Nonmyeloablative Allogeneic Transplantation Research Articles

Comparison of ARF after myeloablative and nonmyeloablative hematopoietic cell transplantation

Acute renal failure (ARF) occurs with significant frequency after myeloablative and nonmyeloablative allogeneic hematopoietic cell transplantation (HCT). Myeloablative (conventional) HCT is the standard of care for cure of various malignant disorders. The newer modality of nonmyeloablative ("mini-allo") HCT is reserved for patients with advanced age and comorbidities who are ineligible for myeloablative HCT. The present study compares the incidence of ARF between patients undergoing concurrent myeloablative and nonmyeloablative HCT in the same period at the same institution. This retrospective cohort study from 1997 to 2003 compares 140 myeloablative and 129 nonmyeloablative patients from the Fred Hutchinson Cancer Research Center. Severity of ARF was classified into 4 grades based on the increase in serum creatinine levels in the first 100 days after HCT. Mortality was studied at 100 days and 1 year. Nonmyeloablative patients were significantly older and had greater pretransplantation comorbidity at baseline. Despite this, patients undergoing myeloablative HCT had a greater incidence of severe ARF (grades 2 and 3, 73% versus 47%; P < 0.001). The incidence of dialysis also was 4-fold greater (12% versus 3%; P < 0.001) in the myeloablative than nonmyeloablative group. On multivariate analysis after controlling for baseline characteristics, myeloablative HCT was associated with a 4.8-fold greater incidence of ARF compared with nonmyeloablative HCT. Nonrelapse mortality also was greater in the myeloablative group at 100 days and 1 year. The incidence and severity of ARF, as well as nonrelapse mortality, occurring after nonmyeloablative HCT is significantly lower compared with myeloablative HCT.

Comparison of renal injury in myeloablative autologous, myeloablative allogeneic and non-myeloablative allogeneic haematopoietic cell transplantation

Comparison of renal injury in myeloablative autologous, myeloablative allogeneic and non-myeloablative allogeneic haematopoietic cell transplantation

Molecular monitoring of tumour load kinetics predicts disease progression after non-myeloablative allogeneic stem cell transplantation in multiple myeloma

Non-myeloablative allogeneic stem cell transplantation followed by immunomodulatory therapies is considered a potentially curative approach in the treatment of multiple myeloma and most effective in a minimal residual disease setting. The aim of this study was to find the most sensitive real-time PCR assay (TaqMan), based on the IGH rearrangement, to quantify the tumour load of 11 patients with multiple myeloma after non-myeloablative allogeneic transplantation. Patient-allele specific primers (ASO) and the TaqMan probe were derived from CDR2 and CDR3 hypervariable regions of IGH, while consensus primers were located within the FR3 and FR4/JH regions. Four different approaches of primer combinations were tested. ASO-forward and -reverse primers together with the clone-specific TaqMan probe were the most sensitive approach compared with the JH (P=0.071) or the FR3 consensus primer (P <0.001). The detection limit amounted to 1/10(4)-1/10(5) cells. Consecutively, 120 samples from 11 patients prior and post allogeneic transplantation were analysed. Three patients reached complete clinical remission accompanied by molecular remission. Disease progression or relapse was seen in six patients. In five, molecular progressive disease was detected prior to the clinical diagnosis of progression or relapse. Patient-specific real-time IGH-PCR provides the opportunity for earlier treatment intervention.

Persistence of recipient plasma cells and anti‐donor isohaemagglutinins in patients with delayed donor erythropoiesis after major ABO incompatible non‐myeloablative haematopoietic cell transplantation

Delayed donor erythropoiesis and pure red-cell aplasia (PRCA) complicate major-ABO mismatched non-myeloablative allogeneic stem-cell transplantation. To characterize these events, we analysed red-cell serology and chimaerism in lymphohaematopoietic lineages, including plasma cells and B cells, in 12 consecutive major-ABO incompatible transplants following cyclophosphamide/fludarabine-based conditioning. Donor erythropoiesis was delayed to more than 100 days in nine (75%) patients including six (50%) who developed PRCA. During PRCA, all patients had persistent anti-donor isohaemagglutinins and recipient plasma cells (5-42%), while myeloid and T cells were completely donor in origin. In contrast, B-cell chimaerism was frequently full-donor when significant anti-donor isohaemagglutinins persisted. Four patients with early mixed haematopoietic chimaerism and the prolonged presence of anti-donor isohaemagglutinins and recipient plasma cells developed delayed-onset (>100 days post-transplant) red cell transfusion dependence and PRCA after myeloid chimaerism converted from mixed to full donor. These findings confirm that donor-erythropoiesis is impacted by temporal disparities in donor immune-mediated eradication of recipient lymphohaematopoietic cells during major-ABO incompatibility and suggest that plasma cells are relatively resistant to graft-versus-host haematopoietic effects.

