Family Donor Research Articles

P1832IGG4 RELATED DISEASE: NEPHROPATHY AND BONE MARROW FAILURE IN A 2 YEAR-OLD CHILD

Abstract Background and Aims IgG4 related disease (IgG4 RD) is a recently recognized systemic immune-mediated disorder. Pathophysiology of the disease is still unclear. It is characterized by fibro-inflammatory damage of the tissues, IgG-4 positive plasma-cells and often by elevated serum IgG4. This systemic disease can potentially affect every organ. Renal involvement can include tubulo-interstitial nephritis (TIN), membranous glomerulopathy (MGP) and retroperitoneal fibrosis. The epidemiology is still poorly described, but the disease seems more frequent in men over 50 years of age. Only few cases of IgG4 RD are reported in pediatric patients. Method We describe the first case of IgG4 related kidney disease (IgG4 RKD) in a child with concomitant bone marrow failure. Results M.C., a 2 year-old child, was diagnosed in 2017 with a trilinear bone marrow failure (HB 7.2 g/dL; PLT 6.000/mmc; PMC 923/mmc). Bone marrow biopsy showed poor and dyshomogeneous cellularity (20%) and lymphoplasmacytic infiltrate organized in two follicular structures. All investigations performed to rule out inherited bone marrow failure were negative (DEB test, telomere lenght measurement, c-Mpl mutation analysis, mithocondrial DNA analysis) IgG subclass analysis showed elevated serum levels of IgG4 subclass (353 mg/dL- normal level < 120 mg/dL). During the hospitalization, kidney failure with tubular acidosis was also found (creatinine 1.3 mg/dL, eGFR 28.5 mL/min/1.73 mq, bicarbonate 8.3 mEq/L). Urine analysis showed microematuria, proteinuria (1.07 g/L) and granular casts. Renal ultrasound did not demonstrate abnormal findings. A renal biopsy was performed and a kidney sample with up to 40 glomeruli was obtained. Light microscopy (H&E, JSM, PAS and Masson’s trichrome stains) showed tubule-interstitial inflammatory infiltrate (mainly composed of lymphoplasmacytic cells), irregular thickening of the glomerular basement membranes. IHC stains for C4D showed subepithelial deposits (++). IF was negative for IgA, IgM, C4 and C1q while showed subepithelial glomerular membrane IgG deposits (+++) with granular pattern and tubular wall deposits; glomerular deposits (+) and focal tubular deposits (+++) of C3. A diagnosis of MGP associated with TIN was made. IHC staining for IgG4 was also performed, which demonstrated plasmacells with overlapping positivity for IgG and IgG4. After the diagnosis of IgG4 RKD, an immune-suppressive therapy with steroids (1 mg/kg/die)– targeting both the haematological disorder and glomerulopathy - was started, without clinical response. Thereafter the patient underwent bone marrow transplant from HLA-identical family donor. Conclusion GMP indeed is a very uncommon disease in childhood. Moreover, the association of GMP with TIN is reported in few cases in the literature. Only in the last decade some case of TIN and GMP have been recognized as IgG4 RD and few cases have been reported in adults of IgG4 RKD with simultaneous TIN and GMP. To exclude primary GMP we will perform also the research of antiPLA2r1 antibodies in kidney biopsy. However, the specificity of antiPLA2r in children is lower than in adults and the association of primary GMP with IgG4 TIN is unlikely. IgG4 RD is an emerging systemic disease and it should be taken into account in differential diagnosis in systemic auto-immune diseases, also in the pediatric age. IgG4 RKD and bone marrow failure IgG4 RD are very rare in children but its real incidence among pediatric patients could be still underestimated.

Kiedy pacjent jest oporny na leczenie – historia dziewczynki z aplazją szpiku

Acquired aplastic anemia (AAA) is a rare disease of the haematopoietic system in children. In the absence of a compatible family donor of bone marrow, immunosuppressive therapy is used in combination with anti-thymocytic globulin and cyclosporine. We present a 6-year-old girl diagnosed with severe aplastic anemia (SAA), initially treated only with cyclosporine (CSA) due to lack of a drug in Ukraine. In 2 months of therapy, the child was admitted to a Polish clinic. Due to the persistence of aplasia, she received standard treatment with CSA and anti-lymphocyte globulin, to which she did not respond. In view of disease progression and the lack of a completely compatible unrelated donor. It was decided to transplant from a 9/10 compatible donor, which was successful. Now the child is in remission of the disease and has 100% donor chimerism. Despite the difficulties in therapy, the girl has been healthy for over 2 years.

Kidney transplantation and other methods of renal replacement therapy in children: 30 years of observations in one center.

