1
|
Hefazi M, Litzow M, Hogan W, Gastineau D, Jacob E, Damlaj M, Hashmi S, Al-Kali A, Patnaik MM. ABO blood group incompatibility as an adverse risk factor for outcomes in patients with myelodysplastic syndromes and acute myeloid leukemia undergoing HLA-matched peripheral blood hematopoietic cell transplantation after reduced-intensity conditioning. Transfusion 2015; 56:518-27. [PMID: 26446051 DOI: 10.1111/trf.13353] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/06/2015] [Accepted: 08/13/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND ABO incompatibility is not a contraindication to hematopoietic cell transplantation (HCT), but it has been associated with additional risks including delayed engraftment, pure red cell aplasia (PRCA), and higher transfusion needs. Data on these events and on patient survival after reduced-intensity conditioning (RIC) HCT are limited. STUDY DESIGN AND METHODS A total of 127 consecutive patients, 86 with acute myeloid leukemia and 41 with myelodysplastic syndromes, who underwent HLA-matched peripheral blood RIC allogenic HCT between 2005 and 2014 were retrospectively analyzed. RESULTS Eighty ABO-compatible, 26 major/bidirectional, and 21 minor-ABO-mismatch HCT were identified. Compared to the ABO-compatible group, major/bidirectional mismatches had increased red blood cell (RBC) transfusion requirement during the first 100 days (p = 0.009), delayed RBC and PLT engraftment (p = 0.0011 and p = 0.005, respectively), and higher incidence of grade II to IV acute graft-versus-host disease (aGVHD; p = 0.037). In multivariable analysis, major/bidirectional mismatches had significantly higher non-relapse mortality (NRM) and inferior disease-free survival (DFS) and overall survival (OS) compared with ABO-compatible patients (p = 0.01, p = 0.04, and p = 0.035, respectively). Minor ABO mismatch had no impact on survival (p = 0.99). Four (15%) of 26 major/bidirectional mismatches developed PRCA. There was a significant association between fludarabine plus busulfan conditioning and PRCA (p = 0.0046). CONCLUSION Major/bidirectional ABO mismatch is associated with higher NRM and shortened DFS and OS in the setting of RIC HCT. Increased transfusion need, delayed RBC and platelet engraftment, PRCA, and increased severity of aGVHD are additional complications contributing to the morbidity.
Collapse
Affiliation(s)
- Mehrdad Hefazi
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark Litzow
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - William Hogan
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Dennis Gastineau
- Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota
| | - Eapen Jacob
- Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota
| | - Moussab Damlaj
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Aref Al-Kali
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
2
|
Abstract
Hypoproliferative anemia results from the inability of bone marrow to produce adequate numbers of red blood cells. The list of conditions that cause hypoproliferative anemia is long, starting from common etiologies as iron deficiency to rarer diagnoses of constitutional bone marrow failure syndromes. There is no perfect diagnostic algorithm, and clinical data may not always clearly distinguish "normal" from "abnormal", yet it is important for practicing clinicians to recognize each condition so that treatment can be initiated promptly. This review describes diagnostic approaches to hypoproliferative anemia, with particular emphasis on bone marrow failure syndromes.
Collapse
Affiliation(s)
- Kazusa Ishii
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD.
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| |
Collapse
|
3
|
Vaughn JE, Anwer F, Deeg HJ. Treatment of refractory ITP and Evans syndrome by haematopoietic cell transplantation: is it indicated, and for whom? Vox Sang 2015; 110:5-11. [PMID: 26178735 DOI: 10.1111/vox.12314] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 05/27/2015] [Accepted: 05/28/2015] [Indexed: 12/13/2022]
Abstract
Several lines of therapy have been established for patients with immune thrombocytopenia (ITP) and Evans syndrome. However, these therapies generally require prolonged administration, lead to profound immunosuppression and increased infectious risk, and are often poorly tolerated. While most patients with these disorders will respond to first-line steroid therapy, others will prove refractory or intolerant to multiple treatments. In these patients (and possibly even selected patients who are not considered refractory), autologous or allogeneic haematopoietic stem cell transplantation (HCT) may provide definitive therapy. We review the literature on the treatment of ITP and Evans syndrome with HCT and discuss its use in the management of these disorders. We also pose, for the purpose of discussion, research questions that will be important to address if HCT is to be considered a viable option for more patients with these diseases.
