HLA-identical Bone Marrow Transplantation Research Articles

Disease Burden and Pre-Transplant Health-Related Quality of Life in Pediatric Sickle Cell Disease Patients Receiving Nonmyeloablative HLA-Identical Sibling Donor Transplantation

Title: Disease Burden and Pre-transplant Health-related Quality of Life in Pediatric Sickle Cell Disease Patients Receiving Nonmyeloablative HLA-identical Sibling Donor TransplantationBackground: Sickle cell disease (SCD) is a hemoglobinopathy characterized by recurrent pain crises, severe organ damage, and reduced health-related quality of life (HRQL). Bone marrow transplantation (BMT) is a proven curative treatment for SCD that can improve both disease burden and HRQL. Despite the benefits, relatively few patients pursue a cure through BMT. The decision to receive a BMT is nuanced and likely to be influenced by a number of factors. One study by Roth et al. showed SCD patients interested in BMT had a higher HRQL than those uninterested in BMT, suggesting some variability between SCD patients pursuing transplant and the general SCD patient population. To date the factors that may affect pre-transplant HRQL of pediatric SCD patients remain unclear, particularly in the nonmyeloablative setting.Objective: To evaluate the impact of disease-burden, patient demographics, and hydroxyurea treatment on pre-transplant HRQL.Methods: Children and young adults with SCD set to receive a nonmyeloablative HLA-identical sibling donor BMT were administered HRQL surveys (PedsQL) in the six months leading up to the start of the conditioning regimen. Patients' disease history and demographic information were captured and analyzed for their relationship to HRQL. PedsQL parent surveys were used when patient surveys were unavailable. The mean difference in HRQL between groups were compared using an unpaired t test or linear regression.Results: 32 patients were enrolled onto this study. Six of the 32 patients HRQL were not included due to withdrawal, delay of transplant, or completion of the survey outside of window. The median age at the time of survey administration was 13.5 years (range 2-21). 57.7% of patients were male and 88% of patients had genotypes hemoglobin SS or Sβ 0thalassemia. 12% of patients had a history of overt stroke. 52% of patients were hospitalized while receiving HU treatment. 32% of patients received chronic blood transfusions leading up to transplant. The median number of hospitalizations in the two years leading up to transplant was 2 (range 0-10). 16.7% of patients met the AAPT diagnostic criteria for chronic pain. 75% of patients received HU treatment leading up to transplant. The median hemoglobin F percentage was 10.4. The median HRQL for all patients was 77.17 (range 36.9-98.91, SD +/- 15.99).Sickle cell genotype (P=0.88), history of overt stroke (P=0.79), hospitalization while receiving HU treatment (P=0.78), and the number of hospitalizations in the two years before transplant (P=0.39) were not associated with lower HRQL. History of chronic transfusion leading up to transplant approached statistical significance for lower HRQL (P=0.06). Older age (P=0.17) and female gender (P=0.89) were not associated with worse HRQL. Patients receiving HU treatment had significantly higher HRQL than patients not receiving HU (P=0.0034), with median PedsQL scores of 80.06 and 58.64, respectively. The date of survey administration was not associated with HRQL (P=0.40). The number of eligibility criteria met (P=0.63), chronic pain (P=0.17), total number of RBC transfusions (P=0.45), and pre-transplant hemoglobin (P=0.25) were not associated with HRQL.Discussion: Patient demographics and several markers of disease burden appear to have minimal impact on HRQL. Interestingly, the use of HU therapy was associated with significantly higher pre-transplant HRQL. The etiology of this finding is unclear given that disease burden was not associated with HRQL and warrants further investigation. The absence of association between disease burden and HRQL through current disease severity eligibility paradigms suggests that other factors may impact HRQL in SCD patients choosing a low toxicity nonmyeloablative BMT. DisclosuresNo relevant conflicts of interest to declare.

Evidence That CD31, CD49b, and CD62L Are Immunodominant Minor Histocompatibility Antigens in HLA Identical Sibling Bone Marrow Transplants

Despite complete matching of siblings for the HLA loci, after bone marrow transplantation (BMT), approximately 20% develop graft-versus-host disease (GVHD). This is presumably due to incompatibility of minor histocompatibility antigens (mHa). We investigated the polymorphisms of 14 adhesion molecules (CD2, CD28, CD31, CD34, CD36, CD42, CD44, CD48, CD49b, CD54, CD62L, CD86, CD102, and CD106) in Japanese subjects and their association with the occurrence of GVHD after allogeneic HLA identical BMT. Six molecules (CD2, CD31, CD42, CD49b, CD54, and CD62L), which were found to be polymorphic, were then examined in 118 HLA identical sibling donors and recipients who had undergone BMT. Association of the incompatibility of the polymorphic molecules with the presence or absence of GVHD was examined. In these six, we observed a significant correlation between acute GVHD and the compatibility of CD31 (codons 563/670) (Pcorrected = .018), and CD31 (codons 563/670) + CD62L (Pcorrected = .018) in patients with the HLA-B44–like superfamily. In patients with the HLA-A3–like superfamily, the compatibility of CD62L (Pcorrected= .03) and CD62L + CD49b (P = .004,Pcorrected = .078) was associated with acute GVHD. Therefore, CD31, CD49b, and CD62L might be candidates for immunodominant mHa.© 1998 by The American Society of Hematology.

