Negative CMV Research Articles

Stability of CMV CD4 and CD8 T Cell Responses in Seropositive Donors and Evaluation of Immunosuppressed Patients

Introduction A frequent complication after transplantation, CMV infection may cause a series of direct and indirect effects that lead to increased incidence of graft rejection, opportunistic infections, and decreased allograft and patient survival. Antiviral therapy is often used to control CMV infections, but presents problems of toxicity, antiviral resistance and excessive costs. Currently, treating physicians are limited in the information and data available to assess a patient's risk for CMV infection post-transplant. Objectives Recent studies have shown that measuring a patient's CMV specific T cell mediated immunity may provide valuable information to physicians for monitoring CMV infection/disease in transplant patients and may aid in determining which patients need antiviral therapy. Questions have been raised about the variability of these responses. The goal of this study is to evaluate the stability of the CMV T cell response in seropositive individuals over time. Methods Over an 18 month period, five seropositive donors were evaluated for their CMV-specific CD4 and CD8 T cell responses. Briefly, freshly collected whole blood is stimulated with a CMV lysate, pp65 CMV peptide mix, SEB, or left unstimulated. CMV T cell responses are assessed via flow cytometry upon the cellular activation surface marker CD69 in conjunction with IFNg production. Additionally, the spectrum of results obtained from an unselected patient population was assessed. Results Analysis of the percent coefficient of variation (%CV) for both CD4 and CD8 responses following CMV and SEB stimulated responses in each of five donors, with 2-13 samples evaluated per donor. When evaluating responses, twelve of these had %CVs less than or equal to 25%, and an additional six %CVs were between 25% and 35%. Evaluation of responses from an unselected population (n>350) of patients revealed considerable heterogeneity. Patients demonstrating normal (positive) results for both CD4 and CD8 responses following CMV and SEB stimulated responses was at 31%. An additional 12% of patients had normal CD4 and CD8 SEB responses but negative responses to CMV in both the CD4 and CD8 compartment. Interestingly, a further 11% had positive responses to CD4 SEB, CD8 SEB, and CD8 CMV, but a negative CMV CD4 response. The final 36% of responses were a mix of positive and negative responses and low cell counts. Conclusion These analyses demonstrate that the functional T cell responses in CMV seropositive donors are stable enough to provide utility in the analysis of patient responses. These patient responses can vary depending on the situation. The use of CMV T cell analysis can provide useful information for physicians in tailoring a CMV prevention plan following treatment.

Cord Blood Transplantation in Adolescents and Young Adults with Acute Leukemia: On Behalf of Eurocord, Ctiwp and PDWP of EBMT

▪Outcomes for adolescents and young adults (AYA) might be considerably different from children and older adults with acute leukemia (AL). Patients in this transitory period tend to be considered at higher risk for poorer outcomes. However, AYA is still underrepresented in most hematopoietic stem cell transplant (HSCT) studies. Recent evidence shows superior outcomes for AYA with acute lymphoblastic leukemia (ALL) using pediatric rather than adult first line chemotherapy regimens. The aim of this study is to analyze outcomes of umbilical cord blood transplant (UCBT) in AYA patients with ALL or acute myeloid leukemia (AML) after myeloablative conditioning regimen (MAC).Eligibility criteria included patients with AL aged 15-25 (median 19) years, transplanted between 2004 and 2016 in EBMT centers, with single or double UCBT as first allogenic transplantation after MAC regimen and reported to Eurocord. A total of 504 patients were included. Primary endpoint was overall survival (OS).Median follow-up for survivors was 38 months (1 month-11 years). Median time from diagnosis to UCBT was 11 months (1 month-17 years) (interquartile range 5-29 months). Diagnosis was ALL in 59% (n=297) and AML in 41% (n=207); 64% of patients were male. Disease status at UCBT were 42% in 1st complete remission (CR) (n=203), 2nd CR in 38% (n=183), and advanced disease in 20% (n=96).Fifty eight percent of patients (n=293) received single and 42% (n=211) double UCBT. Cyclophosphamide + TBI ± fludarabine (45%) was the most frequently used conditioning regimen. Anti-thymoglobulin (ATG) was used in 54% and GVHD prophylaxis was cyclosporine A + mycophenolate mofetil in 44% of patients. Median nucleated cell dose at collection was 3.63 (range 0.9-9.0) X107/Kg for single and 5.25 (range 2.3-10.6) X107/Kg for double UCBT.The 3-year OS was 45±2%; 3-year leukemia free survival (LFS) was 41±2% and refined GVHD free/relapse free survival (rGRFS) was 32±2%.OS was similar in ALL and AML (45±3% vs 45±4%, p-value=0.69). According to disease status at UCBT, 3-year OS was 54±4% for patients in CR1, 48±4% for CR2 and 20±4% for advanced disease (p-value<0.001).Cumulative incidence function (CIF) for neutrophil engraftment at day-60 was 88% [95% confidential interval (CI) 85-90] in a median time of 24 days. CIF of acute GVHD grade II-IV at day-100 was 28% (95%CI 24-32) and out of the 233 patients with aGVHD, 73 (21%) had grade III-IV.The 1-year CIF of chronic GVHD was also 28% (95%CI 24-33) and out of the 124 patients with cGVHD, 52 (42%) had the extensive form.The 3-year CIF of transplant related mortality (TRM) was 31% (95%CI 24-33). The 3-year CIF of relapse was 28% (95%CI 24-32), and according to disease status at UCBT, relapse was 28% (95%CI 21-34) for patients in CR1, 24% (95%CI 18-31) for those in CR2 and 37% (95%CI 27-47) for advanced disease.Main causes of death were relapse (41%) and TRM (57%, mainly infections and GVHD).In multivariate analysis, disease remission at UCBT (HR 0.46, 95%CI 0.32-0.66, p-value<0.001) and transplant performed in more recent years (HR 0.75, 95%CI 0.62-0.90, p-value=0.002) were independently associated with increased OS. A similar effect was observed for LFS (recent transplantation: HR 0.80, 95%CI 0.66-0.95, p-value =0.01 and disease remission: HR 0.51, 95%CI 0.36-0.72, p-value <0.001). On the other hand, negative CMV serology (HR 0.77, 95%CI 0.61-0.99, p-value =0.042), recent transplantation (HR 0.85, 95%CI 0.73-0.99, p-value=0.49) and disease remission (HR 0.61, 95%CI 0.44-0.84, p-value =0.002) were significantly associated with increased rGRFS. For grade II-VI aGVHD, ATG use (HR 0.52, 95%CI 0.32-0.82, p-value=0.005), single UCBT (HR 0.63, 95%CI 0.42-0.96, p-value=0.03), and recent transplant (HR 0.76, 95%CI 0.59-0.98, p-value=0.034) reduced the risk. However, no factor was associated to cGVHD.This large series of AYA patients with AL provides detailed information on UCBT for this particular cohort with results comparable with other sources of HSCT.Due to the lack of information on pre-transplant chemotherapy (pediatric versus adult protocols), we were unable to evaluate its effect on outcomes. Nevertheless, this study contributes to a better understanding of HSCT for an age group that is not thoroughly described in most publications. Demonstrating the feasibility of UCBT in AYA patients is important to facilitate the decision of stem cell source selection when a more standard donor is not available. DisclosuresHough:University College London Hospital's NHS Foundation Trust: Employment. Angelucci:Vertex Pharmaceuticals Incorporated (MA) and CRISPR CAS9 Therapeutics AG (CH): Other: Chair DMC; Celgene: Honoraria, Other: Chair DMC; Jazz Pharmaceuticals Italy: Other: Local ( national) advisory board; Novartis: Honoraria, Other: Chair Steering Comiittee TELESTO Protocol; Roche Italy: Other: Local (national) advisory board. Bader:Medac: Patents & Royalties, Research Funding; Neovii: Research Funding; Riemser: Research Funding; Cellgene: Consultancy; Novartis: Consultancy, Speakers Bureau.

