Twenty years of experience on stem cell transplantation in iran

The Middle East and North Africa Diagnosis and Management Guidelines for Inborn Errors of Immunity

Human inborn errors of immunity (IEI) are a group of 485 distinct genetic disorders affecting children and adults. Signs and symptoms of IEI are heterogeneous, and accurate diagnosis can be challenging and depends on the available human expertise and laboratory resources. The Middle East and North Africa (MENA) region has an increased prevalence of IEI because of the high rate of consanguinity with a predominance of autosomal recessive disorders. This area also exhibits more severe disease phenotypes compared with other regions, probably due to the delay in diagnosis. The MENA-IEI registry network has designed protocols and guidelines for the diagnosis and treatment of IEI, taking into consideration the variable regional expertise and resources. These guidelines are primarily meant to improve the care of patients within the region, but can also be followed in other regions with similar patient populations.

Risk Factors of Graft-Versus-Host Disease in the Iranian Allogeneic Hematopoietic Stem Cell Transplantation: A 10-Year Experience

Background: Graft-versus-host disease (GVHD) is a serious complication associated with allogeneic hematopoietic stem cell transplantation (allo-HSCT). Thus, it is necessary to evaluate the risk factors of GVHD in allo-HSCT. Herein, we studied the effects of some risk factors on GVHD incidence in patients with allo-HSCT. Methods: We retrospectively evaluated the GVHD incidences and risk factors in 199 patients diagnosed with hematological disorders who underwent allo-HSCT in Taleghani hospital, Tehran, Iran, between 2007 and 2017. The univariable and multivariable analyses of time to event data were performed using the Logistic regression model. Computations were performed using SAS, and the level of statistical significance for univariable and multivariable analyses was set at 20% and 10%, respectively. Results: Acute GVHD (aGVHD) was seen in 59 (29.6%) patients, and 18 (9%) patients developed chronic GVHD (cGVHD). The odds of GVHD incidence in male to female transplants was 3.49 times greater than the male-to-male transplantations (CI, 1.16, 11.5; p<0.001). The patients with body mass index (BMI) below 18.5 had 96% lower odds of GVHD incidence compared with those with BMI above 30 (CI, 0.007-0.27; p=0.013). The odds of GVHD incidence in patients who were negative for cytomegalovirus (CMV) antigen was 76% lower than patients with positive CMV antigen (CI, 0.06-0.93; p=0.081). Conclusion: In a nutshell, our results indicated that the donor-recipient gender disparity, the recipient's BMI, and CMV infection/reactivation status might be pivotal risk factors, which should be taken into account for prevention and management of GVHD.

Radiation-Free myeloablative allogeneic hematopoietic stem cell transplantation for adult acute lymphoblastic leukemia: A comparison of outcomes between patients with and without central nervous system involvement

For patients with acute lymphoblastic leukemia (ALL) undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), total body irradiation (TBI) has been particularly advocated as a part of the conditioning regimen in case of extramedullary involvement in sanctuary sites such as the central nervous system (CNS), to ensure greater tissue penetration. In resource-limited countries lacking TBI facilities; however, ALL patients undergo radiation-free myeloablative conditioning, though its impacts on post-HSCT outcomes of the patients with pre-HSCT CNS involvement have not been analyzed. In this 14-year series of 278 adult (> 18 y) ALL patients undergoing TBI-free busulfan/cyclophosphamide conditioning allo-HSCT, we found that the long-term probabilities of overall survival, disease free survival, relapse and non-relapse mortality were not significantly different between CNS-involved and CNS-spared patients. Moreover, there was no statistically significant difference in the incidence of post-HSCT CNS relapse between CNS-involved and CNS-spared patients. Pre-HSCT cranial radiation therapy (CRT) showed no significant preventive effect on the likelihood of post-HSCT CNS relapse. Through multivariable regression analysis, grade III-IV acute graft-versus-host disease (GvHD), extensive chronic GvHD and post-HSCT relapse were ascertained as independent determinants of mortality (Adj.R² = 53.9 %, F_(12,265) = 28.1, P < 0.001), while other parameters including Philadelphia translocation, pre-HSCT CNS involvement and CRT were found to have no independent effect. Although this study was not an attempt to compare TBI-based vs. non-TBI conditioning, the TBI-free myeloablative allo-HSCT was shown to be feasible and an option for adult ALL patients with CNS involvement, considering the comparable outcomes between patients with and without CNS involvement.

