Hematopoeitic Stem Cell Transplantation Research Articles

Rare red cell enzymopathies in the Indian population: A comprehensive review

Red blood cell enzyme deficiencies are a rare category of hemolytic anaemia that typically present in children with varying degrees of hemolysis, indirect hyperbilirubinemia and splenomegaly. Glucose 6-phosphate dehydrogenase (G6PD) is the most common enzyme deficiency, followed by pyruvate kinase deficiency (PKD). This article aims to understand the pathophysiology of the rare enzymopathies due to deficiencies in the Embden-Meyerhoff pathway, glutathione metabolism, hexose monophosphate shunt and nucleotide metabolism pathway, and to study the incidence, clinical symptoms, diagnostic strategy, and management of enzyme deficiencies in the Indian patients. Most red blood cell (RBC) enzyme deficiencies are inherited in an autosomal recessive fashion except for G6PD, and phosphoglycerate kinase deficiency which has X-linked inheritance. Presentation depends on the representation of the enzyme on different tissues of the body, hence some enzyme deficiencies may present with neurological or muscular manifestations. In patients with suspected hemolytic anaemia, complete blood count and peripheral smear help in differentiating from hemoglobinopathies, etc. To clinch the diagnosis enzyme levels and genetic testing may be required. These tests guide antenatal diagnosis in subsequent pregnancies. Management of RBC enzymopathies depends on the predominant symptoms and severity of hemolysis. Patients with marked hemolysis require regular blood transfusions and hence appropriate chelation therapy. Hematopoeitic stem cell transplant is attempted in patients with severe spectrum with variable results. Newer drugs, including mitapivat have proven to be beneficial in adults with PKD and ongoing trials in children are showing promising results.

SY12-3 Hematopoietic transplantation for AML

Hematopoeitic stem cell transplantation (HSCT) has been an important modality for the treatment and cure of patients with high risk acute myeloid leukemia (AML). Improved stratification of AML patients with genetic markers (e.g. FLT3, CEBPA, NPM1 and others) has allowed better selection of patients for HSCT. Outstanding results from cord blood and haploidentical transplants have also increased the availability of donors for transplantation. Novel drugs like hypomethylating agents, BCL-2 inhibitors and various FLT 3 inhibitors have also improved the remission status of patients before transplant while also facilitating post-transplant consolidation and maintenance to improve disease control. Transplantation of older patients has also been made possible by the reduction of transplant-related mortality and morbidity through improved pre-transplant conditioning regimens and better management of post-transplant complications. Cellular engineering has also made possible the expansion of hematopoietic stem and progenitor cells to improve the results of HSCT while genetic engineering and expansion of cellular subsets has facilitated targeted therapy against viruses and leukemia. The outcomes of HSCT for the treatment of AML has improved significantly due to the above measures and HSCT remains a mainstay in the treatment of this disease.

Day 5 Peripheral Blood Blasts and Day 14 Bone Marrow Studies As Predictors for Response to Therapy in Acute Myeloid Leukemia (AML): An Experience from Indian Subcontinent