Collapse
Affiliation(s)
- J E Vaughn
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - F Anwer
- University of Arizona Cancer Center, Tucson, AZ, USA
| | - H J Deeg
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| |
Collapse
|
4
|
Watz E, Remberger M, Ringden O, Lundahl J, Ljungman P, Mattsson J, Wikman A, Uhlin M. Analysis of donor and recipient ABO incompatibility and antibody-associated complications after allogeneic stem cell transplantation with reduced-intensity conditioning. Biol Blood Marrow Transplant 2013; 20:264-71. [PMID: 24274982 DOI: 10.1016/j.bbmt.2013.11.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 11/13/2013] [Indexed: 10/26/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) can be performed across the ABO blood group barrier. The impact of ABO incompatibility on clinical outcome is controversial. A retrospective analysis of 310 patients who underwent HSCT with reduced-intensity conditioning between 1998 and 2011 was performed to investigate the frequency and clinical implications of anti-RBC antibodies in passenger lymphocyte syndrome (PLS) after minor ABO mismatch (mm), persistent or recurring recipient type ABO antibodies (PRABO) after major ABO mm HSCT, and autoimmune hemolytic anemia (AIHA). Transplantation characteristics and clinical outcome were analyzed by univariate and multivariate analysis for groups with or without anti-RBC antibodies. ABO blood group incompatibility did not affect clinical outcome despite an increased requirement of blood transfusion. Twelve patients with AIHA, 6 patients with PLS, and 12 patients with PRABO post-HSCT were identified. AIHA did not affect overall survival (OS) or transplant-related mortality (TRM), but patients with AIHA had a lower incidence of grades II to IV acute graft-versus-host disease (P = .05). OS in the PLS group was 0% compared with 61% in the whole group receiving minor ABO mm transplants (P < .001). Comparing PRABO patients with those receiving a major ABO mm HSCT, the OS was 17% versus 73% (P = .002) and TRM was 50% versus 21% (P = .03). At our center, PLS after minor ABO mm and PRABO antibodies after major ABO mm HSCT are significant risk factors for decreased OS and TRM. Our results suggest that occurrence of unexpected ABO antibodies after HSCT warrant a wider investigation individual to find the underlying cause.
Collapse
Affiliation(s)
- Emma Watz
- Therapeutic Immunology Unit, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden.
| | - Mats Remberger
- Therapeutic Immunology Unit, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Olle Ringden
- Therapeutic Immunology Unit, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Joachim Lundahl
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Per Ljungman
- Department of Hematology, Karolinska University Hospital and Division of Hematology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Mattsson
- Therapeutic Immunology Unit, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Wikman
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden; Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Michael Uhlin
- Therapeutic Immunology Unit, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden; Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
5
|
Aung FM, Lichtiger B, Bassett R, Liu P, Alousi A, Bashier Q, Ciurea SO, de Lima MJ, Hosing C, Kebriaei P, Nieto Y, Oran B, Parmar S, Qazilbash M, Shah N, Khouri I, Champlin RE, Popat U. Incidence and natural history of pure red cell aplasia in major ABO-mismatched haematopoietic cell transplantation. Br J Haematol 2013; 160:798-805. [PMID: 23330820 DOI: 10.1111/bjh.12210] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 11/12/2012] [Indexed: 11/30/2022]
Abstract
Major ABO mismatching is not considered a contraindication to allogeneic haematopoietic stem cell transplantation (HSCT). Modern reduced-intensity conditioning and reduced-toxicity regimens cause much less myeloablation than conventional myeloablative regimens, such as cyclophosphamide with busulfan or total body irradiation, which may affect the incidence of pure red cell aplasia (PRCA). We estimated the incidence and described the natural history of PRCA in patients with major ABO-mismatched donor stem cells. Between 2007 and 2008, 161 (27% of all patients undergoing HSCT) underwent allogeneic HSCT with major ABO-mismatched stem cells and 12 (7·5%) of these patients developed PRCA. Thirty and ninety day T-cell and myeloid cell chimerism and neutrophil and platelet engraftment did not differ between patients who developed PRCA and those who did not. The only risk factor associated with PRCA was the use of a fludarabine/busulfan conditioning regimen. All patients with PRCA needed red cell transfusion for several months after HSCT resulting in significant iron overload. Pure red cell aplasia resolved spontaneously in the majority (seven patients) but only resolved after stopping tacrolimus in three patients. Hence, after major ABO-mismatched HSCT, the incidence of PRCA was 7·5% and it resolved spontaneously or after withdrawal of immunosuppression in the majority of patients.
