monitoring. Determination of serum ferritin level is considered a simple method to monitor body iron load; however, it highlights that other methods of liver iron level determination, such as magnetic resonance imaging (MRI), are more precise.
Materials and Methods: In order to contribute to understanding of liver iron load in thalassemia, liver iron level results of 14 transfusion-dependent thalassemia patients who underwent liver biopsy in preparation for stem cell transfusion were compared with liver T2 MRI and serum ferritin results.
Results: The mean serum Ferritin value was 2488.43±1520.18 mg/L. When liver iron load was evaluated according to T2*MRI results, mild iron accumulation was found in eight patients, moderate level in five patients, and advanced iron accumulation in a patient. According to the modified Scheuer classification, iron level in biopsies was grade 1 in two patients; grade 2 in seven patients; It was grade 3 in three patients and grade 4 in two patients. As the ferritin level increased, the liver iron biopsy score also increased statistically significantly (r=0.544 and p=0.044). There was a statistically significant and inverse correlation between liver T2*MRI level and liver iron biopsy score (r=-0.724 and p=0.003). Ferritin level was not found statistically significant in differentiating iron level according to liver biopsy iron score (p=0.096). The area under the ROC curve for T2*MRI measurements was statistically significant (AUC=0.967; 95% CI: 0.880-1,000 and p=0.005).
Conclusıon: In our study, we found that serum ferritin and T2 MRI results were correlated with liver biopsy iron levels. However, we found that the sensitivity and specificity of ferritin level in liver biopsy to show iron level was low, and the sensitivity and specificity of T2 MRI was high.
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Affiliation(s)
- Fatma YILDIRIM
- Ankara Şehir Hastanesi, Patoloji Bölümü, Ankara, Türkiye
| | - Ayça KOCA YOZGAT
- Sağlık Bilimleri Üniversitesi Tıp Fakültesi, Ankara Şehir Hastanesi, Çocuk Hastalıkları Anabilim Dalı, Çocuk Hematoloji ve Onkolojisi Bilim Dalı, Ankara,Türkiye
| | - Hayriye TATLI DOĞAN
- Ankara Yıldırım Beyazıt Üniversitesi Tıp Fakültesi, Ankara Şehir Hastanesi, Patoloji Anabilim Dalı, Ankara, Türkiye
| | - Nesrin TURHAN
- Sağlık Bilimleri Üniversitesi Tıp Fakültesi, Ankara Şehir Hastanesi, Patoloji Anabilim Dalı, Ankara, Türkiye
| | - Hüsniye Neşe YARALI
- Ankara Yıldırım Beyazıt Üniversitesi Tıp Fakültesi, Ankara Şehir Hastanesi, Çocuk Hastalıkları Anabilim Dalı, Çocuk Hematoloji ve Onkolojisi Bilim Dalı, Ankara, Türkiye
| | - Namık Yaşar ÖZBEK
- Sağlık Bilimleri Üniversitesi Tıp Fakültesi, Ankara Şehir Hastanesi, Çocuk Hastalıkları Anabilim Dalı, Çocuk Hematoloji ve Onkolojisi Bilim Dalı, Ankara,Türkiye
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16
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Yesilipek MA, Uygun V, Kupesiz A, Karasu G, Ozturk G, Ertem M, Şaşmaz İ, Daloğlu H, Güler E, Hazar V, Fisgin T, Sezgin G, Kansoy S, Kuşkonmaz B, Akıncı B, Özbek N, İnce EÜ, Öztürkmen S, Küpesiz FT, Yalçın K, Anak S, Bozkurt C, Karakükçü M, Küpeli S, Albayrak D, Öniz H, Aksoylar S, Okur FV, Albayrak C, Yenigürbüz FD, Bozkaya İO, İleri T, Gürsel O, Karagün BŞ, Kintrup GT, Çelen S, Elli M, Aksoy BA, Yılmaz E, Tanyeli A, Akyol ŞT, Siviş ZÖ, Özek G, Uçkan D, Kartal İ, Atay D, Akyay A, Bilir ÖA, Çakmaklı HF, Kürekçi E, Malbora B, Akbayram S, Demir HA, Kılıç SÇ, Güneş AM, Zengin E, Özmen S, Antmen AB. Thalassemia-free and graft-versus-host-free survival: outcomes of hematopoietic stem cell transplantation for thalassemia major, Turkish experience. Bone Marrow Transplant 2022; 57:760-767. [PMID: 35210564 DOI: 10.1038/s41409-022-01613-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 02/07/2023]
Abstract
We report the national data on the outcomes of hematopoietic stem cell transplantation (HSCT) for thalassemia major (TM) patients in Turkey on behalf of the Turkish Pediatric Stem Cell Transplantation Group. We retrospectively enrolled 1469 patients with TM who underwent their first HSCT between 1988 and 2020 in 25 pediatric centers in Turkey. The median follow-up duration and transplant ages were 62 months and 7 years, respectively; 113 patients had chronic graft versus host disease (cGVHD) and the cGVHD rate was 8.3% in surviving patients. Upon the last visit, 30 patients still had cGvHD (2.2%). The 5-year overall survival (OS), thalassemia-free survival (TFS) and thalassemia-GVHD-free survival (TGFS) rates were 92.3%, 82.1%, and 80.8%, respectively. cGVHD incidence was significantly lower in the mixed chimerism (MC) group compared to the complete chimerism (CC) group (p < 0.001). In survival analysis, OS, TFS, and TGFS rates were significantly higher for transplants after 2010. TFS and TGFS rates were better for patients under 7 years and at centers that had performed over 100 thalassemia transplants. Transplants from matched unrelated donors had significantly higher TFS rates. We recommend HSCT before 7 years old in thalassemia patients who have a matched donor for improved outcomes.
