Abstract
Aim Donor specific anti-HLA antibodies (DSA) in hematopoietic cell transplantation (HCT) have been associated with graft failure. Single-center, desensitization of a small number of patients with DSA in HLA haplo-identical HCT has been reported. We report a case of a highly sensitized 50 year old, African-American, female with chronic myeloid leukemia. Patient lacked HLA-matched related and unrelated donors. She was enrolled in our hapoidentical cord blood transplant protocol. DSA existed against all donor options. Donors with the lowest number and strength of DSA were selected. Methods Sera were tested by solid-phase immunoassays. Strength of DSA was estimated according to the cutoff values of flow-cytometric crossmatches (FCXM) from solid organ transplant data and mean fluorescent intensity (MFI). Desensitization protocol consisted of tacrolimus and mycophenolate mofetil, therapeutic plasma exchange (TPE) (5x), and low dose IVIG after each TPE. Patient sera were tested pre- and post-desensitization to monitor effectiveness of treatment. Results Preformed DSA were to class II antigens. Afterdesensitization, by the day of transplant, DSA were no longer present. Patient received haplo-identical and cord blood infusions. She developed an anaphylactic reaction during infusion of first cord, and required a second cord infusion. The same precautions were taken in selection of second cord. By this time, class II antibodies were no longer present. Neutrophil engraftment occurred on day 10. One month post-transplant, chimersim showed haplo donor accounted for 95% of total DNA and 68% of CD3+ cells. Cord donor accounted for the remaining, demonstrating success of the haploidentical graft. On day 50 post-transplant, absolute neutrophil count is 2.8 K/Ul. Thrombocytopenia persists and platelet engraftment is not fully evaluable due to platelet infusions for different procedures. Conclusions Desensitization with TPE, low dose IVIG and immune suppression can eradicate DSA and allow engraftment.
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