Collapse
Affiliation(s)
- Fleur M Aung
- Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Ratanatharathorn V, Pavletic S, Uberti JP. Clinical applications of rituximab in allogeneic stem cell transplantation: Anti-tumor and immunomodulatory effects. Cancer Treat Rev 2009; 35:653-61. [DOI: 10.1016/j.ctrv.2009.07.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 07/15/2009] [Accepted: 07/18/2009] [Indexed: 11/24/2022]
|
7
|
Alderuccio F, Chan J, Scott DW, Toh BH. Gene therapy and bone marrow stem-cell transfer to treat autoimmune disease. Trends Mol Med 2009; 15:344-51. [PMID: 19665432 DOI: 10.1016/j.molmed.2009.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 06/09/2009] [Accepted: 06/09/2009] [Indexed: 12/14/2022]
Abstract
Current treatment of human autoimmune disease by autologous bone marrow stem-cell transfer is hampered by frequent disease relapses. This is most probably owing to re-emergent self-reactive lymphocytes. Gene therapy combined with bone marrow stem cells has successfully introduced genes lacking in immunodeficiences. Because the bone marrow compartment has a key role in establishing immune tolerance, this combination strategy should offer a rational approach to prevent re-emergent self-reactive lymphocytes by establishing solid, life-long immune tolerance to causative self-antigen. Indeed, we have recently demonstrated the success of this combination approach to prevent and cure an experimental autoimmune disease. We suggest that this combination strategy has the potential for translation to treat human autoimmune diseases in which causative self-antigens are known.
Collapse
Affiliation(s)
- Frank Alderuccio
- Department of Immunology, Nursing and Health Sciences, Monash University, Victoria 3181, Australia.
| | | | | | | |
Collapse
|
8
|
Passweg JR, Rabusin M. Hematopoetic stem cell transplantation for immune thrombocytopenia and other refractory autoimmune cytopenias. Autoimmunity 2009; 41:660-5. [DOI: 10.1080/08916930802198436] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
9
|
Marmont AM. Will hematopoietic stem cell transplantation cure human autoimmune diseases? J Autoimmun 2008; 30:145-50. [DOI: 10.1016/j.jaut.2007.12.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
10
|
Ebihara Y, Manabe A, Tsuruta T, Ishikawa K, Hasegawa D, Ohtsuka Y, Kawasaki H, Ogami K, Wada Y, Kanda T, Tsuji K. The effect of donor leukocyte infusion on refractory pure red blood cell aplasia after allogeneic stem cell transplantation in a patient with myelodysplastic syndrome developing from kostmann syndrome. Int J Hematol 2007; 86:446-50. [DOI: 10.1007/bf02984003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
11
|
Park JH, Spitzer T, Kuter DJ. Successful treatment of pure red cell aplasia with autologous stem cell transplantation. Am J Hematol 2007; 82:812-4. [PMID: 17546635 DOI: 10.1002/ajh.20975] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We report a case of 64-year-old patient with pure red cell aplasia (PRCA) who was intolerant of conventional immunosuppressive therapies but achieved a complete long-term remission following autologous hematologic stem cell transplant (HSCT). The patient was initially treated with high-dose prednisone, cyclophosphamide, cyclosporine, antithymocyte globulin, and then rituximab. With the exception of rituximab, all of the above regimens achieved a transient response. However, because of the persistent requirement for red blood cell transfusions and intolerance to the multiple immunosuppressive therapies, autologous HSCT was eventually performed. The patient remains in complete remission and on no other therapy for 36 months following the autologous HSCT.