Kidney transplantation (Tx) is regarded as the optimal treatment method for renal replacement therapy (RRT) for end-stage renal disease (ESRD) patients. Children qualified for Tx should receive the organ as soon as possible in order to improve their chances for healthy development. In our center, RRT for children with ESRD has been conducted for 36 years: hemodialysis (HD) since 1982, peritoneal dialysis (PD) since 1992 and the first transplant in 1987. To analyze the rates of different RRT methods in children with ESRD. Special attention was paid to Tx. We compared the rates of RRT methods over 3 subsequent decades (1987-1996, 1997-2006 and 2007-2017). In the period analyzed, 153 children aged from 2 weeks to 18 years were dialyzed. The mean age of the start of RRT was 9.4 years. In 80 children (52.2%), first method was HD, while in 73 patients (47.7%) it was PD. In 25 children, the type of dialysis was changed. Kidney transplantation was performed in 40%, 60.34% and 73% of patients dialyzed in the periods 1987-1996, 1997-2006 and 2007-2017, respectively. The average waiting time for a transplant in the abovementioned decades was 2.25 years, 2.65 years and 1.97 years, respectively. Three children underwent transplantation with a family donor; 1 boy received a transplanted kidney and liver. Two children underwent a preemptive transplant from a deceased donor. The percentage of children with ESRD treated with Tx continues to increase, but in our assessment, it still remains too low. Among the types of dialysis, PD was much more frequently used, which is consistent with pediatric recommendations. Small number of transplants from a living donor and preemptive transplants indicates the need to promote organ donation in Polish society.

CD56bright/CD16bright NK-cell adoptive immunotherapy in patients with concurrent CNS disease and relapsed or refractory (R/R) AML.

3025 Background: Patients (pts) with R/R AML and concurrent CNS disease rarely respond to chemotherapy and have a dismal prognosis. Adoptive immunotherapy (AI) with haploidentical ex vivo-activated/expanded NK cells shows promise in R/R AML, but it is unknown whether the blood–brain barrier (BBB) represents an obstacle to this approach. Here we present data from 4 pts with CNS disease from a phase 1 study of 13 pts receiving NK AI for R/R AML (NCT02809092). Methods: Double bright (CD56bright/16bright) activated NK cells (DBNK) were expanded from haploidentical family donors on feeder cells expressing membrane-bound IL-21. DBNK were infused thrice weekly for six doses 3–7 days after fludarabine, cytarabine, and G-CSF (FLAG). Pts received doses ranging from 106 to 107 DBNK/kg/infusion. CNS responses at day 30 were assessed using Response Assessment in Neuro-Oncology criteria. RNA sequencing was used to compare gene expression in DBNK vs unexpanded NK cells. Results: Demographics of the 4 pts with CNS disease are shown (Table). All pts had received a prior stem cell transplant and were heavily pretreated (median 6 prior treatments), and 1 had primary refractory disease. All pts completed 6 NK-cell infusions without dose-limiting toxicities. No cytokine storm syndrome was reported. Other toxicities were manageable, including CNS hypertension symptoms. Imaging studies showed inflammation localized to disease sites. All 4 pts showed a response (Table), with complete, long-lasting resolution of CNS lesions documented in pts #1 & #5, almost complete resolution of bone and nerve root leukemic infiltration in pt #4, and a 50% reduction of CNS chloromas in pt #6. Responses were durable, lasting up to 7 months. DBNK showed upregulation of homing receptors associated with CNS trafficking. Conclusions: Multiple infusions of ex vivo IL-21-expanded DBNK were tolerable and demonstrated unprecedented CNS responses in patients with R/R AML. These data support effectiveness of DBNK across the BBB. Clinical trial information: NCT02809092 . [Table: see text]

Experiences and unmet needs of family members requested to donate haematopoietic stem cells to an ill relative: findings from a prospective multi-centre study.

Despite well-documented physical effects of haematopoietic stem cell (HSC) donation, far less attention has been focused on the psychosocial impact for family donors. This study aimed to better understand the psychosocial aspects of HSC donation by family members, focusing, in particular on their needs for information and supportive care. Thirty-one adult HSC family donors from two clinical hospitals were interviewed before, during and 1month after HSC donation. Interviews explored ambivalence, motivation, perceived pressure, preparedness, the donor-recipient relationship, information and support received and suggestions for improvement. Three main themes about the donation experience were identified: 'call to arms' (focused on the recipient, stressful urgency, making meaning of being a donor, decisional ambivalence), 'proceeding with donation' (living in limbo, unsettling uncertainty, pervasive pain, feeling supported) and 'after the dust settles' (feeling discarded, downplaying role, residual symptoms, dealing with adverse recipient outcomes). Underlying system and communication issues included time for consideration prior to donor work-up, management of confidentiality, information inadequacy and access to support. Donors wanted information about the emotional challenges specific to being a family donor, such as ways in which previous donors coped with recipient death. For donors whose recipient had died, the priority for improved care was follow-up support. Our findings emphasise a gap in information and supportive care for family donors and the need for a protocol specifically designed to inform and support family donors before, during and after HSC donation.