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Affiliation(s)
- M Akif Yesilipek
- Medicalpark Antalya Hospital, Pediatric Hematology and Stem Cell Transplantation Unit, Antalya, Turkey.
| | - Vedat Uygun
- Medicalpark Antalya Hospital, Pediatric Hematology and Stem Cell Transplantation Unit, Antalya, Turkey
- Istinye University School of Medicine Department of Pediatric Hematology and Oncology Unit, Istanbul, Turkey
| | - Alphan Kupesiz
- Akdeniz University School of Medicine, Department of Pediatrics, Division of Hematology/Oncology, Antalya, Turkey
| | - Gulsun Karasu
- Medicalpark Göztepe Hospital, Pediatric Hematology and Stem Cell Transplantation Unit, Istanbul, Turkey
| | - Gulyuz Ozturk
- Acıbadem University School of Medicine, Altunizade Hospital, Istanbul, Turkey
| | - Mehmet Ertem
- Ankara University Faculty of Medicine, Division of Pediatric Hematology Oncology, Dikimevi, Ankara, Turkey
| | - İlgen Şaşmaz
- Acıbadem Adana Hospital, Pediatric Hematology and Stem Cell Transplantation Unit, Adana, Turkey
| | - Hayriye Daloğlu
- Medicalpark Antalya Hospital, Pediatric Hematology and Stem Cell Transplantation Unit, Antalya, Turkey
- Antalya Bilim University Faculty of Health Sciences, Antalya, Turkey
| | - Elif Güler
- Akdeniz University School of Medicine, Department of Pediatrics, Division of Hematology/Oncology, Antalya, Turkey
| | - Volkan Hazar
- Medicalpark Göztepe Hospital, Pediatric Hematology and Stem Cell Transplantation Unit, Istanbul, Turkey
| | - Tunç Fisgin
- Altınbaş University School of Medicine Department of Pediatric Hematology and Oncology BMT Unit, Istanbul, Turkey
| | - Gülay Sezgin
- Çukurova University School of Medicine Department of Pediatric Oncology and BMT Unit, Adana, Turkey
| | - Savaş Kansoy
- Ege University School of Medicine Division of Pediatric Hematology Oncology, İzmir, Turkey
| | - Barış Kuşkonmaz
- Hacettepe University Faculty of Medicine BMT Unit, Ankara, Turkey
| | - Burcu Akıncı
- Acıbadem University School of Medicine, Altunizade Hospital, Istanbul, Turkey
| | - Namık Özbek
- University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Elif Ünal İnce
- Ankara University Faculty of Medicine, Division of Pediatric Hematology Oncology, Dikimevi, Ankara, Turkey
| | - Seda Öztürkmen
- Medicalpark Antalya Hospital, Pediatric Hematology and Stem Cell Transplantation Unit, Antalya, Turkey
| | - Funda Tayfun Küpesiz
- Akdeniz University School of Medicine, Department of Pediatrics, Division of Hematology/Oncology, Antalya, Turkey
| | - Koray Yalçın
- Medicalpark Göztepe Hospital, Pediatric Hematology and Stem Cell Transplantation Unit, Istanbul, Turkey
- Bahcesehir University School of Medicine Departments of Pediatrics, Istanbul, Turkey
| | - Sema Anak
- Medipol University School of Medicine Division of Pediatric Hematology Oncology, Istanbul, Turkey
| | - Ceyhun Bozkurt
- Istinye University School of Medicine Department of Pediatric Hematology and Oncology Unit, Istanbul, Turkey
| | - Musa Karakükçü
- Erciyes University KANKA Pediatric BMT Center, Kayseri, Turkey
| | - Serhan Küpeli
- Çukurova University School of Medicine Department of Pediatric Oncology and BMT Unit, Adana, Turkey
| | - Davut Albayrak
- Medicalpark Samsun Hospital Pediatric BMT Unit, Samsun, Turkey
| | - Haldun Öniz
- University of Health Sciences, İzmir Tepecik Hospital, İzmir, Turkey
| | - Serap Aksoylar
- Ege University School of Medicine Division of Pediatric Hematology Oncology, İzmir, Turkey
| | - Fatma Visal Okur
- Hacettepe University Faculty of Medicine BMT Unit, Ankara, Turkey
| | - Canan Albayrak
- Ondokuzmayıs University School of Medicine Department of Pediatric Hematology and Oncology BMT Unit, Samsun, Turkey
| | | | - İkbal Ok Bozkaya
- University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Talia İleri
- Ankara University Faculty of Medicine, Division of Pediatric Hematology Oncology, Dikimevi, Ankara, Turkey
| | - Orhan Gürsel
- University of Health Sciences, Division of Pediatric Hematology Oncology, Ankara, Turkey
| | - Barbaros Şahin Karagün
- Acıbadem Adana Hospital, Pediatric Hematology and Stem Cell Transplantation Unit, Adana, Turkey
| | - Gülen Tüysüz Kintrup
- Akdeniz University School of Medicine, Department of Pediatrics, Division of Hematology/Oncology, Antalya, Turkey
| | - Suna Çelen
- Medicalpark Göztepe Hospital, Pediatric Hematology and Stem Cell Transplantation Unit, Istanbul, Turkey
- Bahcesehir University School of Medicine Departments of Pediatrics, Istanbul, Turkey