Day 5 Peripheral Blood Blasts and Day 14 Bone Marrow Studies as Predictors for Response to Therapy in Acute Myeloid Leukemia (AML): An Experience from Indian SubcontinentAuthorsShilpa Prabhu1, Swasti Sinha1, Vellaichamy M. Annapandian2, Sharat Damodar1, Shoba Badiger1, Sunil Bhat1, K.S. Nataraj1Author affiliations1 Department of Hematology and Bone Marrow Transplant, Narayana Health City, Bangalore, India.2 Department of Academic Research, Narayana Hrudayalaya Foundations, Bangalore, India.AbstractBackgroundThe major limitations of treating Acute Myeloid Leukemia (AML) in India are limited resources, patient affordability and utilization of health care services. It is vital to identify easily evaluable prognostic markers to plan for appropriate treatment that enables healthcare providers to deliver treatment at an affordable cost. AML is a most common leukemia in adults and has poor survival and response to treatment. However, with advances in treatment strategies, overall survival has improved in adults and there has been marginal increase in overall survival in older individuals. Studies have showed that immunophenotying to detect blasts by multiparameter flow cytometry on day 5 of induction chemotherapy as a predictor to remission. Financial constraint is the major concern in developing countries, hence peripheral smear examination can be used as an cheaper alternative to look for morphological evidence of blast. Morphological assessment at day 5 peripheral blood blasts can be used as a predictor for remission status, in addition to day 14 bone marrow studies. This strategy will enable us to identify a subset of patients who will benefit from early haematopoeitic stem cell transplant (HSCT) and prognosticate the patients. In this present study we assessed peripheral blast at day5 and day 14 bone marrow studies to predict remission on day 28.MethodsWe analyzed a cohort of 80 AML patients who presented to our centre (Mazumdar Shaw Medical Center, Narayana Health City, Bangalore, India) between April 2013 and April 2017. Diagnosis was confirmed by bone marrow studies based on the morphology, cytochemistry, immunophenotyping and cytogenetics. Clinico-pathological features, immunophenotyping, cytogenetics, mutation profile were recorded at the time of presentation. Day 5 peripheral blood blast percentage, day 14 bone marrow studies (aspiration & biopsy) and day 28 remission bone marrow (or bone marrow done at later dates) studies were recorded.ResultsAmong 80 patients, 48(60%) were male. The median age was 35 years (range; 10, 59 years). Seventeen (20%) were pediatric patients. Fifty-six (70%) patients were denovo and 24 (30%) were relapse at presentation. The most common presenting symptom was fever 68.75%(n=55). The median WBC count at presentation was 11.95x103/µl (1.5-280 x103). The median blast percentage on the day of diagnosis, day 5 peripheral blood , day 14 bone marrow were 68%, 3% and 4% respectively. According to ELN risk stratification, patients were grouped as favorable risk (3.75%, n=3), intermediate risk (51.25%, n=41) and adverse risk (37.5%, n=30). Thirty eight (47.5%) patients had no blasts in peripheral blood on 5th day of chemotherapy. Of, whom 34(89.4%) had attained remission on day 28 (p<0.01). Day 14 bone marrow blast was absent in 27 cases out of whom 26(96.3%) attained remission on day 28 (p<0.01). The clinicopathological details of the study patients are summarized in table 1.The overall survival rate was 62% in patients with absence of day 14 bone marrow blast and 32% in patients with persistent disease at the end of 48 months (Figure 1). Patients who attained remission on day 28 had 55% survival at the end of 48 months compared to those who had persistent disease on day 28 (16% survival). Analysis of risk stratification of patients showed that those in favorable risk, intermediate risk and adverse risk had overall survival of 80%, 39% and 21% respectively at the end of 48 months.ConclusionsDay 5 peripheral blood blasts and day 14 bone marrow status are most important factors that help predicting remission on day 28 in patients with AML, surpassing the prognostic information obtained from analysis of pretreatment characteristics alone. Day 14 bone marrow blasts can be used as a surrogate marker in predicting overall survival and disease free survival. Also, day 14 bone marrow studies can help in identifying subset of patients who can be benefit from HSCT. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Minimal Residual Disease (MRD) Assessment after Induction Chemotherapy in Children and Adults with Acute Lymphoblastic Leukemia (ALL): A Valuable Strategy in Resource Constraint Settings in the Indian Subcontinent

Background: In a developing country with limited resources and insurance coverage, it is very important to risk stratify patients early in the treatment of Acute Lymphoblastic Leukemia (ALL). This strategy will enable better utilization of resources and also identify a subset of patients who will benefit from early haematopoeitic stem cell transplant (HSCT). Historically, clinical and laboratory features such as age, gender, white blood cell counts at diagnosis, organomegaly, mediastinal mass, morphology, immunophenotyping and cytogenetics have been used to assess the outcome of patients with ALL. However recent studies have shown that assessment of minimal residual disease (MRD) was the most important prognostic determinants of both childhood and adult ALL. Currently multiparameter flow cytometry and quantitative polymerase chain reaction (PCR) of the immunoglobulin or TCR genes are most commonly used for the assessment of MRD. However availability of this technology is very limited. In this present study, we assessed the MRD at day 33 post induction chemotherapy by flowcytometry at our center, and risk stratified patients to determine outcomes.Methods: We analyzed a cohort of 70 de novo ALL patients who presented to our Hospital (Mazumdar Shaw Medical Center, Narayana Health City, Bangalore, India) between April 2014 and April 2017. Diagnosis was confirmed by bone marrow aspiration based on the morphology, cytochemistry, immunophenotyping and cytogenetics. Clinico-pathological features, immunophenotyping, cytogenetics were recorded at the time of presentation. Day 8 prednisolone response was recorded and MRD assessment was done at day 33, using 8 Color multiparameter Flowcytometry. The cost of MRD analysis is 220 US$.Results: Out of 70 patients, 47 (67%) were male. The median age was 9 years (range: 8 months, 69 years). Among the subtypes, B-ALL was found in 83% (n=58) and T-ALL in 17% (n=12). The most common presenting symptom was fever (66%). Hepatosplenomegaly was seen in 35% (n=23), lymphadenopathy in 35% (n=24). CNS involvement at presentation was seen in 8.6% (n=6). The median WBC count at presentation was 11x103/µl (0.8-437). Majority of adults (39%) and pediatric patients (44%) had normal cytogenetics. This was followed by hyperdiploidy (27%, n=11) in children and t(9;22) in adults (26%, n=6). Intermediate risk cytogenetics were seen in most of the patients (44%, n=26). 57 patients (81%) showed good prednisolone response at day 8. Twenty-seven (40%) patients were MRD positive at day 33. Among the MRD positive cases, nearly 50% patients were aged <1 yr or >10 yr. Seventy-five percent of patients in the age group between 1-9 yrs were MRD negative. 72% patients with WBC >50x103/µl, 40% of patients with CNS involvement and 50% of patients with PPR group had MRD positivity. The incidence of MRD positivity was similar in both B-ALL and T-ALL patients (40% vs 42%). The MRD status and clinical details are summarized in table 1. The disease free survival was significantly higher in MRD negative patients compared to MRD positive patients at 24 months (97% vs 58%, p<0.01) (Figure 1).CONCLUSION: MRD assessment at day 33 post chemotherapy is the most important factor in determining risk of relapse in patients with ALL, surpassing the prognostic information obtained from analysis of pretreatment characteristics alone. This determinant helps to take the decision on offering stem cell transplant to MRD positive patients, on the background of resource constraints, and poor outcomes of CR2 transplants. [Display omitted] Figure 1: Overall Survival at 24 months: MRD positive vs. MRD negative DisclosuresNo relevant conflicts of interest to declare.