Thewithdrawal of consent to haematopoietic stem cells (HSC) donation: The complicated balance between donor’s rights and patient’s protection

Hematopoietic stem cells donation is an essential prerequisite of allogeneic transplantation. Both family donors and matched unrelated donors should have a conscious involvement in every phase of the overall path, from selection to HSC collection. Donors also should be informed about the right to withdraw at any time as well as the extreme risk for recipient’s life coming from the decision of interrupting, if the donation is not carried out once the patient’s preparative regimen has commenced. We report our challenging experience about a donor who withdraws her consent to HSC donation after 3 days of mobilization with G-CSF. The possibility of withdrawal protects the donor but it also puts at risk both a chance for a transplant and the patient's life if preparative regimen has started. Can the donor really be free to withdraw the consent to HSC donation at any time even when this endangers the life of a recipient? Is this ethical? However, if the donor decides to withdraw, would we really be ready to manage promptly all the consequences coming from the consent revocation? At the moment there is not a well-defined "plan B" in case of impossibility to proceed with the transplant when conditioning has already started or has even been completed. In our opinion, because of this hard balance and such a high risk, it would be necessary to plan every time an alternative strategy which may be different according to different circumstances.

Progressive multifocal leukoencephalopathy in a patient post allo-HCT successfully treated with JC virus specific donor lymphocytes

BackgroundProgressive multifocal leukoencephalopathy is a demyelinating CNS disorder. Reactivation of John Cunningham virus leads to oligodendrocyte infection with lysis and consequent axonal loss due to demyelination. Patients usually present with confusion and seizures. Late diagnosis and lack of adequate therapy options persistently result in permanent impairment of brain functions. Due to profound T cell depletion, impairment of T-cell function and potent immunosuppressive factors, allogeneic hematopoietic cell transplantation recipients are at high risk for JCV reactivation. To date, PML is almost universally fatal when occurring after allo-HCT.MethodsTo optimize therapy specificity, we enriched JCV specific T-cells out of the donor T-cell repertoire from the HLA-identical, anti-JCV-antibody positive family stem cell donor by unstimulated peripheral apheresis [1]. For this, we selected T cells responsive to five JCV peptide libraries via the Cytokine Capture System technology. It enables the enrichment of JCV specific T cells via identification of stimulus-induced interferon gamma secretion.ResultsDespite low frequencies of responsive T cells, we succeeded in generating a product containing 20 000 JCV reactive T cells ready for patient infusion. The adoptive cell transfer was performed without complication. Consequently, the clinical course stabilized and the patient slowly went into remission of PML with JCV negative CSF and containment of PML lesion expansion.ConclusionWe report for the first time feasibility of generating T cells with possible anti-JCV activity from a seropositive family donor, a variation of virus specific T-cell therapies suitable for the post allo transplant setting. We also present the unusual case for successful treatment of PML after allo-HCT via virus specific T-cell therapy.

Case report: a 58 -year -old man with small kidneys and elevated liver enzymes

BackgroundThe conjunction of hepatitis and renal disease can be seen in several clinical context, including karyomegalic nephritis (KIN). Karyomegalic nephritis (KIN) is a rare genetic disease, with less than 50 cases reported, which incidence is probably underestimated. We report here an unusual case presentation of KIN with obtention of several organ biopsies and a novel mutation leading to the disease.Case presentationA 58 year old Caucasian without relevant family history presents with advanced chronic kidney disease, elevated liver enzymes and recurrent pulmonary infection. Familial history was negative. Renal biopsy revealed a chronic tubulo-intertsitial nephritis with enlarged and irregular hyperchromatic nuclei. Karyomegalic nephritis (KIN) was confirmed by genetic testing with a non-sense mutation and a deletion in the Fanconi anemia associated nuclease 1 (FAN1) gene.ConclusionsKIN is rare disease to be suspected in the presence of renal disease, biological hepatitis and recurrent pulmonary infections, even without a familial history. Diagnosis of this condition is crucial to perform family screening, avoid progression factors, and adapt post transplantation immunosuppression. Finally, avoiding familial heterozygote donors appears of major importance in this condition.

Improved transplant survival and long-term disease outcome in children with MHC class II deficiency

AbstractMHC class II deficiency is a rare, but life-threatening, primary combined immunodeficiency. Hematopoietic cell transplantation (HCT) remains the only curative treatment for this condition, but transplant survival in the previously published result was poor. We analyzed the outcome of 25 patients with MHC class II deficiency undergoing first HCT at Great North Children's Hospital between 1995 and 2018. Median age at diagnosis was 6.5 months (birth to 7.5 years). Median age at transplant was 21.4 months (0.1-7.8 years). Donors were matched family donors (MFDs; n = 6), unrelated donors (UDs; n = 12), and haploidentical donors (HIDs; n = 7). Peripheral blood stem cells were the stem cell source in 68% of patients. Conditioning was treosulfanbased in 84% of patients; 84% received alemtuzumab (n = 14) or anti-thymocyte globulin (n = 8) as serotherapy. With a 2.9-year median follow-up, OS improved from 33% (46-68%) for HCT before 2008 (n = 6) to 94% (66-99%) for HCT after 2008 (n = 19; P = .003). For HCT after 2008, OS according to donor was 100% for MFDs and UDs and 85% for HIDs (P = .40). None had grade III-IV acute or chronic graft-versus-host disease. Latest median donor myeloid and lymphocyte chimerism were 100% (range, 0-100) and 100% (range, 64-100), respectively. Latest CD4+ T-lymphocyte number was significantly lower in transplant survivors (n = 14) compared with posttransplant disease controls (P = .01). All survivors were off immunoglobulin replacement and had protective vaccine responses to tetanus and Haemophilus influenzae. None had any significant infection or autoimmunity. Changing transplant strategy in Great North Children's Hospital has significantly improved outcomes for MHC class II deficiency.