| | - Murat Elli
- Medipol University School of Medicine Division of Pediatric Hematology Oncology, Istanbul, Turkey
| | - Basak Adaklı Aksoy
- Altınbaş University School of Medicine Department of Pediatric Hematology and Oncology BMT Unit, Istanbul, Turkey
| | - Ebru Yılmaz
- Erciyes University KANKA Pediatric BMT Center, Kayseri, Turkey
| | - Atila Tanyeli
- Çukurova University School of Medicine Department of Pediatric Oncology and BMT Unit, Adana, Turkey
| | | | - Zuhal Önder Siviş
- University of Health Sciences, İzmir Tepecik Hospital, İzmir, Turkey
| | - Gülcihan Özek
- Ege University School of Medicine Division of Pediatric Hematology Oncology, İzmir, Turkey
| | - Duygu Uçkan
- Hacettepe University Faculty of Medicine BMT Unit, Ankara, Turkey
| | - İbrahim Kartal
- Ondokuzmayıs University School of Medicine Department of Pediatric Hematology and Oncology BMT Unit, Samsun, Turkey
| | - Didem Atay
- Acıbadem University School of Medicine, Altunizade Hospital, Istanbul, Turkey
| | - Arzu Akyay
- Inönü University School of Medicine Department of Pediatric Hematology and Oncology BMT Unit, Malatya, Turkey
| | | | - Hasan Fatih Çakmaklı
- Ankara University Faculty of Medicine, Division of Pediatric Hematology Oncology, Dikimevi, Ankara, Turkey
| | - Emin Kürekçi
- University of Health Sciences, Division of Pediatric Hematology Oncology, Ankara, Turkey
| | - Barış Malbora
- İstanbul Yeni Yüzyıl University Gaziosmanpaşa Hospital Pediatric BMT Unit, Istanbul, Turkey
| | - Sinan Akbayram
- Gaziantep University School of Medicine Department of Pediatric Hematology and Oncology BMT Unit, Gaziantep, Turkey
| | - Hacı Ahmet Demir
- Memorial Ankara Hospital Pediatric Hematology and Oncology, Ankara, Turkey
| | - Suar Çakı Kılıç
- Ümraniye Education and Research Hospital, Department of Pediatric Bone Marrow Transplantation Unit, Istanbul, Turkey
| | - Adalet Meral Güneş
- Uludağ University School of Medicine Department of Pediatric Hematology and Oncology BMT Unit, Bursa, Turkey
| | - Emine Zengin
- Kocaeli University School of Medicine Department of Pediatric Hematology and Oncology BMT Unit, Kocaeli, Turkey
| | - Salih Özmen
- Behçet Uz Children's Hospital Pediatric BMT Centre, İzmir, Turkey
| | - Ali Bülent Antmen
- Acıbadem Adana Hospital, Pediatric Hematology and Stem Cell Transplantation Unit, Adana, Turkey
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Iftikhar F, Rahman S, Khan MBN, Khan K, Khan MN, Uddin R, Musharraf SG. In Vitro and In Vivo Studies for the Investigation of γ-Globin Gene Induction by Adhatoda vasica: A Pre-Clinical Study of HbF Inducers for β-Thalassemia. Front Pharmacol 2022; 13:797853. [PMID: 35422700 PMCID: PMC9002120 DOI: 10.3389/fphar.2022.797853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/24/2022] [Indexed: 11/13/2022] Open
Abstract
Fetal hemoglobin (HbF) is a potent genetic modifier, and the γ-globin gene induction has proven to be a sustainable therapeutic approach for the management of β-thalassemia. In this study, we have evaluated the HbF induction ability of A. vasica in vitro and in vivo, and the identification of potential therapeutic compounds through a bioassay-guided approach. In vitro benzidine-Hb assay demonstrated strong erythroid differentiation of K562 cells by A. vasica extracts. Subsequently, an in vivo study with an aqueous extract of A. vasica (100 mg/kg) showed significant induction of the γ-globin gene and HbF production. While in the acute study, the hematological and biochemical indices were found to be unaltered at the lower dose of A. vasica. Following the bioassay-guided approach, two isolated compounds, vasicinol (1) and vasicine (2) strongly enhanced HbF levels and showed prominent cellular growth kinetics with ample accumulation of total hemoglobin in K562 cultures. High HbF levels were examined by immunofluorescence and flow cytometry analysis, concomitant with the overexpression in the γ-globin gene level. Compound 1 (0.1 µM) and compound 2 (1 µM) resulted in a greater increase in F-cells (90 and 83%) with marked up (8-fold and 5.1-fold) expression of the γ-globin gene, respectively. Molecular docking studies indicated strong binding affinities of (1) and (2) with HDAC2 and KDM1 protein that predict the possible mechanism of compounds in inhibition of these epigenetic regulators in the γ-globin gene reactivation. Altogether, these observations demonstrated the therapeutic usefulness of A. vasica for fostering HbF production in clinical implications for blood disorders.