Significant decline in pulmonary engraftment syndrome after nonmyeloablative allogeneic hematopoietic cell transplantation associated with less amphotericin use for febrile neutropenia

Significant decline in pulmonary engraftment syndrome after nonmyeloablative allogeneic hematopoietic cell transplantation associated with less amphotericin use for febrile neutropenia

Allogeneic Hematopoietic Cell Transplantation for Metastatic Renal Cell Carcinoma after Nonmyeloablative Conditioning

This phase I trial assessed the safety, efficacy, and immunologic responses to minor histocompatibility antigens following nonmyeloablative allogeneic hematopoietic cell transplantation as treatment for metastatic renal cell carcinoma. Eight patients received conditioning with fludarabine and low-dose total body irradiation followed by hematopoietic cell transplantation from an HLA-matched sibling donor. Cyclosporine and mycophenolate mofetil were administered as posttransplant immunosuppression. Patients were monitored for donor engraftment of myeloid and lymphoid cells, for clinical response by serial imaging, and for immunologic response by in vitro isolation of donor-derived CD8(+) CTLs recognizing recipient minor histocompatibility (H) antigens. All patients achieved initial mixed hematopoietic chimerism with two patients rejecting their graft and recovering host hematopoiesis. Four patients developed acute, grade 2 to 3, graft-versus-host disease and four patients developed extensive chronic graft-versus-host disease. Five patients had progressive disease, two patients had stable disease, and one patient experienced a partial response after receiving donor lymphocyte infusions and IFN-alpha. CD8(+) CTL clones recognizing minor H antigens were isolated from five patients studied. Clones from three patients with a partial response or stable disease recognized antigens expressed on renal cell carcinoma tumor cells. Treatment of metastatic renal cell carcinoma with allogeneic hematopoietic cell transplantation after nonmyeloablative conditioning with fludarabine/total body irradiation is feasible and may induce tumor regression or stabilization in some patients. CD8(+) CTL-recognizing minor H antigens on tumor cells can be isolated posttransplant and could contribute to the graft-versus-tumor effect. Such antigens may represent therapeutic targets for posttransplant vaccination or adoptive T-cell therapy to augment the antitumor effects of allogeneic hematopoietic cell transplantation.

Dendritic-cell therapy after non-myeloablative stem-cell transplantation for renal-cell carcinoma

Treatment of advanced renal-cell carcinoma is generally by nephrectomy before systemic therapy, even in patients with metastatic disease. Most patients with metastasis are treated with interferon alfa and interleukin 2 after surgery because advanced renal-cell carcinoma is highly resistant to chemotherapy and radiotherapy. However, studies have shown that non-myeloablative allogeneic peripheral-blood stem-cell transplantation leads to a graft-versus-tumour effect in patients with metastatic renal-cell carcinoma.

Factors affecting engraftment of allogeneic hematopoietic stem cells after reduced-intensity conditioning

Several factors influence the engraftment of allogeneic hematopoietic stem cells (HSC). Recently, there has been increased utilization of transplant-conditioning regimens that use reduced doses of chemotherapy and radiation that are considered to be non-myeloablative. These non-myeloablative (or reduced-intensity) allogeneic HSC transplants (RIST) decrease early post-transplant complications, but they are associated with higher incidences of mixed chimerism and graft rejection compared with transplantation after myeloablative condition-ing. RIST provides a unique opportunity to study allogeneic HSC engraftment. In particular, host immune status and stem cell graft composition have emerged as important factors affecting engraftment after RIST Based on these observations, it has been hypothesized that conditioning regimens and allograft composition can be tailored to an individual patients immune and disease status prior to transplant.

Nonmyeloablative allogeneic bone marrow transplantation for treatment of myelodysplastic syndrome complicated by recent intracerebral hemorrhage

A patient with intracerebral hemorrhage is considered ineligible for hematopoietic stem cell transplantation (HSCT). We report a 49-year-old woman with myelodysplastic syndrome (MDS) complicated by refractoriness to platelet transfusion and intracerebral hemorrhage, who underwent allogeneic bone marrow transplantation from an HLA-identical unrelated male donor. Nine days before the scheduled transplantation, she developed dysarthria and right hemiparesis; computed tomography (CT) of the brain disclosed an acute hematoma in the left parietal lobe exceeding 3 cm in diameter. She underwent conditioning with reduced-intensity, including fludarabine (30 mg/m2/day on days -8 to -3), busulfan (4 mg/kg/day on days -6 and -5), and total body irradiation (4 Gy on day -2). Two weeks after transplantation, dysarthria and right hemiparesis began to resolve, and CT showed spontaneous resolution of the hematoma. Simultaneously, engraftment was confirmed. Thus, recent stroke may be not an absolute contraindication for HSCT.