Matched Family versus Alternative Donor Hematopoietic Stem Cell Transplantation for Patients with Thalassemia Major: Experience from a Tertiary Referral Center in South India.

Hematopoietic stem cell transplantation (HSCT) is the only curative option available for patients with thalassemia major in India with increasing access to alternate donor transplantation for patients with no matched family donor. We aimed to analyze the impact of family and alternate donor HSCT on morbidity and mortality post-HSCT. We conducted a retrospective study in the department between July 2007 and December 2018 where all children who underwent HSCT for thalassemia major were included. A total of 264 children were included with a median age of 6 years (male/female, 1.4:1). The graft source was matched related donor (MRD) (76%; parent 15%, sibling 85%) and matched unrelated donor (MUD) (22%). All children received a myeloablative conditioning regimen with treosulfan/thiotepa/fludarabine in 93% and busulfan/cyclophosphamide in 7%. The source of stem cells was peripheral blood in 61%, bone marrow in 38%, and umbilical cord blood in 3%. The incidence of bacteremia was 14% versus 25% in MRD versus MUD groups. There was a higher incidence of posterior reversible encephalopathy syndrome (PRES) in the MUD group (10% versus 3%). Engraftment occurred in 97% with a higher trend toward mixed chimerism in the MRD group (12% versus 2%). When indicated, whole-blood donor lymphocyte infusion was used to ensure complete chimerism in children in the MRD group. A statistically significant difference was found in the incidence of graft versus host disease (GVHD), both acute and chronic between the MUD versus MRD groups, 60% versus 20% and 41% versus 17%, respectively (P=.001). Similarly, immune cytopenia and cytomegalovirus reactivation were also significantly higher in the MUD group, 27% versus 1.4% and 25% versus 2%, respectively (P=.001). Thalassemia-free survival in our cohort was 96%, 94%, and 84% with a median follow-up of 65 months in the matched sibling donor, matched family donor, and MUD groups, respectively. Overall survival of 95% and 90% with a median follow-up of 65 months was noted in those who underwent transplantation less than and greater than 7 years of age, respectively. MUD transplantation for patients with thalassemia major involves specific challenges such as PRES and unusual manifestations of GVHD such as immune cytopenia. Early interventions to optimize supportive care and measures to reduce GVHD are required to ensure survival rates of over 90%.

T Cell Depleted Haploidentical Hematopoietic Stem Cell Transplantation for Patients with Familial Hemophagocytic Lymphohistiocytosis Who Do Not Have Matched Family Donors: Experience in Oman.

Familial hemophagocytic lymphohistiocytosis (FHLH) is a potentially fatal disorder of immune regulation. Management includes chemotherapy followed by hematopoietic stem cell transplantation (HSCT). T cell depleted (TCD)-haploidentical HSCT could be an option for those patients who do not have HLA matching family donor. The objective of this study was to report on the outcome of TCD-haploidentical HSCT in patients with FHLH who underwent transplantation at Sultan Qaboos University Hospital (SQUH). This is a retrospective report on 12 patients with FHLH who received TCD- haploidentical HSCT at SQUH between August 2010 and December 2018. Epidemiologic characteristics and details on the transplantation procedures and complications were collected from patients' electronic records. Twelve patients with FHLH received TCD-haploidentical HSCT after a myeloablative conditioning regimen composed of treosulfan/thiotepa/fludarabine/anti-thymocyte globulin and rituximab. The mean age at transplantation was 11.67 ± 8 months. All patients had Perforin gene mutations, except 1 patient who had an UNC-13D mutation. Most patients received TCRαβ+/CD19+ depleted grafts for faster immune reconstitution. Seven patients (58.3%) have been cured with a mean follow-up duration of 3.44 years. Four patients died of multiorgan failure secondary to gram-negative sepsis. One patient had primary graft failure, and 2 patients had mild graft-versus-host disease. Two patients had Pneumocystis carinii pneumonia, 2 had adenoviremia, and 9 patients had cytomegalovirus (CMV) viremia. Among patients with CMV viremia, 2 had evidence of disease (retinitis, enteritis). All patients with CMV viremia were treated successfully with foscarnet pre-engraftment and ganciclovir postengraftment, respectively. TCD-haploidentical HSCT could be a viable option for patients with FHLH who do not have HLA matching family donors. Infectious complications are the leading cause of death in that setting. CMV viremia was the most frequently encountered infectious complication.