Quality Assessment of Cytomegalovirus PCR Testing at an Academic Tertiary Referral Hospital

BackgroundCytomegalovirus (CMV) Polymerase chain reaction (PCR) test is a valuable tool for diagnosis and therapeutic monitoring of CMV infection. Academic medical centers with a high volume of organ transplant and immunosuppressed patients often utilize CMV quantitative and qualitative PCR testing. CMV qualitative PCR typically does not alter clinical management, and positive CMV qualitative test often needs follow up quantitative test. Despite its lack of usefulness, CMV qualitative PCR is often over-ordered and may unnecessarily raise the cost of hospitalization. We evaluated utility of CMV PCR testing at a tertiary care medical center.MethodsWe reviewed CMV PCR testing done from June 2015-November 2016 at Hahnemann University Hospital in Philadelphia, PA. CMV qualitative test was performed at LabCorp and CMV quantitative test was done at Focus Labs. Data collected included demographics, length of stay, and immunosuppression. Selected patients had either CMV qualitative PCR positive without follow up quantitative PCR, or negative CMV qualitative PCR with unnecessary CMV quantitative PCR ordered.ResultsWe evaluated 226 CMV PCR test results including 162 qualitative and 64 quantitative CMV PCR in 139 patients. 39 (28%) patients had superfluous CMV testing. Mean age was 52.6 years, 61% were male, 46% were African American. Mean length of stay was 24 days. A half (N = 19,49%) were immunocompromised. 28 (17.2%) results were positive for CMV qualitative PCR, 7 (25%) of whom follow up CMV quantitative PCR were not sent. Thirty-two patients had negative CMV qualitative testing yet had CMV quantitative PCR sent. Six had redundant CMV quantitative PCR tests within 7 days likely resulting from delayed result report from send out. After performing cost analysis, these unnecessary tests would have saved $3930.ConclusionIn our cohort, significant unnecessary CMV testing resulted in increased health care cost and patient discomfort. Positive Qualitative CMV PCR without Quantitative testing impairs diagnosis and treatment follow up. Given complicated testing algorithm and limited value of CMV qualitative PCR testing in the adult population, we plan to simplify CMV testing to quantitative only and perform in house testing to shorten result time.Disclosures All authors: No reported disclosures.

Endoscopic Remission After Infliximab Treatment in a Patient with Ipilimumab-Induced Colitis

Biological medications may result in serious side effects. Some effects relate to immunosuppression while others are from immunostimulation. Our case demonstrates severe ipilimumab-induced colitis in a patient being treated for stage 4 malignant melanoma, which responded to treatment with infliximab. A 78 year old man with stage 4 malignant melanoma treated with ipilimumab and radiation was admitted to our hospital with three weeks of abdominal pain and severe refractory bloody diarrhea. Prior to hospitalization he received four infusions of ipilimumab. Stool analysis revealed leukocytosis and no Clostridium difficile toxin, Cryptosporidium, or Giardia. There was a negative serum CMV antigen screen. The patient was started on metronidazole, ciprofloxacin, and prednisone although these did not provide resolution of his symptoms. CT abdomen and pelvis with contrast revealed extensive colonic wall thickening that extended up to the proximal transverse colon. Sigmoidoscopy demonstrated severe colitis with mucosal edema, erythema, and ulceration. Colonic mucosal biopsies were obtained and the results revealed acute colitis with ulceration as well as negative CMV and HSV histochemistries. Despite continued high dose steroids and bowel rest there was no clinical improvement. The patient was started on Infliximab, and he noticed progressive improvement in his diarrhea. The patient was discharged for outpatient GI clinic follow up and continued infusions. The patient's clinical course was complicated by pulmonary embolism and he required anticoagulation. At a three-month follow up sigmoidoscopy, the ulcers showed healing change, normal rectal mucosa, and resolved colitis. The nine-month follow up colonoscopy demonstrated remission. The Infliximab was stopped and patient was followed clinically. Ipilimumab related colitis is the result of hyperactive cytotoxic T lymphocytes. Ensuing necrotizing colitis can cause bloody diarrhea, bowel wall perforation, or toxic megacolon. Aggressive medical management decreases excessive inflammatory reaction in areas of large immunologic cell populations, such as the colon. Infliximab, tacrolimus and corticosteroids have efficacy against the excessive inflammatory side effects of hypersensitivity colitis. Unfortunately, medical management cannot prevent colectomy in all cases which is a last resort for necrotizing colitis. Our case presents the management of complicated colitis with colon-sparing medical management.Figure 1Figure 2

Use of Novel Anticoagulation to Treat Pulmonary Thromboembolism in an Ulcerative Colitis Patient with Cytomegalovirus Superinfection

Crohn's disease and ulcerative colitis are the two major types of inflammatory bowel disease, and affect mainly the gastrointestinal tract but also have extraintestinal sequelae, such as arterial and venous thromboembolism. Thromboembolic complications, particularly pulmonary thromboembolism, can be life threatening and require prompt management with anticoagulants. Conventional vitamin K antagonists have been used for the treatment of thromboembolic complications, but the development of novel oral anticoagulants has shifted the paradigm. We report a case of a 42-year-old female with ulcerative colitis with complaints of fever, rectal bleeding, abdominal and chest discomfort of 1-week duration. Initial sigmoidoscopy revealed multiple longitudinal ulcerations with a friable mucosa and easy touch bleeding in all colonic fields. Random biopsies and tissue CMV PCR were performed. The results indicated acute and chronic colitis, together with negative CMV immunohistochemistry, but positive CMV PCR. CMV IgG was positive and CMV real-time PCR using whole blood yielded a viral load of 633 copies/mL (19900 IU/mL). Initial chest dynamic computed tomography (CT) and lower-extremity CT showed diffuse deep vein thrombosis from the left common iliac vein to the calf veins of the lower left leg and filling defects in the lobar and segmental branches of the right lung, suggesting pulmonary thromboembolism. She was treated with oral mesalamine, intravenous steroid and ganciclovir and low-molecular-weight heparin, followed by rivaroxaban, a novel oral anticoagulant. Her symptoms resolved after treatment, and no recurrence was noted during a 6-month post-treatment follow-up.Figure 1Figure 2Figure 3We believe that in the near future, NOACs should replace VKAs for treatment of thrombotic complications in IBD patients.

