Pretransplant Desensitization of Donor-Specific Anti-HLA Antibodies with Plasmapheresis and Immunoglobulin Produces Equivalent Outcomes to Patients with No Donor Specific Antibodies in Haploidentical Hematopoietic Cell Transplant

In patients requiring haploidentical hematopoietic cell transplant (haplo-HCT), the presence of donor specific anti-HLA antibodies (DSAs) is associated with high rates of primary graft failure and poor overall survival (OS). There is limited data regarding the effect of desensitization. Adult patients undergoing haplo-HCT at Washington University School of Medicine from 2009-2021 were identified. Patients were divided into three cohorts: no DSA, untreated DSA or treated DSA. DSA testing was performed. Desensitization therapy using plasmapheresis and IVIg (immunoglobulin) was performed. We retrospectively identified 304 patients for study inclusion. 14 of 30 patients with DSAs underwent desensitization. By day +2, 57% of patients cleared all DSAs. OS was expectedly worse in patients with untreated DSAs. There were similar results between treated DSA and patients without DSA (OS median: control: 352 days vs. treated: 1331 days vs. untreated: 137 days, p = 0.02). RFS was also significantly different between the groups however with similar RFS in treated DSA and control groups (RFS median: control: 248 vs. treated: 322 v. untreated: 119, p = 0.03). Desensitization before haplo-HCT produces similar outcomes to patients without DSAs. While the optimal desensitization protocol has not been established, all patients received a backbone of plasmapheresis and immunoglobulin.

Donor chimerism and immune reconstitution following haploidentical transplantation in sickle cell disease

Introduction

We previously reported the initial results of a phase II multicenter transplant trial using haploidentical parental donors for children and aolescents with high-risk sickle cell disease achieving excellent survival with exceptionally low rates of graft-versus-host disease and resolution of sickle cell disease symptoms. To investigate human leukocyte antigen (HLA) sensitization, graft characteristics, donor chimerism, and immune reconstitution in these recipients.

Methods

CD34 cells were enriched using the CliniMACS^® system with a target dose of 10 x 10⁶ CD34⁺ cells/kg with a peripheral blood mononuclear cell (PBMNC) addback dose of 2x10⁵ CD3/kg in the final product. Pre-transplant HLA antibodies were characterized. Donor chimerism was monitored 1-24 months post-transplant. Comprehensive assessment of immune reconstitution included lymphocyte subsets, plasma cytokines, complement levels, anti-viral T-cell responses, activation markers, and cytokine production. Infections were monitored.

Results

HLA antibodies were detected in 7 of 11 (64%) evaluable patients but rarely were against donor antigens. Myeloid engraftment was rapid (100%) at a median of 9 days. At 30 days, donor chimerism was 93-99% and natural killer cell levels were restored. By 60 days, CD19 B cells were normal. CD8 and CD4 T-cells levels were normal by 279 and 365 days, respectively. Activated CD4 and CD8 T-cells were elevated at 100-365 days post-transplant while naïve cells remained below baseline. Tregs were elevated at 100-270 days post-transplant, returning to baseline levels at one year. At one year, C3 and C4 levels were above baseline and CH50 levels were near baseline. At one year, cytokine levels were not significantly different from baseline.

Discussion

These results suggest that haploidentical transplantation with CD34-enriched cells and peripheral blood mononuclear cell addback results in rapid engraftment, sustained donor chimerism and broad-based immune reconstitution.

Familial Haploidentical Stem Cell Transplant in Children and Adolescents With High-Risk Sickle Cell Disease: A Phase 2 Clinical Trial

This phase 2 clinical trial in patients with high-risk sickle cell disease assesses the feasibility, safety, and 1-year event-free survival after myeloimmunoablative conditioning and familial haploidentical stem cell transplant.

Efficacy of extracorporeal photopheresis in clearance of antibodies to donor-specific and lung-specific antigens in lung transplant recipients

BACKGROUND

Extracorporeal photopheresis (ECP) has been used to treat chronic rejection after lung transplantation (LTx). We investigated the effect of ECP on several immune parameters that have been associated with poor lung function, including donor-specific antibodies (DSA) to human leukocyte antigen (HLA), antibodies against the lung-associated self-antigens (SAg), Kα1-tubulin (Kα1T), collagen I and V, and circulating levels of pro-inflammatory and anti-inflammatory cytokines.