Hematopoietic stem cell transplantation for people with β-thalassaemia

BACKGROUND

Thalassaemia is an autosomal recessive blood disorder, caused by mutations in globin genes or their regulatory regions, resulting in a reduced rate of synthesis of one of the globin chains that make up haemoglobin. In β-thalassaemia there is an underproduction of β-globin chains combined with excess of free α-globin chains. The excess free α-globin chains precipitate in red blood cells, leading to their increased destruction (haemolysis) and ineffective erythropoiesis. The conventional treatment is based on the correction of haemoglobin through regular red blood cell transfusions and treating the iron overload that develops subsequently with iron chelation therapy. Although, early detection and initiations of such supportive treatment has improved the quality of life for people with transfusion-dependent thalassaemia, allogeneic hematopoietic stem cell transplantation is the only widely available therapy with a curative potential. Gene therapy for β-thalassaemia has recently received conditional authorisation for marketing in Europe, and may soon become widely available as another alternative therapy with curative potential for people with transfusion-dependent thalassaemia. This is an update of a previously published Cochrane Review.

OBJECTIVES

To evaluate the effectiveness and safety of different types of hematopoietic stem cell transplantation, in people with transfusion-dependent β-thalassaemia.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries. Date of the most recent search: 07 April 2021.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials comparing hematopoietic stem cell transplantation with each other or with standard therapy (regular transfusion and chelation regimen).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened trials and had planned to extract data and assess risk of bias using standard Cochrane methodologies and assess the quality using GRADE approach, but no trials were identified for inclusion in the current review.

MAIN RESULTS

No relevant trials were retrieved after a comprehensive search of the literature.

AUTHORS' CONCLUSIONS

We were unable to identify any randomised controlled trials or quasi-randomised controlled trials on the effectiveness and safety of different types of hematopoietic stem cell transplantation in people with transfusion-dependent β-thalassaemia. The absence of high-level evidence for the effectiveness of these interventions emphasises the need for well-designed, adequately-powered, randomised controlled clinical trials.

Outcome of Patients Treated with Hematopoietic Stem Cell Transplantation: Results from A Single Center

Objective:

Hematopoietic stem cell transplantation (HSCT) is known as one of the most advanced and modern treatments in the world for various diseases which do not respond well to other therapies. Evaluating outcomes of these patients, especially in newly developed centers, can crucially help in developing and improving the quality of these centers.

Methods:

In a retrospective analytical cohort study, we statistically analyzed all patients treated with HSCT in the Bone Marrow Transplant Unit of the Ali-Asghar Pediatric Hospital affiliated to Iran University of Medical Sciences. The demographic information as well as all information concerning each patient's transplant process was extracted and statistically analyzed using SPSS Version 23.

Results:

The mean neutrophilic and platelet engraftment days were, respectively, 16 (range = 12–21) and 22 (range = 15–34) days after HSCT, while the neutrophilic engraftment occurred significantly earlier in allogeneic transplants compared to the autologous ones (P = 0.020). The total event-free survival (EFS) rate of the patients based on the median follow-up of 12 months was 11.50% ± 53.60%. Based on the total follow-up period, the estimated total EFS rate of the patients was calculated as 35.20% ± 13.50%. The estimated EFS rate was found to be better in patients who had undergone allogeneic transplantation than those who received an autologous transplant (P = 0.780).

Conclusions:

The HSCT results at our center are comparable to those at other centers in Iran. We argue that the facility can provide adequate therapy to patients requiring HSCT, on the proviso that some organizational limitations are addressed.

The Effect of Family-Centered Supportive Program on Chemotherapy-Induced Symptoms in Patients with Acute Lymphoblastic Leukemia (ALL)

Background: Acute lymphoblastic leukemia is a disease of the hematopoietic system and chemotherapy is recommended as the primary treatment. As many chemotherapeutic agents have severe adverse effects, patients require to be supported by their family to deal with chemotherapy-related symptoms. This study attempted to investigate the effect of family-centered supportive programs on chemotherapy symptom control in patients with acute lymphoblastic leukemia.