Accelerated T Cell Senescence after Allogeneic Hematopoeitic Stem Cell Transplantation

Long-term survivors of allogeneic hematopoietic stem cell transplantation (HSCT) remain susceptible to opportunistic infections, relapse of primary malignancy and development of secondary malignancy, features that are consistent with continued immune deficiency. Reconstitution of T cell populations following HSCT and the preceding conditioning regimens occurs via two main routes: a thymic-dependent generation of naive T cells from progenitors via thymopoeisis, and a thymic-independent peripheral expansion of adoptively transferred, mature T cells in the graft. We hypothesized that dependence on peripheral expansion for reconstitution in individuals over forty years old leads to T cell populations that are prematurely senescent. In this retrospective study of patients who underwent matched, related allogeneic transplantation, we compared PBMCS from a cohort of long-term (4-5 years) survivors of transplant and their original donor infusion products (n=13), evaluating the expession of markers of immunosenescence and aging (CD28, KLRG1, CD57 and PD-1) at each time point. Using multi-parameter flow cytometry, we determined that CD8 cells expressed significantly higher levels of markers of T cell terminal differentiation and senescence post-transplant. Both the frequency and absolute number of Effector Memory and TEMRA, as well as the incidence of cells expressing senescence markers increased. Although there was no significant change in frequency of CD8+ T-cells actively proliferating (% Ki-67+), TREC analysis revealed that the frequency of recent thymic emigrants in the peripheral T-cell pool was reduced long-term. Additionally, we assessed the telomere lengths of CD8+ T-cells using Flow-FISH and, in line with our hypothesis that reliance on peripheral expansion results in replicative senescence, found that they were significantly shorter post-transplant. In conclusion, our study suggests that a contributory factor underlying the disposition for opportunistic infections in long-term survivors of transplant may be premature T cell dysfunction resulting from immune reconstitution-related senescence.Figure Captions:Figure I. Immune reconstitution post-transplant(A) Absolute T, B, and NK cell counts were measured at the donor infusion and post-transplant time points in 13 donor-recipient pairs. Lines indicate median values for each time point. (B) Individual CD4+ and CD8+ T cell changes post-transplant relative to the donor infusion time point. (C) Inversion of the normal CD4:CD8 ratio at the post-transplant time point. (D) Median values for absolute CD4 and CD8 cell counts per uL for the patient cohort throughout the post-transplant time period.Figure II. Alterations in T cell subsets post-transplant(A) Frequencies of Naive (CCR7+ CD45RA+), Central Memory (CCR7+ CD45RA-), Effector Memory (CCR7- CD45RA-), and Effector Memory cells that re-express CD45RA (TEMRA; CCR7- CD45RA+) subsets for both CD4 and CD8 cells at the donor infusion and post-transplant time points. Boxes indicate the 25th quartile, median, and 75th quartile values; whiskers indicate the minimum and maximum values. (B) Absolute cell numbers per uL for each CD4 and CD8 T cell subset. (C) Ratio of absolute cell number for Naïve/Central Memory + Effector Memory populations at the donor infusion and post-transplant time points. (D) TREC analysis of the CD4 and CD8 populations assessing thymic generation of naive T cells at the donor infusion and post-transplant time points (n=6). [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

A study on some factors affecting CMV reactivation in allogeneic hematopoietic stem cells transplantation