Allogeneic Stem Cell Transplantation for MDS Patients More Than 70 Years of Age: a Retrospective Study of the MDS Subcommittee of the Chronic Malignancies Working Party (CMWP) of the EBMT

IntroductionMyelodysplastic syndromes (MDS) are diagnosed at median age of 70 years. Allogeneic stem cell transplantation (HSCT) is the only curative treatment option, but with an increasing age, morbidity escalates. Treatment guidelines suggest HSCT for intermediate-II and high risk constellations up to the age of 65, and reduced intensity conditioning (RIC) regimens are commonly used up to 70 years of age. However, increasing life expectancy, availability of RIC regimens and good Karnofsky performance status (KPS) of MDS patients more than 70 years of age, has led to an increased use of HSCT. We performed a retrospective analysis to investigate results after HSCT for those patients and influence of KPS on outcome.Patients and methodsWe analyzed data of 345 patients in the EMBT database older than 70 years with MDS/sAML. The disease status at transplantation was available in 233 patients and most of the them were in more advanced stage of the disease: RA/RARS,RCMD (n=25) , RAEB (n=68) and RAEB-T/secondary acute leukemia (sAL, n=140). Donor were: related (n=88) and unrelated (n=257). Cytogenetic data were available only in 73 patients and classified as good (58), intermediate (6), poor (5) and very poor (4). Median follow up was 29.7 months. Median age at transplantation was 72 years (70-79 years) with 249 male and 96 female patients. KPS was defined in 300 cases, being 90-100% in 61% and 80% or less in 39%. Stem cell source was peripheral blood (94%) or bone marrow (6%). The intensity of the conditioning regimen was mainly reduced intensity (78%) rather than myeloablative (22%). Negative or positive CMV sero-status of the patient were seen in 35% and 65%, respectively.ResultsThe number of HSCT for MDS patients of 70 years or more has increased over time. While 2000-2004 only 19 patients received transplantation, the following 3-year periods included 28 (2005-2007), 97 (2008-2010) and 200 (2011-2013) patients, respectively. The estimated 3-year OS was 33% (27-39%). A significant better 3 year OS in the univariate analysis was seen for Karnofsky (90-100%) vs 80% or less (41 vs 23%, p=0.008) and for CMV negative sero-status (46% vs 27%, p> <0.001) while disease status, remission status, intensity of the conditioning regimen, and donor source did not influence OS significantly. The cumulative incidence of relapse at 3 years was 40% (95% CI: 32-48) and significantly lower with unrelated than related donors (24% vs 43%, p =0.004). There was only a trend for a lower incidence of relapse after myeloablative conditioning in comparison to RIC (22% vs 31%, p=0.09), while remission status, T-cell depletion or disease stage did not influence the risk of relapse. The cumulative incidence of non-relapse mortality at 1 year was 36% (95% CI: 30-42) and significantly influenced by CMV sero-negativity of the recipient (22% vs 38%, p=0.02) and by Karnofsky index 90-100% (29% vs 34% and at 2 years: 32% vs 46%, p=0.01). A trend for lower NRM was seen for related donors (24% vs 35%, p=0.07) and after reduced intensity conditioning (29% vs 41%, p=0.09). No impact on NRM was seen for disease and remission status.In a multivariate analysis (MVA) significant factor for improved OS was Karnofsky index of 90-100% (HR 0.65: 95% CI: 0.48-0.88, p=0.001) and for worse survival CMV sero-positivity (HR 1.61; 95% CI: 1.15-2.21, p<0.001). For relapse the only significant factor was the use of unrelated donors (HR 0.50; 95% CI: 0.32-0.80, p=0.004). Significant factors for NRM in the MVA were Karnofsky index 90-100% (HR 0.63; 95% CI: 0.42-0.96, p=0.03), CMV sero-positivity of the recipient (HR 1.76; 95% CI: 1.12-2.76, p=0.001) and unrelated donors (HR 1.67; 95% CI: 0.16-2.76, p=0.04).ConclusionHSCT from related or unrelated donor after myeloablative or dose reduced intensity conditioning for advanced MDS patients 70-years and more is a curative treatment option with a 3-year OS of 33%. Good performance, determined by KPS, and sero-negativity for CMV in the patient increase the 3 year estimated overall survival to 41 and 46%, respectively. DisclosuresPlatzbecker:Boehringer: Research Funding; Novartis: Honoraria, Research Funding; Celgene: Honoraria, Research Funding. Niederwieser:Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Einsele:Novartis: Consultancy, Honoraria, Speakers Bureau; Janssen: Consultancy, Honoraria, Research Funding, Speakers Bureau; Amgen/Onyx: Consultancy, Honoraria, Speakers Bureau; Celgene: Consultancy, Honoraria, Research Funding, Speakers Bureau. Tischer:Sanofi-Aventis: Other: advisory board. Nagler:Novaratis Pharmaceuticals Corporation: Consultancy, Honoraria, Research Funding. Glass:Roche, MSD, Takeda, Riemser, Ctilifesciences: Honoraria, Research Funding. Sill:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding. de Witte:Novartis: Research Funding.

Selecting Double Cord Blood Units for Adults with Hematological Malignancies: Impact of ABO, HLA and Cell Dose on Outcomes after Double Cord Blood Transplants a CBC-Cellular Therapy & Immunobiology Working Party, EBMT and Eurocord Study

Despite the increased inventory of "rich" and more diverse HLA cord blood units (CBUs), most adults are still transplanted with double unrelated CBUs. Many studies have described criteria for CBU selection for single UCBT (SUCBT) based on cell dose, low and high resolution (LR and HR) HLA typing, KIR and NIMA. However, the criteria based on these factors for selecting double CBUs are still not as well defined. Moreover, most of SUCBT are performed in children whereas double UCBT (DUCBT) are commonly used for adults, therefore CBUs selection criteria may be different between in these two settings.With the aim of studying the impact of CBUs, patient and transplantation-related factors in DUCBT, we conducted a retrospective registry-based study in a large series of adults transplanted with DUCBT in EBMT centers, for whom we had available data on cell dose and HLA for both CBUs. Overall, 934 adults met the eligibility criteria: 55% had acute leukemia, 21% lymphoid mature malignancies, 10% MDS and 14% MPD or multiple myeloma. Patients' median age at DUCBT was 47 years (y) and median weight was 71 kg. Median time from diagnosis to DUCBT was 17 months. Conditioning regimen was myeloablative (MAC) in 32% and antithymocyte globulin (ATG) was used in 24% of the cases. GvHD prophylaxis consisted mostly of cyclosporine+mycophenolate mofetil. Median number of TNC at collection and infusion were 4.9 x107/kg (n=934) and 3.6x107/kg (n=735), respectively. Median number of collected and infused CD34 cells were 1.9x105/kg (n=893) and 1.6 x105/kg (n=695), respectively. Number of HLA disparities was defined according to the CBU with the highest degree of mismatches with the recipient, based on LR typing for HLA-A and -B and HR typing for -DRB1. Overall, 1% of the patients received a 6/6, 26% a 5/6, 67% a 4/6 and 6% a 3/6 HLA-matched DUCBT. ABO match was also classified according to the CBU with the highest incompatibility with the recipient: 18% of the patients received two ABO compatible CBUs, 30% at least one CBU with minor ABO incompatibility and 52% received at least one CBU with a major ABO incompatibility.At day 60, estimated absolute neutrophil count (ANC>500) recovery was 87%. In multivariate analysis (MVA) greater ANC recovery was associated with TNC dose at collection≥ 4.9x107/kg (HR:0.66; p=0.002), as well as female recipient, negative CMV serology and other diagnosis than MDS. Impact of CD34 cell dose was observed in univariate analysis: probability of ANC recovery was 91% if ≥1.9x105/kg versus 84% for a lower dose (p<0.001). At day-100, the incidence of acute GvHD (aGvHD) grade II-IV was 42% and III-IV was 20%. In MVA, increased aGVHD (II-IV) was associated with absence of ATG, use of MAC and HLA-match ≥4/6 (HR: 1.51, p=0.007), whereas increased aGVHD (III-IV) was associated with recipient's age (>47y), advanced disease, HLA-match ≥4/6 (HR: 1.55; p=0.048) and ABO major incompatibility (HR:1.44; p=0.039). The 2y NRM was 35%. Factors associated with higher NRM were positive CMV serology, advanced disease, use of ATG, ABO incompatibility (HR:1.55; p=0.023) and HLA-match ≥4/6 (HR:1.39; p=0.046). Relapse incidence (RI) at 2y was 20% and none of the CBU related factors impacted on RI. Overall Survival (OS) at 2y was 47%. In MVA, positive CMV serology, diagnosis of MDS and use of ATG were associated with decreased OS. Number of HLA disparities and degree of ABO compatibility were also associated with survival: 2y OS was 45% for patients transplanted with at least one ≥4/6 HLA-matched CBU, and 54% for those transplanted with both 6/6 or at least one 5/6 HLA-matched CBU (HR:1.26; p=0.05). Interestingly, OS at 2y was 57% for patients transplanted with both ABO compatible CBUs, 47% for those transplanted with at least one CBU with ABO minor incompatibility and 39% for those transplanted with at least one major ABO incompatibility (HR:1.16; p=0.029). In MVA for DFS, positive CMV serology, advanced disease, use of ATG and ABO incompatibility (HR:1.46;p=0.004) were associated with decreased DFS.This analysis suggests that a dose at collection of TNC ≥ 4.9x107/kg and/or of CD34 ≥ 1.9x105/kg, as well as better ABO and HLA compatibility are important factors that should be included in the selection algorithm for CBUs in DUCBT. DisclosuresNo relevant conflicts of interest to declare.