Nonmyeloablative Allogeneic Stem Cell Transplantation: Hacettepe University Institute of Oncology Experience.

The purpose of this study was to determine the feasibility and efficacy of nonmyeloablative allogeneic stem cell transplantation in patients with hematologic malignancies and metastatic renal cell carcinoma (RCC). Thirty patients with various pathologies (AML/MDS, n=9; CML, n=5; lymphoid malignancy, n=6; Multiple Myeloma, n=7; RCC, n=3) received a fludarabine (F)-based nonmyeloablative regimen (F+Busulphan, n=5; F+TBI, n=18; F+Cyclophosphamide, n=3; others, n=4), followed by unmanipulated peripheral stem cells from HLA-identical sibling donors. Prophylaxis for graft-versus-host disease (GVHD) consisted of cyclosporine and mycophenolate mofetil. Median age was 43 years (range, 17–62), median time from diagnosis to transplant was 1.6 years (range, 0.4–9.1). Patients underwent a median of 2 prior chemotherapy regimens (range, 0–7). Prior stem cell transplantation failed in seven patients (23%) (autologous, n=6; ablative allogeneic, n=1). Disease phase prior to transplant was complete or partial remission in 16 patients (CR, n=12; PR, n=4) and active disease in 14 patients (Primary refractory, n=1; Relapse, n=10; Untreated, n=3). Recipients were male and donors were female in 15 transplants (50%). The median numbers of mononuclear and CD34+ cells infused were 8.8 x 108/kg (range, 4–26 x 108/kg) and 9.7 x 106/kg (5.2–32.5 x 106/kg) respectively. Neutrophil engraftment achieved after a median of 9 days (range, 6–12) and platelet engraftment occurred after a median of 11 days (range, 9–19). In twelve (40%) patients, absolute netrophil count did not fall below 500/mm3 and 14 patients (47%) required no platelet transfusions. The patients received a median of 2 donor lymphocyte infusions (range, 0–8). Nine patients (30%) had acute GVHD (Grade II-IV, n=5, 17%) and 12 patients (40%) had chronic GVHD (limited, n=4; extensive, n=8, 27%). Three patients (10%) died of nonrelapse treatment-related complications within 100 days post-transplant (Pneumonia, n=2; Bronchoalveolar hemorrhage, n=1). Two patients had graft failure at day 100 post-transplant. Twenty two patients (73.4%) are currently alive with a median follow-up of 6 months. Primary causes of deaths (n=8, 26.6%) are as follows; GVHD (n=3), pneumonia (n=2), bronchoalveolar hemorrhage (n=1), and relapse (n=2). Among 22 evaluable patients, response was obtained in 18 patients (82%) (CR, n=14; PR, n=2; stable disease, n=2) and 4 patients relapsed. Our data suggest that nonmyeloablative allogeneic transplantation is a safe and effective treatment strategy in hematological malignancies.

Non-Myeloablative Allogeneic Transplantation in Patients with Relapsed or Refractory Multiple Myeloma.

Patients with recurrent and refractory multiple myeloma have a very limited survival expectance. Allogeneic transplantation might offer an option for cure in myeloma and the recent development of non-myeloablative conditioning regimens has reduced transplant related morbidity and mortality and rendered this treatment feasible in elderly patients.The role of non-myeloablative allogeneic transplantation for multiple myeloma however, has not yet been defined. We have analyzed the results of patients with relapsed or refractory multiple myeloma treated at our institution.Between 08/1999 and 02/2004, 56 patients with relapsed (n=54) or refractory (n=2) myeloma were treated with non-myeloablative allogeneic transplantation. The median beta2microglobulin at the time of diagnosis was 2.75 mg/l, and median age at the time of transplant was 54.5 years (39.2–67.8). The median time from diagnosis to transplant was 3.6 years. Prior to allogeneic transplantation, patients received reinduction chemotherapy which included an autologous transplantation for 30 patients. The median number of previous cycles of conventional chemotherapy was 9. The conditioning regimen was 2 Gy TBI with (n=43) or without (n=3) fludarabin 3 x 30 mg/m² for 46 patients, the remaining 10 patients received a melphalan containing regimen.Acute toxicity was low with a WBC < 500/μl and platelets < 50/μl for a median of 0 days. Engraftment was prompt with 90 % of patients having achieved > 90 % donor chimerism by day 56. Acute GvHD Grade II-IV occurred in 36 % of patients with 22 % Grade III-IV, and 61 % experienced chronic GvHD. Total transplant related mortality reached 20 %, with a day 100 TRM of 5 %. 32 patients experienced relapse or progressive disease, and 32 % of patients died due to relapse. The Kaplan-Meier estimate of overall survival and progression free survival at 18 months was 40 % and 25 %, respectively, with a median follow up of survivors of 21 months. Patients who experienced cGvHD had a significantly higher overall survival estimate (60 % vs. 20 % at 18 months, p=0.03). The number of cycles of pretreatment before allogeneic transplantation had a statistically significant negative influence on overall (p=0.02) and progression free survival (p=0.006).We conclude that non-myeloablative allogeneic transplantation is feasible in patients with relapsed multiple myeloma. The significant poor prognostic factors we identified were absence of chronic GvHD and number of cycles of pretreatment. Allogeneic transplantion should therefore be considered as an option earlier in the course of the disease.

