Anti-thymoglobulin Research Articles

Impact of HLA of Winning Cord Blood Unit on Outcomes after Double Umbilical Cord Blood Transplantation in Adults with Acute Leukemia: A Retrospective Study on Behalf of Eurocord, the Cord Blood Committee Cellular Therapy and Immunobiology Working Party and the Acute Leukemia Working Party of the EBMT

Umbilical cord blood transplantation (UCBT) from unrelated donor is a valid alternative for patients (pts) with acute leukemia (AL) who lack an HLA matched donor. Double UCBT (dUCBT) has extended the use of UCBT to adults. In the majority of the cases, chimerism analysis shows that one unit emerges as the sole source of long term hematopoiesis in the recipient (rcp) following dUCBT. However, no clear factor has yet been identified to reliably predict which unit will emerge as the predominant one.With the aim of analyzing factors that may predict cord blood unit (CBU) predominance and the impact of the winning CBU characteristics on outcomes after dUCBT, we studied adults with AL who underwent dUCBT as first transplant between 2004 and 2013 at EBMT centres. We selected pts who achieved engraftment and who had available chimerism data assessed within day 130 after dUCBT, with one of the CBUs representing at least 50% of the rcp hematopoiesis (winCBU). According to these criteria, 347 pts were included: 323 had full donor (18 being dual chimera) and 24 had mixed chimerism (>5% of donor cells). At diagnosis, 35% had ALL and 65% AML. At dUCBT 45% were in first complete remission (CR), 44% in second CR and 11% had more advanced disease. Overall, 33% had high risk cytogenetic features. Median time from diagnosis to dUCBT was 12 months (range, 2-202), median age was 40 years (y) (18-76). Conditioning regimen (CT) was reduced intensity (RIC) in 52%. Cyclophosphamide+fludarabine+total body irradiation was the most frequent CT (63%). Anti-thymoglobulin (ATG) was administrated in 25% of the transplants. Median number of total nucleated cells (TNC) and CD34+ cells at cryopreservation were 5.1x107/Kg (range, 2.3-13.7) and 1.3x105/Kg (range, 0.4-10.7), respectively. Considering the unit with the highest number of HLA mismatches (MMs) with the rcp, 73% of the donors were matched at 4 or less loci (≤4/6). For winCBUs, median number of TNC and CD34 cells at cryopreservation were 2.5x107/Kg (range, 0.95-6) and 1x105/Kg (range, 0.06-10), respectively. Only 4% of the winCBUs were 6/6 HLA-matched to the rcp, while 37% were 5/6, 55% were 4/6 and 4% were 3/6 HLA-matched. Overall, 54% of the winCBUs were gender matched and 38% were ABO compatible with the rcp. WinCBUs median age was 3.4 years (range, 0.2-14). As for inter unit characteristics, 50% of the pts received gender matched units. Units were ABO compatible in 40% of the cases, while 30% had minor and 30% had major ABO incompatibility.In our study population, median follow-up for survivors was 35 months (range, 3-99). All pts engrafted with neutrophil >0.5x109/L in a median time of 25 days (range, 6-66) post DCBT. No secondary graft failure was reported. The cumulative incidence (CI) of acute GvHD grade II-IV at 100 days was 41% with a median time of onset of 29 days (range, 7-106). The 3y-CI of chronic GvHD was 41% (50% of the pts had extensive). The 3y-CI of relapse (RI) and transplant related mortality (TRM) were 27% and 24%, respectively. At 3y, leukemia free survival (LFS) was 49% and overall survival (OS) was 54%.In multivariate analysis (MVA) including unit characteristics (HLA and gender matching, type of HLA MMs, number of TNC and CD34 cells at cryopreservation, ABO compatibility and unit age) and inter unit features (gender match, ABO compatibility), no significant factor predicting the winCBU was identified.Analyzing the impact of winCBU on dUCBT outcomes, the HLA matching between CBU and the rcp was the only characteristic related to the winCBU significantly affecting results. The 3y-LFS for pts with 6/6 or 5/6 HLA-matched winCBUs was 56% as compared to 44% for those with 4/6 (p=0.03), while OS was 62% versus 49% (p=0.01), respectively. Acute GvHD was increased in pts receiving a 4/6 HLA-matched winCBU (46% versus 35% for those 6/6 or 5/6, p=0.04). In MVA, 4/6 HLA-matched winCBU was associated with decreased LFS (HR 1.5, p=0.03) and OS (HR 1.5, p=0.03), and with increased TRM (HR 1.9, p=0.03) and acute GvHD (HR 1.7, p=0.01). Notably, older winCBUs (>3.4y) were associated with higher acute GvHD (48% versus 35%; HR 1.6, p=0.02). Other factors associated with poor outcomes were advanced disease status and the use of ATG.Although we failed to identified any factor predicting CBU predominance, we were able to demonstrate that a 4/6 HLA matched winCBU is associated with poor outcomes. Therefore, selecting units with lower number of HLA MMs for dUCBT may improve final outcomes. DisclosuresRussell:Therakos: Other: shares. Mohty:Riemser: Honoraria, Research Funding. Nagler:Biokine LTD: Consultancy.

Risk factors and outcomes of cytomegalovirus viremia in pediatric hematopoietic stem cell transplantation patients.