Second-Generation Relative Donor for T-Replete Haplo-Identical Allogeneic Stem Cell Transplantation with High-Dose Post-Transplant Cyclophosphamide: Towards Disappearance of the HLA Barrier

Introduction: Allogeneic stem cell transplantations (allo-SCT) using alternative donors are increasingly used in patients lacking suitable matched sibling or unrelated donor. Recently, the use of post-transplant cyclophosphamide (CY) has allowed to re-consider first-generation relatives (brother, sister, father, mother, son or daughter) as haplo-identical donors for allo-SCT. Indeed, the incidence of severe acute GVHD is lowered by post-transplant administration of CY, due to the early destruction of putative alloreactive T cells. Still, some patients may not have a suitable relative donor for various reasons such as older age of the parents, no siblings nor children, no cord blood available, or because use of a graft from a first-generation haplo-identical relatives is contra-indicated. The probability of having a haplo-identical donor among siblings is 50% while it is almost 100% when considering both biological parents and offspring. When considering as a potential donor the child of a matched or haplo-identical sibling, the probabilities for the donor to be haplo-identical with the recipient remain 50% and 25%, respectively. Thus, second-generation relative donor (i.e. nephew or niece) may be finally considered as a source of stem cell graft.Methods: Here we report the case of a 61-year old man who received a T-replete haplo-identical allo-SCT with high-dose post-transplant CY from his second-generation relative nephew. In 2010, the patient was diagnosed with ALK- CD30+ anaplastic T-cell lymphoma and received 8 cycles of CHOD allowing to obtain morphologic and metabolic partial response. The patient received an allo-SCT from a sibling matched donor (brother) on November 2010 after an FB2A2 reduced-intensity conditioning regimen but secondary graft failure was rapidly documented in spite of donor lymphocyte infusions. Relapse occurred in September 2014 and brentuximab vedotin was administered each 21 days for seven cycles allowing to obtain a complete morphologic and metabolic response. It was decided to perform a second allograft using a different donor. The patient was childless and no unrelated donor or cord blood units were available. It was thus chosen to ask for donor the son of the matched brother, who was haplo-identical and had no antibodies directed against the patient's HLA specificities. This nephew had a O- blood group and negative CMV serology while the recipient was O+ and CMV+.Results: The second allograft was performed on April 2nd 2015 using the Baltimore (Luznik, BBMT 2008) conditioning regimen with 2 days of post-transplant CY. A megadose of peripheral blood stem cell was administered (14.16x106 CD34+ cells/Kg) at day 0. Neutrophils and platelets recovery (>50 Giga/L) were achieved as early as days +18 and +33, respectively, with full donor whole blood chimerism (99.8%) at day +30, persisting on day +60 and +100 (both whole blood 99.9%, CD3+ T cells: 99.9%).Grade 2 acute cutaneous GVHD occurred at day +21. The evolution was favorable after initiating corticosteroids at 2 mg/kg/day with tapering thereafter. Not surprisingly, CMV reactivation was documented at day+22, controlled by ganciclovir treatment. Immune reconstitution evaluated at days +30, +60 and +100 showed normal monocyte counts while B lymphocytes were undetectable. NK cells increased from 42/mm3 at day+30 to 453/mm3 at day +60 and 665/mm3 at day +100. Interestingly, after profound lymphopenia within the first 100 days post-transplant, CD8+ T large granular lymphocytes expansion was documented at day + 110. At four months post-transplant, the patient is alive in persistent metabolic remission with no active acute or chronic GVHD nor active infection. His outcomes will be updated for the meeting.Conclusion: T-replete haplo-identical allo-SCT with high-dose post-transplant CY using a second-generation relative donor was feasible allowing for full engraftment and moderate acute GVHD in our patient. This result expands the possibility to find a donor for a selected patient, meanwhile paving the way for using unrelated haplo-identical donor, which could be of interest when considering solid transplantation. Indeed, combining solid organ transplantation and allo-SCT from the same haplo-identical donor may open the door to withdraw immunosuppression in this particular setting, because stable tolerance may be induced, as it has been already reported for kidney transplant (Kawai, NEJM 2013). DisclosuresMoreau:Celgene: Honoraria, Other: Adboard; Amgen: Other: Adboard; Takeda: Other: Adboard; Janssen: Other: Adboard; Novartis: Other: Adboard.

The Impact of Graft/Recipient ABO Compatibility on Outcomes after Umbilical Cord Blood Transplant for Non-Malignant Disease