Materials and Methods: Sixty-six patients with acute lymphoblastic leukemia undergoing chemotherapy along with their caregivers participated in this nonrandomized clinical trial. Patients in Shariati and Taleghani Hospital were assigned to intervention (n=33) and control group (n=33), respectively. A survey of family-centered supportive program was conducted via in-person and telephone up to 6 cycles of chemotherapy. The chemotherapy symptom assessment scale was administered to record the data during 6 cycles of chemotherapy treatment. The control group only received routine interventions. Data were analyzed using Chi-square and Mann–Whitney U tests.

Results: The results of the study indicated that there was a statistically significant difference in terms of the frequency of 9 chemotherapy-induced symptoms including nausea, shortness of breath, problems related to skin and nails, a sore/sensitive mouth or throat, anorexia, weight gain or loss, headache and sore/scratchy/dry eyes between the control and intervention group. There was also a statistically significant difference in the severity and level of discomfort of 19 chemotherapy-induced symptoms between the control and intervention group.

Conclusion: Family-centered supportive program can be considered as an approach to decrease the frequency, severity and discomfort level of chemotherapy-induced symptoms.

Successful treatment of metastatic pancreatoblastoma in an adult with autologous hematopoietic cell transplant

BACKGROUND

Pancreatoblastoma is a rare pediatric malignant neoplasm characterized by its histological resemblance to fetal pancreatic tissue and poor clinical outcomes. Preoperative diagnosis of the neoplasm is difficult due to its rarity, variable clinical presentation, and its lack of distinct laboratory markers. Current mainstay of treatment is surgical resection of the tumor, although a standard of care has not yet been established.

METHODS

Data were collected on one patient admitted to the University of Virginia Hospital System. Radiology, hematopoietic cell transplant, and biopsy data were collected according to the best clinical practice.

RESULTS

Herein, we describe the case of an adult patient with pancreatoblastoma treated with high-dose chemotherapy and autologous peripheral blood hematopoietic cell transplantation. To the authors' knowledge, this is the first documented successful treatment of pancreatoblastoma using autologous hematopoietic cell transplantation in the United States, and the first successful treatment in an adult patient worldwide.

CONCLUSIONS

While it is difficult to draw conclusions based on a single case, we would like to highlight the success of this treatment modality in the management of our patient with a 51-month remission and open further discussion into exploring the use of autologous hematopoietic cell transplantation for pancreatoblastoma. Our patient is currently living 57 months after diagnosis despite the average survival rate being less than 18 months.

Worldwide Network for Blood and Marrow Transplantation (WBMT) Recommendations Regarding Essential Medications Required To Establish An Early Stage Hematopoietic Cell Transplantation Program

Establishing a hematopoietic cell transplantation (HCT) program is complex. Planning is essential while establishing such a program to overcome the expected challenges. Authorities involved in HCT program establishment will need to coordinate the efforts between the different departments required to start up the program. One essential department is pharmacy and the medications required. To help facilitate this, the Worldwide Network for Blood and Marrow Transplantation organized a structured survey to address the essential medications required to start up an HCT program. A group of senior physicians and pharmacists prepared a list of the medications used at the different phases of transplantation. These drugs were then rated by a questionnaire using a scale of necessity based on the stage of development of the transplant program. The questionnaire was sent to 30 physicians, in different parts of the world, who have between 5 and 40 years of experience in autologous and/or allogeneic transplantation. This group of experts scored each medication on a 7-point scale, ranging from an absolute requirement (score of 1) to not required (score of 7). The results are presented here to help guide the prioritization of required medications.

Resiliency, the Lived Experience of Patients Undergoing Hematopoietic Stem Cell Transplantation

Background: Hematopoetic stem cell transplantation is considered as a standard treatment for cancer patients to stay hopeful toward treatment outcome. However, these patients experience many complications which might affect different aspects of their life. The aim of this study was to investigate the lived experience of patients after hematopoetic stem cell transplantation and introduce supportive care strategies. Materials and Methods: In this study, Van Manen's Hermeneutic phenomenological approach was used. Eleven patients (7 males and 4 females) were chosen by targeted sampling from visitors of Shariati Hospital's outpatient clinic. Semi-structured interviews were conducted and the final data were analyzed by MAXQDA 10 software. Results: Data analysis revealed that the main theme was resiliency with two sub-themes of "not surrendering to disease" and "feeling closer to God". Conclusion: Participants declared that transplantation was like a second chance for life and considered this opportunity as a gift from God to overcome their disease. According to our findings, spirituality aids can help patients control the disturbances following HSCT and health professionals can use constructive strategies to support patients with spiritual needs.