Cytomegalovirus (CMV) is a major pathogen causing significant mortality and morbidity in immunocompromised hosts. It is important to find risk factors associated with CMV viremia and its outcome. We investigated the incidence, time of onset, risk factors for CMV viremia, and characteristics of CMV diseases in 57 pediatric patients receiving hematopoietic stem cell transplantation (HSCT). Between August 2011 and March 2014, cases of pediatric HSCT patients at the National Taiwan University Children's Hospital were reviewed. Viremia was identified by plasma CMV real-time polymerase chain reaction (RT-PCR) assay. Eighteen (32%) of the 57 patients developed CMV viremia at a median of 23 days post-HSCT (range -3 to +721 days). Eighty-nine percent (16/18) of CMV viremia occurred within 100 days posttransplantation. Four patients finally had CMV diseases (1 with CMV colitis and 3 with CMV pneumonitis) and one patient died of CMV pneumonitis complicated with pulmonary hemorrhage and sepsis. Significant risk factors associated with CMV viremia via univariate analysis include older age (p=0.03), leukemic patients [odds ratio (OR): 5.2, 95% confidence interval (CI): 1.52∼17.7, p=0.008), allogeneic HSCT (OR: 14.57, 95% CI: 1.76∼120.5, p=0.002), antithymoglobulin (ATG) use before transplantation (OR: 5.09, 95% CI: 1.52∼16.9, p=0.007), graft-versus-host disease (GvHD) (OR: 10.1, 95% CI: 2.7∼38.7, p<0.001), and gastrointestinal GvHD (OR: 10.9, 95% CI: 2.72∼43.9, p=0.001). In pediatric posttransplantation patients, CMV viremia mostly occurred within 100 days after transplantation. Risk factors associated with CMV viremia include older diagnostic age, leukemic patients, unrelated donor HSCT, pretransplant ATG use, GvHD, and gastrointestinal GvHD.

P115 : PRIMARY GRAFT DYSFUNCTION AFTER 0 MM KIDNEY TRANSPLANTATION SECONDARY TO ACUTE CELL MEDIATED REJECTION

Aim To present a highly sensitized patient with end stage renal disease who received his third kidney transplant from HLA-A, -B, -DR zero mismatched (0 MM) deceased donor (DD) and developed early acute cellular rejection (ACR – BANFF 2A) in absence of DSA. Methods Donor and recipient were HLA typed by RSSOP Luminex assay for HLA loci A, B and C, DRB1, DRB3/4/5, DQB1, DQA1, DPB1, and DPA1. HLA antibody identification were performed with One Lambda Luminex single antigen bead assay. Sera were tested untreated, treated with heat inactivation (HI) and 1:8 dilutions. CDC (with and without HI) and flow XM for T and B cells were tested at the day of transplant. Results A 40 years old man, highly sensitized (CPRA 100%) with a history of two previous renal transplants (lost due to non-immunological cause) with multiple class II DP antibodies with high MFI. The patient received a local zero mismatched donor was offered and with confirmatory testing an antigen level match for all HLA including DP. CDC and flow XM for T and B cells were negative. No DSA was detected pre or post-transplant. In post-operative day 1, the patient presented with anuria and hyperkalemia that mandated dialysis, and underwent dialysis throughout the rest of hospitalization as needed. Due to delayed graft function, he had a biopsy on post-operative day 8 that showed ACR – BANFF 2A – with negative C4d, peritubular capillaritis, and DSA. Treatment with anti-thymo globulin (ATG) did not show improvement. Consequently the patient received 3 sessions of plasmapheresis plus IvIG but the patient remained dialysis dependent. In post-operative day 50, biopsy showed chronic active T cell mediated rejection with no DSA. The graft remained non-functioning and graft nephrectomy was performed. This case suggests that highly sensitized kidney transplant candidates are at increased risk of cell mediated rejection and graft loss even in the context of 0 MM, negative DSA and flow crossmatch.

Outcomes After Unrelated Cord Blood Transplantation For Adults With Primary Or Secondary Myelofibrosis: A Retrospective Study On Behalf Of Eurocord and Chronic Malignancy Working Party-EBMT

