Mismatched Family Donors Research Articles

Haploidentical hematopoietic stem cell transplantation: state of art.

For patients with hematologic malignancies at high risk of relapse who do not have matched donors, a suitable alternative stem cell source is the HLA-haploidentical 2- or 3-loci mismatched family donor who is readily available for nearly all patients. Transplantation across the major HLA barrier is associated with strong T-cell alloreactions, which were originally manifested as a high incidence of severe GVHD and graft rejection. The present overview of the 7th symposium on haplidentical transplantation that took place at the Weizmann Institute on February 2014, shows how these obstacles to successful transplantation can now be overcome. The review also discusses the advantages and drawbacks of current options for full haplotype-mismatched transplantation and highlights innovative approaches for rebuilding immunity, reducing leukemia relapse and improving survival after transplantation. In addition, new modalities for immune tolerance induction following nonmyeloablative conditioning are discussed, showing new options for treatment of elderly patients who cannot tolerate myeloablative conditioning protocols, as well as novel strategies for immune tolerance and chimerism induction as a platform for cell therapy and organ transplantation.

Future of Allogeneic Hematopoietic Stem Cell Transplantation for Chemotherapy-Resistant Pediatric Acute Leukemia: Potential Advances

Fred Hutchinson Cancer Research Center, Seattle, WA, USA University of Washington Department of Pediatrics, Seattle, WA, USA Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle, WA, USA *Author for correspondence: Tel.: +1 206 667 6572; Fax: +1 206 667 7983; mbleakle@fhcrc.org Transplantation as a curative strategy for high-risk leukemia Allogeneic hematopoietic stem cell transplantation (HCT) is curative for many children with life-threatening, chemotherapy-resistant leukemia. HCT works by two major mechanisms: high-intensity chemotherapy, or chemoradiotherapy pretransplant conditioning; and an immunologic antileukemia effect mediated by donor lymphocytes in the graft, the ‘graftversus-leukemia effect’ (GVL). Survival rates for pediatric leukemia HCT recipients have steadily increased over time with current overall survival rates for pediatric acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) of >50%. The improvements in survival principally reflect major reductions in early postHCT treatment-related mortality (TRM) that have occurred as a result of better supportive care. The decrease in TRM in unrelated donor, cord blood (CBT) and mismatched family donor HCT has been particularly notable, and survival rates after ‘alternative donor HCT’ are now broadly comparable to HLA-matched sibling donor HCT. Unfortunately, relatively little reduction has been achieved in relapse rates, making relapse now the most frequent cause of failure of HCT for leukemia [1]. Relapse occurs in 10–30% of HCTs performed for pediatric leukemia in remission and has a dismal prognosis: the median survival of children with postHCT relapse is 4 months [2]. In order to further improve overall survival after allogeneic HCT for pediatric leukemia, novel strategies to address post-HCT leukemia relapse are crucial.

Hematopoietic Stem Cell Transplantation in Children and Young Adults with Secondary Myelodysplastic Syndrome and Acute Myelogenous Leukemia after Aplastic Anemia

Secondary myelodysplastic syndrome and acute myelogenous leukemia (sMDS/sAML) are the most serious secondary events occurring after immunosuppressive therapy in patients with aplastic anemia. Here we evaluate the outcome of hematopoietic stem cell transplantation (HSCT) in 17 children and young adults with sMDS/sAML after childhood aplastic anemia. The median interval between the diagnosis of aplastic anemia and the development of sMDS/sAML was 2.9 years (range, 1.2 to 13.0 years). At a median age of 13.1 years (range, 4.4 to 26.7 years), patients underwent HSCT with bone marrow (n = 6) or peripheral blood stem cell (n = 11) grafts from HLA-matched sibling donors (n = 2), mismatched family donors (n = 2), or unrelated donors (n = 13). Monosomy 7 was detected in 13 patients. The preparative regimen consisted of busulfan, cyclophosphamide, and melphalan in 11 patients and other agents in 6 patients. All patients achieved neutrophil engraftment. The cumulative incidence of grade II-IV acute graft-versus-host disease (GVHD) was 47%, and that of chronic GVHD was 70%. Relapse occurred in 1 patient. The major cause of death was transplant-related complication (n = 9). Overall survival and event-free survival at 5 years after HSCT were both 41%. In summary, this study indicates that HSCT is a curative therapy for some patients with sMDS/sAML after aplastic anemia. Future efforts should focus on reducing transplantation-related mortality.

Comparable Allogeneic Hematopoietic Cell Transplantation Outcome Of Haplo-Identical Family Donor With Matched Unrelated/Mismatched Family Donor In Adult Aplastic Anemia