HLA Class I Alloimmunization and Platelet Transfusion Support in HLA-Identical Bone Marrow Transplant for Sickle Cell Disease: A Sickle Transplant Alliance for Research Study

Introduction: HLA alloimmunziation has been described in patients, including pediatric patients with sickle cell disease (SCD), who received only leukocyte-reduced red blood cell (RBC) transfusions. While HLA alloimmunization has significant implications in bone marrow transplant (BMT) with an HLA-disparate donor (donor-specific HLA antibodies increase the risk of graft rejection), the clinical significance of this alloimmunization in HLA-identical BMT is unclear. In particular, it is unknown whether HLA class I alloimmunization affects platelet transfusion support during BMT. Platelet transfusions are especially important in BMT for SCD because of the historic high incidence of intracranial bleeding and the subsequent adoption of a relatively high platelet transfusion threshold.Methods: We tested for HLA class I alloimmunization using pre-BMT serum or plasma from 32 pediatric patients with SCD undergoing BMT with an HLA-identical sibling donor. HLA class I alloimmunization was evaluated using the FlowPRA® (panel reactive antibody) screening test which detects IgG antibodies to the majority of HLA class I antigens. Pre-BMT, patients had received leukocyte-reduced RBC transfusions. All patients undergoing BMT received leukocyte-reduced, irradiated, apheresis platelet transfusions to maintain a platelet count greater than 50 x 109/L. The number of platelet transfusions received in the first 45 days post-BMT was compared between those with a positive PRA versus those with a negative PRA using a two-sample t-test.Results: Among the 32 patients studied, the mean age at BMT was 9.4 years (range 1-21 years). Pre-BMT, 40% had received greater than 10 RBC transfusions and 32% of the entire cohort was receiving chronic RBC transfusions. BMT conditioning regimens included: traditional myeloablative busulfan, cyclophosphamide, antithymocyte globulin (BU-CY-ATG) (n=10); dose-reduced BU-CY-ATG + fludarabine (flu) (n=16); reduced intensity conditioning (RIC) alemtuzumab, flu, melphalan +/- thiotepa (n=5); and RIC BU-flu-ATG (n=1). All patients received HLA-identical sibling donor bone marrow, with 3 patients receiving a combined bone marrow and cord blood graft. All patients engrafted with 100% survival at day +45. Six patients developed acute graft-versus-host disease (GVHD): 1 grade I, 3 grade II, 1 grade 3, 1 grade 4. No patient had an intracranial bleed or other serious bleeding.From testing of the pre-BMT sample, 11/32 (34%) of patients had a positive HLA class I antibody screen. HLA class I alloimmunized patients received significantly more platelet transfusions than non-alloimmunized patients: mean 19.2 (SD 13.9) vs. 11.2 (SD 8.0) transfusions, p=0.049 (Figure). On univariate analysis, age, sex, conditioning regimen, and GVHD were each not significantly associated with the number of platelet transfusions (p>0.1). Only two patients developed hepatic sinusoidal obstruction syndrome (one HLA alloimmunized patient, one non-alloimmunized patient). Mean day of platelet engraftment was not significantly different between alloimmunized compared to non-alloimmunized patients: day +34.6 (SD 10.6) vs. day +30.2 (SD 11.3), p=0.28. Among HLA class I alloimmunized patients, the mean positive PRA was 19.7% (range 4-55%); there was no association with this PRA value and the number of platelet transfusions (r2=0.0064, p=0.81).Conclusion: In pediatric HLA-identical sibling BMT for SCD, pre-BMT HLA class I alloimmunization (but not the absolute PRA value) appears to be associated with more platelet transfusions. It is unclear if this increased platelet transfusion requirement is due directly to HLA antibody immune-mediated clearance of transfused platelets or other inherent differences of HLA class I alloimmunized patients. [Display omitted] DisclosuresQayed:Novartis: Consultancy.