Background:Existing literature shows mixed conclusions regarding the impact of ABO incompatibility on outcomes following hematopoietic cell transplantation (HCT). As the future for umbilical cord blood (UCB) expansion technologies is bright, we assessed whether this typically-overlooked graft characteristic impacted various outcomes following UCB transplantation (UCBT) for non-malignant disorders (NMD).Patients and Methods:A prospectively maintained institutional BMT program database was queried for all patients undergoing first UCBT for NMD and their demographic, disease and transplant-related characteristics. For each transplant, UCB and recipient ABO compatibility was considered (1) matched, (2) major mismatched (recipient isoagglutinins against UCB antigen), (3) minor mismatched (UCB isoagglutinins against recipient antigen), or (4) bi-directional mismatched. In double UCBT, only the compatibility status of the dominant unit was considered.The impact of ABO incompatibility was assessed on the following outcomes using Kaplan-Meier and cumulative incidence functions: graft failure, aGvHD (grade II - IV and III - IV), cGvHD, platelet recovery, and overall survival. Cumulative red blood cell transfusion exposure per patient between HCT days 0 and +100 (c-RBC) was obtained from laboratory records. Donor hematopoietic chimerism values on the myeloid fraction of peripheral blood were reviewed at day +100 and most recent time assessed. HLA typing was at the antigen level for HLA-A and -B and allele level at -DRB1; in double UCBT, the matching status of the dominant unit was considered.Results:Through December 2014, 270 patients have undergone first UCBT for various NMD (inherited metabolic disorder = 165; marrow failure = 71; other = 34). The mean age at UCBT was 7.9 years (± 9.6). Most patients had a maximal performance score before UCBT (Lansky/Karnofsky of 100, n = 162; 60%) and were male (n = 164; 61%). Most patients received a single UCB unit (n = 225; 83%) and the majority of grafts were unrelated (n = 253; 94%). The average total nucleated cell dose was 8.0 x 107/kg (± 6). With respect to HLA-matching, 79 (29%) received matched, 133 (49%) single-mismatched and 57 (21%) two-mismatched grafts. Most patients received myeloablative conditioning (n = 209; 77%) and GvHD prophylaxis with cyclosporine and mycophenolate mofetil (n = 150; 56%). Negative CMV serostatus in both the graft and recipient was most common (n = 172; 64%).ABO compatibility for the cohort was as follows: matched, n = 93 (34%); major mismatch, n = 72 (27%); minor mismatch, n = 80 (30%); bi-directional mismatch, n = 23 (9%). ABO compatibility status was indeterminate in 2 transplants. Among all 4 ABO compatibility groups, no significant difference was seen in age, gender, NMD diagnosis category, conditioning intensity, HLA-matching, cell dose, number of UCB units, transplant era, performance score, GvHD prophylaxis, or CMV serostatus. Related UCB unit transplants were more likely to be ABO matched.Table 1 shows outcomes by ABO compatibility group with a median follow-up time of 4.5 years (range, 0.5 - 20). ABO compatibility status did not appear to impact any outcomes assessed, though a trend toward increased grade III - IV aGvHD was seen in recipients of major mismatched units.Table 1Outcomes after UCBT for NMD by ABO Compatibility StatusOutcomeABO Match (n=93)Minor Mismatch (n=80)Major Mismatch (n=72)Bidirectional Mismatch (n=23)P-valueOverall survival, 5 y estimate (95% CI)65% (53-74)72% (59-81)68% (54-78)76% (51-89)0.62aGVHD (II - IV) (95% CI)20% (12-29)25% (15-35)27% (16-38)28% (8-49)0.75aGVHD (III - IV) (95% CI)8% (2-15)8% (2-14)20% (10-29)5% (1-14)0.09cGVHD at 5 y (95% CI)8% (2-15)7% (1-13)8% (1-15)5% (1-15)0.96Graft failure (95% CI)19% (11-28)20% (11-29)25% (15-35)17% (2-34)0.83Platelet recovery at 1 y (95% CI)74% (65-83)75% (65-85)67% (55-78)70% (48-91)0.77Day 100 chimerism, ≥ 80% (95% CI)69% (58-79)70% (60-81)66% (54-78)75% (56-94)0.89Most recent chimerism, ≥ 80% (95% CI)79% (71-87)75% (65-84)66% (55-77)74% (56-92)0.33c-RBC (Day 0 to +100) median (inter-quartile range)11 (6-16)10 (6-20)10 (6-19)14 (8-21)0.75y = year; CI = confidence intervalConclusion:ABO compatibility status did not seem to impact outcomes following UCBT for our large NMD cohort. Further analysis of the cohort to exclude interference on some outcomes assessed will be needed for a more definitive conclusion. DisclosuresNo relevant conflicts of interest to declare.

Disease-Free Survival in Adult Patients with Acute Leukemia and Advanced CML Supports Use of Double-Unit Cord Blood Grafts As an Immediate Alternative to 8/8 HLA-Matched Unrelated Donors (URD)

Background: Double-unit cord blood transplantation (DCB-T) is a rapidly available alternative to unrelated donor transplantation (URD-T) for patients with high-risk acute leukemia or advanced CML. Retrospective analyses in adult DCB-T suggest that double-unit CB grafts may be associated with improved disease-free survival (DFS). However, the prioritization of URD-T vs DCB-T is controversial.Methods: We evaluated 175 consecutive adult allograft recipients (120 URD-T and 55 DCB-T) aged 16-60 years transplanted 10/2005-11/2012 for acute leukemia in morphologic remission or aplasia (113 AML/ biphenotypic, 50 ALL), or advanced CML (n = 12). URD grafts were 7-8/8 HLA-matched (74 8/8, 46 7/8). CB grafts were 4-6/6 donor-recipient HLA-matched (4 6/6, 51 5/6, 55 4/6). All patients received either high dose or reduced intensity myeloablative conditioning. The majority of URD-T recipients (n = 111, 93%) received T-cell depleted (TCD) grafts with rabbit ATG, whereas GVHD prophylaxis for DCB-T was calcineurin-inhibitor/mycophenolate mofetil.Results: The median ages of URD-T (43 years) and DCB-T (42 years) recipients were similar (p = 0.713). Distributions of gender, recipient CMV positivity, HCT-CI scores, time from diagnosis or relapse to transplant, diagnoses, disease risk, and percentage of patients with minimal residual disease pre-transplant were also similar. Neutrophil engraftment was slower in DCB-T (95%, median 24 days) than URD-T (100%, median 11 days) (p <0.001). While the incidence of grade II-IV acute GVHD at day 100 was lower in TCD URD-T recipients (15%) than in unmodified URD-T (56%) and DCB-T (55%), p = 0.002, the incidence of day 100 grade III-IV acute GVHD was similar in TCD URD-T, unmodified URD-T, and DCB-T recipients (p = 0.794). With a comparable survivor follow-up [URD-T median 51 months (range 15-99) vs DCB-T median 46 months (range 15-92)], transplant-related mortality was similar (3-year estimates: URD-T 25% vs DCB-T 24%, p = 0.838) whereas the relapse risk was decreased after DCB-T (3-year estimates: URD-T 23% vs DCB-T 9%, p = 0.008). Overall, the 3-year DFS after URD-T was 52% and 68% after DCB-T (p = 0.056). When split into 3 groups, the 3-year DFS was 59% in 8/8 URD-T, 40% in 7/8 URD-T, and 68% in DCB-T, p = 0.043 (Figure). Multivariate analysis was performed to determine risk factors for disease relapse or death in the 175 patients (Table). Female gender (HR 1.65, p = 0.029), diagnosis of ALL (HR 2.11, p = 0.002), and mismatched URD-T (HR 1.97, p = 0.027) were each significantly associated with treatment failure.Conclusions: DCB-T can achieve favorable DFS in adults with acute leukemia and CML with low relapse rates. In this series, multivariate analysis demonstrated that mismatched URD-T was independently associated with lower DFS. Our findings support use of DCB-T as an immediate alternative for high-risk acute leukemia and advanced CML in adult patients without a readily available 8/8 allele HLA-matched unrelated volunteer donor. This could have the additional benefit of speeding time to transplant in high-risk patients.TableVariableMultivariateHR (95% CI)P-valueMale FemaleReference 1.65 (1.05-2.59)0.029 Recipient CMV Negative Recipient CMV PositiveReference 1.34 (0.85-2.12)0.201HCT-CI score 0-2 HCT-CI score > 3Reference 1.56 (0.98-2.47)0.059AML/CML ALLReference 2.11 (1.30-3.41)0.002DCB-T 8/8 URD-T 7/8 URD-TReference 1.32 (0.72-2.41) 1.97 (1.08-3.60)- 0.365 0.027 [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Comparable 3-Year Disease-Free Survival Regardless of Anti-Thymocyte Globulin Inclusion in Pediatric Myeloablative Cord Blood Transplantation for Acute Lymphoblastic Leukemia