Collapse
Affiliation(s)
- Jae H Park
- MGH Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
| | | | | |
Collapse
|
12
|
Marmont AM, Gualandi F, Occhini D, Morandi F, Ferretti E, Pezzolo A, Strada P, Ravetti JL, Pistoia V, Falanga A, Bacigalupo A. Catastrophic relapse of Evans syndrome five years after allogeneic BMT notwithstanding full donor chimerism. Terminal hemolytic-uremic syndrome. Autoimmunity 2007; 39:505-11. [PMID: 17060030 DOI: 10.1080/08916930600847598] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A patient with severe Evans syndrome received an allo-BMT from his HLA-identical sister on November, 2000. Full marrow and blood donor chimerism were achieved only after 5 donor lymphocyte infusions (DLI), and coincided with complete clinical remission and disappearence of auto-antibodies. Five years later, hemolytic anemia recurred with rapid increase of serum bilirubin to over 50 mg%: he responded to combined therapy, but died on day +17 from admission of an acute hemolytic uremic syndrome (HUS). All circulating blood cells, including erythrocytes, were 100% donor. Ex vivo cultured and expanded T and B cells from the peripheral blood were also 100% donor. The supernatants from B cell cultures, containing either IgM or IgG, did not react with a panel of erythrocytes. Thus in this typical autoimmune disease with a predominant B cell pathogenesis the donor immune system resulted "innocent of autoimmunity". The persistence of long-lived recipient autoreactive plasma-cell lines in survival niches, still producing autoantibodies, may be hypothesized for this and similar cases. The postulated graft-versus-autoimmunity (GVA) effect was apparently not sufficient to eradicate autoimmunity in this patient.
Collapse
Affiliation(s)
- A M Marmont
- Division of Hematology and Stem Cell Transplantation Center, Istituto G. Gaslini, Genova, Italy.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Marmont AM. Allogeneic haematopoietic stem cell transplantation for severe autoimmune diseases: great expectations but controversial evidence. Bone Marrow Transplant 2006; 38:1-4. [PMID: 16788682 DOI: 10.1038/sj.bmt.1705394] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
14
|
Numata A, Yasuda K, Fukuda T, Baba E, Yamasaki S, Takase K, Miyamoto T, Nagafuji K, Nakano S, Harada M. Non-myeloablative allogeneic haemopoietic stem-cell transplantation for treatment of metastatic invasive thymoma. Lancet Oncol 2005; 6:626-8. [PMID: 16054574 DOI: 10.1016/s1470-2045(05)70285-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Akihiko Numata
- First Department of Internal Medicine, Kyushu University Hospital, Fukuoka, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Marmont AM. Stem cell transplantation for autoimmune disorders. Coincidental autoimmune disease in patients transplanted for conventional indications. Best Pract Res Clin Haematol 2004; 17:223-32. [PMID: 15302336 DOI: 10.1016/j.beha.2004.04.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The practice of stem cell transplantation for severe autoimmune diseases refractory to conventional therapy originated from two landmark discoveries: the excellent results of animal experiments, and serendipitous observations in human coincidental diseases. The latter include patients with an often long-standing autoimmune disease who have developed a haematological condition (aplasia, leukaemia, lymphoma) requiring stem cell transplantation (from marrow as well as from blood). Allogeneic and autologous transplants have been performed. The initial information deriving from both procedures is their feasibility, even more convincing since the patients were affected by two simultaneous severe diseases. The information derived from autologous transplants has, however, now been superseded by the considerable and increasing number of those transplants performed for primary autoimmune diseases. On the other hand, allogeneic stem cell transplantation for very severe autoimmune diseases is being cautiously explored in current protocols. Allogeneic transplants in coincidental disease have also suggested a graft-versus-autoimmunity effect, which may become relevant in conjunction with non-myeloablative, less toxic condition regimens.
Collapse
Affiliation(s)
- Alberto M Marmont
- Division of Hematology and Stem Cell Transplantation Centre, S Martino's Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy.
| |
Collapse
|