Engraftment Syndrome (ES) After HLA Identical Bone Marrow and Kidney Transplant (BKT): A Case Report

Engraftment Syndrome (ES) After HLA Identical Bone Marrow and Kidney Transplant (BKT): A Case Report

A Multicenter Phase II Trial of Unrelated Donor Reduced Intensity Bone Marrow Transplantation for Children with Severe Sickle Cell Disease (SCURT): Results of the Blood and Marrow Transplant Clinical Trials Network (BMT CTN 0601) Study

▪Background:Children with severe sickle cell disease (SCD) experience organ damage, poor quality of life, and a risk of premature mortality. Allogeneic bone marrow transplantation (BMT) halts disease progression when stable donor erythropoiesis is established. Myeloablative conditioning (MAC) followed by HLA matched sibling donor BMT is effective, but most patients with SCD lack a matched sibling donor and long term side effects from MAC (e.g., infertility) can be barriers to patient acceptance of BMT. The SCURT trial was designed as a prospective, multicenter phase II trial to evaluate outcomes after HLA matched unrelated donor (MUD) BMT with reduced intensity conditioning (RIC). We hypothesized that an intensely immunosuppressive RIC regimen would be sufficient for donor engraftment and could limit toxicity. The primary endpoint was one year event free survival (EFS) (alive and disease free) ≥75%. All patients were evaluable for the primary endpoint for the purpose of this report.Methods:Children between 3 and 19.75 years of age who had ≥1of the following complications - stroke, high transcranial doppler velocity, recurrent acute chest syndrome, or significant vaso-occlusive pain crises were eligible. An independent review committee confirmed eligibility. The preparative regimen consisted of alemtuzumab (48 mg) (day-22 to -19), fludarabine (150 mg/m2) (day-8 to -4), and melphalan (140mg/m2) (day-3). Donors and recipients were matched at the HLA allele-level at HLA-A, -B, -C and -DRB1 loci. Graft-versus-host disease (GVHD) prophylaxis consisted of tacrolimus or cyclosporine, methotrexate (7.5 mg/m2)on days +1, +3 and +6, and methylprednisolone (1 mg/kg/day) from day +7, tapered after day +28.Results:Thirty patients were enrolled between 2008 and 2014. One patient was excluded from analysis for a major eligibility violation at the DSMB's recommendation. Twenty-nine patients (16 M, 13F), 5.9-19.3 years old (median 14.0 years) from 19 centers were evaluable with median follow up of 25.2 months (range, 12-61.5 months). All patients recovered neutrophils (median 12 days) and platelets >50x109/L (median 24 days). Graft rejection (GR) in 3 patients (10%) occurred before day +100, and was followed by autologous hematopoietic recovery. No late GR has been observed. The primary endpoint was met with1-year EFS of 76% (Figure 1A). The 1-year probability of overall survival (OS) was 86% (Figure 1B). The cumulative incidence (CINC) of grade II-IV and III-IV acute GVHD at day 180 were 31% and 17% respectively (Figure 2A). The CINC of chronic GVHD at 1-year was 62%. Chronic GVHD was extensive in 38% (Figure 2B). GVHD when present was noted by 12 months post-BMT. There were 7 deaths, all in patients >14 years at time of BMT. One death occurred after a second transplant for graft rejection. The other 6 deaths occurred between 143 and 960 days post BMT, from GVHD. Non-fatal toxicities included posterior reversible encephalopathy syndrome (PRES) associated with hypertension and seizures in 35%. All cases were observed in the first 6 months post-BMT; all patients recovered with no obvious sequelae. No patient developed veno-occlusive disease, idiopathic pneumonia syndrome or cerebral hemorrhage. Infections were common, and occurred in 76% of patients. CMV and EBV reactivation each occurred in 23% of recipients. Surviving patients report performance scores of 100% (n=14), 90% (n=5), and 80% (n=3) at 2 years or at the time of last assessment. At last follow up, 13 patients had successfully discontinued immunosuppressive therapy.Conclusion:In summary, the RIC regimen employed in this trial of MUD BMT in children with severe SCD resulted in low rates of regimen-related organ toxicity (other than a high rate of PRES) and 1-year EFS of 76%, associated with regression of SCD manifestations. . The risk of graft rejection/disease recurrence was similar to that observed after conventional HLA-identical sibling donor BMT. Chronic GVHD occurred in 62% of patients and was the leading cause of toxicity and mortality. Future trials should focus on effective GVHD prophylaxis after URD BMT. Secondary outcome analyses including health-related quality of life and neurocognitive performance are ongoing. [Display omitted] [Display omitted] DisclosuresWalters:ViaCord and AllCells, Inc: Other: Medical director. Levine:Novartis: Consultancy.