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Affiliation(s)
- Fizza Iftikhar
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, Pakistan
| | - Saeedur Rahman
- H.E.J. Research Institute of Chemistry, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, Pakistan
| | - Muhammad Behroz Naeem Khan
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, Pakistan
| | - Kanwal Khan
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, Pakistan
| | - Muhammad Noman Khan
- H.E.J. Research Institute of Chemistry, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, Pakistan
| | - Reaz Uddin
- H.E.J. Research Institute of Chemistry, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, Pakistan
| | - Syed Ghulam Musharraf
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, Pakistan
- H.E.J. Research Institute of Chemistry, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, Pakistan
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18
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Tucci F, Galimberti S, Naldini L, Valsecchi MG, Aiuti A. A systematic review and meta-analysis of gene therapy with hematopoietic stem and progenitor cells for monogenic disorders. Nat Commun 2022; 13:1315. [PMID: 35288539 PMCID: PMC8921234 DOI: 10.1038/s41467-022-28762-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Ex-vivo gene therapy (GT) with hematopoietic stem and progenitor cells (HSPCs) engineered with integrating vectors is a promising treatment for monogenic diseases, but lack of centralized databases is hampering an overall outcomes assessment. Here we aim to provide a comprehensive assessment of the short and long term safety of HSPC-GT from trials using different vector platforms. We review systematically the literature on HSPC-GT to describe survival, genotoxicity and engraftment of gene corrected cells. From 1995 to 2020, 55 trials for 14 diseases met inclusion criteria and 406 patients with primary immunodeficiencies (55.2%), metabolic diseases (17.0%), haemoglobinopathies (24.4%) and bone marrow failures (3.4%) were treated with gammaretroviral vector (γRV) (29.1%), self-inactivating γRV (2.2%) or lentiviral vectors (LV) (68.7%). The pooled overall incidence rate of death is 0.9 per 100 person-years of observation (PYO) (95% CI = 0.37-2.17). There are 21 genotoxic events out of 1504.02 PYO, which occurred in γRV trials (0.99 events per 100 PYO, 95% CI = 0.18-5.43) for primary immunodeficiencies. Pooled rate of engraftment is 86.7% (95% CI = 67.1-95.5%) for γRV and 98.7% (95% CI = 94.5-99.7%) for LV HSPC-GT (p = 0.005). Our analyses show stable reconstitution of haematopoiesis in most recipients with superior engraftment and safer profile in patients receiving LV-transduced HSPCs.
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Affiliation(s)
- Francesca Tucci
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefania Galimberti
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
| | - Luigi Naldini
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Grazia Valsecchi
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
| | - Alessandro Aiuti
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
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19
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Tan Y, Lin J, Hong X, Lu J, Lu Q. Polymyositis in a child with thalassemia after hematopoietic stem cell transplantation: A case report. Medicine (Baltimore) 2021; 100:e27388. [PMID: 34731108 PMCID: PMC8519230 DOI: 10.1097/md.0000000000027388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/15/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Polymyositis (PM) is a rare neuromuscular phenotype of chronic graft-versus-host disease (cGVHD). Although glucocorticoids have been shown to be effective in the treatment of PM, most people experience poor treatment response and poor prognosis. PATIENT CONCERNS A six-year-old boy with thalassemia received allogeneic hematopoietic stem cell transplantation (HSCT) and consequently developed sudden myasthenia of limbs 17 months after the transplant. DIAGNOSES Medical history, current symptoms, laboratory examinations, and imaging findings of the patient indicated cGVHD complicated with PM. INTERVENTIONS He was then given high-dose corticosteroid therapy, including tacrolimus, ruxolitinib, and rituximab. OUTCOMES Twenty-three months after transplantation, creatine kinase levels returned to normal range, and the MRI showed that the original muscle edema signal was significantly improved. The patient's muscle weakness continued to improve, and his overall condition was good. LESSONS This report suggests that glucocorticoids combined with immunosuppressants may be effective against polymyositis. Rituximab and ruxolitinib may be a good choice in treating polymyositis.
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20
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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: 15] [Impact Index Per Article: 5.0] [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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21
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Bingöl Kızıltunç P, Büyüktepe TÇ, Yalçındağ FN, Ertem M, İnce E, İleri T, Atilla H. Ocular Findings of Pediatric Dry Eye Related to Graft-Versus-Host Disease. Turk J Ophthalmol 2021; 51:134-138. [PMID: 34187145 PMCID: PMC8251675 DOI: 10.4274/tjo.galenos.2020.88137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objectives: To evaluate the frequency and findings of dry eye associated with ocular graft-versus-host disease (GVHD) in pediatric hematopoietic stem cell transplantation (HSCT) patients. Materials and Methods: Retrospectively the records of pediatric patients with ocular GVHD were evaluated and ophthalmologic examination findings as well as Schirmer test results, tear film break-up time, and corneal staining grades were recorded. In severe dry eye patients topical cyclosporine-A was prescribed and the results were evaluated. Results: GVHD was detected in 51 (23.4%) of 218 HSCT patients, 4 of whom died during follow-up. Thirty (63.8%) of the remaining 47 patients had chronic ocular GVHD and 4 patients with severe dry eye were treated with topical cyclosporine-A with a median follow-up of 12.1 months. Severe dry eye symptoms and findings significantly improved in 2 patients. However, 1 patient had to stop treatment due to side effects. Conclusion: In children, chronic ocular GVHD is a common finding of GVHD after HSCT. Therefore, these patients should be examined periodically for dry eye.