Background: In developing countries, cytomegalovirus (CMV) seropositivity has been widely propagated. Following hematopoeitic stem cell transplantation, the apparent risk of CMV reactivation increases. With effective surveillance and study of the effect of some factors on CMV reactivation, timely treatment with anti-viral treatment may decrease morbidity and mortality associated with CMV reactivation. Aim: This study aimed to evaluate the effect of some factors on CMV reactivation in allogeneic hematopoietic stem cell transplantation (HSCT). Materials & Methods: We retrospectively analyzed 25 patients with Serostatus positive of CMV IgG antibodies who underwent allogeneic hematopoietic stem cell transplantation at two Bone Marrow Transplantation centers in Egypt from November 2016 to June 2017. Results: In our study, the patient male percentage was 57.1% in CMV reactivation group with the most common pre-transplantation diagnosis was FA, CML and βTM. All donors in the reactivation group (100 %) were positive for CMV IgG ab. This group had 42.9% matching donors in sex and blood groups. While the stem cell source was 92.9% peripheral blood source with a median dose of 7.0 cells ×106 ∕ kg. Conclusion: The incidence of CMV infection following hematopoietic stem cell transplantation is comparable to that recorded in Western literature because of a higher seroprevalence rate in developing countries. More research is needed to study factors affecting cytomegalovirus reactivation in allogeneic hematopoietic stem cells transplantation (HSCT).

Role of intravesical granulocyte-macrophage colony-stimulating factor in controlling hemorrhagic cystitis in patients undergoing stem cell transplantation - A retrospective cohort study

Introduction: Hemorrhagic cystitis (HC) is a well-known complication in patients undergoing hematopoeitic stem cell transplantation (HSCT), contributing considerably to morbidity and prolonged hospital stay. Granulocyte-macrophage colony-stimulating factor (GM-CSF) affects the proliferation and differentiation of hematopoietic stem/progenitor cells and the functioning of monocytes, granulocytes, lymphocytes, and endothelial cells. The objective of this study was to evaluate the efficacy and safety of GM-CSF bladder irrigation for HC post-HSCT. Materials and Methods: We conducted a retrospective cohort study to assess the clinical effects of GM-CSF (GM-CSF group) in controlling HC in patients who had undergone HSCT at our institute. We also compared these patients with those who did not receive GM-CSF. Results: There were 12 patients in the GM-CSF group and seven patients in the non-GM-CSF (control) group. The median ages were 16 years (range: 4–33 years) and 19 years (range; 6–41 years), respectively. Median time-to-resolution of HC from day of onset was 9.5 days in the GM-CSF group versus 59 days in the non GM-CSF group (P = 0.001). Mortality was 85% in the control group as compared to 16% in GM-CSF group (P = 0.008). Among the GM-CSF responders, complete response was seen in eight patients (67%). None of the patients developed any systemic or local side effects to GM-CSF. Overall survival in the two groups was 75% and 14%, respectively (P = 0.043). Conclusion: GM-CSF was shown to be effective in controlling HC in post-HSCT patients, without any major side effects, along with decreased mortality and improved overall survival.

Evaluation of the Cost of Survivorship Care After Allogeneic Hematopoeitic Stem Cell Transplantation-An Analysis of 2 German Transplantation Centers.

The aim of the presented study was to analyze the care expenditure for outpatients after allogeneic hematopoietic stem cell transplantation (alloHSCT) done in accordance with the national, European guidelines and the German Social Law. We performed an analysis of the National and European survivorship care guidelines and in parallel recorded the time expenditure and staff costs separated according to different occupational groups involved in outpatient care at two German transplantation centers [University Hospital Regensburg (UKR) and University Hospital Hamburg-Eppendorf (UKE)]. In addition, we performed a comparison of real costs vs. reimbursed costs according to the standard rating benchmark catalog (EBM), which was supplemented by a survey of German transplantation centers. The results showed that the staff costs are only covered by the EBM for patients without complications during long-term follow-up care—notably, this accounts for 15% of alloHSCT patients. Staff costs for patients requiring treatment of graft-vs.-host disease or relapse of the malignant underlying malignancy exceed to the factor 6.5 (UKR) to 12 (UKE) of the EBM revenue, caused both by the increased duration and frequency of the outpatient visits. As a result of the survey at German transplant centers, 15 out of 18 responding centers reported a lack of cost coverage for follow-up care. Two/15 centers reported that survivorship care is limited to a restricted time, independent of patient's needs, due to a lack of cost reimbursement. The results show that alloHSCT survivorship care of patients requires significant staff resources, which are not covered by the current version of the German EBM catalog. New approaches to finance labor intensive after care of transplant patients are required.