Isolation of Human CD4/CD8 Double-Positive, Graft-Versus-Host Disease–Protective, Minor Histocompatibility Antigen–Specific Regulatory T Cells and of a Novel HLA-DR7–Restricted HY-Specific CD4 Clone

Minor histocompatibility (H) Ags are classically described as self-peptides derived from intracellular proteins that are expressed at the cell surface by MHC class I and class II molecules and that induce T cell alloresponses. We have isolated three different T cell populations from a skin biopsy of a patient suffering from acute graft-versus-host disease following sex-mismatched HLA-identical bone marrow transplantation. The first population was: 1) CD4(+)/CD8(+) double-positive; 2) specific for an HLA class I-restricted autosomal Ag; 3) expressed a Tr1 profile with high levels of IL-10, but low IL-2 and IFN-γ; and 4) exerted regulatory function in the presence of recipient APCs. The second was CD8 positive, specific for an HLA class I-restricted autosomally encoded minor H Ag, but was only weakly cytotoxic. The third was CD4 single positive, specific for an HLA-DR7-restricted HY epitope and exerted both proliferative and cytotoxic functions. Identification of the peptide recognized by these latter cells revealed a new human HY epitope, TGKIINFIKFDTGNL, encoded by RPS4Y and restricted by HLA-DR7. In this paper, we show human CD4/CD8 double-positive, acute graft-versus-host disease-protective, minor H Ag-specific regulatory T cells and identify a novel HLA-DR7/ HY T cell epitope, encoded by RPS4Y, a potential new therapeutic target.

522 Aspergillus Niger: an Unusual Cause of Invasive Pulmonary Aspergillosis

ObjectiveReport two cases of chronic granulomatous disease presenting with uncommon cause of invasive pulmonary aspergillosis (IPA).MethodsWe report two cases of IPA in two 6-year-old twin girls with a family history...

Manifestación inicial de leucemia linfoblástica aguda en la mama. Descripción de un caso y revisión de la bibliografía

We present a case of acute lymphoblastic leukaemia (ALL) in a 19-year female who presented with solitary mass in the right breast as an initial presentation of the disease. The patient received chemotherapy treatment with the PETHEMA LAL-high risk 2003 protocol, and later an HLA-identical bone marrow transplantation was performed. Two years after onset of the disease she had a recurrence, having multiple nodes in both breasts. She then had an HLA-identical bone marrow transplantation from was performed. Two years later, she showed recurrence of ALL in both breasts.To the best of our knowledge, only 33 cases have been reported in the literature, and in only 11 of them, including our, the infiltration of the breast was the initial presentation of the disease.A high level of suspicion is important in those cases of young women with bilateral and multiple masses, because unfortunately there is no reliable imaging pattern suggestive of leukemic infiltration of the breast. In addition to a histological study, a complete blood count should be performed at start up to speed up the diagnosis.

Role of reduced intensity conditioning in T-cell and B-cell immune reconstitution after HLA-identical bone marrow transplantation in ADA-SCID

The treatment of choice for severe combined immunodeficiency is bone marrow transplantation from an HLA-identical donor sibling without conditioning. However, this may result in low donor stem cell chimerism, leading to reduced long-term immune reconstitution. We compared engraftment, metabolic, and T-cell and B-cell immune reconstitution of HLA-identical sibling bone marrow transplantation performed in 2 severe combined immunodeficiency infants with adenosine deaminase deficiency from the same family treated with or without a reduced intensity conditioning regimen (busulfan/fludarabine). Only the patient who received conditioning showed a stable mixed chimerism in all lineages, including bone marrow myeloid and B cells. The use of conditioning resulted in higher thymus-derived naïve T cells and T-cell receptor excision circles, normalization of the T-cell repertoire, and faster and complete B-cell and metabolic reconstitution. These results suggest the utility of exploring the use of reduced intensity conditioning in bone marrow transplantation from HLA-identical donor in severe combined immunodeficiency to improve long-term immune reconstitution.

Outcome of bone marrow transplantation from HLA-identical sibling donor in children with hematological malignancies using methotrexate alone as prophylaxis for graft-versus-host disease

Most previous studies of graft-versus-host disease (GVHD) prophylaxis with methotrexate (MTX) alone in patients undergoing HLA-identical sibling donor bone marrow transplantation were performed in adults. With this background, we attempted to analyze the incidence and risk factors of GVHD in bone marrow transplantation (BMT) from an HLA-identical sibling donor in children with hematological malignancies using MTX alone as a prophylaxis for GVHD. Ninety-four patients received MTX by intravenous bolus injection, with a dose of 15 mg/m(2) on day +1, followed by 10 mg/m(2) on days +3, +6, and +11, and then weekly until day +60. The probability of developing grade II-IV acute GVHD and chronic GVHD was 19.1 and 31.8%, respectively. Age at transplantation and a female donor to male recipient were identified as risk factors for chronic GVHD in multivariate analysis, but no factors were identified for acute GVHD. The cumulative incidence of transplant-related mortality during the first 100 days was 9.6%. Disease-free survival at 5 years for standard- and high-risk patients was 82.1 and 39.5%, respectively. These results suggest that GVHD prophylaxis with MTX alone is safe and effective in young children under 10 years old at transplantation and in a setting other than female donor to male recipient.