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Affiliation(s)
| | - Tuna Çelik Büyüktepe
- Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | | | - Mehmet Ertem
- Ankara University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
| | - Elif İnce
- Ankara University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
| | - Talia İleri
- Ankara University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
| | - Huban Atilla
- Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
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22
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Karamperis K, Tsoumpeli MT, Kounelis F, Koromina M, Mitropoulou C, Moutinho C, Patrinos GP. Genome-based therapeutic interventions for β-type hemoglobinopathies. Hum Genomics 2021; 15:32. [PMID: 34090531 PMCID: PMC8178887 DOI: 10.1186/s40246-021-00329-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/28/2021] [Indexed: 12/18/2022] Open
Abstract
For decades, various strategies have been proposed to solve the enigma of hemoglobinopathies, especially severe cases. However, most of them seem to be lagging in terms of effectiveness and safety. So far, the most prevalent and promising treatment options for patients with β-types hemoglobinopathies, among others, predominantly include drug treatment and gene therapy. Despite the significant improvements of such interventions to the patient's quality of life, a variable response has been demonstrated among different groups of patients and populations. This is essentially due to the complexity of the disease and other genetic factors. In recent years, a more in-depth understanding of the molecular basis of the β-type hemoglobinopathies has led to significant upgrades to the current technologies, as well as the addition of new ones attempting to elucidate these barriers. Therefore, the purpose of this article is to shed light on pharmacogenomics, gene addition, and genome editing technologies, and consequently, their potential use as direct and indirect genome-based interventions, in different strategies, referring to drug and gene therapy. Furthermore, all the latest progress, updates, and scientific achievements for patients with β-type hemoglobinopathies will be described in detail.
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Affiliation(s)
- Kariofyllis Karamperis
- Department of Pharmacy, School of Health Sciences, Laboratory of Pharmacogenomics and Individualized Therapy, University of Patras, Patras, Greece
- The Golden Helix Foundation, London, UK
| | - Maria T Tsoumpeli
- School of Veterinary Medicine and Science, University of Nottingham, Nottingham, UK
| | - Fotios Kounelis
- Department of Computing, Group of Large-Scale Data & Systems, Imperial College London, London, UK
| | - Maria Koromina
- Department of Pharmacy, School of Health Sciences, Laboratory of Pharmacogenomics and Individualized Therapy, University of Patras, Patras, Greece
| | | | - Catia Moutinho
- Garvan-Weizmann Centre for Cellular Genomics, Garvan Institute of Medical Research, Darlinghurst, Sydney, Australia
| | - George P Patrinos
- Department of Pharmacy, School of Health Sciences, Laboratory of Pharmacogenomics and Individualized Therapy, University of Patras, Patras, Greece.
- College of Medicine and Health Sciences, Department of Pathology, United Arab Emirates University, Al-Ain, United Arab Emirates.
- Zayed Center of Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.
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23
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Frati G, Miccio A. Genome Editing for β-Hemoglobinopathies: Advances and Challenges. J Clin Med 2021; 10:482. [PMID: 33525591 PMCID: PMC7865242 DOI: 10.3390/jcm10030482] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/19/2021] [Accepted: 01/25/2021] [Indexed: 02/08/2023] Open
Abstract
β-hemoglobinopathies are the most common genetic disorders worldwide and are caused by mutations affecting the production or the structure of adult hemoglobin. Patients affected by these diseases suffer from anemia, impaired oxygen delivery to tissues, and multi-organ damage. In the absence of a compatible donor for allogeneic bone marrow transplantation, the lifelong therapeutic options are symptomatic care, red blood cell transfusions and pharmacological treatments. The last decades of research established lentiviral-mediated gene therapy as an efficacious therapeutic strategy. However, this approach is highly expensive and associated with a variable outcome depending on the effectiveness of the viral vector and the quality of the cell product. In the last years, genome editing emerged as a valuable tool for the development of curative strategies for β-hemoglobinopathies. Moreover, due to the wide range of its applications, genome editing has been extensively used to study regulatory mechanisms underlying globin gene regulation allowing the identification of novel genetic and pharmacological targets. In this work, we review the current advances and challenges of genome editing approaches to β-hemoglobinopathies. Special focus has been directed towards strategies aimed at correcting the defective β-globin gene or at inducing fetal hemoglobin (HbF), which are in an advanced state of clinical development.
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Affiliation(s)
- Giacomo Frati
- Laboratory of Chromatin and Gene Regulation during Development, Imagine Institute, Université de Paris, INSERM UMR 1163, F-75015 Paris, France
| | - Annarita Miccio
- Laboratory of Chromatin and Gene Regulation during Development, Imagine Institute, Université de Paris, INSERM UMR 1163, F-75015 Paris, France
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24
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Rajendiran S, Boyer SW, Forsberg EC. A quantitative hematopoietic stem cell reconstitution protocol: Accounting for recipient variability, tissue distribution and cell half-lives. Stem Cell Res 2020; 50:102145. [PMID: 33486300 PMCID: PMC8239062 DOI: 10.1016/j.scr.2020.102145] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/03/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022] Open
Abstract
Hematopoietic stem and progenitor cell (HSPC) transplantation is the paradigm for stem cell therapies. The protocol described here enables quantitative assessment of the body-wide HSPC reconstitution of different mature hematopoietic cells in mice based on their presence in circulating blood. The method determines donor-derived mature cell populations per mouse, over time, by quantitatively obtaining their absolute numbers in the peripheral blood and utilizing previously assessed tissue-distribution factors. A Markov-based birth/death computational model accounts for the drastic differences in mature cell half-lives. By quantifying the number of cells produced and eliminating host variability, the protocol can be used to directly compare the lineage output of different types of HSPCs on a per cell basis, thereby clarifying the lineage potential and expansion capacity of different cell populations. These protocols were developed for hematopoiesis, but can readily be extended to other contexts by simply replacing the cell types and distributions.
