Recipient Weight Research Articles

The Registry of the International Society for Heart and Lung Transplantation: Eighteenth Official Pediatric Heart Transplantation Report—2015; Focus Theme: Early Graft Failure

The Registry of the International Society for Heart and Lung Transplantation: Eighteenth Official Pediatric Heart Transplantation Report—2015; Focus Theme: Early Graft Failure

Live Donor Renal Anatomic Asymmetry and Posttransplant Renal Function.

Relationship between live donor renal anatomic asymmetry and posttransplant recipient function has not been studied extensively. We analyzed 96 live kidney donors, who had anatomical asymmetry (>10% renal length and/or volume difference calculated from computerized tomography angiograms) and their matching recipients. Split function differences (SFD) were quantified with technetium-dimercaptosuccinic acid renography. Implantation biopsies at time 0 were semiquantitatively scored. A comprehensive model using donor renal volume adjusted to recipient weight (Vol/Wgt), SFD, and biopsy score was used to predict recipient estimated glomerular filtration rate (eGFR) at 1 year. Primary analysis consisted of a logistic regression model of outcome (odds of developing eGFR>60 mL/min/1.73 m(2) at 1 year), a linear regression model of outcome (predicting recipient eGFR at one-year, using the chronic kidney disease-epidemiology collaboration formula), and a Monte Carlo simulation based on the linear regression model (N=10,000 iterations). In the study cohort, the mean Vol/Wgt and eGFR at 1 year were 2.04 mL/kg and 60.4 mL/min/1.73 m(2), respectively. Volume and split ratios between 2 donor kidneys were strongly correlated (r = 0.79, P < 0.001). The biopsy scores among SFD categories (<5%, 5%-10%, >10%) were not different (P = 0.190). On multivariate models, only Vol/Wgt was significantly associated with higher odds of having eGFR > 60 mL/min/1.73 m (odds ratio, 8.94, 95% CI 2.47-32.25, P = 0.001) and had a strong discriminatory power in predicting the risk of eGFR less than 60 mL/min/1.73 m(2) at 1 year [receiver operating curve (ROC curve), 0.78, 95% CI, 0.68-0.89]. In the presence of donor renal anatomic asymmetry, Vol/Wgt appears to be a major determinant of recipient renal function at 1 year after transplantation. Renography can be replaced with CT volume calculation in estimating split renal function.

Totally laparoscopic living donor right hepatectomy in a donor with trifurcation of bile duct

Donor operation in adult living donor liver transplantation is associated with significant postoperative morbidity. To avoid laparotomy wound complications and shorten postoperative recovery, laparoscopic liver graft harvest has been developed recently. However, to determine the cut point of bile duct is challenging. Herein, we report the application of totally laparoscopic approach for right liver graft harvest in a donor with trifurcation of the bile duct. A19-year-old man volunteered for living donation to his father who suffered from hepatitis B virus-related cirrhosis of liver and hepatocellular carcinoma. The graft was 880 mL with a single right hepatic artery and portal vein. The graft to recipient weight ratio was 1.06. The middle hepatic vein was preserved for the donor and the liver remnant was 42.3%. Two branches of middle hepatic veins were > 5 mm in diameter and needed reconstruction with cryopreserved allograft. Ductoplasty using laparoscopic intracorporeal suture technique was done to achieve single orifice of the graft bile duct. The postoperative course was uneventful for the donor. This report adds evidence of the feasibility of pure laparoscopic right donor hepatectomy and describes the necessary steps for bile duct division in donors with trifurcation of bile duct.

Prediction of hematopoietic stem cell yield after mobilization with granulocyte-colony-stimulating factor in healthy unrelated donors.