Allogeneic hematopoeitic cell transplantation (alloHCT) is a curative therapy for severe/very severe aplastic anemia (sAA) in adult. alloHCT from haplo-identical family donor (HD) is an alternative approach while alloHCT from matched sibling donor (MSD) is the choice of therapy. Our previous study suggested that alloHCT from matched unrelated donor (MUD) were comparable with MSD when pre-transplantation conditions were well-matched. It means poor outcome of MUD might come from poor pre-transplantation clinical factors such as delayed alloHCT. Same will be applied to HD. In this study we compared HD with alternative donors (AD; MUD or mismatched family donor) by matched case study.We selected AD cases from KSBMT2007-01 study population who had comparable pre-transplantation clinical factors with HD by propensity-score matching. Pre-tranplatation clinical factors such as age, ATG conditioning or ABO-compatibility were matched. Therefore 48 AD cases were selected for the comparison with 16 HD cases.Male (p=0.009) and female to male transplantation (p=0.002) were more frequent in HD. AD received prior immune suppression therapy (IST) frequently (p=0.092). Cyclophosphamide (p<0.001) and total body irradiation (p=0.055) were frequent in AD while fludarabine (p=0.006) and busulfan (p<0.001) were common in HD as a conditioning regimen. Bone marrow was used frequent in AD (60.4%; p<0.001) and peripheral blood was used in all HD (100%; p<0.001) as stem cell source. Despite this differences, ATG as prior IST (p=0.769), ABO compatibility (p=0.111), T-cell ex vivo depletion (0%, both), age at diagnosis (p=0.622), age at alloHCT (p=0.400), time from diagnosis to alloHCT (p=0.822), unit of red blood cell transfusion prior to alloHCT (p=0.655), unit of platelet cell transfusion prior to alloHCT (p=0.604) and infused CD34+ cell dose (p=0.087) were similar. All transplantation outcomes except for extensive chronic graft versus host disease (GvHD) were similar. The frequencies of hepatic sinusoidal obstruction syndrome (p=1.000), acute GvHD (p=0.769), grade 3/4 acute GvHD (p=0.258), chronic GvHD (p=0.173), extensive GvHD (p=0.099), primary neutrophil engraftment failure (p=1.000), secondary graft failure (p=1.000), platelet engraftment failure (p=0.505), all graft failure (p=0.745) were similar (Table 1). Time to neutrophil engraftment was faster in HD (p=0.003) while cumulative incidence of platelet engraftment (p=0.505), acute GvHD (p=0.378), grade 3/4 acute GvHD (p=0.255), chronic GvHD (p=0.202), extensive GvHD (p=0.918) were similar. Overall survival was also similar between AD and HD (p=0.730; Figure 1). [Display omitted] In conclusion, alloHCT from HD in sAA is comparable with alloHCT from AD when pre-transplantation clinical factors were similar although extensive chronic GvHD seemed frequent in HD. Therefore alloHCT from sAA could be alternative approach of alloHCT from MUD in adult sAA. Disclosures:No relevant conflicts of interest to declare.

Comparison Of Umbilical Cord Blood and Haploidentical Donor Grafts In Adults With High Risk Hematologic Diseases After Fludarabine Cyclophosphamide and TBI 2 Gy Based Reduced-Intensity Conditioning Regimen Stem Cell Transplantation

IntroductionHuman leukocyte antigens (HLA)-matched sibling or unrelated donor are available for around only 50-60% of patients. However, for patients without a suitably matched related donor, Alternative donors such as mismatched unrelated, cord blood and mismatched family donors could be searched. The aim of this retrospective study was to compare the results of graft source on outcome of patients after haploidentical related donor (Haplo), and the unrelated umbilical cord blood (UCB) transplantation in the setting of Non myeloabalative conditioning regimen (NMA). Patients and methodsWe retrospectively analyzed outcomes in 150 adult patients with high risk hematologic diseases who received Allo-SCT from alternative donors from two centers (Institut Paoli-Calmettes at Marseille France and Humanitas cancer center at Rozzano, Italy): These two centres have been applying common transplant approaches and procedures during the study period. 69 patients received Haplo and 81 patients received UCB. In the UCB group, the NMA regimen consisted of fludarabine (Flu), cyclophosphamide (Cy) and low dose TBI (2 Gy) combination in the two groups. The GVHD prophylaxis consisted of Cyclosporine A (CsA) and MMF in all patients in the two groups. In the Haplo group all patients received also 50 mg/kg Cy at day 3 and 4 post transplant. Of note, supportive care was the same during the whole study period. CMV infection management was also homogeneous. Patient characteristics are shown in Table 1.Table 1Patient and transplantation characteristics:Characteristic Total =150 patientsHaplo transplant (n = 69)CB transplant (n = 81)P valuePatients Age years (median) [range]44 (19-68)47 (18-66)Patients sexnsMale39 (57)46 (57)Female30 (43)35 (43)Disease typeAML3 (4)37 (46)<0.0001ALL1 (1)14 (17)<0.0001NHL24 (35)14 (17)nsHL30 (43)2 (2)<0.0001MM4 (6)2 (2)nsCLL5 (7)4 (5)nsCML01 (1)nsMDS/ MPS2 (3)7 (9)nsStatus of diseaseCR37 (54)56 (69)nsPR/SD24 (35)12 (15)0.04PD8 (11)13 (16)nsDonor typeSibiling32 (46)Parent18 (26)Child18 (26)cousin1 (2)Donor/recipient sex mis-match34 (49)56 (69)nsABO incompatibility24560.02Conditioning regimenFlu 5+Cy 1+ TBI075 (93)Flu 5+Cy 2+ TBI69 (100)6 (7)Stem cell sourcePeripheral Blood19 (28)Bone Marrow50 (72)Stem cell dose median [range] CD34+ x 106/kg3,96 (0,8-14)0,9 (0,08-1,28)GvHD prophylaxisCSA+MMF69 (100)81 (100)nsCy post transplant69 (100)0Days with ANC< 500 x 109/l20 (14-39)22 (6-67)nsDays with platelets<20 x 109/l29 (14-50)41 (18-80)ns ResultsWith a median follow-up of 59 months (8-101) and 18 months (3-51), in the UCB group versus the Haplo group, respectively. Nine patients (11%) in the UCB and 8 patients (12%) in the Haplo group had a spontaneous autologous reconstitution subsequent to primary graft failure. The median times to neutrophil and platelet recovery were 20 d (14–39) and 29 d (14–50) after Haplo and 22 d (6–67) and 41 d (18–80) after cord blood. All supportive care measures included red blood cell, and platelet transfusions were significantly increased in cord blood transplantation group. The cumulative incidence of transplant related mortality (TRM) at one year was 23% in the UCB group versus 17% in the Haplo group (P=0.39). Grade 2-4 acute graft-vs.-host disease (GVHD) and extensive chronic GVHD incidences were 52% versus 29% (P=0.05), and 12% versus 6% (P<0.0001), in the UCB group versus the Haplo group, respectively. The Kaplan-Meier estimate of overall survival at 2 years was 45% (95%CI, 34-56%) in the UCB group versus 69% (95%CI, 58-80%) in the Haplo group, (P=0.10). The estimate of progression-free survival at 2 years was 36% (95%CI, 25-47%) in the UCB group versus 65% (95% CI, 53-77%) in the Haplo group (P=0.01). Figure 1 ConclusionIn this study, relapse and PFS was lower in Haplo group than in UCB transplants. The main difference between the 2 groups was the significantly higher incidence of acute and chronic GVHD in the UCB group. Surprisingly, this did not translate into a decrease of the cumulative incidence of OS nor increase of the TRM, which may be explained by a slightly shorter follow-up in this group. Our results suggest that haploidentical transplants are a good and promising alternative option for patients with high risk hematological diseases who lack an HLA-matched donor (sibling or unrelated donor). This should be now investigated in prospective comparative studies. Disclosures:No relevant conflicts of interest to declare.