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Affiliation(s)
- Smrithi Rajendiran
- Institute for the Biology of Stem Cells, Department of Biomolecular Engineering, University of California, Santa Cruz, Santa Cruz, CA 95064, USA
| | - Scott W Boyer
- Institute for the Biology of Stem Cells, Department of Biomolecular Engineering, University of California, Santa Cruz, Santa Cruz, CA 95064, USA
| | - E Camilla Forsberg
- Institute for the Biology of Stem Cells, Department of Biomolecular Engineering, University of California, Santa Cruz, Santa Cruz, CA 95064, USA.
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25
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Pondrom M, Monpoux F, Rocher F, Gastaut N, Bailly-Piccini C, Poirée M. Tolerance induction to deferasirox in a child with transfusion-dependent beta thalassemia. Arch Pediatr 2020; 28:101-103. [PMID: 33250331 DOI: 10.1016/j.arcped.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/11/2020] [Accepted: 10/02/2020] [Indexed: 10/22/2022]
Abstract
Beta thalassemias are autosomal recessive hemoglobin disorders related to a defect in the beta-globin chain production. Most of the major forms of beta-thalassemia are transfusion dependent leading to iron overload. Today, three iron chelators are available in France. We report the case of a patient suffering from β+ major transfusion-dependent thalassemia who presented with severe skin reactions to deferoxamine and deferasirox as well as with agranulocytosis after deferiprone administration. The patient benefited from successful tolerance induction to deferasirox. With the increasing number of children suffering from iron overload, we believe that our protocol can be useful to pediatric hematology teams confronted with multiple iron chelator reactions.
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Affiliation(s)
- Morgane Pondrom
- Unité d'Hémato-Oncologie Infantile. Hôpital de l'Archet 2, 151, route de Saint Antoine de Ginestière, 06202 Nice Cedex 3, France
| | - Fabrice Monpoux
- Unité d'Hémato-Oncologie Infantile. Hôpital de l'Archet 2, 151, route de Saint Antoine de Ginestière, 06202 Nice Cedex 3, France.
| | - Fanny Rocher
- Centre Régional de PharmacoVigilance de Nice, CHU de Nice, Hôpital de Cimiez, 4, Av Victoria, BP 1179, 06003 Nice Cedex 1, France
| | - Nadia Gastaut
- Pharmacotechnie, Pôle Pharmacie-Stérilisation Hôpital de l'Archet 2, 151, route de Saint Antoine de Ginestière, 06202 Nice Cedex 3, France
| | - Carole Bailly-Piccini
- Unité d'Allergo-Pneumologie infantile, Hôpital pour enfants Lenval, Avenue de la Californie, 06200 Nice, France
| | - Maryline Poirée
- Unité d'Hémato-Oncologie Infantile. Hôpital de l'Archet 2, 151, route de Saint Antoine de Ginestière, 06202 Nice Cedex 3, France
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26
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Abstract
Hemoglobinopathies are the most common single-gene diseases and are estimated to affect millions of people worldwide. Thalassemia and sickle cell disease are the most prevalent diseases of this group. Today, despite the decreasing number of newborns diagnosed with a hemoglobinopathy, it remains an important health problem for many countries. Although regular red blood cell (RBC) transfusions, advanced iron chelation, and supportive therapy alternatives have improved life expectancy, allogeneic hematopoietic stem cell transplantation (HSCT) is the only curative option for patients with hemoglobinopathies to prevent irreversible organ damage. Modern transplantation approaches and careful posttransplantation follow-up of patients have improved survival outcomes, and HSCT has now been performed in several patients with hemoglobinopathies worldwide. Considering current experiences, hematopoietic stem cell transplantation is recommended in cases of β-thalassemia (β-thal) in the presence of a matched family or unrelated donor, without secondary organ damage due to transfusion. In patients with sickle cell anemia, transplantation indications include transfusion dependence and cases of secondary organ damage. Recently, gene therapy as a possible treatment option has yielded promising results, though it is not in routine clinical use at its current stage.
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Affiliation(s)
- M Akif Yesilipek
- Department of Pediatric Hematology and Pediatric Stem Cell Transplantation Unit, Medicalpark Antalya Hospital, Antalya, Turkey
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27
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Hamed EM, Meabed MH, Aly UF, Hussein RRS. Recent Progress in Gene Therapy and Other Targeted Therapeutic Approaches for Beta Thalassemia. Curr Drug Targets 2020; 20:1603-1623. [PMID: 31362654 DOI: 10.2174/1389450120666190726155733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/17/2019] [Accepted: 07/05/2019] [Indexed: 01/19/2023]
Abstract
Beta-thalassemia is a genetic disorder characterized by the impaired synthesis of the betaglobin chain of adult hemoglobin. The disorder has a complex pathophysiology that affects multiple organ systems. The main complications of beta thalassemia are ineffective erythropoiesis, chronic hemolytic anemia and hemosiderosis-induced organ dysfunction. Regular blood transfusions are the main therapy for beta thalassemia major; however, this treatment can cause cardiac and hepatic hemosiderosis - the most common cause of death in these patients. This review focuses on unique future therapeutic interventions for thalassemia that reverse splenomegaly, reduce transfusion frequency, decrease iron toxicity in organs, and correct chronic anemia. The targeted effective protocols include hemoglobin fetal inducers, ineffective erythropoiesis correctors, antioxidants, vitamins, and natural products. Resveratrol is a new herbal therapeutic approach which serves as fetal Hb inducer in beta thalassemia. Hematopoietic stem cell transplantation (HSCT) is the only curative therapy for beta thalassemia major and is preferred over iron chelation and blood transfusion for ensuring long life in these patients. Meanwhile, several molecular therapies, such as ActRIIB/IgG1 Fc recombinant protein, have emerged to address complications of beta thalassemia or the adverse effects of current drugs. Regarding gene correction strategies, a phase III trial called HGB-207 (Northstar-2; NCT02906202) is evaluating the efficacy and safety of autologous cell transplantation with LentiGlobin. Advanced gene-editing approaches aim to cut DNA at a targeted site and convert HbF to HbA during infancy, such as the suppression of BCL11A (B cell lymphoma 11A), HPFH (hereditary persistence of fetal hemoglobin) and zinc-finger nucleases. Gene therapy is progressing rapidly, with multiple clinical trials being conducted in many countries and the promise of commercial products to be available in the near future.