BackgroundAllogeneic hematopoietic stem cell transplantation (HSCT) is currently the only curative option for patients (pts) with myelofibrosis (MF). Patients with MF transformed to Acute Myeloid Leukemia (AML) have a very short life expectancy without transplantation (< 4 months). Umbilical cord blood transplantation (UCBT) from unrelated donor is a valid alternative to conventional allogeneic HSCT for pts with hematologic malignancies who do not have an HLA matched donor. Delayed engraftment and graft failure are the limitations of this procedure and represent a major issue for MF. Patients and MethodsWe analyzed 42 adults (28 males and 14 females) who underwent a single (n=15) or double (n=27) HLA mismatched UCBT between 2005 and 2012 in 26 EBMT centers reported to Eurocord. At diagnosis, 21 had primary MF (PMF), 5 polycythemia vera (PV), and 16 essential thrombocytemia (ET). Twelve patients transformed to acute myeloid leukemia (AML) before UCBT. Among pts with pre-transplant information available, 13/25 had severe marrow fibrosis; 8/16 had a high Lille score at diagnosis and 13/27 had JAK2 V617F mutation; 13/35 underwent splenectomy and 16/30 had an abnormal karyotype. The median time from diagnosis to transplant was 80 months (range 5-316), while in the subgroup of pts with transformation to AML, it was 119 months (range 5-246). Five pts had a prior transplant (1 autologous, 3 allogeneic and 1 had 2 consecutive allogeneic transplants). The median age at UCBT was 54 years (range 28-69). Conditioning regimens were reduced intensity (RIC) (n= 29) or myeloablative (MAC) (n=13). The most common conditioning in both MAC (n=5) and RIC (n=16) was Cyclophosphamide and Fludarabine associated with total body irradiation (TBI). Overall, 27 pts received TBI with a dose of 12-14 Gy in MAC (n=6) and 2-4 Gy in RIC (n=21); 20 pts received anti-thymoglobulin (ATG) in the conditioning regimen. The median infused total nucleated and CD34+ cells were 3,4x107/Kg (range 0,3-6,8) and 1,3x105/Kg (range 0,04-3,8),respectively. ResultsMedian follow-up for survivors was 25 months (range 6 -72). The cumulative incidence (CI) of neutrophil engraftment was 64% (28 pts) with a median time of 29 days, and among the 12 pts transformed to AML, 10 engrafted in a median time of 30 days, while 18 of 30 pts without transformation engrafted in a median time of 28 days. Of the 14 pts who did not reach neutrophil engraftment, 7 had no hematological recovery, 6 of them died after a median of 3 months and 1 pt is alive at 14 months post UCBT. The remaining 7 pts had an autologous reconstitution, and 4 of them are alive with progressive disease at a median time of 42 months. Pts who received RIC conditioning had better engraftment (79% versus 36%, p=0.02).Twelve pts developed acute GvHD of grades II-IV; 7 pts had limited chronic GvHD with a median time of onset of 144 days.Overall, 17 pts relapsed (6 had transformed into AML before transplantation) at a median time of 5 months. The CI of relapse at 2 years was 29%±2%. The CI of transplant-related mortality at 1 year was 33%±2%. Causes of death were relapse (n=9), post-transplant lymphoproliferative disease (n=3), GvHD (n=3), multiorgan failure (n=1), bacterial infection (n=3), acute respiratory distress syndrome (n=2), infection of unknown origin (n=3), cardiac toxicity (n=1) and fungal infection (n=1). OS at 2 years was 44±8%: 80%, 21% and 52% for pts transplanted respectively for MF secondary to PV, ET and PMF (p=0.07). No difference in OS was seen in the subgroup of pts with JAK2 mutation. OS was 51% versus 29% for pts receiving double or single UCBT (p=0.15), and it was 37% for AML-transformed pts. Pts who did not receive ATG, had an OS of 59% versus 24% for those who received ATG (p=0.01). Among pts who underwent RIC (n=29), 13 had a TBI based conditioning without ATG, and 7 are alive. Failure-engraftment free survival at 2 years was 29±7%, better in pts receiving double UCBT as compared with single (40% versus 8% , p=0,01), and in pts receiving TBI (43% versus 7%, p=0,03). ConclusionGraft failure was a major concern for these pts. Despite a limited number of patients, our results indicate that life expectancy can be increased with UCBT particularly for patients with advanced stage MF. Furthermore, the use of RIC TBI based regimen without ATG and double CB might improve outcomes. Disclosures:Gluckman:Cord use: Honoraria; gamida: Honoraria.

Influence of Stem Cell Source On GvH and NRM: Comparison of 10/10 HLA-Matched Unrelated Donor (MUD) with 9/10 HLA-Mismatched Unrelated Donor (MMUD) and Unrelated Cord Blood (UCB) Transplants.

AbstractAbstract 3135▪▪This icon denotes a clinically relevant abstract Background:When an HLA-matched donor is not available for allogeneic Hematopoietic Stem Cell Transplantation (HSCT), the use of an alternative HLA-mismatched stem cell source may be considered. In Europe, HLA compatibility for HSCT is calculated for 10 alleles (HLA-A, -B, -C, -DRB1, -DQB1). The aim of this study was to retrospectively compare outcomes after transplantation from 10/10 HLA-MUD, 9/10 HLA-MMUD and UCB performed at the Hospital Saint Louis (Paris, Fr). Methods:Patients receiving a first allogeneic transplantation from a 10/10, 9/10 UD or UCB from 2000 to 2011 were included.High resolution HLA typing was performed by PCR SSO and SSP for HLA loci: A, B, C, DRB1 and DQB1. The following variables were studied as risk factors for transplant outcomes: disease, disease risk (standard/high risk), age at transplant, gender, donor/recipient sex-matching, ABO matching, donor/recipient CMV status, conditioning regimen, and use of anti-thymoglobulin (ATG). Results:355 consecutive patients with hematologic malignancies were analyzed. One hundred and ninety-six were transplanted with MUD, 84 with MMUD (mismatches for HLA-A: 16%, -B: 16%, -C: 39%, -DRB1: 8%, -DQB1: 21%) and 75 with UCB (52% with single and 48% with two UCB unit; 87% of all UCB transplants were 4–6/6 HLA-matched). Median patient age was 31 (range: 5–55). Patient characteristics differed between the 3 groups: (i) median age at transplant: 36 in MUD, 31 in MMUD, 22 in UCB (p<0.0001), (ii) high risk disease: 37%, 51%, 68% (p<0.0001), (iii) CMV negative donor/positive recipient: 31%, 36%, 60% (p<0.0001), (iv) use of ATG: 37%, 64%, 55% (p<0.0001).Cumulative incidences of grade II-IV and grade III-IV acute GvHD disease (aGvHD) were 61% (66% for MUD, 60% for MMUD and 48% for UCB) and 17% (17%, 24% and 15%), respectively. Three-year cumulative incidence of chronic GvHD (cGvHD) was 46% (51% for MUD, 49% for MMUD and 29% for UCB). Three-year NRM was 34% (28% for MUD, 31% for MMUD and 51% for UCB). Graft failure occurred in 15% of UCB patient, 8% in MMUD group and 3% in MUD group (significant difference between UCB and MUD: OR=5.44, 95%CI 1.93–15.3, p=0.001).Multivariate analysis is summarized in table 1. It showed that MMUD tented to have a higher incidence of aGvHD III-IV than MUD and UCB. UCB had a lower incidence of cGvHD than MMUD. No significant effect of HSCT source on NRM was demonstrated. Conclusion:Compared to MMUD, UCB-HSCT induces less cGvHD and non significantly increased NRM. Compared to MUD, MMUD and UCB-HSCT did not result in a clear increase of NRM. UCB and 9/10 HLA-MMUD are both suitable stem cell sources for patients who cannot benefit from 10/10 HLA-MUD transplant.Table 1:Multivariate analysis of outcomesAdjusted HR (p value)aGvHD II-IVaGvHD III-IVcGvHDNRM10/10 MUD11119/10 MMUD0.90 (p=0.54)1.75 (p=0.054)1.30 (p=0.18)1.18 (p=0.50)UCB0.63 (p=0.074)*0.86 (p=0.67)*0.75 (p=0.23)*1.82 (p=0.099)*CMV status D-/R-1D-/R+2.05 (p=0.001)Major ABO incompatibility: no1yes1.40 (p=0.019)ATG: no111yes0.40 (p<0.0001)0.29 (p<0.0001)0.40 (p<0.0001)*UCB vs 9/10 MMUD: HR 0.69 (p=0.22) for aGvHD II-IV, HR 0.49 (p=0.061) for aGvHD III-IV, HR 0.58 (p=0.039) for cGvHD and HR 1.53 (p=0.30) for NRM. Disclosures:No relevant conflicts of interest to declare.