Background: Cord blood (CB) is routinely used as an alternative stem cell source for the treatment of children with acute leukemia and has been associated with high rates of disease-free survival (DFS). However, one controversial issue in pediatric CB transplantation is the role of anti-thymocyte globulin (ATG) as immunoprophylaxis. While inclusion of ATG in the conditioning may decrease the risk of graft-versus-host disease (GVHD), it could potentially abrogate graft-versus-leukemia effects and increase the risk of opportunistic infections. Thus, we compared outcomes in a uniform group of pediatric patients with acute lymphoblastic leukemia (ALL) who underwent myeloablative CB transplantation with or without ATG.Methods: Patients with ALL in morphologic remission (CR1 n=106, CR2 n=146, CR3 n=45) aged ≤ 20 years transplanted between 01/2007-12/2011 with high-dose total body irradiation-based conditioning and single or double unit CB grafts were eligible for analysis. CB units were 4-6/6 HLA-A,-B at the antigen-level, -DRB1 allele matched to the recipient and had CB unit with cryopreserved total nucleated cell dose of ≥ 2.5 x107/kg/unit. Cox regression models were built to evaluate potential differences in outcome in ATG versus non-ATG CB transplant recipients. The primary endpoint was 3-year DFS.Results: Of 297 patients, 92 received ATG and 205 did not. Age and disease status were similar in each group whereas ATG recipients were less likely to be CMV seropositive and more likely to receive single unit CB grafts. While neutrophil engraftment was similar in each group, the risk of day 100 grade II-IV acute GVHD [30% (95%CI: 21-40) versus 54% (95%CI: 47-61), p = 0.0002] and 3-year chronic GVHD [22% (95% CI: 14-31) versus 43% (95% CI: 36-50), p = 0.0008] were decreased in ATG recipients. However, day 100 grade III-IV aGVHD was comparable: 11% (95%CI: 5-18) in ATG versus 17% (95%CI: 12-23) in non-ATG recipients, p = 0.15]. The 3-year TRM was similar in both groups: 16% (95%CI: 10-25) in ATG versus 17% (95%CI: 13-23) in non-ATG recipients (p = 0.98). Relapse was also similar in ATG and non-ATG recipients: 17% (95%CI: 10-23) versus 27% (95%CI: 21-34, p = 0.12), respectively. In multivariate analysis, negative CMV serostatus was associated with reduced TRM risk [HR 0.55 (95%CI: 0.30-0.98), p = 0.004] whereas remission status CR2 or CR3 significantly increased relapse risk [HR 2.18 (95%CI: 1.22-3.89), p = 0.008], but inclusion of ATG had no effect on either outcome. With a median follow-up of survivors of 36 months (range 5-72), the 3-year DFS was 66% (95%CI: 56-76) and 55% (95%CI: 48-62) in ATG and non-ATG recipients, respectively (p = 0.23, Figure 1). The distribution of causes of death was similar in each group. In multivariate analysis, treatment failure risk was increased in patients transplanted in CR2 or CR3, but the inclusion of ATG had no effect (p = 0.24) (Table 1).Conclusion: Inclusion of ATG in pediatric myeloablative CB transplant for ALL is associated with a decreased risk of grade II-IV acute GVHD and chronic GVHD but not severe grade III-IV acute GVHD. There was no difference in 3-year DFS in each group and multivariate analysis revealed ATG inclusion had no impact upon treatment failure risk. These results indicate that optimization of both ATG and non-ATG conditioning platforms are needed in order to further improve CB transplantation survival in children with ALL. Unanswered questions include the impact of the formulation, dose and timing of ATG administration. These findings cannot be extrapolated for other diagnoses, reduced intensity conditioning, or adults.Table 1Hazard ratio(95% confidence interval)p-valueATG useConditioning without ATG Conditioning with ATG1.00 0.78 (0.52 – 1.18)0.24 Disease statusCR1 CR2, CR31.00 2.01 (1.31 – 3.08)0.001 [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Pleural Effusion, Ascites, and Periportal Edema in the Absence of Fulminant Hepatic Failure Secondary to Nimesulide

Introduction: Nimesulide is a non-steroidal antinflammatory drug that has been associated with hepatoxicity leading to acute hepatitis, as well as fulminant hepatic failure. The mechanisms have been studied, but are still poorly understood. We hereby report the first case of nimesulide leading to ascites in the presence of bilateral pleural effusions in the absence of fulminate hepatic failure. Case Report: A 44-year-old Brazilian woman with no remarkable past medical history presented with sharp right upper quadrant epigastric pain following a recent 2-week trip to Brazil. She was visiting her family, who lived in a mountainous region and owned a farm that housed cows and pigs, but she did not have any direct contact with animals during her visit. However, she did drink local, unfiltered tap water. Prior to travel, she had sustained an ankle sprain and in Brazil; she was prescribed nimesulide 200 mg 3 tablets a day for 5 days. On presentation, she reported nausea with episodes of non-bloody emesis with body aches, chills, and weakness. On exam, she was afebrile with no scleral icterus. Abdomen was tender to palpation in the right upper quadrant, with positive Murphy’s sign. Her lungs exhibited absent to decreased breath sounds in the bilateral bases. Her white blood cell count was 7,600 per μL. Liver tests showed an AST 327 U/L and ALT 518 U/L. CT abdomen revealed large-volume ascites, periportal edema, and bilateral pleural effusions. Hepatitis A IgM antibody, hepatitis B core IgM antibody, hepatitis B surface antigen, hepatitis B surface antibody, hepatitis C, and hepatitis E antibodies were all negative. Anti-smooth muscle antibodies, antinuclear antibodies, antineutrophil cytoplasmic antibodies, and antimitochondrial antibodies were also negative. She subsequently underwent a transjugular liver biopsy, which was noted for acute lobular hepatitis with prominent zone 3 necrosis and a trans-sinusoidal gradient of 5 mm Hg. Additionally, a simultaneous diagnostic paracentesis was also obtained, which was significant for a SAAG gradient of 1.1. Further infectious work-up revealed a negative HIV, HSV, EBV, and CMV. Yellow fever, Strongyloides, Dengue fever, Leptospira, Schistosoma, and Brucella antibodies were also negative. Conclusion: There have been reports associating nimuselide with fulminant hepatic failure, but none involving nimuselide with pleural effusions and ascites without frank hepatic failure. Although the exact mechanism remains unclear, a clinician still needs to be aware of nimesulide as a possible cause of ascites and pleural effusion in spite of the absence of fulminant liver failure, as documented in our patient, and a thorough drug history is very pivotal.

Changes in Plasma Levels of VEGF-C and Endothelin-1 During the First Post-Transplant Year Are Predictive of Cardiac Allograft Vasculopathy: Results From the CTOT-05 Study.

Background: We tested the hypothesis that sequential monitoring of angiogenesis-related factors predicts early cardiac allograft vasculopathy (CAV). Subjects were randomly selected from 106 subjects in the CTOT-05 study who had paired IVUS evaluations; 20 test subjects, who had an increase in MIT of > 0.5 mm in the LAD in the first year after transplant (CAV group), and 40 control subjects were included. We measured 17 candidate biomarkers by Luminex multiplex analysis. Data on pre-transplant plasma samples (N=52) and paired pre-transplant and 1 year post-transplant plasma samples (N=46), were analyzed using logistic regression in a multivariate forward selection model. Results: The study population was 20% female with a mean age of 53 years. Indication for transplant was idiopathic DCM in 41% and ischemic CM in 32% of patients. Clinical characteristics associated with CAV included white race (P=0.03), male recipient (P=0.04), and negative recipient CMV IgG (P=0.03). In pre-transplant samples, higher plasma levels of Endothelin-1 (OR 20.2; CI 1.42-286) and Leptin (OR 11.32; CI 1.13-113) were associated with an increased risk of CAV, while EGF (OR 0.11; CI 0.01-0.95), FGF-2 (OR 0.04; CI 0-1.03) and IL-8 (OR 0.36; 0.1-1.2) were protective. A bootstrapped multivariate model using these 5 molecules was used to construct a receiver operating characteristic (ROC) curve with an area under the curve (AUC) of 0.768. An increase in VEGF-C (OR 2.6; CI 1.12-6.20) and FGF-1 (OR 12; CI 0.8-177) from the pre-transplant visit to 1 year post-transplant was associated with CAV, while Endothelin-1 was found to be protective (OR 0.25; CI 0.07-0.91). A second bootstrapped multivariate model using changes in concentrations of these 3 molecules revealed a ROC with an AUC of 0.766. Conclusions: Increases in plasma levels of VEGF-C and decreases in levels of Endothelin-1 over the first post-transplant year are associated with the development of CAV by IVUS. Sequential measurements of these biomarkers will identify patients in whom medical interventions to prevent CAV can be tested in future clinical trials.