Transplantation Of TcRαβ/CD19 Depleted Stem Cells From Haploidentical Donors In Children: Current Results

▪T-cell depletion of the graft is an effective method to prevent or completely avoid Graft-versus-Host Disease (GvHD) in haploidentical stem cell transplantation. In order to increase the T-cell depletion efficacy while maintaining the anti-tumor and anti-infectious properties of the graft, we have investigated a new T-cell depletion method which removes αβ+ T-lymphocytes via a biotinylated anti-TcRαβ antibody followed by an anti-biotin antibody conjugated to magnetic microbeads while retaining γδ+ T-lymphocytes, Natural killer (NK) cells and other cells in the graft. In addition, CD19+ B-lymphocytes were concomitantly depleted for the prevention of posttransplant EBV-associated lymphoproliferative disease. The CliniMACS system was used for manipulation of peripheral stem cell grafts from full haplotype mismatched family donors in 35 patients. ResultsThe overall depletion of αβ+ T-cells was highly effective with 4.6 log (range 3.8–5.0). Patients received a median number of only 14 x 103/kg residual αβ+ T-cells. Recovery of CD34+ stem cells was 72%, and the median number of infused CD34+ stem cells was 12 x 106/kg (range 5-38 x 106/kg). Additionally, the patients received 2 types of potential antileukemic effector cells: 107 x 106/kg (range 35 -192 x 106/kg) CD56+ NK-cells and 11 x 106/kg (range 5–30 x 106/kg) γδ+ T-lymphocytes. Diagnoses wereALL (n=20), AML/MDS/JMML (n=9), nonmalignant diseases (n=4), solid tumors (n=2); disease status: CR2-CR6 (n=17), active disease (n=18). 23 patients received a second or third SCT (65%). A toxicity reduced conditioning regimen (fludarabin 40mg/m² or clofarabin 50mg/m² (day -8 to d -5), thiotepa 10mg/kg (d -4), melphalan 70mg/m² (d -3 and d -2) was used. The anti CD3 specific OKT3 antibody was used as rejection prophylaxis from day -8 to day -1 without affecting cotransfused effector cells because of its short half-life period in the first 7 patients. However, due to its restricted availability, the substance was substituted since 2011 by a reduced ATG-F dose (15mg/kg) given at start of the conditioning regimen in order not to impair NK and γδ+ T-cells of the grafts (1 mg/kg d -12, 4 mg/kg d -11, 5 mg/kg d -10 and -9; n=28 patients). Short course MMF (until day +30) was given in 25 patients. Graft rejection occurred in 14% of the patients. However, after reconditioning and second stem cell donation, final engraftment was achieved in all patients. The median time to reach neutrophil and platelet recovery in patients with primary engraftment was 10 and 11 days respectively. All patients showed a rapid immune reconstitution with 250 (OKT3 conditioning) and 273 (ATG conditioning) CD3+ T-cells/µl, 30 (OKT3) and 47 (ATG) CD3+4+/µl and 300 (OKT3) and 382 (ATG) CD56+ NK-cells/µl at day +30 posttransplant. γδ+ T-cells started to expand faster than αβ+ T-cells in the early post-transplant period (156 vs. 82 cells/µl at day +30) whereas at day +90, αβ+ T-cells were predominant (170 vs. 134 cells/µl). Acute GvHD grade 0-I occurred in 25 patients (71%); 6 patients had GvHD II (17%), 3 patients had GvHD III (9%) and one patients experienced GvHD grade IV (3%). 3 patients experienced chronic GvHD (8%). Incidence of acute GvHD was not influenced by the number of residual T cells or by the type of serotherapy. 1 year EFS for patients with acute leukemias was 66% (any CR) and 14% (active disease).TRM at 1 year was 20%. ConclusionsThese data indicate that transplantation of TcR αβ+/CD19 depleted cells from a haploidentical donor results in sustained engraftment, remarkably fast immune reconstitution and low incidence of both acute and chronic GvHD. OKT3 could be substituted by ATG without negative effects. The anti-leukemic efficacy of this approach in comparison to other methods of T-cell depletion needs to be evaluated with a longer patient follow-up. Disclosures:No relevant conflicts of interest to declare.

Response to Rituximab-Based Therapy and Risk Factor Analysis in Epstein Barr Virus–Related Lymphoproliferative Disorder After Hematopoietic Stem Cell Transplant in Children and Adults: A Study From the Infectious Diseases Working Party of the European Group for Blood and Marrow Transplantation

The objective of this analysis was to investigate prognostic factors that influence the outcome of Epstein-Barr virus (EBV)-related posttransplant lymphoproliferative disorder (PTLD) after a rituximab-based treatment in the allogeneic hematopoietic stem cell transplant (HSCT) setting. A total of 4466 allogeneic HSCTs performed between 1999 and 2011 in 19 European Group for Blood and Marrow Transplantation centers were retrospectively analyzed for PTLD, either biopsy-proven or probable disease. One hundred forty-four cases of PTLD were identified, indicating an overall EBV-related PTLD frequency of 3.22%, ranging from 1.16% for matched-family donor, 2.86% for mismatched family donor, 3.97% in matched unrelated donors, and 11.24% in mismatched unrelated donor recipients. In total, 69.4% patients survived PTLD. Multivariable analysis showed that a poor response of PTLD to rituximab was associated with an age ≥30 years, involvement of extralymphoid tissue, acute GVHD, and a lack of reduction of immunosuppression upon PTLD diagnosis. In the prognostic model, the PTLD mortality increased with the increasing number of factors: 0-1, 2, or 3 factors being associated with mortality of 7%, 37%, and 72%, respectively (P < .0001). Immunosuppression tapering was associated with a lower PTLD mortality (16% vs 39%), and a decrease of EBV DNAemia in peripheral blood during therapy was predictive of better survival. More than two-thirds of patients with EBV-related PTLD survived after rituximab-based treatment. Reduction of immunosuppression was associated with improved outcome, whereas older age, extranodal disease, and acute graft-vs-host disease predicted poor outcome.