Engraftment and Survival Following Non-Myeloablative Allogeneic Peripheral Blood Hematopoietic Cell Transplantation for Malignant Diseases Is Affected by CD8+ T-Cell Dose.

The influence of graft composition on clinical outcomes after non-myeloablative allogeneic hematopoietic transplantation is not well characterized. In this report we evaluated the influence of CD34+, CD3+, CD4+, and CD8+ cell doses on donor engraftment, graft-versus-host disease (GVHD), freedom from progression (FFP), and overall survival (OS). Patients (n=63) were given total body irradiation 200 cGy (n=8) or total body irradiation 200 cGy plus fludarabine (n=55) followed by allografting with granulocyte colony-stimulating factor-mobilized peripheral blood mononuclear cell (G-PBMC). The median age was 53 years, and donors were HLA-identical siblings (n=38) or HLA-matched unrelated individuals (n=25). Almost all patient were treated for a hematologic malignancy (n=60), with 30 patients (48%) characterized as having advanced diseases. G-PBMC cell doses were prospectively enumerated by FACS analysis at the time of collection. Median donor G-PBMC cell doses were 7.4x106 CD34+/kg (range: 1.9–17.7), 3.2x108 CD3+/kg (range: 0.8–6.4), 2.1x108 CD4+/kg (range: 0.4–4.1), and 1.1x108 CD8+/kg (range: 0.2–3.4). By univariate analysis only G-PBMC CD8+ T-cell dose ≥ the 50th percentile favorably correlated with attainment of full donor blood T-cell chimerism (P = .03). The incidences of grade 2–4 acute GVHD was 16.3% (95% CI: 6.9–25.8) and extensive chronic GVHD was 42.9% (95% CI: 27.8–57.9). No G-PBMC cell dose significantly influenced grade 2–4 acute or extensive chronic GVHD. With a median follow-up of 13 months (range: 5–45), estimates for FFP was 53.7% (95% CI: 37.7–69.7) and OS was 33.4% (95% CI: 17.4–49.4). G-PBMC CD8+ T-cell dose ≥ the 50th percentile T-cell dose was favorably prognostic for both FFP (P = .001) and OS (P = .01). Survival curves for FFP and OS are shown in Figure 1. Extensive chronic GVHD also predicted better FFP (P = .02), but in multivariate analysis only G-PBMC CD8 + T-cell dose (P = .004; RR = 0.2, 95% CI = 0.1–0.6) was associated with improved FFP. Infusion of low G-PBMC CD8+ T-cell dose for non-myeloablative allografting with total body irradiation 200 cGy plus fludarabine may adversely affect donor T-cell engraftment, disease progression and survival outcomes. [Display omitted]

Acute Graft Versus Host Disease after Nonmyeloablative Allogeneic Stem Cell Transplantation with Low-Dose TBI, Fludarabine and Antithymocyte Globulin (ATG).