Prevalence and Clinical Impact of Cytomegalovirus Infection and Disease in Renal Transplantation: Ten Years of Experience in a Single Center

IntroductionRenal transplantation is regarded as the optimal treatment for patients with end-stage renal disease. Despite significant improvements in surgical techniques and immunosuppressive therapy, long-term graft survival has not markedly increased over the years, due in part to the occurrence of cytomegalovirus (CMV) infection. Patients and MethodsBetween January 2001 and September 2011, we performed 592 kidney transplantations (214 living and 378 cadaveric donors). All patients received induction therapy with interleukin (IL)-2 monoclonal antibodies or antithymoglobulin (ATG) combined with calcineurin inhibitors, mycophenolate mofetil, or mTOR antagonists and steroids. All CMV-seronegative patients and all subjects receiving ATG induction were prescribed prophylactic therapy with ganciclovir—intravenous (IV) for 15 days 2.5 mg/kg BW bid and thereafter oral valgancyclovir once a day. CMV infection was diagnosed using a CMV-PVR of ≥600 copies. We analyzed the time to manifestations of CMV infection, or positive CMV-PCR, patient and graft survival, serum creatinine (Cr), and blood urea nitrogen (BUN) values before and after CMV infection, as well as type of immunosuppression therapy. ResultsThe overall incidences of CMV infection and CMV disease were 76/592 (12.8%) and 23/592 (3.9%), respectively. The mean ± standard deviation (SD) times to positive CMV-PCR and CMV disease were 16.66 ± 23.38 months and 106 ± 61.2 (range, 28–215) days, respectively. Mortality was 1% (6/592) among our whole population, 7.9% (6/76) for CMV-infected, and 26% (6/23) in the CMV disease cohort. Cr and BUN showed no significant differences among the groups. ConclusionsCMV infection and CMV disease comprise significant clinical problems, increasing morbidity and mortality. The use of prophylactic anti-CMV treatment is of paramount importance.

Acute GVHD is a strong predictor of full donor CD3+ T cell chimerism after reduced intensity conditioning allogeneic stem cell transplantation

The monitoring of chimerism is a standard procedure to assess engraftment and achievement of full donor lymphoid cells after reduced intensity conditioning (RIC) stem cell transplantation (Allo-SCT). However, there is no consensus on when and how often to monitor post-transplant chimerism. We retrospectively analyzed our experience regarding the impact of acute graft versus host disease (GVHD) for the prediction of allograft chimerism. One-hundred-and-fifteen patients transplanted between 2001 and 2010 were identified. This group included 57 females and 58 males with a median age of 50 years (range: 26-68). Patients evaluated in this study were adult patients with hematologic malignancies, who received transplants from an HLA-matched sibling donor or matched unrelated donor (MUD) at allele level so-called 10/10, and received the RIC regimen including fludarabine/busulfan and anti-thymoglobulin (ATG). Mixed T-cell chimerism was defined as between 5 and 94% recipient cells, and full chimerism was defined as the presence of more than 95% donor T-cell chimerism (TCC). Full donor TCC was achieved in 93 patients (81%) at a median of 77 days (range: 30-120) post-transplant. The cumulative incidence of Grade 2-4 GVHD in our population was 25% (95% CI 17-34). The analysis of the population of patients with acute GVHD grade ≥2 showed that at day 120 after Allo-SCT they all had a total full donor TCC. On the other hand, 78 (68%) patients without acute GVHD grade ≥2 presented with mixed chimerism (p = 0.002) on day 120 post-transplant. Interestingly, patients who received ATG 5 mg/kg obtained a higher probability of complete chimerism compared with those receiving 2.5 mg/kg (p = 0.03). In conclusion, our study demonstrates that acute GVHD was predictive of full donor TCC after RIC Allo-SCT. Therefore, our data may challenge the concept of the frequent or close monitoring of donor chimerism in some patients with ongoing acute GVHD. However, chimerism testing could represent an attractive modality for minimal residual disease detection or for impeding relapse warranting further prospective studies.