A case report of severe veno-occlusive disease following autologous stem cell transplantation successfully treated with Defibrotide

Veno-occlusive disease (VOD) is one of the complications of hematopoietic stem cell transplantation that can also be caused by high-dose chemotherapy. This complication can lead to high mortality following bone marrow transplantation. It is more common after allogeneic stem cell transplantation, and is rare after autologous stem cell transplantation. While mild cases of VOD may reduce over a period of a few weeks, very severe cases can cause multi-organ damage, which has a high mortality. is therefore required with early diagnosis and treatment of this complication. In this paper, we present a sever VOD case after autologous stem cell transplantation, that was treated successfully with Defibrotide. The patient was a 14-month-old girl who has neuroblastoma with bone metastasis. VOD should be considered in the differential diagnosis of haematopoietic stem cell transplantation recipients who present with unexplained liver injuries, ascites and/or multi organ failure. Recipients of haematopoeitic stem cell transplantation who present with unexplained liver injuries, ascites and/or multi organ failure should have VOD considered in their differential diagnosis. If there is severe VOD diagnosed, then Defibrotide could be an option for treatment.

A case report of severe veno-occlusive disease following autologous stem cell transplantation successfully treated with Defibrotide.

Veno-occlusive disease (VOD) is one of the complications of hematopoietic stem cell transplantation that can also be caused by high-dose chemotherapy. This complication can lead to high mortality following bone marrow transplantation. It is more common after allogeneic stem cell transplantation, and is rare after autologous stem cell transplantation. While mild cases of VOD may reduce over a period of a few weeks, very severe cases can cause multi-organ damage, which has a high mortality. is therefore required with early diagnosis and treatment of this complication. In this paper, we present a sever VOD case after autologous stem cell transplantation, that was treated successfully with Defibrotide. The patient was a 14-month-old girl who has neuroblastoma with bone metastasis. VOD should be considered in the differential diagnosis of haematopoietic stem cell transplantation recipients who present with unexplained liver injuries, ascites and/or multi organ failure. Recipients of haematopoeitic stem cell transplantation who present with unexplained liver injuries, ascites and/or multi organ failure should have VOD considered in their differential diagnosis. If there is severe VOD diagnosed, then Defibrotide could be an option for treatment.

Effect of different conditioning regimens on survival and engraftment for children with hemophagocytic lymphohistiocytosis undergoing allogeneic hematopoeitic stem cell transplantation: A single institution experience.

Hemophagocytic lymphohistiocytosis (HLH), a rare hyperinflammatory immuneregulatory disorder, is a challenge in hematopoietic stem cell transplantation (HSCT) because of the high rate of mixed chimerism, relapse, and graft failure (GF) unless intensive myeloablative regimens are used. However, historically conventional myeloablative regimens (convMA) are associated with high toxicity and mortality. We retrospectively compared transplant outcomes between three preparative regimens of varying intensities: Conv MA (n=15), reduced-intensity conditioning (RIC, n=12), and a treosulfan-based reduced-toxicity conditioning (RTC, n=9). Patients in the RIC cohort had a higher incidence of mixed donor chimerism and five patients (42%) developed secondary GF (P=.002) compared to the other two regimens. There was a higher incidence of veno-occlusive disease and intensive care unit (ICU) admissions in the Conv MA cohort. With the RTC regimen, there was a similar 2-year overall survival (89, 73, and 83%; P=.87), but improved compound EFS (lack of relapse, GF, second transplant or additional donor cell infusions, or death; 89, 73, and 42%, P=.041) in RTC, Conv MA, and RIC regimen, respectively. The intensity of the preparative regimen has a significant impact on outcome of HSCT for HLH. The newly described treosulfan-based RTC provides for a stable graft with a reasonable toxicity profile.

Thalassaemia Care in Terengganu – A Local Report

Inherited thalassaemia disease is commonly found in many countries of the world. Care of the disease requires comprehensive management strategies comprising of clinical management of both transfusion dependant thalassaemia (TDT) and non-transfusion dependant thalassaemia (NTDT). It also includes preventive measures such as screening programmes and genetic counseling in order to contain the genetic transmission. At the moment, the only cure is through haematopoeitic stem cell transplant (HSCT). This report illustrates thalassaemia disease prevalence in the Terengganu state and the evolution of care since National Thalassaemia Programme was launched in 2009.

Nuclear factor-κB1 and MicroRNA-146a polymorphisms and risk of acute graft versus host disease post allogeneic stem cell transplantation.