METHODS

Sera were collected from post-LTx patients diagnosed with bronchiolitis obliterans before and 6 months after initiation of ECP. DSA and cytokine levels were measured by Luminex (Invitrogen, Carlsbad, CA). Changes in lung function over the 6 months preceding and after the initiation of ECP were measured by retrospective analysis of spirometry performed at routine clinic visits.

RESULTS

ECP was associated with a significant decline in DSA levels as well as antibodies to lung-associated SAg. ECP also reduced circulating levels of pro-inflammatory cytokines and increased levels of anti-inflammatory cytokines. These immunologic changes were associated with a significant 63% reduction in the rate of decline in forced expiratory volume in 1 second over a 1-year period. Though statistically insignificant, a higher rate of clearance of antibodies to lung-associated SAg was strongly associated with better response to ECP.

CONCLUSIONS

ECP is associated with a reduction in the levels of circulating DSA, antibodies to lung-associated SAg (Kα1T, collagen I, and collagen V), and circulating levels of several pro-inflammatory cytokines. We propose that these changes contribute to the beneficial effect of ECP in reducing the decline in lung function.

A national survey of transfusion-related acute lung injury risk reduction policies for platelets and plasma in the United States

BACKGROUND

Little information exists on the specific transfusion-related acute lung injury (TRALI) risk reduction practices used by multiple blood collecting institutions in the United States.

STUDY DESIGN AND METHODS

An AABB-appointed TRALI working group designed a set of questions about TRALI risk reduction for platelets (PLTs) and plasma. AABB member institutions were asked to respond via an Internet-based survey during a 3-week period in August through September 2009.

RESULTS

Valid responses were received from 47 US blood centers (accounting for 1.57 million apheresis PLT units and 3.15 million whole blood-derived transfusable plasma units) and 56 hospital blood collectors. Among the blood centers, 87 and 98% had initiated some PLT and plasma risk reduction, respectively. HLA antibody testing of plateletpheresis donors was performed by 20 (43%) blood centers. There was substantial variation in the number of pregnancies (from one to more than four) that triggered testing and most centers did not screen based on a transfusion history. Almost all centers had policies to redirect HLA antibody-positive donors to whole blood donation and to potentially retest HLA antibody-negative donors. There were no blood centers performing HNA antibody testing. Sex-based risk reduction policies for plasma included all male, or predominantly male, and never-pregnant females; these varied by blood center, blood group, and method of plasma collection. A majority of centers indicated increased production of plasma frozen within 24 hours after phlebotomy.

CONCLUSIONS

Almost 3 years after the publication of the initial AABB bulletin on this issue, TRALI risk reduction strategies are commonly employed at most US blood centers. However, procedures are not uniform.

Barriers and motivators to blood and cord blood donations in young African-American women

The primary aim of this study was to assess potential barriers and motivators to blood and cord blood donation among African-American women. A telephone survey of African-American women, ages 18-30 years, in the St. Louis metropolitan area was performed. The survey was administered by trained telemarketing personnel using a Computer-Assisted Direct Interview (CADI) system. One hundred sixty-two women were surveyed. Common barriers to blood donation were inconvenience of donor sites (19%), fear of needles (16%), and too much time required to donate (15%). Potential motivators were increasing awareness of need for blood (43%), increasing the number of convenient donor locations (19%), and encouragement by spiritual leaders to have blood drives at their church (17%). Lack of awareness was the only identified barrier to cord blood donation. Most women surveyed (88%) indicated that they definitely or probably would donate cord blood. Strategies to increase the proportion of African-American blood and cord blood donations may include educating potential donors about the process and benefits of donation to particular patient populations and engaging church leadership in supporting blood and cord blood donations.