Unrelated Cord Blood Transplantation in India: Breaking the Cost Barrier

Abstract 4768 Background –India, with more than a billion population, has a huge burden of blood and cancer disorders many of which can be cured only by hematopoietic stem cell transplantation (HSCT). More than 1500 transplants have been done till 2005 over a 20 year period in about 10 centers out of which 880 have been allogeneic HSCT and all have been from matched related donors (MRD).Unrelated HSCT is the only option for the patients without a MRD. It is almost impossible to find an unrelated matched donor in India due to ethnic diversity and lack of unrelated donor registries. Some public cord blood banks have been set up in India. So finding a suitable cord blood unit within India is possible. Unrelated Cord Blood Transplant (UCBT) is the only feasible option for patients who need to undergo unrelated HSCT in India but lack of experience and huge costs are perceived barriers. Data from USA showed mean cost of graft for pediatric UCBT was $58,910 and mean cost per day survived in first 100 days (excluding graft cost) was $4522 ((Majhail NS et al. Pediatr Blood Cancer 2010;54:138–143). The costs of UCBT among children in India have not been described previously. Method -We calculated the costs of UCBT within the first 100-days among four children who received UCBT at Sir Ganga Ram hospital from April 2008 to Dec 2010. We also analyzed costs of transplantation in relation to patient age, weight, single vs. double cord, conditioning, Graft vs. Host Disease (GVHD) and mean duration of stay before day 100. Results -The 100-day probability of overall survival was 100%. The mean cost per day survived (excluding costs of graft acquisition) was $402 (range $360-460)) for UCBT recipients. Average total cost of each UCBT was $43500 (Range $32000-52000). Average duration of stay in hospital in first 100 days was 89 days (range 75–100). All grafts were procured from a public cord bank in India. Average cost of graft per cord unit was $5000. Diagnosis was thalassemia major-2, Familial Hemophagocytic Lympho Histiocytosis (HLH)-1 and AML-1. Lowest cost was for AML ($32000) and highest was for Pesaro class III thalassemia major ($52000). Mean age was 2.75 years (range 1–5 year). Mean weight was 12.25 kg (range 10–16 kg). Mean cell dose infused was 7 × 107 nucleated cells/kg weight of recipient (range 3–10 × 107nucleated cells/kg). Conditioning was Busulfan and Cyclophosphamide (BuCY) and Rabbit Anti-Thymoglobulin (ATG) for two patients (1 Thalassemia, 1 AML) costing $1500 per patient, Fludarabine & Melphalan and Campath for HLH costing $2500 and Treosulfan, Thiotepa, Fludarabine and ATG for class III thalassemia costing $7500. Mean cost per day for single cord was $385 and for double cord UCBT was $420. One patient rejected the graft. Three engrafted at median of 32 days (range 28 –39 days). GVHD was seen in two patients (both with double cord). CMV reactivation was seen in all cases. Invasive aspergillosis was seen in one patient who had thalassemia and it lead to highest expenditure. Campath based conditioning was associated with maximum hospital stay in child with HLH. All had Lansky score >90 pre-transplant No one needed dialysis, mechanical ventilation or hepatic veno-occlusive disease. Conclusions -Total cost of UCBT in India is less than the cost of the UCBT graft in USA and mean cost per day in India is almost one tenth of cost per day in USA. Low cost of UCBT in India would make this treatment feasible for many more patients who need to undergo unrelated HSCT. Disclosures:No relevant conflicts of interest to declare.

Use of Rituximab As a Pre-Emptive Therapy for Epstein-Barr Virus (EBV)-Associated Lymphoproliferative Disorders in 86 Adult Patients Having Allogeneic Stem Cell Transplantation