Haematopoietic stem cell transplantation: activity in Switzerland compared with surrounding European countries

Haematopoietic stem cell transplantation (HSCT) is a highly specialised procedure used to treat malignancies of the lymphohaematopoietic system as well as some acquired and inherited disorders of the blood. This analysis by the Swiss Blood Stem Cell Transplantation Group, based on data from 2008-2011, describes, treatment rates in Switzerland for specific indications and compares this with data from Germany, France, Italy and the Netherlands, corrected for the size of the population. Differences in transplant rates, in rates for particular indications, and in the use of specific transplant technologies such as use of unrelated donors, use of cord blood or mismatched family donors are described. These data are put in correlation with donor availability from international registries and with number of transplant teams and number of procedures per team all corrected for population size.

Haploidentical Hematopoietic Stem Cell Transplantation With a Megadose T-Cell–Depleted Graft: Harnessing Natural and Adaptive Immunity

For patients with high-risk acute leukemia who do not have a matched donor or who urgently need a transplant, transplantation from a full human leukocyte antigen (HLA) haplotype mismatched family donor should be considered a viable option. Clinical trials have shown that a strategy for haploidentical transplantation based on the infusion of high numbers of T-cell-depleted hematopoietic progenitor cells and no post-transplant immunosuppression controls bi-directional T-cell alloreactivity, ie, graft rejection and graft-versus-host disease (GvHD) in patients with leukemia. Overall, event-free survival compares favorably with reports of transplants using sources of stem cells other than the matched sibling. This transplant modality has highlighted the crucial role of donor-versus-recipient natural killer cell (NK) alloreactivity in the control of leukemia relapse. Current studies are focusing on rebuilding post-transplant immunity to improve clinical outcomes.

Treatment and hematopoietic SCT in aplastic anemia

This edition of the journal Bone Marrow Transplantation is the dedicated to the diagnosis and treatment of aplastic anemia, a disease that has had an important role in developing SCT and maybe even modern hematology. This was borne out of a project to design algorithms for the diagnosis and treatment of this disease, comprising different clinical issues such as different age groups and disease severity, as well as strategies arising from the unavailability of a specific type of donor. Aplastic anemia is an orphan disease with an incidence of 1–2 patients per million inhabitants per year, and given the different paths in the algorithms this breaks down into even smaller distinct sub-entities. Without wishing to stress the common place of personalized medicine, these distinct situations require individualized attention. Often, the approach to patient care has to differ, be it while caring for the child or the older person being diagnosed with aplastic anemia, according to severity of the disease and response to initial treatment as well as depending on the availability or not of a matched donor. Given the difficulty to study rare diseases, we also designed these algorithms with the intention to standardize treatment and to record treatment outcome. Diagnostic procedures need to be standardized; congenital disease has to be ruled out in the young, hypoplastic myelodysplastic syndrome in the older patient and procedures are discussed in the chapter on the diagnosis of acquired aplastic anemia. Outcome of patients with aplastic anemia has greatly improved over the past decades and to a large part this is due to progress in supportive care, given that our currently used immunosuppressive and transplant regimens were developed in the 1970s. This progress includes treatment of infectious complications and transfusional support, among others. In younger patients, the primary decision in treatment is to choose between transplantation versus immunosuppression. We have learned recently through a randomized trial conducted at the National Institutes of Health that not all antithymocyte globulin regimens are equal.1 Standards for immunosuppression are to be found in the chapter on front line immunosuppressive treatment as well as current standards on upfront BMT with a sibling donor. Older patients with a donor are recommended to be treated with immunosuppression, but patients failing this treatment are candidates for BMT using a reduced intensity regimen containing fludarabine. Patients without a sibling donor failing immunosuppressive treatment may have an unrelated donor search initiated and may undergo marrow transplantation from an unrelated donor. Transplant rates in Europe for aplastic anemia continue to increase2 and this is mostly due to the increased use of unrelated donors following publications showing that outcomes with unrelated donors were similar to outcomes with sibling donors. The average age of patients with aplastic anemia is ~16 years, that is, half the patients are children, but the disease can occur in all age groups. There is a specific chapter on the management of aplastic anemia in children and also on the management of aplastic anemia in the older adults. The issue is rounded up by particular chapters on second- and third-line treatment options, including cord blood transplantation, transplantation from mismatched family donors (that is, haploidentical donors) and experimental immunosuppressive regimens including Campath. These specific protocols are detailed here to incite treating physicians to manage these patients according to common treatment protocols and to report outcomes in order for us to progress toward improved outcomes for these patients. All these chapters have been written by members of the aplastic anemia working party of the European Group for Blood and Marrow Transplantation and the algorithms are the fruits of many discussions held during our biannual group meetings. We hope to provide a platform for the reader that may help him in all clinical situations that can be encountered with these patients. For this reason, the working title of this project had been ‘the complete treatment algorithm’.