Worldwide Network for Blood and Marrow Transplantation (WBMT) recommendations for establishing a hematopoietic cell transplantation program (Part I): Minimum requirements and beyond

Hematopoietic cell transplantation (HCT) is a highly complex procedure that requires a dedicated multidisciplinary team to optimize its safety. In addition, institutions may have different needs regarding indications based on regional disease prevalence or may have an interest in developing specialized services. Yet, structured recommendations are not commonly available. Here, the Transplant Center and Recipient Issues Standing Committee for the Worldwide Network for Blood and Marrow Transplantation (WBMT) organized a structured review of all pertinent elements to establish a transplant program. First, we solicited components from committee members and grouped them in domains (infrastructure, staff, cell processing laboratory, blood banking, laboratory, radiology, pharmacy, HLA testing, ancillary services and quality). Subsequently, reviewers scored all elements on a 7-point scale, from an absolute requirement (score of 1) to not required (score of 7). An independent group of five experienced transplant physicians reviewed the rankings. Minimum requirements to establish any HCT program were identified among elements with mean score of ≤2.0, and specific elements for allogeneic and autologous HCT were identified. Mean scores >2.0-4.0 were classified as preferred recommendation, and mean scores of >4.0 to ≤7.0 were considered ideal recommendations for advanced and complex types of transplantation. This structured set of recommendations guides the prioritization of minimum requirements to establish a transplant program and to set the path for expansion and further development.

Caring Process in Hematopoietic Stem Cell Transplantation: A Grounded Theory Study

Background: Caring is one of the main concepts in nursing and its modes of delivery in different diseases have been widely studied. Hematopoietic Stem Cell Transplantation (HSCT) is a novel, complex, and time-consuming clinical intervention which is applied as a final medical choice in several life-threatening diseases. The aim of the current study was to explore the process of caring for patients undergoing HSCT. Materials and Methods: In this article, we present a qualitative research study conducted between 2011 and 2013 in accordance with the procedures of grounded theory methodology. Data were gathered by interviewing and observing health professionals involved in HSCT process, as well as patients and their families. The study participants consisted of 18 HSCT nurses, 2 physicians, 12 patients, and 7 members of patients' families. The initial sampling in the study was purposeful, followed by theoretical sampling. Data were analyzed using the Corbin & Strauss (2008) method. Results: Four main categories, reflecting 13 sub-categories, were emerged by analyzing the data: struggling of patients between life and death, trying to reduce the chance of patient's death, enforcing patients' spirit and caring achievements. The core variable of study, defined as "supporting patients to go through the HSCT process successfully", represented the nature and efficiency of care delivered to HSCT patients in the study setting. Conclusion: HSCT patients enter the caring process in the context of life-and-death limbo. The caring strategy in HSCT patients is aimed at trying to reduce the chance of the patient's death, as well as enforcing patients' spirit. The HSCT process affects all areas involved in various ways and has some outcomes. The findings and the theoretical conclusions of this study are potentially valuable in improving nursing practice, designing of educational programs and setting of caring policies.

A Survey of Infection in Allogenic Hematopoietic Stem Cell Transplantation in Patients with Acute Myeloid Leukemia

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (HSCT) is a potentially cure for acute myeloid leukemia (AML). Patients who undergone HSCT are at increased risk of infection due to impaired immunity.

OBJECTIVE

To evaluate the rate of bacterial, viral and fungal infection and its relationship with 2-year overall survival of AML patients who had undergone HSCT.

METHODS

This was a retrospective cross-sectional study of 49 patients who underwent allogenic bone marrow transplantation (BMT) from full-matched donors at BMT Center, Imam Khomeini Hospital Complex, Tehran, Iran, from 2006 to 2013. All autologous transplantations and promyelocytic leukemia (PML) transplantations were excluded.

RESULTS

All patients, except for one, had fever for a mean of 7 days post-transplantation and received broad-spectrum antibiotic. The rate of severe sepsis was 6.1%. None of the patients developed fungal infection during admission. The rate of admission due to sepsis after discharge was 27% in the alive group (mean onset of 54 days), and 73% in the deceased group (mean onset of 52 days) (p<0.05). The most common site of infection was lung (70%). The rate of cytomegalovirus (CMV) antigenemia (positive PP65) was 20% during the 2-year period after HSCT.