Abstract 1995 Background:Allogeneic stem cell transplantation may induce Epstein Barr Virus (EBV) reactivation. Some risk factors were identified. Despite the lack of guideline for treatment in such a situation, rituximab is commonly used. Objective: To assess the efficiency and tolerance of rituximab, we have conducted a retrospective study between 2005 and 2009 in the unit of transplantation. All the patients having allogenic transplantation with a viral load >500 copy/ml and receiving rituximab (375mg/m2/week) until negative viral load were included in this study. Earlier EBV reactivation was defined by occuring within 1 year after allogeneic transplantation. Results:86 patients had EBV-reactivation treated by rituximab. Median age was 49.5 years (39–58). Eighteen (21%) patients had a chronic B-cell malignancy. Thirty (35%) patients received myeloablative regimen, 56 (65%) had reduced intensity conditioning regimen. Graft were peripheral blood stem cells for 66 (77%) patients, bone marrow for 10 (11.5%) and cord blood for 10 (11.5%) patients. Forty-seven (68%) EBV-reactivations occurred with unrelated donor transplantation (MUD), and 30 (33.4%) concerned mismatched allografts. Twenty (23%) patients received anti-thymoglobulin (ATG), 38 (44%) received Fludarabine and 10 (12%) both. 30 (35%) patients reactivated another herpes virus in the same time. Seventy (82%) patients were in complete response or in very good partial response at the time of the reactivation.Most of the reactivations occurred before 1 year (90%, n=77) with a median day at D165 (5–1531). In 76 (88%) cases, couple recipient-donor had a positive EBV serology before allogenic transplantation and in 7 cases (8%), only the recipient was positive.The rate of complete response after rituximab was 82.5% (n=66). Relapse rate after the end of treatment was 45%. Two patients developed a post-transplant lymphoma disorder despite preemptive treatment. Use of ATG (OR 14.3 (4–51), EBV negative recipient serology (OR=7.5 (1.7-33.5), acute haematological malignancy or myelodysplastic syndrome versus chronic B-cell malignancies (OR 7 (2.1–22), and previous autologous transplantation (OR 14.7 (4.7-46.4) were poor prognosis factor for response to rituximab. The type of the disease, the type of the donor, the conditioning regimen, the type of match and chimerism, the use of ATG did not influence the time to response. Rituximab decreased the rate and the severity of acute Graft versus Host Disease (GvHD) (p<0.01). Rituximab did not modify CD4 and CD8 lymphocyte counts. NK cell number increased, starting at 6 months after the end of treatment, and B-lymphocytes from 6 months. Median overall survival (OS) was not reached at 2 years. There is a trend for a better survival in later EBV-reactivation than the earlier (p=0.08) one. In MUD allograft, EBV reactivation occurred statistically later than with sibling donor allograft (p=0.013). Conclusion:Rituximab is an efficient and safe pre-emptive therapy for EBV reactivation. Furthermore, the use of rituximab for EBV reactivation may support a positive effect for acute GvHD. Disclosures:No relevant conflicts of interest to declare.

Anti-thymoglobulin (ATG) treatment does not reverse type 1 diabetes in the acute virally induced rat insulin promoter-lymphocytic choriomeningitis virus (RIP-LCMV) model

Immune modulators such as anti-thymoglobulin (ATG) are under clinical evaluation for the treatment of type 1 diabetes (T1D). Although such agents have cured T1D in the non-obese diabetic (NOD) model, their clinical efficacy has been much lower. In order to improve the odds of successful translation from bench to bedside, we propose to evaluate this agent under more stringent conditions. Here, we evaluated the capacity of ATG to reverse T1D in the acute rat insulin promoter-lymphocytic choriomeningitis virus (RIP-LCMV) model. RIP-LCMV-glycoprotein (GP) mice were treated after new-onset T1D with murine ATG antibodies. Although ATG treatment did not impair viral clearance it failed to reverse new-onset T1D in this model. The CD4:CD8 ratio was reduced drastically upon LCMV infection due to an expansion of CD8 effectors but ameliorated in ATG-treated mice. Although the percentage of CD4(+) CD25(+) regulatory T cells (T(regs) ) within the CD4(+) population was increased significantly after ATG therapy, their frequency in the periphery was reduced dramatically and never returned to normal baseline. The inability of ATG treatment to cure T1D in a stringent viral model (RIP-LCMV mice) is due at least partially to the inability to maintain or increase a sufficient CD4(+) CD25(+) T(regs) frequency, in striking contrast with what was reported in the NOD model. Our data would argue for the use of multiple animal models to assess efficacy of promising immune-based interventions and select the most potent therapies for future clinical trials.

Impact of genetic abnormalities after allogeneic stem cell transplantation in multiple myeloma: report of the Société Française de Greffe de Moelle et de Thérapie Cellulaire

Abstract Abstract 1187 Poster Board I-209 Background and aim: Del (13q), t (4;14) and del (17p) are well-recognized poor prognostic genetic abnormalities in multiple myeloma after standard chemotherapy and autologous stem cell transplantation (SCT). We investigated the prognostic impact of these genetic abnormalities, detected by fluorescence in situ hybridization (FISH), on the outcome in patients who underwent allogeneic SCT. Patients and methods: This is a retrospective study performed in 20 centres for a total of 175 patients, using the database register of the SFGM-TC and the cytogenetic files of the IFM and MAG groups. The median age of the population at diagnosis was 51 years (range, 28-62 years). FISH analysis was performed either at diagnosis or at relapse before allograft. Chromosomal abnormalities were found in 127 of 175 patients (73%), distributed as follows (in percent of patients evaluable for each abnormality): 59% for del (13q), 26% for t (4;14), 25% for del (17p), 24% for t (11;14) and 4% for t (14;16). Beta2microglobuline was superior to 4 mg/L in 51% and more than 92% had received at least one prior high-dose therapy followed by autologous SCT. Forty percent of patients were transplanted in the first course of the disease. Most patients (79%) received two or less lines of treatments before transplantation. Prior treatments included thalidomide and bortezomib in, respectively, 25% and 27% of cases. At transplant, 12% of patients were in complete response (CR), 6% in very good partial response (VGPR), 66% in partial response (PR), 8% in stable disease (SD) and 8% in progressive disease (PD). The median time from diagnosis to transplant was 15 months (range, 4-175 months). Seventy seven percent of patients received reduced conditioning regimen, including antithymoglobulin (ATG) in 52% of cases. Peripheral blood and bone marrow were used as the source of cells in 78% and 19%, respectively. Most donors (69%) were match related donors. Results: Best response to transplant was CR, VGPR, PR, SD and PD in, respectively, 38%, 12%, 33%, 7% and 10% (among 130 patients with available data). With a median follow-up of 36 months, the 3-year progression free survival (PFS) and overall survival (OS) were 34% and 52%, respectively. Three-year post-transplant progression occurred in 53%. One-year transplant-related mortality (TRM) was 21%. Grade II to IV acute graft-versus-host disease (GvHD) was present in 33%. Limited and extensive chronic GvHD occurred respectively in 16% and 23% of evaluable patients. In univariate analysis, del (13q), t (4;14) and del (17p) had no impact on the PFS, OS and progression. Three-year PFS and OS were, respectively, 39% and 53% for del (13q), 29% and 38% for del (17p), 26% and 38% for t (4;14), 25% and 43% for t (11;14), 31% and 45% for the group of patients without any of these cytogenetic abnormalities. Patients transplanted in the first course of the disease with t (4;14) (n=14) and with del (17p) (n=6) had a 3-year PFS of 36% and 44%, respectively. In multivariate analysis, better PFS was significantly associated with younger age (P= 0.02, HR=1.1), sensitive disease status at transplant (P=0.04, HR=0.55) and two or less prior lines of treatments (P Conclusion: These data suggest no impact of genetic abnormalities after allogeneic SCT for multiple myeloma and did not confirm the encouraging results of allogeneic SCT for t (4;14) myeloma (Schilling et al., Leukemia, 2008). More studies are warranted to better define the possible role of early allograft in poor prognostic myeloma and to further develop risk-adapted strategy based on cytogenetics. Disclosures: No relevant conflicts of interest to declare.