Acute GvHD is a frequent complication of non-myeloablative transplantation although it is seen at a lower rate and severity than after myeloablative transplantation. The use of ATG in transplant conditioning produces substantial host immunosuppression. Furthermore, the persistence of ATG in the circulation after transplantation is thought to accomplish an in-vivo T-cell depletion of the stem cell inoculum. Non-myeloablative stem cell transplantation using low dose TBI (200cGy) and fludarabine results in a high rate of full donor chimerism. We previously showed that the addition of ATG to TBI 200 cGy and fludarabine can improve donor engraftment. Whether it also impacts on acute and chronic GvHD and on graft versus tumor effect is less known. Forty-seven patients, not eligible for conventional fully ablative allogeneic SCT by virtue of age or co-morbidities, underwent non-myeloablative allogeneic transplantation using ATG 15 mg/kg/day (equine) or 1.5mg/kg/day (rabbit) days −4 to −1, TBI 200 cGy on a single fraction on day −5, fludarabine 30 mg/kg/day on days −4 to −2. Oral immunosuppression with MMF and CSA were started on day −5. Allografts were unmanipulated peripheral blood progenitor cells collected on day 5 of mobilization with filgrastim 10 mcg/kg/day. Thirty-two patients (68%) had match related donors, 9 (19%) match unrelated (10/10), 1(2%) mismatch related (9/10) and 5 (10.6%) mismatch unrelated donors (9/10). Twenty-five patients had sex matched donors (53.2%). Full donor chimerism was documented in 85% and partial (>50%) in 11% of patients. At a median follow up of 309 days, graft versus host disease grade II–IV developed in 13 patients (27.6%). Fatal GvHD of liver and/or gut occurred in 8 patients (17%). The mean age of patients who developed GvHD was 54 years and 57 for those who did not (p=ns). The corresponding mean ages for their donors were 47 vs. 50 years (p=ns). Seven out of fourteen (50%) unrelated transplants recipients and 6/33 (18%) with related donors develop GVHD (p=0.023). Infectious complications were seen in 8 patients (17%) and were the cause of death in 6 (12%). Thirteen of the 47 patients (27.6%) underwent transplant for AML. Six patients had relapsed/refractory disease at the time of transplant, 3 were in CR2 and 4 in CR1. Eleven patients (84.6%) relapsed with AML after transplant. Previously reported data on non-myeloablative stem cell transplant using 200 cGy of TBI and fludarabine with no ATG showed an incidence of acute GvHD grade II–IV of 64% and 24% GvHD related mortality. Similar rates have been reported with fludarabine and melphalan reduced-intensity conditioning. In our cohort of 47 patients the addition of ATG resulted in decreased incidence of acute GvHD grade II–IV and GvHD related mortality without a high rate of infectious complications. A high incidence of disease relapse in patients with AML may reflect the high proportion of patients with advanced leukemia enrolled in the study. However, it also warrants further investigation to rule out that ATG may hinder graft versus leukemia effect.

Entry Bias: Order of Patient Entry Influences Outcome in Trials of Allogeneic Transplant for Renal Cell Carcinoma.

Early trials evaluating nonmyeloablative allogeneic hematopoietic transplant (NST) for metastatic renal cell carcinoma (RCC) have reported widely discordant results. We performed a meta-analysis of the published literature to identify prognostic factors for NST. However, known RCC prognostic factors are not often detailed in these studies, hindering the identification of patient differences among studies. We explored the order of patient entry as a surrogate marker for patient selection, hypothesizing that patient selection, rather than treatment differences, accounted for early promising results. Patient specific data and adequate follow-up were available for 76 patients from six studies. The rank of patient entry on each individual trial was recorded as well as ≥ grade 2 acute graft-versus-host disease (aGVHD), recipient age, recipient sex, response (partial plus complete), and survival. Multivariable analyses for response and survival were modeled using logistic and cox proportional hazards regression, respectively. The mean overall response rate was 22/76 (29%), with responses across individual studies significantly varying from 0% to 57% P =.009 by Chi-square). Median Kaplan-Meier survival was 263 days. Neither age nor sex was significantly ( associated with response or survival. Acute GVHD occurred in 42% of individuals and correlated with response (OR=9.9, P =0.012) but not survival (HR=1.53, P=0.28). When adjusting by study, later patient entry rank reduced the probability of response (OR=0.30, P =0.007) and survival (HR=1.89, P =0.006). Alternatively, being among the first five patients enrolled in a given study relative to subsequent patients, increased the probability of response (OR=6.69, 95% CI 1.95–39.1, P=0.005), even when adjusting for aGVHD, and afforded a survival benefit (HR= 0.45, 95% CI 0.022 −0.92, P=0.028). The prognostic strength of patient entry rank strongly suggests “entry bias” in patient selection. This bias potentially accounts for the large variation in outcome among studies and for the promising results in early studies. Entry bias analysis offers a novel method to assess early phase trials for selection bias, when detailed individual prognostic information is lacking. Further study is warranted to determine to what extent, if any, entry bias occurs in other clinical trial settings. [Display omitted]

A Psychosocial Assessment of Patients before and after Autologous Stem Cell Transplantation.