Donor CMV Status Influence On the Outcome of Allogeneic Stem Cell Transplantation (HSCT); A Study by the Infectious Diseases Working Party (IDWP) of the EBMT

AbstractAbstract ▪465▪This icon denotes a clinically relevant abstractA previous study from the IDWP of the EBMT showed that CMV seropositive patients undergoing unrelated donor HSCT had increased NRM and decreased survival if they were grafted from a CMV seronegative donor. This finding has been controversial and we therefore decided to revisit the question with a larger number of patients and including new factors such as conditioning intensity.Patients were selected from the EBMT database who had received an allogeneic HSCT from 1992 – 2008 and for whom both the donor and recipient CMV status were known. Patients receiving cord blood grafts were excluded. 54660 patients were identified and included in the study; 32320 seropositive and 22340 seronegative patients. The different donor categories (sibling, mis-matched family, unrelated) were analyzed separately. Cox multivariate models were fitted to estimate the effect of donor serological status (positive versus negative) on outcome both in CMV seropositive and CMV seronegative patients adjusted for year of HSCT, donor and patient gender, recipient age, stem cell source, diagnosis, use of alemtuzumab or ATG, country, and conditioning intensity (RIC vs. MAC).Seronegative patients receiving grafts from seropositive unrelated donors had an decreased overall survival (OS; HR 1.13; p<.01); relapse free survival (RFS; HR 1.10; <p<.01) and increased non-relapse mortality (NRM; HR 1.13; p<;.01) while no significant effect was seen on relapse incidence (RI; HR 1.06). There were no significant effects in patients receiving HLA-identical or mis-matched family donors. Seropositive patients receiving grafts from seropositive unrelated donors had improved OS (HR 0.91; p<.01), RFS (HR 0.94; p<.05), and decreased NRM (HR 0.87; p<.01) if they had received MAC. No effect of donor serostatus was seen in patients receiving unrelated donor grafts after RIC. No effect of donor status was seen on RI. There were no significant effects in patients receiving HLA-identical or mis-matched family donors. Based on the recent study of Elmaagacli et al showing a decreased relapse risk in patients transplanted for AML of early CMV replication, a separate analysis regarding RI was performed only in AML patients in first CR. However, no effect of donor serostatus on RI was found in either seropositive or seronegative patients.In this analysis we confirm the negative effect on OS, RFS, and NRM if a CMV seropositive unrelated donor is selected for a CMV seronegative patient. It therefore remains important to select a seronegative donor when the patient is seronegative. For a CMV seropositive patient our data support the choice of a CMV seropositive donor if the patient is planned to receive a myeloablative conditioning regimen. Disclosures:No relevant conflicts of interest to declare.

Analysis of Infection-Related Mortality in Allogeneic Hematopoietic Stem Cell Transplantation Recipients with Refractory/Relapse Acute Leukemia

Abstract 4513 BackgroundInfection-related mortality (IRM) is a major cause of transplant-related mortality (TRM) in recipients of allogeneic hematopoietic stem cell transplant (allo-HSCT). However, the data about IRM in refractory/relapse acute leukemia patients undergoing allo-HSCT was scarce. We conducted a retrospective study to describe the incidence, causes and risk factors for IRM in recipients with refractory/relapse acute leukemia at a single center. MethodsClinic datas of 127 cases received transplant for refractory/relapse acute leukemia between January 1997 and August 2011 were reviewed. There were 67 cases died at the end of follow-up. In this 67 cases, 27 patients were female and 40 were male; the media age was 31 years (range, 11–61).Uderlying disease was acute myeloid leukemia (AML) in 37 cases, acute lymphoblastic leukemia (ALL) in 21 and acute leukemia of ambiguous lineage in 9. Status of underlying diseases was CR in 19 cases, PR in 15 and NR in 33. There were 25 cases with residual infection diseases before HSCT, including 21 in stable state and 4 in active state with effective control. A total of 59 cases received the conditioning regimen which is 4.5Gy TBI for 2 days and CTX 60mg·kg−1·d−1 for 2 days and 8 patients received busulfan 3.2 mg·kg−1·d−1 for 4 days and CTX 60mg·kg−1·d−1 for 2 days. Patients with PR and NR status of underlying diseases also received fludarabine 50mg·d−1 for 5 days and cytarabine 2 g·d−1 for 5 days as the conditioning regimen. Forty-two cases received related-donor transplant and 25 received unrelated-donor transplant; 30 cases had HLA typing (HLA-A, B and DR) matched-family donor, 12 cases has mismatched-family donors and 25 cases had unrelated-donors. The most common source of stem cells for HSCT was the peripheral blood (n=49), followed by bone marrow plus peripheral blood (n=10) and bone marrow (n=8). Cyclosporine A (CsA) with methotrexate (MTX) (on days +1, +3 and +6) was administered for GVHD prophylaxis in patients undergoing HLA-matched sibling donor transplantation. CsA only or CsA with MTX (on days +1 and +3) was administered for GVHD prophylaxis in patients not received CR before transplant. Patients receiving an unrelated donor or HLA-mismatched sibling donor transplant received CsA + MTX and human antithymocyte globulin (ATG 6–7.5 mg/kg) as GVHD prophylaxis. Logistic regression was used for the identification of risk factors of IRM. ResultsWithin a median 23 months follow-up for patients alive, 67 cases died including 36 died of leukemia relapse and 31 died of TRM. The incidence of 5-years overall survival was 35.2% whereas disease-free survival was 30.8%. Of the 127 cases, 36 cases occurred IRM and the 2-year cumulative incidence of IRM was 36.6%. Fungal infections were responsible for a major proportion of the cases of IRM followed by virus and bacteria infections. Multivariate analyses showed II∼IV°aGVHD (OR=3.017, 95%CI 1.007–9.041, P=0.049) and IFI (OR=3.223, 95%CI 1.103–9.421, P=0.032) were the risk factors of IRM. ConclusionsAs a common cause of transplant-related mortality, IRM occurred more frequently in refractory/relapse acute leukemia than in the standard-risk patients. Reduction of IRM will require effective prophylaxis and treatment of severe GVHD. Disclosures:No relevant conflicts of interest to declare.