Acute graft-versus-host disease (aGVHD) is a severe inflammatory complication of haematopoeitic stem cell transplantation. The nuclear factor- Kappa Beta (NF-κB) signaling pathway regulates T cell activation. The NF-κB controls the expression of microRNA-146a (miR-146a) that in turn regulates NF-κB activation through a negative feedback loop. We aim to analyze the association between NF-κB1 encoding p50 (rs28362491, -94 in.ertion/deletion ATTG) and miR-146a (rs2910164, G > C) polymorphisms and risk of aGVHD. Genotyping was performed for 135 HLA-matched donors using polymerase chain reaction- restriction fragment length polymorphism (PCR-RFLP).The incidence of aGVHD grades II-IV was 24/135 (17.8 %). NF-κB1 genotype and cytomegalovirus infection were significantly associated with risk of aGVHD II-IV (p = 0.022, HR = 3.17, 95 % CI:1.18-8.51 and p = 0.048, HR = 2.56, 95 % CI:1.01-6.52, respectively). In multivariate analysis, NF-κB1homozygous deletion/deletion genotype was the only independent risk factor associated with aGVHD II-IV (p = 0.013, HR = 3.50, 95 % CI:1.30-9.44). No significant association could be observed between miR-146a polymorphism and aGVHD. Combined NF-κB1 and miR146a genotype analysis warrants investigation in a larger cohort. Our preliminary data do not support the association between miR146a and aGVHD, but suggest an association between NF-κB1 and risk of aGVHD that may pave the way for the development of a novel targeted therapy if proved in a larger cohort.

Prevalence of Bronchiolitis Obliterans Syndrome (BOS) Following Allogeneic Hematopoietic Stem Cell Transplant (alloHSCT) in the USA, Europe and Japan

Background: Bronchiolitis obliterans syndrome (BOS), also known as respiratory chronic Graft versus Host Disease (cGvHD) is an obstructive airway disease of the lungs mainly associated with alloHSCT or lung transplantation. BOS is characterized by T-cell mediated inflammation and fibrosis of bronchiolar walls that reduces the diameter of the bronchioles resulting in progressive and irreversible airflow obstruction. BOS is a well described complication following lung transplant with a 5-year prevalence rate of 50%. It can also be a complication following alloHSCT with similar histopathology and clinical symptoms. Currently, there are no approved treatments for BOS. The aim of this study is to describe the prevalence of BOS following alloHSCT. A review and analysis of the following data sources was performed: AlloHSCT activity reports from The European Society for Blood and Marrow Transplant 2016 the Center for International Blood and Marrow Transplant Research 2016, and the Japanese Data Center Hematopoeitic Stem Cell Transplantation 2015 in order to identify the number of procedures performed. Further a PubMED literature search was also conducted and identified publications with &gt; 100 patients using the key terms "bronchiolitis obliterans and haematopoietic stem cell", and "bronchiolitis obliterans after stem cell transplant" from 2011 to 2017. Case reports and redundant publications were excluded from the analysis. Results Approximately 30,000 alloHSCTs were performed each year in the USA (8766 in 2016), Europe (17,617 in 2016) and Japan (3700 in 2015). Based on seven eligible studies published between 2011 and 2016, the reported prevalence of BOS in patients who underwent alloHSCT ranged from 3.4% to 10%. Median time to diagnosis of BOS following alloHSCT was 273 to 547 days post-transplant. Those with routine Forced Expiratory Volume at 1 second (FEV1) monitoring had a higher likelihood of being diagnosed with BOS and a shorter time to diagnosis. Conclusion Based on estimated prevalence, up to 3000 patients following alloHSCT per year could be diagnosed with BOS. Routine monitoring may positively impact early and shorten time to diagnosis and allow treating such a population. Figure Disclosures Hofstetter: Breath Therapeutics GmbH: Consultancy. Henig:Breath Therapeutics Inc.: Employment. Kappeler:Breath Therapeutics GmbH: Consultancy.

883 – Integration of Clinical, Immunologic and Genomic Data in Children with Very-Early Onset Inflammatory Bowel Disease Leads to Identification of Candidates for Curative Therapy with Hematopoeitic Stem Cell Transplantation

883 – Integration of Clinical, Immunologic and Genomic Data in Children with Very-Early Onset Inflammatory Bowel Disease Leads to Identification of Candidates for Curative Therapy with Hematopoeitic Stem Cell Transplantation

Bloodless Autologous Hematopoeitic Stem Cell Transplant: An Alternative for Jehovah's Witnesses and Others Who Prefer to Go Bloodless