Improved outcomes of allogeneic hematopoietic stem cell transplantation including haploidentical transplantation for childhood myelodysplastic syndrome.

This retrospective study aimed to investigate the outcomes of allogeneic hematopoietic stem cell transplantation (HSCT) for childhood myelodysplastic syndrome (MDS). Thirty-six patients (low-grade MDS, 24; advanced MDS, 12) received HSCT at the Asan Medical Center over two decades (early period, 1997-2007; recent period, 2008-2017). The transplantation outcomes were analyzed according to disease status, conditioning regimen, various donor types, and period of HSCT. During a median follow-up of 5.6 (range, 1.4-21.1) years, the probability of overall survival (OS) and failure-free survival was 77% and 69%, respectively. The cumulative incidence of transplantation-related mortality (TRM) was 12%. Significantly reduced TRM and improved OS were observed in patients who received HSCT during the recent period vs. the early period (TRM, 4% vs. 30%, P = 0.021; OS, 87% vs. 50%, P = 0.006). Comparable outcomes were observed for HSCT from haploidentical family donors vs. HLA-identical donors (TRM, 10% vs. 14%, P= 0.837; OS, 86% vs. 79%, P = 0.625). This study identified the improved outcomes of allogeneic HSCT for childhood MDS over time, in addition, the feasible outcomes of haploidentical HSCT suggested its use as an attractive alternative in the future procedures.

Outcome of children relapsing after first allogeneic haematopoietic stem cell transplantation for acute myeloid leukaemia: a retrospective I-BFM analysis of 333 children.

Outcome of 333 children with acute myeloid leukaemia relapsing after a first allogeneic haematopoietic stem cell transplantation was analyzed. Four-year probability of overall survival (4y-pOS) was 14%. 4y-pOS for 122 children receiving a second haematopoietic stem cell transplantation was 31% and 3% for those that did not (P=<0·0001). Achievement of a subsequent remission impacted survival (P=<0·0001). For patients receiving a second transplant survival with or without achieving a subsequent remission was comparable. Graft source (bone marrow vs. peripheral blood stem cells, P=0·046) and donor choice (matched family vs. matched unrelated donor, P=0·029) positively impacted survival after relapse. Disease recurrence and non-relapse mortality at fouryears reached 45% and 22%.

Upfront Haploidentical Stem Cell Transplant with Post Transplant Cyclophosphamide in Children with Severe Aplastic Anemia

Introduction In children with severe acquired aplastic anemia, although matched sibling donor (MSD) hematopoietic stem cell transplant (HSCT) is standard of care. If it's not available then usually immune suppressive therapy (IST) is offered. But the success of IST at best is 50-70% and many children only achieve partial response and still have risk of developing clonal disorders or relapse in follow up. Recent data has shown upfront matched unrelated donor (MUD) HSCT can be as good an option as MSD. However, MUD is not easily available in the developing world due to lack of registries and Non-Caucasian population and multiple ethnicities. Recently, John Hopkins group showed in a series of 14 patients of severe aplastic anemia, refractory to initial therapy with IST, that haploidentical donor HSCT with post-transplant cyclophosphamide (PTCy) can be offered as a treatment with event free survival (EFS) and overall survival (OS) of 100%. In the developing world, due to lack of funds, usually the first chance at therapy is the best chance and most people can't afford further therapy after failure of IST. So, we offered upfront haploidentical HSCT with PTCy to 4 children with severe aplastic anemia and here we describe outcomes of the same. Methods After informed consent of the parents four children (median age- 4 years, range 2-11 years and male: female = 1:3)) underwent haploidentical HSCT with PTCy from a family donor. Conditioning was Rabbit ATG 1.5 mg/kg x 3 days (day-8 to day-6), Fludarabine 40 mg/m2 × 4 days (day-5 to -2), Cyclophosphamide 14.5 mg/kg x 2 days (day-5 & -4) and total body irradiation 2 Gy (day-1). Peripheral blood stem cell was the graft in all cases (median CD34 cell dose -9 million/kg; range-5 to 11 million/kg). Donor was father in 3 cases and mother in 1. GVHD prophylaxis was PTCy 50 mg/kg on day +3 & +4 and cyclosporine and MMF. Results All children were transplanted within 2-months from diagnosis of aplastic anemia. All four children engrafted (Neutrophil engraftment on median day+17; range-16-19 and platelet median engraftment on day+16; range12-27). All were fully donor on day+30, 60 and 100. Acute GVHD grade 1 was seen in 1 child. No chronic GVHD was seen. CMV reactivation was seen in 2 children. All are alive and disease free and GVHD free at median follow up of 1 year (range 6 month to 30 months). Two are off immune suppression whilst one is on tapering dose and one with 6 months follow up is still on immune suppression. Conclusion Upfront haploidentical HSCT with PTCy is safe and effective option for children with aplastic anemia lacking a matched donor.