The Impact of ATG/Alg in Preconditioning On the Allogeneic Stem Cell Transplantation for Patients with Acute Leukemia

AbstractAbstract 4185 Background:Since the clinical implication of anti-lymphocyte globulin (ATG/ALG) in allogeneic stem cell transplantation (allo-SCT) is not fully understood, we tried to identify the clinical impact of ATG/ALG in patients with acute leukemia who received allo-SCT in Japan. Patients and Methods:We analyzed patients with ALL (n=5494) and AML (n=8115) who received first allogeneic SCT from 1983 to 2009 with (n=356) or without (n=13253) ATG/ALG. Their stem cell sources were bone marrow (BM, n=9056), peripheral blood (PB, n=1918), and cord blood (CB, n=2575) and they were transplanted at 1st complete remission (CR1, n=5681), 2nd CR (CR2, n=2495), and advanced stages (>CR3, n=5033). Results:Five year overall survival (5y OS) of all patients with or without ATG/ALG was 33.6% vs 44.5%, respectively (P<0.001) and multivariate analysis showed that ATG/ALG significantly reduced acute GVHD (P<0.001, HR=1.980) as well as chronic GVHD (P<0.001, HR=1.894). According to stem cell sources, 5y OS with or without ATG/ALG was 35.8% vs 47.5% (P<0.001) in BM, 34.7% vs 37.6% (P=0.067) in PB and 18.3% vs 39.9% (P<0.001) in CB. By multivariate analysis, ATG/ALG significantly reduced A-GVHD (P=0.005, HR=1.565) but decreased OS (P=0.004, HR=0.729) in BM, it reduced A-GVHD (P<0.001, HR=2.376) and C-GVHD (P<0.001, HR=2.691) but lowered engraftment (P=0.046, HR=0.810) in PB, and it increased TRM (P=0.004, HR=0.437) with decreased OS (P=0.011, HR=0.576) in CB. In Haplo transplantation (SCT from 2 or 3 antigens of HLA mismatched family donor, n=337), multivariate analysis showed that ATG/ALG did not affect the relapse, TRM and OS but, it significantly lowered engraftment (P=0.002, HR=0.602), and reduced A-GVHD (P<0.001, HR=2.622) as well as C-GVHD (P<0.001, HR=3.834). In contrast to these results, ATG/ALG did not affect the relapse rate irrespective of stem cell source or diagnosis. Conclusion:In allogeneic stem cell transplantation for patients with ALL and AML, ATG/ALG contribute in reducing acute and chronic GVHD without affecting relapse rates but it was a risk factor of OS for patients who received BM or CB. Disclosures:No relevant conflicts of interest to declare.

Rapid Immune Reconstitution Following Unmanipulated Haploidentical BMT with Post-Transplant High Dose Cyclophosphamide

Abstract 3050 Background.Allogeneic hematopoietic stem cell transplantation (HSCT) is the treatment of choice for the majority of hematological malignancies. Early and successful immunologic reconstitution after HSCT reduces morbidity and mortality due to infection complications and improves survival. Aim of the study. We analyzed immune recovery after HSCT in 444 patients according to donor source. Patients and Methods. From January 2005 to June 2011 176 patients were grafted from HLA identical siblings (MSD), 125 from alternative donors (1 antigen mismatched family or unrelated donors) (ALT), 103 from unrelated cord blood grafted intra bone (CBIB) and 40 from haplo-identical mismatched family donors (HAPLO). All patients received unmanipulated bone marrow: 283 after a myeloablative (MA) conditioning regimen (CY-TBI or BU-CY) and 161 after a fludarabine based reduced intensity regimen (RIC). Graft versus host disease (GvHD) prophylaxis was cyclosporin methotrexate (CyA+MTX) for all patients except for CBIB (CyA and mycophenolate, MMF) and for HAPLO transplants which consisted of CyA+MMF and post-transplant high dose cyclophosphamide (HDCY) according to the Baltimore protocol (Lutznik et al BBMT 2008). Anti-thymocyte globulin (ATG) was used only for ALT transplants. Results. We compared immune reconstitution in MA and RIC transplants according to donor type at different time points post BMT. CD3+ absolute median counts/μl in MA conditioning on day+30, +90, +180 were respectively in MSD 477, 565, 700; in ALT donors were 146, 404, 470; in CBIB were 30, 57, 196; for HAPLO transplants they were 195, 182, 499. CD3+ absolute median counts/μl in RIC conditioning on day+30, +90, +180 were respectively in MSD 301, 660, 700; in ALT donors were 506, 186, 721; in CBIB 234, 399, 522; in HAPLO were 178, 276, 1300. CD4+ absolute median counts/μl in MA conditioning on day+30, +90, +180 were respectively in MSD 166, 170, 198; in ALT donors were 36, 86, 111; in CBIB 7, 36, 106; for HAPLO transplants they were 45, 127, 211. CD4+ absolute median counts/μl in RIC conditioning on day+30, +90, +180 were respectively in MSD 89, 189, 274; in ALT donors were 131, 210, 220; in CBIB 52, 110, 130; for HAPLO transplants they were 41, 205, 385. CD8+ absolute median counts/μl in MA conditioning on day+30, +90, +180 were respectively in MSD 280, 389, 500; in ALT donors were 102, 278, 413; in CBIB 42, 16, 51; in HAPLO transplants were 73, 424, 408. CD8+ absolute median counts/μl in RIC conditioning on day+30, +90, +180 were respectively in MSD 196, 432, 300; in ALT donors were 366, 65, 494; in CBIB 71, 167, 199; for HAPLO transplants they were 137, 129, 900. CD3, CD8, and CD4 counts in HAPLO transplants were not statistically different from MSD with the only exception of day +30, both for MA and RIC conditioning. Platelet median counts/μl on day+30, +90, +180 in MA conditioning were in MSD 142, 129, 180, in ALT 75, 101, 147, in CBIB were 19, 77, 128 and for HAPLO transplants were 67, 126, 128; in RIC conditioning platelets counts were in MSD 137, 156, 168, in ALT 33, 134, 142, in HAPLO were 77, 95, 188. Acute GvHD II-IV developed in 29% (MSD) 38% (ALT) 16% (CBIB) and 12% (HAPLO) (p=0.004) in MA conditioning and 40% (MSD) 18% (ALT) 25% (CBIB) and 10% (HAPLO) (p=0.07). Overall Cumulative Incidence of Non-Relapse Mortality (CI-NRM) was respectively 18% (MSD), 35% (ALT), 34% (CBIB), 22% (HAPLO) (p=0.02) in MA conditioning (p=0.02) and was 30% (MSD), 33% (ALT), 45% (CBIB), 0% (HAPLO) (p=0.02) in RIC conditioning (p=0.02). Day+100 CI-NRM was respectively 10% (MSD), 21% (ALT), 19% (CBIB), 12% (HAPLO) in MA conditioning (p=0.01) and 11% (MSD), 19% (ALT), 26% (CBIB), 0% (HAPLO) in RIC conditioning (p=0.02). Death due to infections were respectively 6% (MSD), 26% (ALT), 30% (IBCB), 17% (HAPLO) in MA conditioning and for RIC were 15 (MSD), 36% (ALT), 32% (IBCB), 0% (HAPLO). Conclusions. HAPLO transplant with HDCY post transplant as proposed by the Baltimore group, is associated with (1) rapid immunologic (CD3, CD4, CD8) recovery (2) low infectious death rate, (3) low overall and Day+100 CI-NRM, (4) rapid hematologic recovery. These results are comparable with those achieved with MSD and warrant further studies with HDCY post transplant as a GvHD prophylaxis. Figure: absolute CD4+ counts/μl on day+30, +90, +180, according to donor type in MA conditioning regimen. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Allogeneic Bone Marrow Transplantation From HLA Mismatched Family Donors in Children with Aplastic Anemia