Impact of Genetic Abnormalities After Allogeneic Stem Cell Transplantation in Multiple Myeloma: Report of the Societe Francaise De Greffe De Moelle Et De Therapie Cellulaire.

Abstract 1187Poster Board I-209 Background and aim:Del (13q), t (4;14) and del (17p) are well-recognized poor prognostic genetic abnormalities in multiple myeloma after standard chemotherapy and autologous stem cell transplantation (SCT). We investigated the prognostic impact of these genetic abnormalities, detected by fluorescence in situ hybridization (FISH), on the outcome in patients who underwent allogeneic SCT. Patients and methods:This is a retrospective study performed in 20 centres for a total of 175 patients, using the database register of the SFGM-TC and the cytogenetic files of the IFM and MAG groups. The median age of the population at diagnosis was 51 years (range, 28-62 years). FISH analysis was performed either at diagnosis or at relapse before allograft. Chromosomal abnormalities were found in 127 of 175 patients (73%), distributed as follows (in percent of patients evaluable for each abnormality): 59% for del (13q), 26% for t (4;14), 25% for del (17p), 24% for t (11;14) and 4% for t (14;16). Béta2microglobuline was superior to 4 mg/L in 51% and more than 92% had received at least one prior high-dose therapy followed by autologous SCT. Forty percent of patients were transplanted in the first course of the disease. Most patients (79%) received two or less lines of treatments before transplantation. Prior treatments included thalidomide and bortezomib in, respectively, 25% and 27% of cases. At transplant, 12% of patients were in complete response (CR), 6% in very good partial response (VGPR), 66% in partial response (PR), 8% in stable disease (SD) and 8% in progressive disease (PD). The median time from diagnosis to transplant was 15 months (range, 4-175 months). Seventy seven percent of patients received reduced conditioning regimen, including antithymoglobulin (ATG) in 52% of cases. Peripheral blood and bone marrow were used as the source of cells in 78% and 19%, respectively. Most donors (69%) were match related donors. Results:Best response to transplant was CR, VGPR, PR, SD and PD in, respectively, 38%, 12%, 33%, 7% and 10% (among 130 patients with available data). With a median follow-up of 36 months, the 3-year progression free survival (PFS) and overall survival (OS) were 34% and 52%, respectively. Three-year post-transplant progression occurred in 53%. One-year transplant-related mortality (TRM) was 21%. Grade II to IV acute graft-versus-host disease (GvHD) was present in 33%. Limited and extensive chronic GvHD occurred respectively in 16% and 23% of evaluable patients. In univariate analysis, del (13q), t (4;14) and del (17p) had no impact on the PFS, OS and progression. Three-year PFS and OS were, respectively, 39% and 53% for del (13q), 29% and 38% for del (17p), 26% and 38% for t (4;14), 25% and 43% for t (11;14), 31% and 45% for the group of patients without any of these cytogenetic abnormalities. Patients transplanted in the first course of the disease with t (4;14) (n=14) and with del (17p) (n=6) had a 3-year PFS of 36% and 44%, respectively. In multivariate analysis, better PFS was significantly associated with younger age (P= 0.02, HR=1.1), sensitive disease status at transplant (P=0.04, HR=0.55) and two or less prior lines of treatments (P<0.001, HR=0.3); better OS was associated with younger age and two or less prior lines of treatments (respectively, P=0.01, HR=1.1; and P=0.02, HR=0.5). Conclusion:These data suggest no impact of genetic abnormalities after allogeneic SCT for multiple myeloma and did not confirm the encouraging results of allogeneic SCT for t (4;14) myeloma (Schilling et al., Leukemia, 2008). More studies are warranted to better define the possible role of early allograft in poor prognostic myeloma and to further develop risk-adapted strategy based on cytogenetics. Disclosures:No relevant conflicts of interest to declare.