There are relatively few reports in the medical literature describing psychosocial assessment of bone marrow transplant patients; what data exists primarily focuses on allogeneic transplant recipients. We have begun to prospectively assess psychosocial parameters of patients undergoing autologous transplantation using the Functional Assessment of Cancer Therapy-BMT (FACT-BMT) tool. The general questions consist of four subscales developed and normed in cancer patients that measure; physical well-being; social/family well-being; emotional well-being; functional well-being; and a specific module to address BMT-specific concerns. Each subscale is positively scored, with higher scores indicating better functioning. A baseline survey is collected by the social worker pre-transplant and a follow-up survey is administered and collected approximately 6 weeks post-transplant by the Transplant Coordinator. 56 consecutive patients undergoing autologous stem cell transplant have FACT-BMT data both pre-transplant and approximately one month post-discharge. Median age was 50. 52% are male; underlying diagnoses include NHL (45%), Hodgkin's disease (32%), myeloma (16%), AML (5%), testicular cancer (2%). 93% had chemosensitive disease at the time of transplant. All patients received peripheral blood progenitor cells (PBPCs), and all received a chemotherapy-only preparative regimen. All patients were hospitalized for approximately three weeks for the transplant. For most of the variables measured by the FACT-BMT tool, there was no significant difference in pre-transplant and post-transplant scores. The one variable that did change was emotional well-being: patients scored statistically significantly higher post-transplant as compared to the pre-transplant score (p<0.001). We also have collected baseline FACT-BMT data on 42 consecutive allogeneic BMT recipients, as well as 12 recipients of non-myeloablative allogeneic BMT transplants. There is no significant difference in any pre-transplant variables measured by the FACT-BMT score between autologous recipients, ablative allogeneic recipients, and non-myeloablative allogeneic recipients. We conclude that patients undergoing an autologous stem cell transplant have a higher sense of emotional well-being after engraftment and hospital discharge. Presumably this reflects positive feelings about accomplishing this intensive treatment for their underlying malignancy, and suggests that emotional and physical recovery after auto-BMT is reasonably rapid. A larger dataset will hopefully allow a more detailed comparison of allo and auto BMT recipients.

Allogeneic Non Myeloablative Blood Stem Cell Transplantation for NHL in a Patient with Systemic Lupus Erythematosus: Clinical Outcome and Long Term Follow-Up.

The severity and clinical course of systemic lupus erythematosus (SLE) varies widely. Overall mortality from SLE at 10 years is 30% (Ward et al., 1995), with a four fold increased risk of death compared to the general population (Moss et al., 2002). Non myeloblative allogeneic HSCT has been suggested as a way of improving disease free survival. We describe the successful treatment of a 47-year-old male with SLE who received a non-myeloablative sibling allogeneic blood stem cell transplant for high grade lymphoma.A 47-year-old man, presented with polyarthropathy and anti nuclear factor (ANA) IgG nuclear of 1:160. He was treated with prednisolone and azathioprine, but his SLE continued to pursue a relapsing aggressive course complicated by encephalitis in 1991 and biopsy confirmed membranous nephritis in 1993. He also developed steroid resistant immune thrombocytopaenia requiring splenectomy. In addition, he developed antiphospholipid syndrome with positive anti cardiolipin antibodies and dilute Russell viper venom test (DRVVT) complicated by pulmonary embolism requiring long term anticoagulation with warfarin.In 1999, he developed a high-grade plasmablastic lymphoma Stage IIIb associated with a serum IgG paraprotein. There was no infiltration of the bone marrow. He continued to have active SLE treated with prednisolone and azathioprine. Six courses of CHOP induction chemotherapy resulted in a partial response (indicated by a persistently elevated LDH, residual lymph nodes on CT and PET scanning). He subsequently received one course of DHAP chemotherapy but 3-months post-treatment he remained with residual lymphoma. Symptomatically, his SLE improved following chemotherapy, but his autoimmune markers remained positive (ANA IgG 1:40 positive nuclear pattern). Post-chemotherapy the patient had a large retroperitoneal bleed necessitating the withdrawal of warfarin. Because the patient had resistant disease and remained in partial remission, a decision was made to consolidate with stem cell transplantation from his histocompatibility (HLA)-matched brotherIn August 2000, transplant conditioning was given using Campath 1H (20mg D-7 to D-4), Fludarabine (30mg/m2 D-7 to D-3) and Melphalan (140mg/m2 on D-2). Cyclosporin was administered as graft versus host disease (GvHD) prophylaxis and LMWH given until the platelet count fell below 50000. The unmanipulated stem cell graft consisted of 5.51 X 106 CD34+ cells/kg body weight. There was no evidence of GvHD.Six months after the non-myeloablative transplant, he achieved CR from his lymphoma with full donor engraftment on chimeric studies. Both CT and PET scans were clear. His symptoms of SLE including the polyarthropathy had resolved and immunologically had become ANA negative with a normal complement level. His anti-cardiolipin antibody and DRVVT were negative and he had no further thrombotic problems. 27-months post-transplant, the patient continues to be in complete clinical and radiological remission from his lymphoma with 100% donor chimerism. Both serologically and clinically his SLE and antiphospholipid syndrome remain in complete remission. He is currently on no medication.We have demonstrated the efficacy and safety of non-myeloablative allogeneic transplantation for SLE. He is three years out from transplantation, he is alive and in clinical remission. We suggest that this approach needs further evaluation in a prospective study.