Abstract 831The first-line therapy for children with severe aplastic anemia (AA) is allogeneic hematopoietic stem cell transplantation (HSCT) from an human leukocyte antigen (HLA)-matched family donor, and immunosuppressive therapy (IST) is indicated for patients without HLA-matched family donors. While the standard therapy for children who fail to respond to IST is allogeneic HSCT from an HLA-matched unrelated donor, HSCT from an HLA-mismatched family donor has also been indicated. Compared with unrelated donors, an HLA-mismatched family donor has some advantages especially for children who need urgent transplantation.We analyzed the clinical outcome of 578 children (325 boys and 253 girls) with AA (age, <20 years) who received allogeneic BMT between 1990 and 2009 in Japan, and registered to the Transplant Registry Unified Management Program (TRUMP). The median age at transplantation was 11 years (0–19), and the donors were serological 6/6 HLA-matched related donors (MRD) (n = 312), 1 locus-mismatched related donor (1MMRD) (n = 44), 2–3 loci-mismatched related (haploidentical) donors (n = 9), and HLA-matched unrelated donors (MUD) (n = 213). Causes of deaths were as follows: acute graft-versus-host disease (GVHD) (n = 4), chronic GVHD (n = 4), acute respiratory distress syndrome (n = 2), severe hemorrhage (n = 7), engraftment failure (n = 5), infection (n = 18), idiopathic pneumonia (n = 8), organ failure (n = 19), secondary malignancy (n = 4), and others (n = 4).The probability of severe acute GVHD (grade III–IV) in patients transplanted from 1MMRD (26.9% ± 7.4%) was significantly higher than that in patients transplanted from MRD (4.9% ± 1.3%) (p < 0.001). The probability of 5-year overall survival (5y OS) of patients transplanted from 1MMRD (93.1% ± 3.9%) was comparable to that of patients transplanted from MRD (93.1% ± 1.5%) (p = not significant, NS), but it was significantly better than that of patients transplanted from haploidentical donors (66.7% ± 15.7%, p =.016) and MUD (79.0% ± 2.9%, p =.014). In the subgroup analysis of 1MMRD, no significant difference was observed between HLA class I-mismatched (n = 32) and class II-mismatched patients (n = 12) (5y OS; 93.8% ± 4.3% vs. 91.7% ± 8.0%, p = NS). Comparison of the survival outcome based on the transplant period (1990–1999 vs. 2000–2009) revealed that the probability of 5y OS of patients transplanted from 1MMRD was not significantly different (92.3% ± 5.2% (n = 26) vs. 94.4% ± 5.4% (n = 18), p = NS), while that of patients transplanted from MUD significantly improved in the same period as we reported previously (67.1% ± 5.5% (n = 73) vs. 86.1% ± 3.1% (n = 140), p =.001)(Yagasaki et al., Blood 2011). In multivariate analysis, haploidentical donors (p <.001), MUD (p <.001), age ≥ 10 years (p <.001), and transplant period (1990–1999 vs. 2000–2009, p =.006) were identified as independent covariates associated with unfavorable OS.In summary, our analysis revealed that an HLA-mismatched related donor, especially 1MMRD, could be selected as a donor candidate for children with AA who need urgent transplantation. Disclosures:No relevant conflicts of interest to declare.

Long-term outcome and lineage-specific chimerism in 194 patients with Wiskott-Aldrich syndrome treated by hematopoietic cell transplantation in the period 1980-2009: an international collaborative study

AbstractIn this retrospective collaborative study, we have analyzed long-term outcome and donor cell engraftment in 194 patients with Wiskott-Aldrich syndrome (WAS) who have been treated by hematopoietic cell transplantation (HCT) in the period 1980- 2009. Overall survival was 84.0% and was even higher (89.1% 5-year survival) for those who received HCT since the year 2000, reflecting recent improvement of outcome after transplantation from mismatched family donors and for patients who received HCT from an unrelated donor at older than 5 years. Patients who went to transplantation in better clinical conditions had a lower rate of post-HCT complications. Retrospective analysis of lineage-specific donor cell engraftment showed that stable full donor chimerism was attained by 72.3% of the patients who survived for at least 1 year after HCT. Mixed chimerism was associated with an increased risk of incomplete reconstitution of lymphocyte count and post-HCT autoimmunity, and myeloid donor cell chimerism < 50% was associated with persistent thrombocytopenia. These observations indicate continuous improvement of outcome after HCT for WAS and may have important implications for the development of novel protocols aiming to obtain full correction of the disease and reduce post-HCT complications.

