A modified conditioning regimen based on low-dose cyclophosphamide and fludarabine for haploidentical hematopoietic stem cell transplant in severe aplastic anemia patients at risk of severe cardiotoxicity.

Abstract

Severe cardiotoxicity is a fatal complication during high-dose cyclophosphamide (Cy)-based conditioning in hematopoietic stem cell transplant (HSCT) for severe aplastic anemia (SAA). This study aimed to evaluate the feasibility and efficacy of a modified conditioning regimen in haploidentical HSCT (haplo-HSCT) for severe-cardiotoxic-risk SAA patients. This BuCylow Flu conditioning utilized busulfan (Bu, 3.2mg/kg for 2 days), low-dose Cy (100mg/kg), fludarabine (150mg/m2 ), and rabbit antithymocyte globulin (rATG, 10mg/kg). Compared to BuCy conditioning using high-dose Cy of 200mg/kg, Bu of 3.2mg/kg for 2 days, and rATG of 10mg/kg, the incidence of severe cardiotoxicity of BuCylow Flu conditioning was significantly decreased (2.17%vs 12.80%, p=.032). The engraftment rates (100% for neutrophil and 84.44% for platelet) were favorable. The probabilities of 100-day transplant-related mortality were similar in the BuCylow Flu and the BuCy group (8.75%vs 10.53%, p=.671). Both 1-year overall survival (88.79%vs 84.66%, p=.357) and 1-year failure-free survival (84.78%vs 81.70%, p=.535) were comparable. The BuCylow Flu group had higher rates of cytomegalovirus and Epstein-Barr virus reactivation. In conclusion, the BuCylow Flu provided reduced severe cardiotoxicity, and achieved favorable engraftment and survival. Our results suggest BuCylow Flu conditioning can be a feasible alternative for haplo-HSCT recipients at risk of severe cardiotoxicity.