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Affiliation(s)
- Eman M Hamed
- Department of Pharmaceutics and Clinical Pharmacy; Faculty of Pharmacy; Nahda University, Nahda, Egypt
| | | | - Usama Farghaly Aly
- Asso. Professor of Pharmaceutics; Faculty of Pharmacy; Minia University, Minya, Egypt
| | - Raghda R S Hussein
- Lecturer of Clinical Pharmacy; Faculty of Pharmacy; Beni- Suef University, Egypt
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28
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徐 艳, 易 甜, 徐 肖, 裴 夫, 何 岳, 吴 学. [Effect of cyclophosphamide on hematopoietic stem cells in mice with iron overload]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:110-117. [PMID: 32376555 PMCID: PMC7040758 DOI: 10.12122/j.issn.1673-4254.2020.01.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To explore the effect of cyclophosphamide on hematopoietic stem cells (HSCs) in mice with iron overload. METHODS Mouse models of iron overload were established in 30 male C57BL/6 mice by intraperitoneal injections of iron dextran at low (0.25 g/kg), moderate (0.5 g/kg), and high (1 g/kg) doses (n=10), with another 10 PBS-treated mice as the control group. The changes in body weight, liver, spleen and bone marrow of the mice were recorded, and serum level of ferritin was detected. The mice receiving a moderate dose of iron dextran were further divided into 8 groups for observation at different time points (D1, D2, D3, D4, D5, D6, D7, and D14 groups) and were given intraperitoneal injection of 50 mg/kg cyclophosphamide (Cy) for 2 consecutive days. Peripheral blood cells, bone marrow mononuclear cells (BMMNCs), and the frequencies of different HSCs (HPCs, HSCs, LT-HSCs) in the BMMNCs were monitored. The cell cycle distribution in the HSCs, level of reactive oxygen species and the microenvironment of the HSCs were analyzed using flow cytometry. RESULTS Compared with the control mice, the mice with iron overload showed obvious weight loss with significantly increased serum ferritin level, enlargement of the liver and spleen, and iron deposition in the organs (P < 0.05). No significant changes were noted in the peripheral blood of the mice with iron overload. The cyclophosphamide-treated mice exhibited significantly decreased number of WBCs and lymphocyte ratio at days 1 to 4 (P < 0.05). The numbers of BMMNCs and HPCs in mice with iron overload did not show significant changes as compared with those in the control mice, but the numbers of HSCs and LTHSCs decreased significantly in the mice with iron overload (P < 0.05). In cyclophosphamide-treated mice, the number of HSCs increased since day 1 and reached the peak level on day 3 (P < 0.05). Compared with those in the control group, the HSCs did not exhibit significant changes in cell cycle distribution in mice with iron overload, but the proportion of G0/G1 cells decreased significantly in cyclophosphamide group since day 1 and reached the lowest level on day 3 (P < 0.05). CONCLUSIONS Iron deposition in the bone marrow causes long- term damages of the HSCs in the bone marrow but does not induce obvious changes in the peripheral blood. In mice with iron overload, intraperitoneal injection of 50 mg/kg cyclophosphamide for two days promotes cell cycle changes of the resting HSCs to mobilize the HSCs, and this effect is the most obvious on day 4.
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Affiliation(s)
- 艳军 徐
- 南方医科大学南方医院儿科,广东 广州 510515Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
- 南方医科大学附属佛山妇幼保健院儿科,广东 佛山 528000Department of Pediatrics, Foshan Women and Children's Hospital Affiliated to Southern Medical University, Foshan 528000, China
| | - 甜甜 易
- 南方医科大学南方医院儿科,广东 广州 510515Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 肖肖 徐
- 南方医科大学南方医院儿科,广东 广州 510515Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 夫瑜 裴
- 南方医科大学南方医院儿科,广东 广州 510515Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 岳林 何
- 南方医科大学南方医院儿科,广东 广州 510515Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 学东 吴
- 南方医科大学南方医院儿科,广东 广州 510515Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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Gabelli M, Veys P, Chiesa R. Current status of umbilical cord blood transplantation in children. Br J Haematol 2019; 190:650-683. [PMID: 31410846 DOI: 10.1111/bjh.16107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/19/2019] [Accepted: 06/19/2019] [Indexed: 12/19/2022]
Abstract
The first umbilical cord blood (UCB) transplantation was performed 30 years ago. UCB transplantation (UCBT) is now widely used in children with malignant and non-malignant disorders who lack a matched family donor. UCBT affords a lower incidence of graft-versus-host disease compared to alternative stem cell sources, but also presents a slower immune recovery and a high risk of infections if serotherapy is not omitted or targeted within the conditioning regimen. The selection of UCB units with high cell content and good human leucocyte antigen match is essential to improve the outcome. Techniques, such as double UCBT, ex vivo stem cell expansion and intra-bone injection of UCB, have improved cord blood engraftment, but clinical benefit remains to be demonstrated. Cell therapies derived from UCB are under evaluation as potential novel strategies to reduce relapse and viral infections following transplantation. In recent years, improvements within haploidentical transplantation have reduced the overall use of UCBT as an alternative stem cell source; however, each may have its relative merits and disadvantages and tailored use of these alternative stem cell sources may be the optimal approach.