Haplo Allogeneic Hematopoietic Stem Cell Transplantation in Patients of 65 Years or Older: A Monocenter Analysis

Advanced hematologic malignancies have a higher incidence in older patients and very often lack effective treatments. Allo-HSCT represents the only potential curative option for most of hematologic malignancies. However, 2 main limitations limited this development for a long period of time in older patients. High rates of fatal non-relapse morbidities have been progressively decreased using reduced toxicity conditioning approaches. This allowed pushing up the age limit of patients considered for transplant. The search for a donor has been also a high limitation in older population, due to the lower incidence of matched sibling donors in this population. The development of allo-HSCT from a familial Haplo donor after a reduced intensity (RIC) or non-myeloablative conditioning (NMAC) has allowed for the recent development of allo-HSCT in older population. Here we analyzed a cohort of 111 consecutive patients aged of 65 years or older transplanted from a haplo donor in a single institution from 2013 to 2018. During this period of time, the search for a one-mismatch haplotype donor (Haplo) has been progressively introduced in our program, the upper limit age for transplant progressively increased and more advanced diseases. Patient characteristics: Median age: 69,3 (65-78) years; Male patients: 64%; Acute leukemia (AL): 34%; Myelodysplastic/myeloproliferative syndromes (MDS/MPS): 45%; Chronic Leukemia: 2%; Lymphoma: 18%; others: 3%. High or very high risk disease index (DRI): 44%. Donor characteristics: median age: 39,2 (22-68); Male gender: 61%; sibling donor: 17%; offspring donor: 83%. Non Myeloablative/ Reduced toxicity conditioning: 51%/49%; All patients received PTCY. PT Immunosuppression included CSA and MMF. Median follow-up: 20 (3-78) months; ANC recovery in 96%: 19 (10-44) days; untransfused platelet recovery above 20 in 75%: 17 (7-56) days. In evaluable patients for aGVHD: No: 59%; Grade 1: 7%; Grade 2: 16%; Grade 3: 11%; Grade 4: 5%; 85% patients were evaluable for cGVHD: No: 62%; limited: 13%; Moderate/severe:25%; 32 patients (25%) patients died from non-relapse mortality at a median of 116 days (13-1373); 16 patients relapsed/progressed at a median of 5,6 (1-63) months. Two year overall and disease-free survivals are respectively of 58% (95% CI: 6.35-7.04) and 54% (95% CI: 7.17-7.55). the only predictive factor was disease risk. Overall these data show that allo haplo HSCT is a valid option in older patients with high-risk malignancies. To improve results we performed from 2015 in patients older than 65 years systematic and combined evaluation of comorbidities score, performance status and geriatric assessment (instrumental activity of daily living (AIDL); vulnerability assessment) that will be presented in the meeting for this population.

Thiotepa Based Conditioning for Haploidentical Stem Cell Transplantation with Post Transplant Cyclophosphamide for Pediatric Acute Leukemia Is Highly Effective

Introduction Haploidentical family donor is universally available and is increasing being used as an alternative donor choice for treating adults with leukaemia needing hematopoietic stem cell transplant (HSCT). Thiotepa is an alkylating agent which has been used successfully as part of conditioning in adult leukemia patients undergoing haploidentical SCT with Post transplant cyclophosphamide (PTCy). But such data is lacking in children. Herein, we describe the experience of treating children with acute leuekmia with thiotepa based conditioning for haploidentical HSCT with PTCy. Methods We retrospectively analysed outcome data of 12 children with acute leukaemia (acute lymphoblastic leukemia-8, acute myeloid leuekmia-3 and Mixed phenotype acute leukemia-1) who underwent haploidentical HSCT with PTCy; median age was 6.5 years (range 1-14 years). All were in complete remission (CR) prior to HSCT (CR1-6, CR2-6). Donors were mobilized with GCSF. The conditioning was myeloablative with Thiotepa 10 mg/kg day-6, Fludarabine 40 mg/m2 day-5 to -2, Cyclophosphamide 14.5 mg/kg on day-5 and -4, Total body irradiation 2 Gray on day-1 in 8 children and Rituximab 100/m2 day-8, Thiotepa 10 mg/kg on day-7, Fludarabine 40 mg/m2 day-6 to -3, Busulfan 3.2 mg/kg day-6 to -3 (TBF) and Rabbit ATG 1.5 mg/kg day-4 to-2 in 4 children. All received PTCy 50 mg/kg on day 3 and 4 as graft vs. host disease (GVHD) prophylaxis along with tacrolimus or cyclosporine and mycophenolate mofetil. A median of 9.5 million of CD34 cells/kg was infused (range 4-20 million/kg). Results All patients engrafted. Median time of neutrophil engraftment was 18 days (range 11-29) and platelet engraftment was 18 days (range 12-26). All achieved fully donor chimerism on day+30. One child with acute myelogenous leukemia died due to steroid refractory grade IV acute gut GVHD on day+38. Child with infant leukemia died on day+330 with chronic GVHD of Lung. One child relapsed 2 years post HSCT. As he had CD20 positive B cell ALL, so he was treated with Rituximab and achieved CR3. He is alive and disease free on monthly rituximab 100 mg/m2 for more than 3 years post his relapse. Chimerism on day +100 and + 180 was fully donor in all patients. Remaining 9 patients are in continued CR. Acute GVHD was seen in 3 patients (grade III-IV in 1) but none in TBF and ATG regimen. Chronic GVHD was seen in four patients (extensive in 3) but only in 1 out of 4 in TBF regimen. Haemorrhagic cystitis with BK virus activation was seen in 4 patients (all 4 received TBF). Viral reactivation of CMV was seen in 5 patients. Overall survival was 83% and event-free survival was 75 % at a median follow-up of 930 days (range 200-1765 days). Transplant related mortality was 17%. Conclusion Thiotepa based myeloablative conditioning is highly effective in children undergoing haploidentical HSCT with PTCy for acute leukemia. Addition of ATG reduced acute and chronic GVHD.