Nonmyeloablative Allogeneic Hematopoietic Stem Cell Transplant in Patients with End Stage Renal Disease Requiring Dialysis – a Single Institution Experience

s / Biol Blood Marrow Transplant 20 (2014) S211eS256 S251 patients with biopsy-proven disease, 43% had lymphocytosis. 100% of patients with CMV viremia and no CMV gut disease were lymphopenic. There did not appear to be any association between CMV PCR copy number and absolute lymphocyte count (r1⁄40.016; p1⁄40.49). There was no apparent pattern or relationship between CMV PCR copy number and degree of cytopathic changes on intestinal biopsy. Conclusion: We hypothesized that all patients with gutassociated CMV disease would have corresponding CMV viremia. One patient with biopsy-proven disease had negative CMV PCR, so we are evaluating for potential sources of false positivity because gut-confined CMV (CMV disease without CMV viremia) is relatively uncommon in the HSCT setting. Our data support that a lack of CMV viremia does not rule out gut-associated CMV disease and that intestinal biopsy by EGD or colonoscopy is warranted in this patient population.

Cytomegalovirus Infection Among Iranian Kidney Graft Recipients

BackgroundCytomegalovirus (CMV) infection is one of the most common infectious problems following kidney transplantation. In this study we sought to investigate CMV infection in the setting of renal transplant recipients in Urmia, Iran, using polymerase chain reaction (PCR) detection. MethodsNinety-six randomly selected renal transplant recipient were enrolled in a cross-sectional study. Blood sampling via venipuncture, yielded sera investigated for anti-CMV IgM. Seropositive as well as 14 randomly selected seronegative cases were investigated with PCR assays. ResultsThirty-three patients (34.3%) were seropositive for anti-CMV IgM; 3 (3.1%) borderline, and 60 (62.5%) seronegative. Considering borderline anti-CMV IgM levels as seropositive, 37.5% were seropositive for anti-CMV IgM. Among the 36 seropositive cases, a CMV infection was confirmed in 19 (52.7%) using PCR. Age (P = .40), educational status (P = .77), history of pretransplantation dialysis (P = .52), prior blood transfusion (P = .52), and immunosuppressive regimen were not significantly different among positive versus negative CMV PCR recipients. ConclusionsThe seroprevalence of CMV infection was high among renal transplant recipients of Urmia, Iran, as confirmed by PCR study.

Exploratory Immunosuppressive Strategy for Recipients of Kidney Transplants from Expanded Criteria Donors (ECD)

Introduction: The use of kidneys from ECD is increasing but the ideal immunosuppressive strategy for these recipients has yet to be established. Calcineurin inhibitor (CNI) free regimens, theoretically ideal strategies, have been associated with higher incidence of acute rejection and inferior graft outcomes compared to CNI-based regimens. Methods: This study was an exploratory investigation in 60 consecutive low risk recipients of kidneys from ECD. Immunosuppressive regimes consisted of a single 3 mg/Kg dose antithymocyte globulin, reduced exposure tacrolimus (3 to 8 ng/mL) and azathioprine (2mg/Kg, fixed dose, for 10 days) with a planned conversion to sirolimus (5-15 ng/mL) after 10 days of the transplant surgery. All patients also received prednisone and none of the patients received CMV prophylaxis. Results: The mean donor age was 60.3 ± 8.2 years, 53.3% had history of hypertension and 55% died due to a cerebrovascular accident. The mean terminal serum creatinine was 1.9 ± 1.2 mg/dL and the mean cold ischemia time was 24.1 ± 4.4 hours. The mean recipient age was 49.7 ± 13.21 years with 55% Caucasian and 66.6% male. There was one donor positive/recipient negative CMV combination. Delayed graft function was observed in 63.3% of patients. The incidence of treated acute rejection was 26.6% (n=16) with 18.3% incidence of biopsy confirmed acute rejection (n=11, 5 IA, 2 IIA, 4 IIB) and 5 focal interstitial nephritis. The incidence of CMV infection was 15% (n=9). Six patients developed CMV infection after treatment for acute rejection and one patient had a recurrent infection. Patient and graft survivals were 89.6% and 73.3% at 1 year, respectively. Mean serum creatinine at 3, 6 and 12 months was: 2.2 ± 1.0, 2.1 ± 0.9 and 2.0 ± 0.9 mg/dL, respectively. Sirolimus was introduced until day 14 in 50% of patients and until day 21 in 80% of patients. Four patients never received tacrolimus and 3 other patients had tacrolimus discontinued due to graft dysfunction. Sirolimus was discontinued in one patient due to peritonitis. Sirolimus associated adverse reactions included wound dehiscence (13.3%), wound infection (13.3 %), urinary fistula (6.6%), lymphocele (1.7%) and dyslipidemia (61.7%). There were 10 (16.6%) graft losses (5 due to vascular thrombosis, 3 due to infection, 1 primary non function and 1 due to acute rejection) and 6 (10%) deaths (4 due to infection and 2 due to cardiovascular event). Conclusions: This exploratory study confirms the challenges related to the use of kidneys from expanded criteria donors, mainly the high incidence of delayed graft function, early graft losses due to vascular complications and suboptimal though stable renal function. Further studies are necessary to optimize this strategy.

1823 The Evaluation of Antibody Responses in Steroid Sensitive Children with Nephrotic Syndrome

Nephrotic syndrome is characterized by massive proteinüria, hypoalbuminemia, and edema. Immunoglobulin changes, T lymphocyte function disorders, and the reduction in complement levels in the nephrotic syndrome cause an increase in...

Liver Toxicity Following Abuse of Kratom (Mitragyna speciosa)

Purpose: 26 year-old Caucasian male presented with fever, abdominal pain and jaundice after using Kratom (Mitragyna speciosa) for recreational purposes. Laboratory studies revealed acute hepatitis with cholestasis (AST 57 ALT 97 TBil 7.8). He has had negative ANA, AMA, SMA, hepatitis serologies, CMV, HSV, and EBV testing. He also had negative studies for hemochromatosis and Wilson's disease. No other causative agent was identified. Right upper quadrant ultrasound was normal. His LFTs normalized over one month after stopping the supplement. Kratom contains the alkaloid mitragynine and is traditionally used as a medical plant in Thailand. It has reported analgesic, euphoric and antitussive effects via its action as an opioid receptor agonist. The use of this medication has been seen with increasing frequency in the western hemisphere. Reports of drug toxicity are rare in the literature. The adverse effects of this medication are poorly understood. Although illegal in many countries, Kratom is legal and uncontrolled in the United States.