Expression of p75 chain of IL-2 receptor in the early immunological reconstitution after allogeneic bone marrow transplantation

Expression of p55 and p75 chains of IL-2 receptor (IL-2R) on the surface of both T and natural killer (NK) circulating lymphocytes was investigated in 14 paediatric patients given allogeneic bone marrow transplantation (BMT) from HLA-identical sibling or partially matched family donors. IL-2-induced proliferative and cytotoxic responses were also studied and all analysis was performed within 45 days from transplant. We found that, early after transplant, the percentage of p55+ and of p75+ peripheral blood lymphocytes (PBL) was not significantly different in patients who had received HLA-identical BMT (p55+ 8.04 +/- 4.87%; p75+ 28.27 +/- 18.85%) compared with healthy controls (p55+ 7.26 +/- 6.17%; p75+ 19.42 +/- 10.49%), while recipients of T cell-depleted marrow included a remarkably high percentage (76-90%) of p75+ PBL, which were mostly CD3- and co-expressed CD56 molecule. Comparable values of p55+ lymphocytes were observed in all patients and controls. However, in contrast to the other two groups, in recipients of T cell-depleted BMT the majority of these cells co-expressed p75 chain and CD56 antigen. IL-2-induced proliferation and lymphokine-activated killer (LAK) activity were detectable in all patients, and their values did not correlate with expression of p55 or p75 chains. Our data suggest that expansion of NK subsets expressing IL-2R chains after T cell-depleted BMT may be related to early reconstitution of natural immunity in the presence of allogeneic stimuli.

Bone marrow transplantation as therapy in chronic myeloid leukemia

Between April 1982 and December 1986, HLA-identical bone marrow transplantations were performed on 25 patients with Philadelphia chromosome-positive chronic myelocytic leukaemia (CML), 18 in the chronic phase, 7 in acceleration or blast crisis. Twelve of the 18 patients (67%) in the chronic phase are still alive a median period of 570 days after transplantation, but only two of the seven (29%) in acceleration or blast crisis a median period of 227 days after transplantation (P less than 0.025). The duration of the chronic phase was of great importance for survival after transplantation: 86% of patients in the chronic phase for less than two years survived, but all patients in the chronic phase for over two years died (P less than 0.001). CML relapses occurred in one patient in a late chronic phase and in two in an advanced stage of the disease. These results confirm the unfavorable outcome of bone marrow transplantation in the accelerated phase or blast crisis, as well as in the late chronic phase. Since at present there are no reliable risk factors for the occurrence of acceleration or blast crisis, bone marrow transplantation should be undertaken as early as possible in the chronic phase of CML.

Mutant TIRAP Gene Polymorphism Is Associated with Outcomes in HLA Genoidentical Bone Marrow Transplants Recipients with Leukemia.

Toll-like receptors (TLRs) and members of their signaling pathway are important in the initiation of the innate immune response to a wide variety of pathogens. The adaptor protein TIRAP, mediates downstream signaling of TLR2 and TLR4. A leucine (Leu) substitution at position 180 serine (Ser) of TIRAP was shown to protect from infections. We hypothesized that the incidence of infections and outcome after bone marrow transplantation (BMT) could be influenced by the TIRAP gene polymorphisms. Genotyping for TIRAP at Ser180 was performed in 107 donor/recipients pairs: 64% of recipients and 63% of donors were homozygote wild type (wt) Ser180/Ser180, 20% and 19% were Ser180/Leu180 and 17% and 18% Leu180/Leu180. Severe bacterial (pneumonia, septicemia and septic shock), viral or invasive fungal infections during 180 days after BMT, TRM (transplant related mortality), acute GVHD and survival were studied retrospectively. An allogeneic HLA-identical BMT was performed in 107 patients (median age was 35 years), with acute (n=39) or chronic Leukemia (n=68). Conditioning regimen consisted of Busulfan+Cyclophosphamide±others (BU-CY) in 73 (68%) patients and TBI+CY in 15 (14%) or TBI+Melphalan in 17 (16%). GVHD prophylaxis consisted of CsA+MTX in 94%. Median follow-up time was 77 months (18–147). Cumulative incidence of neutrophil recovery was 94%. Acute GVHD (II-IV) was observed in 42%, and chronic GVHD in 50 out of 98 at risk. Estimate 5-year survival was 54%. The cumulative incidence of any first infection by day 180 was 56%, being 28% for at least one bacterial infection, 39% for viral infection and 12% for invasive fungal infection (8 invasive aspergillosis, 4 disseminated candidiosis and 1 disseminated Malassezia furfur fungal infection). TRM cumulative incidence at 1 year was 35%. Recipient's TIRAP gene polymorphisms were not associated with outcome. However, patients transplanted from a mutant TIRAP donor (Leu/Ser or Leu/Leu) had a trend to lower incidence of fungal infections (p=0.08); lower incidence of acute GVHD (p=0.03), decreased TRM (p=0.02) and improved overall survival (p=0.02). In a multivariate analysis, adjusting for other prognostic factors, TIRAP donor polymorphisms were associated with decreased TRM (HR=0.49, p=0.02): TRM at 1 year was 43% when donors were wt (Ser/Ser) as compared to 20% when donors were mutants. There was also a trend to decreased incidence of acute GVHD in patients with a mutant TIRAP donor as compared to the others (30% versus 49%; HR 1.88 p=0.06) and better overall survival (67% versus 44%, respectively HR 1.82; p=0.07). Recipients of bone marrow (BM) from wt TIRAP donors seemed to die more frequently from infection (1 yr cumulative incidence 21% vs 8%, p=0.07). In conclusion, the presence of a Leu substitution at position 180 in the TIRAP gene of BM donors decreases the incidence of TRM in HLA-identical BMT, probably reflecting better immune reconstitution and protection against infections. This finding can help defining better surveillance and prophylaxis of bacterial infections in BMT recipients from donors with the wt TIRAP (Ser/Ser) genotype.