Aging and sense of control

Three groups representing different phases of the developmental lifecycle--12 senior citizens, 67 young adults, and 14 healthy middle-aged normal adults--were assessed using a multidimensional control inventory. Senior citizens had a healthy over-all sense of control comparable to those of the other two groups and a significantly lower (healthier) negative sense of control. They also were significantly more likely to endorse acceptance as a way of addressing areas of concern and to complement self as a source of control with a sense of control coming from others (including God, belief in a higher power).

Hepatitis B surface antigenemia in blood donors following vaccination

BACKGROUND

Detection of hepatitis B surface antigen (HBsAg) in recently vaccinated adults has not previously been reported. Transient detectable HBsAg has been observed in newborn infants immunized with a recombinant hepatitis B vaccine.

STUDY DESIGN AND METHODS

Over a 1-year period, eight HBsAg-positive blood donors mentioned during donor notification that they had been vaccinated for hepatitis B virus 1 to 3 days before donation. Follow-up tests for HBsAg, antibodies to HBsAg, and antibodies to hepatitis B core antigen were performed 3 to 37 weeks after immunization. Four months later, a group of 19 donors who were coworkers received hepatitis B vaccination and then donated blood the next day. The coworkers were observed for duration of antigenemia.

RESULTS

A total of nine cases of transient, confirmed (neutralizable) antigenemia occurred in healthy individuals who donated blood 1 to 3 days following vaccination with a recombinant hepatitis B vaccine. Follow-up testing showed no evidence of infection by hepatitis B virus. One (5.3%) of 19 blood donors vaccinated as a group had antigenemia at Day 1 but not on Days 2 and 3 following immunization.

CONCLUSION

Individuals recently vaccinated for hepatitis B may test positive for HBsAg and become permanently disqualified as blood donors. Therefore, blood collection centers should consider temporary deferral of potential donors who recently received hepatitis B vaccine.

A high-sensitivity electrochemiluminescence-based detection system for automated PCR product quantitation

A high-sensitivity nonisotopic system has been developed for post-PCR product detection. The probe-based detection system exploits a chemiluminescent reaction that takes place on the electrode surface in an electrochemical cell. The detection system incorporates a biotin-streptavidin capture reaction onto a solid support that permits fast post-PCR product detection at the attomole level. The system precision is within 5% relative standard deviation over a linear dynamic range of greater than three orders of magnitude. In this paper, the principles and features of the electrochemiluminescent-based detection system, together with its application to PCR product quantitation, are described in detail.

Multiple arteriovenous malformations of the small intestine in a patient with protein S deficiency

The authors report a case of arteriovenous malformations (AVMs) of the small intestine in a young patient with protein S deficiency. These disorders have not been previously reported to occur together. Protein S deficiency may cause thromboses in unusual sites, including the mesenteric veins. Several mechanisms linking protein S deficiency to the occurrence of AVMs in this patient are offered.

Self-esteem, ethnic identity, and behavioral adjustment among Anglo and Chicano adolescents in West Texas

This study provides a comparison of similarities and differences with respect to ethnic identity between Anglo and Chicano adolescents from Texas. A path analysis model was used to test a theoretical assumption concerning proposed antecedents and consequences of self-esteem. Research instruments included the Rosenberg Self Esteem Scale, the Semantic Differential (scales for Myself and My Ethnic Group) and the McGuire White Measure of Social Status. Results were consistent with the interpretation that there is a relationship between being Chicano and having lower self-esteem, lower behavioral adjustment, and higher ethnic esteem. The prediction that ethnic esteem would mediate between ethnic group and self-esteem was upheld. Variables such as ethnic group membership per se and sex appear as or more important to the prediction of behavioral level. Clinical implications include recognizing that Chicanos low in self-esteem or behavioral adjustment should not automatically be considered unusual. The problems faced by this group are considered as having something in common with other groups of people who have more problems, lesser status, fewer resources, and fewer sources of available help.

Different definitions of alcoholism, II: A pilot study of 10 definitions in a treatment setting

The authors have developed the Alcohol Poly-Diagnostic Interview, which permits the operationalization of the 10 leading definitions of alcoholism used in the United States and Europe. In a pilot study of 23 patients in an outpatient alcohol treatment facility, all patients were identified as alcoholic by seven of the diagnostic schemes; the other three diagnostic schemes identified at least 78% of the patients as alcoholic. The authors also found that the Diagnostic Interview Schedule was sensitive to the diagnosis of alcoholism among treated patients. This approach should facilitate further research into the relationship among various definitions of alcoholism and studies of their validity.