Prior Autologous Hematopoietic Cell Transplantation Confers an Adverse Prognosis for Recipients of Allogeneic Transplantation Following Nonmyeloablative Preparative Conditioning.

Allogeneic hematopoietic transplantation following nonmyeloablative preparative conditioning (also know as “mini-dose transplantation”) is frequently applied to patients who, on the basis of prior therapy, organ dysfunction, or co-morbid conditions may be considered ineligible for full, dose-intenstive treatment. This approach assumes that early regimen-related toxicity can be averted by the nonmyeloablative approach. We present the results obtained in a group of consecutive, unselected older adults with advanced hematologic neoplasia who underwent allogeneic transplantation from fully histocompatible siblings or unrelated donors after dose-reduced preparative conditioning in a single center. Thirty-four patients, median age 57 years (range 26–66) underwent allogeneic transplantation from siblings (14 patients) or unrelated donors (20 patients) following preparative conditioning consisting of chemotherapy only (typically fludarabine, cytarabine, and cyclophosphamide) or those drugs plus antithymocyte globulin, respectively. One recipient of a related allograft and one recipient of an unrelated allograft received preparative fludarabine/melphalan and busulfan/fludarabine/ATG, respectively. Diagnoses prior to transplantation included advanced acute leukemia and myelodysplasia (17 patients), nonHodgkin's or Hodgkin's lymphoma (11 patients), and CLL or Multiple Myeloma (6 patients). Allogeneic transplantation followed previous autologous transplantation in 17 patients. Time from previous autologous transplantation to nonmyeloablative allogeneic transplantation varied. Prior autograft conferred a significant adverse risk on recipients of allogeneic transplants following nonmyeloablative conditioning. Only two of 17 patients with a history of prior autograft enjoyed long-term survival as opposed to seven of 17 who had not undergone prior autologous transplant. Mortality before day + 100, typically attributed to treatment-related toxicities, occurred in 11 patients; nine of these patients had had prior autologous transplantation. Prior autologous transplantation typically was done for acute myelogenous leukemia in first complete remission and referral for allotransplant may have been an indicator of more aggressive disease biology. In conclusion, allogeneic transplantation following a nonmyeloablative preparative regimen may be associated with significant risk of early mortality in patients who undergo this treatment after prior autologous transplantation, especially for acute leukemia, suggesting that criteria for allogeneic transplantation after nonmyeloablative condition should take this risk into account. Further studies from multiple centers will be required to confirm this observation.

Retroviral-Mediated Gene Transfer of CD18 into Hematopoietic Stem Cells in Dogs with Canine Leukocyte Adhesion Deficiency Reverses the Severe Deficiency Phenotype.

Background: Canine leukocyte adhesion deficiency (CLAD) represents a disease-specific, large-animal model for the human disease leukocyte adhesion deficiency (LAD). Puppies with CLAD, like children with LAD, experience recurrent life-threatening bacterial infections due to the inability of their leukocytes to adhere and migrate to sites of infection. Mutations in the gene encoding the leukocyte integrin CD18 are responsible for both CLAD and LAD. Allogeneic bone marrow or hematopoietic stem cell transplantation is currently the only curative therapy for LAD. We recently reported the results of non-myeloablative allogeneic transplants in CLAD dogs and showed that very low levels of CD18+ donor-derived neutrophils (less than 300/microliter) were sufficient to reverse the CLAD disease phenotype. These results indicated that CLAD dogs may be amenable to treatment using gene therapy, where there are frequently low numbers of transduced cells. We report the results of retroviral- mediated transduction in autologous hematopoietic stem cells with the canine CD18 gene.Method: Bone marrow was harvested and CD34+ selected from four dogs with CLAD at approximately 3–4 months of age. The purified CD34+ cells were either used immediately or were frozen and subsequently thawed. Cells were pre-stimulated with cSCF, hFlt3-L, hTPO and cIL-6 for approximately 24 hours, then exposed to two rounds of supernatant from the retroviral vector PG13/MSCV-cCD18 for 24 hours each on recombinant fibronectin. At the end of the transduction, the cells were infused back into the animal that had been conditioned with 200 cGy total body irradiation. Post-transplant immunosuppression consisted of cyclosporine given at a dose of 30 mg/kg from day -1 to day 35, then 15 mg/kg from day 36 to day 60, and mycophenolate mofetil at a dose of 20 mg/kg from day 0 to day 28. Peripheral blood samples, as well as pus samples from one animal, were analyzed by flow cytometry at designated time points post-transplant.Results: The four dogs who received autologous, gene-corrected cells have been followed for 7–12 weeks post-infusion. The number of CD18+ CD34+ cells infused per dog ranged from 0.2 to 0.55 x 106 cells/kg. The post-infusion percentage of CD18+ neutrophils in each dog was 0.09%, 0.13%, 0.62% and 0.02% at 12, 10, 8 and 6 weeks respectively. Clinically all four treated CLAD dogs are alive with marked improvement of their CLAD disease. These dogs are now 6–7 months of age. These results contrast with those seen in untreated CLAD dogs who uniformly die or are euthanized within the first few months of life. The reversal of the severe CLAD phenotype despite the very low levels of CD18+ neutrophils in the peripheral blood is likely due to the selective egress of CD18+ neutrophils into the tissue since one treated CLAD dog who had less than 1% CD18+ neutrophils in the blood had nearly 10% CD18+ neutrophils in pus collected from an inflammatory dental lesion.Conclusion: These data suggest that a non-myeloablative conditioning regimen coupled with a minimal immunosuppressive regimen may enable sufficient CD18+ autologous gene-corrected cells to engraft and result in reversal of the severe CLAD phenotype.