Association of bone marrow natural killer cell dose with neutrophil recovery and chronic graft‐versus‐host disease after HLA identical sibling bone marrow transplants

Allogeneic bone marrow (BM) transplant (BMT) outcomes have been correlated with the infused nucleated, CD34(+), and T- cell dose. The potential impact of natural killer (NK) BM infused cell dose has however not been established. We analysed the outcomes of 78 patients receiving an HLA identical BMT. A higher NK cell dose was associated with the speed of neutrophil (P = 0.05) and platelet recovery (P = 0.04). Higher nucleated cells, CD34(+), CD3(+), CD3(+)/4(+), CD3(+)/8(+) and NK cell dose were associated with a lower incidence of chronic GvHD (cGvHD) in univariate analysis. In multivariate analysis, the risk of cGvHD was increased by a lower NK cell dose [hazard ratio (HR) = 2.3 (1.2-4.4) for cell dose <0.9 x 10(6)/kg; P = 0.01] and an older age [HR = 1.4 /10 years (1.1-1.8); P = 0.002]. In addition, a higher CD3(+)/4(+) and NK cell dose were associated with a decreased incidence of viral infections (P = 0.03 and P = 0.06 respectively). No specific cell subpopulation infused dose was associated with survival. In conclusion, a higher BM NK cell dose is associated with an increased speed of neutrophil recovery and a decreased incidence of cGvHD.

Allogeniv HLA Identical Bone Marrow Transplantation in Patient With Juvenile Idiopathic (Chronic) Arthritis (JIA)

Allogeniv HLA Identical Bone Marrow Transplantation in Patient With Juvenile Idiopathic (Chronic) Arthritis (JIA)

Effect of KIR Genotype on Outcome of Related HLA Identical Stem Cell Transplant in Patients with β Thalassaemia Major.