Topic Significance & Study Purpose/Background/Rationale Every year people are diagnosed with Non-Hodgkin's Lymphoma (NHL) and Multiple Myeloma (MM). As an alternative treatment modality, they may seek to have a Hematopoietic Stem Cell Transplant (HSCT), which usually requires blood product transfusions. This poses a challenge when treating Jehovah's Witnesses, who normally refuse whole blood products based on religious beliefs; however, many will accept minor blood fractions and recombinant products, such as erythropoietin and granulocyte colony stimulating factors (G-CSF). Methods, Intervention, & Analysis In this study, five Jehovah's Witnesses were enrolled in the Bloodless Care Program and went through a series of pretransplant testing. Testing included an echocardiogram, electrocardiogram, and stress test to evaluate possible underlying coronary artery disease and cardiac amyloidosis. Once they qualified for a transplant, a conditioning regimen was determined and they were prepared for apheresis. Before apheresis, the patient must have hemoglobin of 11.0 g/dL and platelet count of 100 K/mm3; if not, erythropoietin and intravenous iron were given to achieve that goal. Patients were then prepped with G-CSF and Plerixafor for stem cell collection. The goal for collection was a minimum of 4 million CD34+ cells per kilogram. Post collection, there was a two week window given prior to admission for the bloodless autologous HSCT. The conditioning regimen varied on their diagnosis. For the four MM patients, the regimen was Melphalan 140mg/m2; for the one NHL patient, the regimen was Carmustine, Etoposide, and Cytoxan (BECy). When the platelet count fell below 30 K/mm3 post-transplant, Amicar was administered. Minimal phlebotomy and pediatric tubes were recommended to reduce iatrogenic anemia. Findings & Interpretation The Average length of stay was 16.7 days. After transplant, the median nadir hemoglobin was 9.15 g/dL, while the platelets were 5.5 K/mm3. One patient was readmitted within 30 days after transplant for fever during engraftment. One patient relapsed and received a second bloodless autologous HSCT 9 months later. There were no mortalities. Discussion & Implications Utilizing minor fractions, blood conservation modalities, and appropriate pre-transplant workup, resulted in safely performing bloodless autologous HSCT for Jehovah's Witness; therefore, proving this can be an alternative treatment for those who prefer to go bloodless.

Estratégias de enfrentamento utilizadas durante o tratamento por pacientes submetidos ao transplante de células-tronco hematopoiéticas

Background: Coping strategies in the process of treatment with hematopoeitic stem cell transplantation are crucial to the improvement of the quality of life of these patients. Objective: To describe coping strategies used during treatment by patients submitted to hematopoietic stem cell transplantation. Methodology: Qualitative, descriptive, and exploratory research, with 5 participants, conducted from July to November 2017, in a hospital of reference for this treatment in Brazil. Data were collected by means of semi-structured and self-applied video interview and analysed by the content analysis technique. Results: Coping strategies such as family support and spirituality were the most used, present in every stage of transplant, followed by the increase of feeling of appreciation of life after overcoming this experience. Conclusion: Patients develop coping strategies to endure therapy effects. The knowledge of the strategies can contribute to the enlightenment and stimulation of future patients regarding coping with treatment, as well as to the assistance of health professionals, especially nursing teams in care practice

Immune Mediated Cytopenia's Following Cord Blood Transplantation for Hurler's Syndrome: A Failure of Pre-Transplant Immune Suppression

Background: Hurler's syndrome is the most severe phenotype of Mucopolysaccharidosis 1 (MPS1H) with severe deficiency of the lysosomal enzyme alpha-L-iduronidase causing heparan and dermatan sulfate accumulation, CNS and somatic manifestations and premature death. Haematopoeitic Stem Cell Transplant (HSCT) alters the disease phenotype and prevents early death, and is standard of care in this condition. The use of an established ‘donor hierarchy’ recommending Unrelated Cord Blood Transplantation (UCBT) in the absence of a HLA-matched, non-carrier sibling, has resulted in improved engrafted and surviving rates and better post-enzyme levels with improved somatic and CNS clinical outcomes. However, UCBT for malignant and non-malignant conditions has led to high rates of post-transplant autoimmune disease, most frequently Autoimmune Cytopenia (AIC). We report a large cohort of MPS1H patients receiving busulfan-based UCBT and show that AIC is a frequently encountered complication of treatment with significant associated morbidity and we identify important risk factors for its occurrence.Methods: This was a retrospective observational study of patients undergoing first UCBT for Hurler's Syndrome at the Royal Manchester Children's Hospital between 30th September 2004 and 15th March 2018. An episode of AIC was defined as an episode of single or multi-lineage cytopenia occurring post-engraftment, confirmed by the presence of antibodies or diagnosed on the basis of clinical, biochemical and pathologic features. All patients received pK targeted busulfan to achieve myeloablative levels between 80-90 mg/L x hr. Conditioning between 2004 and May 2010 was with Busulfan and Cyclophosphamide (BuCy), and Fludarabine and Busulfan (FluBu) thereafter based on the reported equivocal efficacy and favourable toxicity profile of FluBu conditioning. All patients received serotherapy with Anti-Thymocyte Globulin (ATG) 10mg/kg for In Vivo T-Cell depletion. Timing of ATG was either distal (day -4 to -1) or proximal (day - 9 to -6) in accordance with international consensus at the time. Variables assessed in statistical analysis were conditioning drugs, ATG timing, Absolute Lymphocyte Count pre-conditioning, age-at-transplant, Graft-versus-Host Disease (GVHD) and Total Nucleated Cell dose.Results and Discussion: Thirty-six patients underwent first UCBT for Hurler's Syndrome. There were 8 episodes of AIC (22%), with median onset post-UCBT of 66 days (range 22-236 days). The median number of therapies required was 4 (range 0-8), with duration of illness ranging from 10 to 215 days. There were no deaths, though there were 2 episodes of life-threatening bleeding. Absolute Lymphocyte Count pre-conditioning (p=0.004), FluBu conditioning (p=0.03) and use of proximal-ATG (p=0.016) were significant risk factors for AIC in univariate analysis(see figure 1). Absolute Lymphocyte Count pre-conditioning was the most significant predictor in multivariable analysis (AOR 5.796, CI 0.921-36.474). This confirms that AIC is a frequent, serious but survivable complication of UCBT for Hurler's Syndrome. This data indicates that the balance between recipient immunity and graft immunity impacts AIC risk and severity, mandating a larger international review of registry data to define the frequency of AIC in this population, and an analysis of the risk factors that predispose to it. By better defining these risk factors, we can identify patients in whom conditioning might be altered to reduce risk.Figure 1. Univariate analysis of variables predicting an episode of Autoimmune Cytopenia. ALC (p=0.004), ATG timing (0.016) and Conditioning drugs (p=0.032) were significant risk factors. GVHD= Graft-versus-Host Disease ATG= Anti-Thymocyte Globulin [Display omitted] DisclosuresWynn:Orchard SAB: Membership on an entity's Board of Directors or advisory committees; Orchard Therapeutics: Equity Ownership; Chimerix: Research Funding; Genzyme: Honoraria; Bluebird Bio: Consultancy; Orchard Therapeutics: Consultancy; Chimerix: Consultancy.