Hematopoietic Stem Cell Transplant Outcomes in Patients with Acute Myeloid Leukemia from a Tertiary Care Center in South Inida

<h3>Background</h3> Allogenic hematopoietic stem cell transplantation (allo-HSCT) is one of the best therapies for acute myeloid leukemia (AML) and a proven post-remission therapy for intermediate and high-risk AML. The best HSCT source seems to be a matched sibling donor (MSD), but in the absence of one, a readily available haplo-identical donor provides an equally high cure rate. This is of relevance in a developing country like India as the cost of an unrelated donor is usually unaffordable. We present our experience from a single centre. <h3>Methods</h3> We analysed retrospective data of 122 AML patients who have undergone HSCT between Jan-2012 to Jun-2019 at our centre. Fludarabine + Busulfan or Fludarabine + Melphalan based conditioning regimen were used in MSD transplant and John Hopkins's protocol was followed in haploidentical HSCT. Cyclosporine + methotrexate was used as GVHD prophylaxis in MSD and unrelated donor group and cyclophosphamide + tacrolimus + mycophenolate was used for haploidentical post-transplant. Day 100 Survival, overall survival, incidence of GVHD and CMV reactivation was computed. <h3>Results</h3> Out of 122 patients, 69 (56.6%) were males, the mean age was 29.05±20.13 (range, 1 -74) years. Peripheral blood stem cell (99%) was the predominant graft source with majority of matched sibling donor (MSD; 54.1%) compared to Haplo-identical donors (30%). Figure 1 shows the demographic and clinical details of the study patients. The incidence of acute GVHD (40.9% vs 32.6%; p=0.372) and chronic GVHD (16.7% vs 15.2%; p=0.837) are similar in MSD and Haplo transplantation. There were 25 (38%) deaths in MSD and 23 (50%) deaths haplo-identical transplantation (p=0.245). The day-100 survival and overall survival function is significantly better in MSD transplantation (p<0.05; Figure 2). Disease status at latest follow up showed that 81% were in remission and 19% had relapsed. <h3>Conclusion</h3> Our study showed comparable outcomes in MSD and Haplo-identical transplant with respect to incidence of GVHD and mortality. However, the survival function is better with MSD transplantation. Haplo-identical transplant is a feasible option in case of non-availability of MSD, due to ease of donor availability and strong motivation from the family donor to donate the stem cells.

T-Cell Replete Haploidentical Stem Cell Transplantation with Post-Transplantation Cyclophosphamide (PTCy) for Pediatric Patients with Primary Immunodeficiencies (PID) - a Survey of the Pediatric Transplantation Working Group of the Brazilian Society of Bone Marrow Transplantation (SBTMO)