Donor Antigen Presenting Cell CD80/86 Function Is Required for Eliciting T Cell Resistance Against Progenitor Cell Engraftment in an MHC Matched Allogeneic Non-Myeloablative Transplantation Model.

Immune mediated resistance is a concern in allogeneic bone marrow transplantation (BMT) particularly in the setting of nonmyeloablative conditioning regimens or in situations where prior sensitization to hematopoietic alloantigens has occurred (ie aplastic anemia). This resistance can lead to both delayed reconstitution and rejection. In this investigation, two models of T cell mediated allogeneic bone marrow graft rejection were employed: 1) an MHC disparate, donor antigen sensitized model, ie BALB/c (H-2d) recipients sensitized to B6 (H-2b) hematopoietic antigens transplanted with a high dose (1x107) of B6 BM-TCD following ablative (9.0Gy TBI) conditioning. Resistance in this model was assessed by the presence of donor CFU progenitors early (Day 5) post transplant and 2) a non-myeloablative mHag disparate model, ie C57BL/6 TCD BM à C3H.SW recipients conditioned with 5.5 Gy TBI. In this latter model, BM from B6 wild-type donors at doses <1x107 cells leads to transient donor peripheral chimerism (assessed by monitoring Ly9.1 expression) peaking at day 7–10 post transplant. To study the role of donor APC function in the transplant innoculum in both models, bone marrow was utilized from donors deficient in CD80 and CD86, yielding a “crippled” APC population incapable of co-stimulation through these two primary pathways. In the antigen sensitized model, (ie Tmemory mediated) both lineage committed (CFU-IL3) and multipotential (CFU-HPP) progenitor activity was absent from recipients of both wild-type or CD80/86 −/− BMC. This data suggests that CD80/86 mediated co-stimulation from direct recognition of donor APC is dispensible for eliciting resistance when memory T cells are involved. However, in the unsensitized model, despite the potential for indirect donor antigen presentation, recipients of CD80/86−/− bone marrow exhibited significant engraftment by one month post-transplant (in contrast, recipients of wt bone marrow had universally these rejected grafts by this time point). Significant chimerism in recipients of CD80/86−/− BM was detectable in the B as well as T lymphocyte compartments (>50%). Consistent with the importance of the presence of these co-stimulatory pathways on the donor APC population, 5/7 recipients of mixed (1:1) BM (CD80/86−/− + B6-wt) transplants rejected their grafts. These findings suggest that removal of CD80/86 dependent co-stimulatory pathways in the donor APC population may be insufficient for promoting engraftment in cases where there has been prior donor antigen sensitization, i.e. in the presence of host Tmemory populations. However, absence of CD80/86 co-stimulatory pathways in the donor APC population may be sufficient for overcoming resistance in an MHC matched allo-transplant setting in which prior donor antigen sensitization has not occurred, ie in the presence of host Tnaive populations. These findings have implications in the development of improved non-myeloablative conditioning protocols to facilitate engraftment without global immunosuppressive conditioning.

Erratum: Long-term remission of myelofibrosis following nonmyeloablative allogeneic peripheral blood progenitor cell transplantation in older age: the Scripps Clinic experience

Correction to: Bone Marrow Transplantation (2004) 34, 273–274. doi:10.1038/sj.bmt.1704578 The following sentence is published correctly below: The patient's splenomegaly resolved and he remains free of disease over 33 months post transplant with minimal cGVHD involving oral mucosa that is under excellent control on low-dose cyclosporine and budesonide.