Effective control of cisplatin-induced nausea using high-dose steroids and droperidol

Seventy-three consecutive patients receiving cisplatin-containing chemotherapy regimens were treated with an initial dose of chlorpromazine (25 mg im), droperidol (1 mg iv, then 1 mg sc every 4 hours), and methylprednisolone (250 mg every 4 hours for four doses). Twenty patients received a combination chemotherapy protocol that included cisplatin at a dose of 40 mg/m2 iv (group 1) and 53 patients received a protocol that included cisplatin at a dose of 120 mg/m2 iv (group 2). The median age of all the patients was 58 years. Seventy-five percent of the patients in group 1 and 45% of those in group 2 had no vomiting at all; the remainder had limited and tolerable vomiting. These results in a group of elderly patients compare favorably with trials of other antiemetic programs.

Hypercalcemia associated with T-cell lymphoma-leukemia

Two adults who had T-cell lymphoma-leukemia and recurrent hypercalcemia in the absence of radiographic evidence of bone disease are described. Bone histopathology showed marked osteoclastic activation. Bone resorbing factors, including both prostaglandin E and a material produced in the presence of a prostaglandin synthetase inhibitor, were detected in the in-vitro culture fluids of malignant cells of one of the patients. Serum levels of parathyroid hormone were not elevated. These findings suggest that hypercalcemia resulted from in-vitro osteoclast activation by tumor cell product(s), one of which may be similar, if not identical, to the lymphocyte product osteoclast-activating factor. Two other patients having T-cell lymphoma-leukemia and hypercalcemia have been identified in the literature: the malignant cells of one of these patients also released a calcium-mobilizing factor in vitro.

Cystic lymphangioma in a colt

A 6-month-old Morgan colt was examined because of preputial edema and multiple nodular masses in the left inguinal region. A tentative diagnosis of lymphatic hamartoma was made on the basis of initial biopsy findings. The prognosis for surgical excision was poor due to the progressive expansile growth of the tumor. Secondary infectious complications developed, and the colt was euthanatized at the owner's request. An abdominal and retroperitoneal mass was seen at postmortem examination. The mass was adherent to the left lumbar musculature, the craniodorsal aspect of the pelvic inlet, the midjejunum, the left testicle, and the left kidney. The mass extended through the left inguinal and femoral canals into the deep intermuscular fascia of the hindlimb. Histologic examination of the mass indicated that it was a cystic lymphangioma.

Movement of sodium into human platelets induced by ADP

1. In normal human platelets the concentrations of Na+ and K+ were 42.1 +/- 4.3 and 98.8 +/- 3.7 mequiv/l of platelet water respectively (mean +/- S.E. of 22 samples). 2. When platelet-rich plasma was incubated with 22Na+ at 37 degrees C for 2-3 h an increase in platelet Na+ concentration was found which was significant after 210 min. Platelet K+ concentration did not change significantly. The platelet 22Na+ radioactivity increased faster than did the total Na+ suggesting a Na+o-Na+ exchange process in unactivated platelets. 3. Addition of ADP to platelet-rich plasma resulted in platelet aggregation and a rapid rise (within seconds) in 22Na+-radioactivity within the platelets and after 300 s this increase diminished toward control levels. 4. Under the same experimental conditions, ADP did not bring about an increase of 36Cl- in the platelets. 5. Ouabain (10-(6) M) added to platelet-rich plasma induced an increase in Na+ concentration and 22Na+ radioactivity in the platelets, as well as a decrease in K+ concentration. ADP produced a further increase in 22Na+, which did not return toward control values, in the presence of ouabain. 6. The association of an increase in 22Na+ but not of 36Cl- accompanying aggregation by ADP suggests a selective mechanism for the movement of Na+ into platelets rather than a movement of NaCl together with water under an osmotic gradient.