Killer immunoglobulin like receptor (KIR) ligand mismatches cause natural killer (NK) cell alloreactivity in haploidentical stem cell transplantation (SCT) affecting engraftment, graft versus host disease (GVHD) and graft versus leukemia effects. The role of patient/donor KIR genotypes in HLA identical bone marrow transplant (BMT) for patients with non-malignant disorders is less clear. We have analyzed the KIR genotypes in patients with β thalassaemia major who underwent HLA-A, B, DR identical related-donor SCT between February, 1996 to June, 2003. Patients who expired before day 30 (n=13) and for whom DNA samples were unavailable (n=25) were excluded from the study. Retrospective analysis was carried out in 59 patients to evaluate the effect of KIR genotype on the outcome of BMT. All patients received unmanipulated bone marrow and standard cyclosporine /short course methotrexate regimen as prophylaxis against GVHD. Genomic DNA was prospectively extracted from recipient and donor peripheral blood mononuclear cells. Genotyping of 14 KIR genes (8 inhibitory -2DL1, 2DL2, 2DL3, 2DL4, 2DL5, 3DL1, 3DL2 and 3DL3; and 6 activating - 2DS1, 2DS2, 2DS3, 2DS4, 2DS5 and 3DS1) was done by PCR-SSP. The effect of other potential risk factors for GVHD and rejection like recipient's age, donor's age, sex mismatch, female donor to male recipient, conditioning regimen, cell dose, and Lucarelli class at BMT was also analyzed. Among 59 patients, 7 (11.8%) rejected the graft. None of the patients who could not be evaluated had rejection of the graft. Two patients had primary graft failure and were not evaluable for the analysis of acute GVHD. Of the remaining 57 patients, 32 (56 %) patients showed evidence of acute GVHD, 10 (31.2%) being grade III-IV. Nine patients expired before day 100 and were not evaluable for chronic GVHD. Of the 50 evaluable patients, 6 (12%) patients developed chronic GVHD. No significant effect of donor/recipient KIR genotype was found on the incidence or severity of acute or chronic GVHD. Among 7 patients who rejected the graft, 6 had identical KIR genotype to their donors. It was disparate in one, with the donor KIR genotype having additional KIR genes (2DL2 and 2DS2) that were absent in the recipient. Further analysis revealed that KIR genotype identical pairs (n=30) had a statistically significant increased risk of graft rejection (Log rank test) in comparison to KIR genotype disparate pairs (n=29) (both graft versus host and host versus graft direction) (p=0.0463). On multivariate analysis including KIR genotype and the other factors listed above, the KIR genotype identical pairs had an 8-fold higher risk of rejection (RR=8.73; 95%CI- 0.83-92.33; p=0.072). Other risk factors assessed in this analysis showed the following relative risks: patient's age (RR=1.031, p=0.792), sex mismatched transplants (RR=1.455, p=0.693), cell dose (RR=1.013, p=0.961), conditioning regimen (RR=1.308, p= 0.790) and status at BMT (Class I/II versus Class III) (RR=2.750, p=0.384). Our data suggests that identical recipient /donor KIR genotype is a risk factor for graft rejection in patients with β thalassaemia major undergoing related HLA identical SCT. The biological basis for this observation needs evaluation.

Minor histocompatibility antigen HA-1 and HPA-5 polymorphisms in HLA-identical related bone marrow transplantation

The minor histocompatibility antigens (mHags), HA-1 and HPA-5, are immunogenic alloantigens shown to be responsible for graft-versus-host disease (GVHD) in HLA-identical bone marrow transplantation. Both antigens have two known alleles each, resulting in a single amino acid polymorphism. The HA-1H allele encodes histidine, whereas the HA-1R allele encodes arginine. The HPA-5b (Br a) allele encodes lysine, whereas the HPA-5a (Br b) encodes glutamic acid. In this study, 49 bone marrow transplant recipients and their genetically related HLA-identical donors were evaluated for the presence of HA-1, whereas 39 recipients, different from the abovementioned ones, and their HLA-identical siblings were analyzed for the presence of HPA-5. The frequencies of the two alleles of HA-1 in the recipient population were HA-1R = 0.663 and HA-1H = 0.336. In the donor population, the respective frequencies were 0.704 and 0.296. Seven donors (14.5%) were mismatched with the recipients for HA-1H. In contrast, the frequencies of the two alleles of HPA-5 in the recipient population were HPA-5a = 0.859 and HPA-5b = 0.141; whereas, among donors, they were 0.820 and 0.180, respectively. Five donors (12.8%) were found to be mismatched with their recipients for HPA-5. These results provide insight into the polymorphism of mH antigens based on the study of their frequencies in bone marrow transplant recipients and their genetically HLA-identical siblings, an endeavor that is essential to investigate the presence of HA-1 and HPA-5 mHags.

Natural killer (NK) cells and bone marrow transplant (BMT) in severe combine combined immunodeficiency (SCID)

Rationale Natural killer (NK) cells are thought to have a possible role in marrow graft acceptance; little has been published about NK effects in SCID patients before and after BMT. Methods SCID patients receiving T cell-depleted haplo-identical or HLA-identical BMT without pre-BMT chemotherapy at Duke from May, 1982 through July, 2003 were eligible. NK and T cells were enumerated by flow cytometry, and T cell function was assessed by determining responses to mitogens. Stimulation indices (SI) (PHA cpm/medium cpm) >/=100 were normal. Demographic and survival data were collected. Statistical analyses were performed using SAS (SAS institute, Cary, NC). Results BMT was performed in 132 patients (mean age 178 days, 83% male, 47% γc deficiency, 77% survive). Sixty-four patients had sufficient data for pre-BMT analyses, 61 for post-BMT. The median pre-BMT NK count didn't differ significantly (p=0.81, Wilcoxon rank sum) between patients who developed an SI >100 (N=48, 61.5 cells/cmm, interquartile range (IQR) 134) and those who did not (N=16, 33.8 cells/cmm, IQR 141). More patients with a post-BMT NK peak and T cells (CD3 >/=2000/cmm) developed SI >/=100 (17/17, 100%) than patients with no NK peak (17/23, 74%) or an NK peak but few T cells (12/21, 57%) (p=0.0037, Fisher's exact). The time to an SI >/=100 did not differ significantly among the three groups (p=0.37, Kruskal-Wallis), nor did survival (p=0.18, Fisher's exact). Conclusions With no pre-BMT chemotherapy, pre-BMT NK cells were not associated with graft failure. More patients with post-BMT NK peaks and T-cells developed SI >/=100, but survival was not significantly improved.