Introduction Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative treatment for several primary immunodeficiencies. In the absence of a matched sibling or a well matched unrelated donor, the use of an haploidentical family donor can be considered. Historically, most part of haploidentical HSCT were performed with in vitro T-cell depletion techniques that aren't worldwide available, especially in middle or low income countries. The use of T-cell replete haploidentical HSCT with PTCy in children with PID has been described in only a few case-series. Objectives To report the outcomes of haploidentical HSCT with PTCy for children with severe PID Methods Retrospective chart review of 73 patients with PID who underwent haploidentical HSCT with PTCy from July 2012 to May 2019 at 9 centers in Brazil. Results Fifty-five patients received first allogeneic transplants, and 18 were rescued after graft failure of a previous transplant. Median age was 1.6 years (2 months to 19 years). Most patients were male (n=54) and had active infection at the time of transplant (n=50). Diagnoses were: severe combined immunodeficiency (n=34), Wiskott-Aldrich Syndrome (n=14), chronic granulomatous disease (n=10) and other PID (n=15). Donors were father (N=46), mother (N=24), or siblings (N=3); and cell source was predominantly bone marrow (94% of patients). Conditioning regimen was non-myeloablative (fludarabine 150mg/m2 + cyclophosphamide 29mg/Kg + TBI 200cGy) in 35 patients; and myeloblative in 38 patients (most part receiving: bussulfan + fludarabine 160mg/m2 + ATG 4-7,5 mg/Kg or alemtuzumab 0,5-1mg/Kg). GVHD prophylaxis was PT-Cy, CsA or Tacrolimus and MMF. The median follow-up of surviving patients was 24 months. Four patients died before 28 days and were not evaluable for engraftment. Sixty-one patients engrafted in a median of 15 days. The 100-day incidence of acute GVHD grades II–IV was 33% and grades III–IV, 14%. The incidence of Chronic GVHD at 1 year was 16%. Twenty-two patients died, most of them due to infection (n=15). The two-year overall survival was 66%. There was no difference in OS between patients receiving first allogeneic or rescue transplants, suggesting survival bias. Patients transplanted for WAS or SCID had a better OS compared to those transplanted for CGD (p=0,02). Conclusion In conclusion, 66% of Brazilian children with severe PID and no matched donor could be cured with haploidentical HSCT with PTCy. The high proportion of patients in our cohort transplanted with an active infection (70%) may have had a major impact in our results. The optimal conditioning regimen for these patients and long term follow up data are the objective of our ongoing studies.

Alterations in NKG2A and NKG2C Subsets of Natural Killer Cells Following Epstein–Barr Virus Reactivation in CTLA4Ig-based Haploidentical Transplantation Is Associated With Increased Chronic Graft-Versus-Host Disease

The impact of newer approaches to haploidentical transplantation on Epstein-Barr virus (EBV) is largely unknown. We prospectively evaluated the incidence of EBV reactivation and its impact on transplantation outcomes in 71 patients undergoing haploidentical transplantation with posttransplantation cyclophosphamide in combination with CTLA4Ig-based T-costimulation blockade. Eight patients developed EBV reactivation at a median of 96 days with no incidence of lymphoproliferative disorder. There was no impact of EBV reactivation on acute graft-versus-host disease (GVHD), nonrelapse mortality, progression-free, or overall survival. Despite an overall incidence of 19%, there was a significant increase in chronic GVHD following EBV reactivation (62.5% versus 8%; P = 0.01). NKG2A subset of CD56 natural killer cells increased substantially and persisted following EBV reactivation and chronic GVHD, with a reciprocal decrease in NKG2C subset, whereas the reverse was witnessed in those without chronic GVHD (P < 0.01). Increase in NKG2C subset and a decrease in the NKG2A subset were witnessed within 3 months of subsidence of chronic GVHD. Thus, CTLA4Ig-based haploidentical transplantation was associated with a low incidence of EBV reactivation without EBV-lymphoproliferative disorder. However, EBV reactivation was associated with a sustained alteration in NKG2A and NKG2C subsets of CD56 natural killer cells which might have a pathogenic role in chronic GVHD.

Clinical significance of HLA-A, -B, -C, -DRB1, -DQB1 haplotype gene frequencies

目的研究单倍型移植中HLA-A、-B、-C、-DRB1、-DQB1单倍型频率，并探讨其临床意义。方法回顾性分析2012–2017年在苏州大学附属第一医院拟行亲缘HLA单倍型移植的3 568个家系，同时采用基因测序（PCR-SBT）和寡核苷酸探针杂交（PCR-SSOP）进行HLA基因分型检测，并进行家系单倍型分析。结果全部3 568个家系可分为3种情况：组1为1 422个完整家系，组2为1 310个仅有患者与一个亲代或子代的家系，组3为836个仅有患者与一个HLA≥5/10基因型相同同胞的不完整家系。组1和组2合并统计后建立单倍型总频率表。总频率≥0.1%的单倍型中：A*11∶01-B*40∶01-C*03∶04-DRB1*11∶01-DQB1*03∶01、A*02∶07-B*51∶01-C*14∶02-DRB1*09∶01-DQB1*03∶03的单倍型频率在组1和组2间差异有统计学意义（P值分别为0.029、0.033）；A*11∶01-B*46∶01-C*01∶02∶01G-DRB1*09∶01-DQB1*03∶03的频率在组1和组3间差异有统计学意义（P=0.035）；A*02∶01-B*40∶01-C*07∶02-DRB1*09∶01-DQB1*03∶03的频率在组1和组2、组1和组3间差异均有统计学意义（P值分别为0.034、0.034）；A*24∶02-B*13∶01-C*03∶04-DRB1*12∶02-DQB1*03∶01的频率在组2和组3间差异有统计学意义（P=0.046）。结论本研究建立了HLA-A、-B、-C、-DRB1、-DQB1单倍型频率总表，同时列举完整家系单倍型研究中分析基因型相同但单倍型完全不合，却被拟作为潜在供者移植的临床病例。家系不完整的供受者可通过本表进行单倍型分析，结合家系中其他成员HLA分型检测结果，为选择最佳供者及检索非血缘供者提供参考。