Rapid Recovery of CD4 Counts Following Low Dose Alemtuzumab Conditioning During HLA Matched Related Bone Marrow Transplant for Children with Haemoglobinopathies

AbstractAbstract 2335CMV viraemia and disease remains a major cause of morbidity and mortality following allogeneic bone marrow transplantation (BMT). We investigated the impact of low dose alemtuzumab conditioning in paediatric matched sibling allogeneic BMT for haemoglobinopathy on immune reconstitution (early and late CD3/4+, CD3/8+, CD3-/CD56+ cell recovery) and subsequent viral infections in 18 consecutive transplants (14 β thalassaemia major and 4 sickle cell anaemia). A secondary aim was to investigate the impact of immune reconstitution on graft versus host disease but due to the extremely low incidence of acute and chronic graft versus host disease with this protocol (acute grade II to IV 11.6% and chronic 4.6%) we were unable to assess this. Transplant protocol: following hypertransfusion to suppress endogenous haemopoiesis, patients were conditioned with oral busulfan 14 mg/kg (days -9 to -6), cyclophosphamide 200 mg/kg (days -5 to -2) and alemtuzumab 0.3 mg/kg (days -8 to -6). Graft versus host disease prophylaxis was provided with ciclosporin for six months and methotrexate 10 mg/m2 on days +4 and +7. All transplants used BM as source of stem cells. CMV PCR surveillance was undertaken twice weekly and CMV reactivation was treated with intravenous foscarnet or ganciclovir, followed by secondary prophylaxis with valganciclovir. Routine peripheral blood immunophenotyping of lymphocyte subsets was performed at 60-, 90-, 120-, 150- and 180- days post-BMT. Results:the median age of transplant recipients was 7 years (range 2 – 17 years) and median follow up 254 days (range 203–378). The median CD3/CD4+ cell count rose above 200 cells/μl by day 180 and above 300 cells/μl by day 254 following the withdrawal of immune suppression at six months (fig 1A), the median CD8+ cell count increased earlier, to >200 cells/μl by day 60 and 300 cells/μl by day 180 (fig 1B) and the median CD56+ cell count reached 200 cells/μl by day 60 and plateaued thereafter (fig 1C). Overall, CMV reactivation occurred in 13 patients (72.2%) after a median interval of 35 days following BM infusion (range day-1 to day +72): 10/13 patients (76.9%) in whom both recipient and donor were CMV positive (CMV +/+); 1/3 patients in whom recipient was CMV negative and donor CMV positive (CMV -/+); and in 1/1 who was CMV positive with a CMV negative donor (CMV +/−). Significantly there was no clinical CMV disease in any patient and with the use of oral valganciclovir there were no subsequent CMV reactivations. CMV reactivation occurred in patients with lower CD4+ cell counts at day 60 (67 cells/μl) compared with the CMV-unaffected group (a median CD4+ count 298 cells/μl; p= 0.0262). Four patients experienced other viral infections: HHV6 infection requiring foscarnet on day +85 (n=1), urinary BK virus not requiring treatment (n=2) and parainfluenza pneumonitis requiring ribavarin on day +12 (n=1). Conclusion:Low dose alemtuzumab conditioning is associated with rapid CD4+ cell recovery (CD4+ >200 cells/μl by day +180) in children undergoing allogeneic matched related donor BMT for haemoglobinopathy. Although there is a high frequency of CMV reactivation (72.2%) in patients with low CD4+ counts at day 60 (median CD4+ count 67 cells/μl), no clinical CMV disease was seen and subsequent reactivations of CMV were prevented by the use of valganciclovir secondary prophylaxis whilst awaiting full immune reconstitution. [Display omitted] [Display omitted] [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Influence of Myeloablative Conditioning Regimens on Outcomes after Single Unrelated Cord Blood Transplantation for Adults with Leukemia: An Analysis on Behalf of Eurocord-EBMT-Netcord

Cyclophosphamide (CY) associated to high dose total body irradiation (TBI) or busulfan (BU) is the gold standard of myeloablative conditioning regimen (MAC) in allogeneic hematopoietic stem cell transplantation (HSCT). In unrelated transplants, anti-T cell serotherapy (ATG/ALG) is often added as immunosuppressive drug. Recently, new drugs such as fludarabine (FLU) or thiotepa (TT) have also shown their value in conditioning regimen. However, no MAC has shown to be significantly superior to the conventional TBICY or BUCY. Unrelated cord blood transplantation (UCBT) has been increasingly used in adult patients lacking a HLA-matched donor, but the impact of MAC in this setting is unknown.In order to do so, we analyzed 226 patients who underwent single UCBT after MAC for leukemia [acute lymphoblastic leukemia (n=80), acute myeloid leukemia (n=86), myelodysplasia (n=33), chronic myeloid leukemia (n=27)]. According to IBMTR classification, 60% of patients had early- or intermediate-risk disease status at transplantation. All patients were transplanted from January 2000 to February 2008 in Europe. Median age was 33 years (18–60) and median follow-up was 21 months (2–96). UCB grafts had ≥ 2 HLA incompatibilities in 62% of cases; median nucleated cell dose infused was 2.5 × 107/kg. Ninety-three percent of patients received ATG/ALG before day 0. Three groups of MAC were observed: group 1- TBICY or BUCY (n=82; 36%), group 2- CY+TT (mostly associated to BU) (n=73; 32%) and group 3- FLU based regimens (mostly associated to intravenous BU 9.6 mg/kg and TT 10 mg/kg) (n=71; 31%). Graftversus- host disease (GVHD) prophylaxis consisted of cyclosporine and corticosteroids in 77% of patients.Patients-, disease- and transplant-related factors were compared among the 3 conditioning groups. All 3 groups showed the same frequency of diagnosis and status of the disease at transplantation. Group 1 (TBICY or BUCY), included a higher number of patients with negative CMV serology, transplanted before 2004, ≥ 2 HLA disparity and higher number of infused cells compared to group 2 and/or group 3. There was no statistical difference of those characteristics between group 2 and 3. Cumulative incidence of 60 day-neutrophil recovery (>500/mm3), 180 day-platelet recovery (>20000/mm3), 100 day-acute GVHD, 100 day non-relapse mortality (NRM) and relapse at 2 years were 80±3%, 52±3%, 24±3%, 28±3% and 24±4%, respectively. Two-year disease-free survival (DFS) was 37%±5 for patients transplanted in remission and 22±5% for those in more advanced phase (p=0.001). The association of groups of MAC and outcomes are shown in the table below. In a center effect adjusted multivariate analysis, among other variables such as CMV recipient serology, disease status and HLA disparity, groups 2 and 3 confirmed an increased incidence of neutrophil recovery [hazard ratio (HR)=0.44 (95% CI 0.32–0.60)] and platelets recovery [HR=0.52 (95% CI 0.34–0.79)]. However, none of the conditioning regimens were associated with acute GVHD, 100-day NRM or DFS.Conclusion: these findings support the use of fludarabine and/or thiotepa based MAC as a strategy to improve neutrophil/platelet recovery after single UCBT in patients with leukemia. Further prospective randomized trials should be performed to address this issue.Conditioning regimensNeutrophil recovery (day+60)Platelets recovery (day+180)AGVHD (II–IV) (day +100)NRM (day +100)DFS (2 years)Group 1 - TBICY or BUCY (n=82)71±5%39±5%17±4%28±5%28±6Group 2 - CY+TT (± BU or TBI) (n=73)78±5%53±6%37±6%38±6%29±5Group 3 - FLU (+ BU + TT) (n=71)92±4%66±6%18±5%17±4%35±7P (overall)<0.0010.0030.0010.0210.400