High pretransplant serum levels of CXCL9 are associated with increased risk of acute rejection and graft failure in kidney graft recipients

Several clinical and experimental models have underlined the role of the CXCR3-binding chemokines in the immune-mediated kidney diseases. This study aimed to investigate the predictive value of measuring pretransplant CXCL9 levels for acute rejection (AR) onset and kidney transplantation outcome. Pretransplantation serum levels of CXCL9 were tested retrospectively in 252 kidney graft recipients, whose stratification in two groups according to CXCL9 levels (<272.1 pg/ml vs. >272.1 pg/ml) showed highly significant differences in 5-year survival rates (97.7% vs. 73.3%; P < 0.001). Multivariate analysis demonstrated that among the analysed variables, CXCL9 [relative risk (RR) 11.708] and AR (RR 3.604) had the highest predictive power of graft loss. Accordingly, patients with AR (254.4 + or - 22.1; P < 0.05) and, even more, those with anti-thymoglobulin (ATG)-treated AR also showed increased pretransplant serum CXCL9 levels (319.3 + or - 28.1, P < 0.001). Moreover, CXCL9 expression and distribution were investigated in tissue specimens obtained from 10 patients affected by AR, and wide CXCL9 expression was detected not only in infiltrating inflammatory cells but also in vascular and tubular structures. Measurement of pretransplant serum CXCL9 levels might represent the tracking of a clinically useful parameter to identify subjects at high risk of AR and graft failure. These findings might be used for the individualization of immunosuppressive therapies.

Is the early cyclosporine A level predictive of the outcome of immunosuppressive therapy in severe aplastic anemia?

Immunosuppressive therapy (IST) has provided an alternative treatment option for cure of aplastic anemia patients who cannot receive bone marrow transplantation. Although there have been many recent studies on the efficacy of antithymoglobulin (ATG) combined with cyclosporine A (CsA), there is no data on the correlation between the variability of CsA levels and the response to IST. Therefore, we retrospectively assessed the factors associated with IST efficacy in patients with acquired severe aplastic anemia (SAA). Sixty-six patients were treated with ATG combined with CsA for 6 months. In the response group, the CsA levels were increased rapidly to more than 200 ng/mL within the first 2 wk after starting the IST. However, the non-response group had a pattern of slower increase of the CsA levels. The CsA levels, during the first and second week of treatment with IST, were significantly different in the responders and non-responders. The factors predictive of response to IST and survival were analyzed. The univariate analysis showed that a younger age at the initiation of IST, a high absolute neutrophil count prior to starting IST, a short interval between the diagnosis and initiation of IST, and high CsA levels during the first and second week of IST treatment were positively associated with the response rate and overall survival. The multivariate analysis showed that these four factors were independent factors associated with a longer patient survival. A high response rate was associated with a short interval between diagnosis and initiation of IST as well as high CsA levels during the first and second week of IST. Therefore, early intensification of CsA levels might improve patient outcome.

Is the Early Cyclosporine a Level Predictive to the Outcome of Immunosuppressive Therapy in Severe Aplastic Anemia?

Although there are many recent studies of efficacy of antithymoglobulin (ATG) combined with cyclosporine A (CsA), there has been no study to clarify the correlation between variability of CsA level and the response rate of immunosuppressive therapy (IST). Therefore, we assessed whether the early CsA level would be important or not for IST in acquired severe aplastic anemia (SAA), retrospectively. Thirty one patients were treated with ATG combined with CsA for 6 months. The patient group that achieved higher mean CsA level (≥200 ng/ml, higher CsA group) during first 2 weeks, was shown to more higher response rate than the group, lower mean CsA level (< 200ng/ml, lower CsA group)(response rate of 82.3% in higher CsA group, 21.4% in lower CsA group, p=0.0023). There was also a significant difference in survival rate during median 785 days between higher CsA group and lower CsA group (survival rate of 64.7% in higher CsA group, 28.6% in lower CsA group, p=0.0115). Therefore, we suggest that early higher CsA level during first 2 weeks would be an important factor to achieve the overall response of IST in severe aplastic anemia.

Very early steroid withdrawal in simultaneous pancreas-kidney transplants

Simultaneous pancreas-kidney (SPK) transplantation is an effective treatment for patients suffering from type 1 diabetes mellitus. Conventional immunosuppressive treatments include steroids that may induce insulin resistance and are responsible for many side effects. In de novo SPK, early withdrawal of corticosteroids may be an important issue. A total of 24 consecutive patients with type 1 diabetes mellitus had been treated by SPK transplantation. All of them had a short induction therapy with anti-thymoglobulin (ATG) and steroids for only 4 days, association with CellCept and tacrolimus. The rate of acute rejection, graft and patient survival and side effects have been analysed. Patient and kidney survival was 100% and the pancreas survival was 95.6% at 1 year. The rate of acute rejection of kidney and pancreas was 4.2% and 8.3% at 6 months, respectively. The mean serum creatinine was 98.9+/-19.6 micromol/l and the mean HbA1c concentration was 5.1%+/-0.5% at 6 months. Only four patients developed a cytomegalovirus primo-infection, associated in one case with pneumonia, whereas 75% of patients developed a bacterial infection. Because of the occurrence of leucopenia and/or diarrhoea, CellCept has been dramatically decreased in 33% of cases and required the re-introduction of steroids. A short induction with ATG and steroids associated with a chronic therapy with CellCept and tacrolimus is safe and efficient in preventing acute renal rejection in SPK.