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Affiliation(s)
- Maria Gabelli
- Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
| | - Paul Veys
- Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
| | - Robert Chiesa
- Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
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30
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Ghiaccio V, Chappell M, Rivella S, Breda L. Gene Therapy for Beta-Hemoglobinopathies: Milestones, New Therapies and Challenges. Mol Diagn Ther 2019; 23:173-186. [PMID: 30701409 DOI: 10.1007/s40291-019-00383-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Inherited monogenic disorders such as beta-hemoglobinopathies (BH) are fitting candidates for treatment via gene therapy by gene transfer or gene editing. The reported safety and efficacy of lentiviral vectors in preclinical studies have led to the development of several clinical trials for the addition of a functional beta-globin gene. Across trials, dozens of transfusion-dependent patients with sickle cell disease (SCD) and transfusion-dependent beta-thalassemia (TDT) have been treated via gene therapy and have achieved reduced transfusion requirements. While overall results are encouraging, the outcomes appear to be strongly influenced by the level of lentiviral integration in transduced cells after engraftment, as well as the underlying genotype resulting in thalassemia. In addition, the method of procurement of hematopoietic stem cells can affect their quality and thus the outcome of gene therapy both in SCD and TDT. This suggests that new studies aimed at maximizing the number of corrected cells with long-term self-renewal potential are crucial to ensure successful treatment for every patient. Recent advancements in gene transfer and bone marrow transplantation have improved the success of this approach, and the results obtained by using these strategies demonstrated significant improvement of gene transfer outcome in patients. The advent of new gene-editing technologies has suggested additional therapeutic options. These are primarily focused on correcting the defective beta-globin gene or editing the expression of genes or genomic segments that regulate fetal hemoglobin synthesis. In this review, we aim to establish the potential benefits of gene therapy for BH, to summarize the status of the ongoing trials, and to discuss the possible improvement or direction for future treatments.
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Affiliation(s)
- Valentina Ghiaccio
- Hematology Division, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Maxwell Chappell
- Hematology Division, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Stefano Rivella
- Hematology Division, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Laura Breda
- Hematology Division, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.
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Li Q, Luo J, Zhang Z, Liu L, Luo L, Yang G, Liu R, Shi L, Huang R, Wu M, Lai Y. G-CSF-Mobilized Blood and Bone Marrow Grafts as the Source of Stem Cells for HLA-Identical Sibling Transplantation in Patients with Thalassemia Major. Biol Blood Marrow Transplant 2019; 25:2040-2044. [PMID: 31207293 DOI: 10.1016/j.bbmt.2019.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/16/2019] [Accepted: 06/07/2019] [Indexed: 12/11/2022]
Abstract
As an inherited anemia, thalassemia major (TM) is currently only curable with allogeneic hematopoietic stem cell transplantation (allo-HSCT). Here we report an allo-HSCT protocol for patients with TM who received a combination of granulocyte colony-stimulating factor-primed bone marrow and peripheral blood stem cells (G-BM & PBSCs) from a matched sibling donor (MSD). The conditioning regimen consisted of i.v. busulfan, cyclophosphamide, fludarabine, and antithymocyte globulin. Chimerism analysis was performed for all patients. Immunosuppressive treatment was terminated if rejection was suspected, and donor lymphocyte infusion was administered once no response was observed. A total of 184 patients with TM were enrolled in the study between July 2007 and July 2018. The cumulative incidence of grade II-IV acute graft-versus-host disease (GVHD) was 13.1%, and that of moderate or severe chronic GVHD was 5.7%. The cumulative incidence of graft rejection was .6%. In the total cohort, the 3-year overall survival, thalassemia-free survival, and GVHD-free, relapse-free survival were 97.8%, 97.3%, and 89.5%, respectively. Collectively, our results indicate that G-BM & PBSCs from an MSD is be a good stem cell source for patients with TM undergoing allo-HSCT.
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Affiliation(s)
- Qiaochuan Li
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jianming Luo
- Department of Pediatrics, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Zhongming Zhang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Lianjin Liu
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Lin Luo
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Gaohui Yang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Rongrong Liu
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Lingling Shi
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Rui Huang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Meiqing Wu
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yongrong Lai
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
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Khandros E, Kwiatkowski JL. Beta Thalassemia: Monitoring and New Treatment Approaches. Hematol Oncol Clin North Am 2019; 33:339-353. [PMID: 31030806 DOI: 10.1016/j.hoc.2019.01.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Beta thalassemias are a significant global health problem. Globin chain imbalance leads to a complex physiologic cascade of hemolytic anemia, ineffective erythropoiesis, and iron overload. Management of the broad spectrum of phenotypes requires the careful use of red blood transfusions, supportive care, monitoring, and management of iron overload. In this article, the authors discuss recommendations for monitoring of individuals with thalassemia, as well as ongoing preclinical and clinical trials of therapies targeting different aspects of thalassemia pathophysiology.
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Affiliation(s)
- Eugene Khandros
- Division of Hematology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Colket Translational Research Building, Room 11024, Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Janet L Kwiatkowski
- Division of Hematology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Colket Translational Research Building, Room 11024, Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
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