Two siblings with PRKDC defect who presented with cutaneous granulomas and review of the literature

V(D)J recombination, during which recognition and repair of broken DNA chains are accomplished by non-homologous end joining pathway, is a critical process in B and T cell development.Null mutations of each enzyme or protein of this pathway result in T- B- NK+ severe combined immunodeficiency whereas hypomorphic mutations result in atypical(leaky)severe combined immunodeficiency forms. We present two siblings with PRKDC (Protein Kinase, DNA-Activated, Catalytic Polypeptide) mutation who presented with granulomatous skin lesions and recurrent lung infections. Primary immune deficiencies may initially present with skin findings. Disruption in central and peripheral B-cell tolerance and impaired intrathymic T-cell maturation,a central player in T-cell tolerance, have been identified as the mechanism of autoimmunity and granuloma seen in patients. The variation in clinical phenotypes of patients with PRKDC mutation suggests that additional factors such as modifying genes, epigenetic and environmental factors may affect the severity and clinical phenotype of the disease. Functional studies during the follow-up and evaluation before and after hematopoeitic stem cell transplantation will hopefully increase our knowledge about the autoimmune and inflammatory process of the disease spectrum.

Gastrointestinal Biopsies for Evaluation of Acute Graft-Versus-Host Disease in Allogeneic Hematopoietic Stem Cell Transplant Patients.

Graft-versus-host disease (GVHD) is the major complication post hematopoeitic stem cell transplantation (HSCT) causing significant morbidity and mortality. Colonic biopsies were performed in 25 post HSCT patients presenting the diarrhea for diagnosis of acute graft versus host disease (A-GVHD). The present study was undertaken to evaluate and illustrate histomorphological features of A-GVHD in GI biopsies and to grade them. Histopathological features of gastrointestinal biopsies from 25 allogeneic HSCT patients having clinical suspicion of A-GVHD were evaluated and compared with colonic biopsies from negative controls. A-GVHD was observed in 17 cases, CMV colitis was present in 3 cases and one case had herpes simplex infection diagnosed in conjunction with serological findings. A-GVHD was graded as grade 1 and 2 in 10 cases and grade 3 and 4 in 7 cases. Apoptosis of crypt epithelial cells was the cardinal feature for diagnosis. Grade 1 and grade 2 A-GVHD cases showed crypt apoptosis in all cases as well as pericryptal apoptosis in lamina propria in many cases. Occasional crypt loss was seen in grade 2 GVHD. Inflammatory infiltrate was composed of lymphocytes and plasma cells. Neutrophils were inconspicuous. Grade 3 and grade 4 A-GVHD cases showed contiguous areas of multiple crypt loss and ulceration with inflammatory infiltrate predominantly composed of lymphocytes and plasma cells, but neutrophils were more prominent than in grade 1 and 2 A-GVHD. Apoptosis of crypt epithelial cells was present in all grade 3 &4 cases except one case. CMV cases were diagnosed by CMV inclusions and IHC stain. Several factors including drug-induced side effects and infections can cause difficulty in histologic interpretation of gastrointestinal biopsies for GVHD. Proper histomorphological interpretation of intestinal A-GVHD is critical for clinical management. A-GVHD is treated with immunosuppression which may worsen infective condition, if present.