EBMT Risk Score Predicts Outcome of Allogeneic Hematopoietic Stem Cell Transplantation in Patients Who Have Failed a Previous Transplantation Procedure

Increasing numbers of allogeneic hematopoietic stem cell transplantation (allo-SCT) are being performed for patients who have failed a previous allogeneic or autologous SCT. We investigated whether the EBMT risk score could predict outcome after a subsequent allo-SCT. We analyzed prognostic factors in 124 consecutive patients who underwent a second transplantation using an allogeneic donor at our institution. Patients with either a first autologous (N = 64) or first allogeneic (N = 60) SCT were included. Age, disease stage, time interval from diagnosis to transplantation, donor type, and donor-recipient sex combination were used to establish a score from 0 to 7 points, from which 3 groups were identified. The 5-year survival probability decreased from 51.7% for risk scores 0-3 (low, n = 25), to 29.3% for risk score 4 (intermediate, n = 42), and only 10.4% for risk scores 5-7 (high, n = 57), P = .001. We propose that the EBMT risk score can identify patients most likely to benefit from a second transplantation.

Haematopoietic cell transplantation for haemophagocytic lymphohistiocytosis: experience at a single centre

<h3>Introduction</h3> Haemophagocytic lymphohistiocytosis (HLH) is a rare disorder of immune dysregulation that may be inherited or acquired. Causative genetic mutations are seen in around 50% of cases of primary HLH. Secondary HLH may be triggered by infections (most commonly viral), or by other conditions including malignancies and rheumatological disorders. Diagnostic criteria include prolonged high fever, hepatosplenomegaly, cytopenias and characteristic biochemical markers including elevated triglycerides, ferritin and low fibrinogen. Haematopoieitic cell transplantation (HCT) is the only curative treatment for primary HLH. The authors present their experience of HCT for HLH in a single centre over a 14 year period. <h3>Materials and Methods</h3> A retrospective case-note review was performed for all patients who fulfilled the diagnostic criteria for HLH, between 1994 and 2008. Data were collected for patients who had undergone HCT, or had died prior to HCT. <h3>Results</h3> 67 patients fulfilled criteria for HLH. Sixteen of 67 (24%) died prior to HCT. Fifty patients proceeded to HCT, of whom 35 (70%) remain alive and in remission. The mean time from diagnosis to HCT was 7 months. The median age at diagnosis was 0.35 years (range 0.1–9.8), 32/50 were male. Twelve received haploidentical grafts, 14 matched family donor, 11 matched unrelated donor, 11 mis-matched unrelated donor and 2 mis-matched family donor grafts. Twenty-three had myeloablative, 25 reduced intensity and 2 minimal intensity conditioning. After 1999 all patients having HCT for HLH underwent reduced intensity HCT. 15/50 (30%) patients died post-HCT. Causes of death were: pneumonitis (3), veno-occlusive disease (2), infections (3), cardiac failure (1), bleeding (1), seizure (1), EBV-related lymphoproliferative disease (1), drug toxicity (1), secondary AML and disease recurrence (1). Overall 9/21 (43%) patients are surviving from the cohort diagnosed prior to 2000, and 31/46 (67%) post 2000. <h3>Conclusion</h3> Outcome for HLH has improved with time reflecting earlier diagnosis and disease control, and the use of reduced intensity HCT with HLA matched donors. However, significant mortality from disease and from HCT related complications still remains and further progress is required.

Fludarabine, Cyclophosphamide, Anti-Thymocyte Globulin, with or without “ 2Gy TBI, for Alternative Donor Transplants in Acquired Aplastic Anemia (SAA): A Report From the EBMT-SAA Working Party.

Abstract 1207Poster Board I-229 Patients.Data from 100 patients with acquired severe aplastic anemia (SAA) undergoing an alternative donor transplant, were analyzed. Patients were prepared with a combination of fludarabine (30 mg/m 2×4), cyclophosphamide (300 mg/m 2×4), antithymocyte globulin (3.75 mg/lgx4) (FCA) (n=52, median age 13 years), or FCA supplemented with low dose (2 Gy) total body irradiation (FCA-TBI), but with a lower dose of ATG (total 7.5 mg/kg) (n=48, median age 27 years). The donor was unrelated (n?87) or a one antigen mismatched family donor (n=13). GvHD.Acute graft versus host disease (GvHD) grade III-IV was seen in 13% and 7% ; extensive chronic GvHD was recorded in 1 FCA patient and in 4 patients receiving FCA-TBI. Graft failure.Rejection/graft failure was seen in 17 patients, equally distributed in the two groups: 9/17 patients survive long term, 3 with autologous recovery, and 6 after a second transplant.. As to predictors of graft failure, patients with a longer interval from diagnosis to transplant (> 2 years) had a trend for a higher risk of GF (22%) as compared to patients grafted <1 year (12%) or between 1-2 years (14%) (p=0.3). Chimerism data:within 100 days from BMT the average donor chimerism was 93% and 84% in the FCA and FCA-TBI regimens. Beyond day +100 the average was 89% and 80%. Survival.With a median follow up of 1204 days, the overall actuarial 5 year survival is 75%, respectively 73% for the FCA and 79% for the FCA-TBI. The interval diagnosis-transplant (<1 year, 1-2 years and >2 years) was a significant predictor of survival in univariate and multivariate analysis : actuarial survival was 87%, 86%, 58% respectively (p=0.004). Older age and HLA mismatch was a significant predictor of survival in the FCA group, but not in the FCA-TBI patients. Causes of death.Twentythree patients died, 13/52 in the FCA group and 10/48 in the FCA-TBI group (p=ns): major causes of death were rejection (n=7), post-transplant-lymphoproliferative-disease (n=4) and GvHD (n=4). Conclusions.This study confirms a significantly improved outcome of alternative donor transplants in SAA patients, and suggests that best results are achieved if the transplant is performed within 2 years from diagnosis. FCA seems appropriate only for children with well matched donors, whereas FCA-TBI is preferable in adults, especially when the donor is HLA mismatched. Complications such as rejection and EBV reactivation need to be addressed with modifications of the transplant regimens. Disclosures:No relevant conflicts of interest to declare.

Pediatric BMT for Malignancy Using Zero/One Antigen Mismatched Family Donors or Unrelated Donors Have Similar Outcomes, Both of Which Are Inferior to Matched Sibling Donors

Pediatric BMT for Malignancy Using Zero/One Antigen Mismatched Family Donors or Unrelated Donors Have Similar Outcomes, Both of Which Are Inferior to Matched Sibling Donors