Successful HLA-identical bone marrow transplantation in a patient with interferon-γ receptor 2 deficiency and disseminated Mycobacterium avium complex infection

Interferon gamma receptor-2 (IFNγR2) deficiency is characterized by increased susceptibility to nontuberculous mycobacteria and intracellular pathogens. We report successful HLA-identical bone marrow transplantation (BMT) of a patient with this defect. A Qatari male born to consanguineous parents presented with a CMV positive urine culture, while blood and urine mycobacterial cultures were initially negative. Bacille-Calmette-Guerin (BCG) vaccine was not administered due to a history of IFN-γ R2 deficiency in his deceased older sister. The patient was found to have the same defect. Parents initially refused BMT. He received prophylactic azithromycin but developed disseminated Mycobacterium avium complex (MAC) infection requiring an aggressive regimen including amikacin, azithromycin, ethambutol, linezolid, rifampin and moxifloxacin. CMV infection was treated with ganciclovir, foscarnet, and CMV immune globulin. Splenectomy was performed at age 9 months, due to massive hypersplenism with subsequent growth of MAC. CMV DNA was positive until age 11 months, while mycobacterial blood cultures were positive until age 10 months. At age 13 months, he underwent bone marrow transplantation from his HLA-identical father. Pre-transplant conditioning included busulfan, cyclophosphamide, and antithymocyte globulin (ATG). Post-transplant graft vs. host disease prophylaxis included methotrexate and cyclosporine. RFLP analysis revealed 98% donor cells on day +32 post-transplant. Transplant course was complicated by Clostridium difficile infection, fevers, hypertension and thrombocytopenia, but he is stable 94 days post-transplantation. Conclusions Our case is the only living patient who has undergone successful BMT for a defect in the IFNγR2. We conclude that bone marrow transplantation for IFNγR2 deficiency is an effective means of correcting this immunodeficiency.

Early host CD8 T-cell recovery and sensitized anti-donor interleukin-2-producing and cytotoxic T-cell responses associated with marrow graft rejection following nonmyeloablative allogeneic bone marrow transplantation.

We developed a nonmyeloablative conditioning regimen for allogeneic bone marrow transplantation (BMT) followed by donor lymphocyte infusions (DLI) for treatment of chemotherapy refractory malignancies. Although the majority of patients who receive this regimen achieve lasting mixed or full allogeneic chimerism, approximately 30% show initial mixed chimerism followed by loss of the donor graft. These patients recover host hematopoiesis without significant cytopenias. To assess the role of immunologic rejection in graft loss, we compared T-cell recovery and in vitro alloresponses in six patients who lost their marrow graft to that in 16 concurrent patients with sustained donor chimerism. Conditioning included pretransplant cyclophosphamide (150-200 mg/kg), thymic irradiation (700 cGy), and pre- and post-transplant equine antithymocyte globulin (ATG; ATGAM). HLA-identical related donor BMT was followed by DLI at approximately day 35 in patients without graft-vs-host disease. The group with transient chimerism showed significantly increased circulating host T-cell (median 416 cells/mm(3) vs 10 cells/mm(3), p<0.05) and CD8 T-cell numbers (354 cells/mm(3) vs 71 cells/mm(3), p<0.05) compared to the group with stable mixed or full donor chimerism within the first 100 days post-BMT. All DLI recipients who lost chimerism following DLI had greater than 80% recipient T cells at the time of DLI, whereas those with persistent chimerism had <60% host T cells. Graft rejection was associated with the development of a sensitized anti-donor bulk cytotoxic T-lymphocyte (CTL) response in 4 of 6 evaluated patients, compared to only 1 of 10 evaluated patients with sustained chimerism (p<0.05). Additionally, 3 of 5 evaluated transient chimeras showed high anti-donor CTL precursor frequencies in limiting dilution assays, and 3 of 4 evaluated transient chimeras showed high anti-donor interleukin-2 (IL-2)-producing T-helper (T(H)) cell frequencies. High anti-donor T(H) or cytotoxic T-lymphocyte precursors were not detected in sustained chimeras. These data indicate that loss of chimerism in patients receiving this nonmyeloablative regimen is due to immune-mediated rejection. This rejection appears to bemediated by recovering recipient cytolytic CD8(+) cells as well as IL-2-producing recipient T(H) cells. These data are the first to demonstrate sensitization of recipient anti-donor IL-2-producing cells in association with human marrow allograft rejection.