CONCLUSION

The rate of infection was a negative prognostic factor for 2-year overall survival. The rate of CMV antigenemia is less than similar studies (51%), which could be due to full-matched donor-recipients requiring less immunosuppression.

Hematopoietic stem cell transplantation for people with ß-thalassaemia major

BACKGROUND

Thalassemia is an inherited autosomal recessive blood disorder, caused by mutations in globin genes or their regulatory regions. This results in a reduced rate of synthesis of one of the globin chains that make up haemoglobin. In ß-thalassaemia major there is an underproduction of ß-globin chains combined with excess of free α-globin chains. The excess free α-globin chains precipitate in red blood cells, leading to their destruction (haemolysis) and ineffective erythropoiesis. The conventional approach to treatment is based on the correction of haemoglobin status through regular blood transfusions and iron chelation therapy for iron overload. Although conventional treatment has the capacity to improve the quality of life of people with ß-thalassaemia major, allogeneic hematopoietic stem cell transplantation is the only currently available procedure which has the curative potential. This is an update of a previously published Cochrane Review.

OBJECTIVES

To evaluate the effectiveness and safety of different types of allogeneic hematopoietic stem cell transplantation, in people with severe transfusion-dependant ß-thalassaemia major, ß-thalassaemia intermedia or ß0/+- thalassaemia variants requiring chronic blood transfusion.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search: 18 August 2016.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials comparing allogeneic hematopoietic stem cell transplantation with each other or with standard therapy (regular transfusion and chelation regimen).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies and had planned to extract data and assess risk of bias using standard Cochrane methodologies but no studies were identified for inclusion.

MAIN RESULTS

No relevant studies were retrieved after a comprehensive search of the literature.

AUTHORS' CONCLUSIONS

We were unable to identify any randomised controlled trials or quasi-randomised controlled trials on the effectiveness and safety of different types of allogeneic stem cell transplantation in people with severe transfusion-dependant ß-thalassaemia major or ß0/+- thalassaemia variants requiring chronic blood transfusion. The absence of high-level evidence for the effectiveness of these interventions emphasises the need for well-designed, adequately-powered, randomised controlled clinical trials.

Hematopoietic stem cell transplantation for people with ß-thalassaemia major

BACKGROUND

Thalassemia is an inherited blood disorder, caused by mutations in regulatory genes and transmitted as an autosomal recessive disorder, which results in a reduced rate of synthesis of one of the globin chains that make up haemoglobin. In ß-thalassaemia major there is an underproduction of ß-globin chains combined with excess of free α-globin chains. The excess free α-globin chains damage the red blood cell membranes, leading to their destruction and a phenomenon termed ineffective erythropoiesis. The conventional approach to treatment is based on the correction of haemoglobin status through regular blood transfusions and iron chelation therapy for iron overload. Although conventional treatment has the capacity to improve the quality of life of people with ß-thalassaemia major, allogeneic hematopoietic stem cell transplantation is the only currently available procedure which has the potential to definitively cure the disease.

OBJECTIVES

To evaluate the effectiveness and safety of different types of allogeneic hematopoietic stem cell transplantation, in people with severe transfusion-dependant ß-thalassaemia major, ß-thalassaemia intermedia or ß0/+- thalassaemia variants requiring chronic blood transfusion.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search: 11 November 2013.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials comparing allogeneic hematopoietic stem cell transplantation with each other or with standard therapy (regular transfusion and chelation regimen).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies and had planned to extract data and assess risk of bias using standard Cochrane Collaboration methodologies but no studies were identified for inclusion.

MAIN RESULTS

No relevant studies were retrieved after a comprehensive search of the literature.

AUTHORS' CONCLUSIONS

We were unable to identify any randomised controlled trials or quasi-randomised controlled trials on the effectiveness and safety of different types of allogeneic stem cell transplantation in people with severe transfusion-dependant ß-thalassaemia major or ß0/+- thalassaemia variants requiring chronic blood transfusion. The absence of high-level evidence for the effectiveness of these interventions emphasises the need for well-designed, adequately-powered, randomised controlled clinical trials.