The collection of hematopoietic stem cells from the peripheral blood of healthy donors has been established as a highly efficient method. Nevertheless, some donors have a moderate or poor chance of harvest success with standard mobilization regimens. We retrospectively reviewed data from 7216 unrelated healthy donors, who underwent granulocyte-colony-stimulating factor mobilization and consecutive leukapheresis for allogeneic stem cell transplantation. We tested different donor variables of potential influence and established a statistical model for prediction of upfront mobilization capacity and harvest success. In addition, we calculated the likelihood of a successful harvest dependent on predicted preapheresis CD34+ count and recipient weight. Female sex, older age, smoking, elevated lactate dehydrogenase, higher relative lymphocyte count, and higher large unstained cell count at baseline were negatively correlated with the CD34+ cell count on Day +5 (p < 0.0001). In contrast, higher platelet count, higher body mass index, higher absolute lymphocyte count, and higher relative monocyte count at baseline showed a positive correlation with the CD34+ count on Day +5 (p < 0.0001). Using a model built on these factors, we could significantly improve the prediction of harvest success compared to a basic model. The model allows the identification of female donors who eventually have a significant risk of harvest failure if requested to donate for recipients with a high body weight.

Survival Outcomes Following Pediatric Liver Transplantation (Pedi-SOFT) Score: A Novel Predictive Index

A prognostic index to predict survival after liver transplantation could address several clinical needs. Here, we devised a scoring system that predicts recipient survival after pediatric liver transplantation. We used univariate and multivariate analysis on 4565 pediatric liver transplant recipients data and identified independent recipient and donor risk factors for posttransplant mortality at 3 months. Multiple imputation was used to account for missing variables. We identified five factors as significant predictors of recipient mortality after pediatric liver transplantation: two previous transplants (OR 5.88, CI 2.88-12.01), one previous transplant (OR 2.54, CI 1.75-3.68), life support (OR 3.68, CI 2.39-5.67), renal insufficiency (OR 2.66, CI 1.84-3.84), recipient weight under 6 kilograms (OR 1.67, CI 1.12-2.36) and cadaveric technical variant allograft (OR 1.38, CI 1.03-1.83). The Survival Outcomes Following Pediatric Liver Transplant score assigns weighted risk points to each of these factors in a scoring system to predict 3-month recipient survival after liver transplantation with a C-statistic of 0.74. Although quite accurate when compared with other posttransplant survival models, we would not advocate individual clinical application of the index.

Infused Bone Marrow Fails to Prevent Vascularized Composite Allograft Rejection in Nonhuman Primate

Vascular composite allografts (VCA) are highly antigenic as demonstrated by near universal rejection rates. Nonetheless, substantial immunosuppressive therapy has permitted VCA to survive currently between 10 (face) and 15 (hand) years. The field of VCA has placed major emphasis on investigating in preclinical and clinical trials whether infused bone marrow combined with standard immunosuppression may improve immunologic outcomes. In contrast to solid organ transplant protocols utilizing bone marrow cells (BMC) and nonmyeloblative conditioning, tolerance (or even the absence of rejection on immunosuppression) has not been observed in any VCA trials (1.Schneeberger S Gorantla VS Brandacher G Upper-extremity transplantation using a cell-based protocol to minimize immunosuppression.Ann Surg. 2013; 257 (et al): 345-351Crossref PubMed Scopus (146) Google Scholar, 2.Devauchelle B Badet L Lengele B First human face allograft: Early report.Lancet. 2006; 368 (et al): 203-209Abstract Full Text Full Text PDF PubMed Scopus (475) Google Scholar, 3.Kawai T Sachs DH Sprangers B Long-term results in recipients of combined HLA-mismatched kidney and bone marrow transplantation without maintenance immunosuppression.Am J Transplant. 2014; 14 (et al): 1599-1611Abstract Full Text Full Text PDF PubMed Scopus (212) Google Scholar). The lack of controlled trials directly evaluating infused BMC as a cellular adjunct leads to ongoing ambiguity regarding the role of BMC infusion without preconditioning in VCA (4.Khalifian S Brazio PS Mohan R Facial transplantation: The first 9 years.Lancet. 2014; 384 (et al): 2153-2163Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar). We have previously shown in a nonhuman primate (NHP) facial transplantation model that cotransplanted vascularized bone marrow (VBM) in the allograft improved outcomes when compared to VCA without VBM (5.Barth RN Rodriguez ED Rodriguez GS Vascularized bone marrow-based immunosuppression inhibits rejection of vascularized composite allografts in nonhuman primates.Am J Transplan. 2011; 11 (et al): 1407-1416Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar). We have further investigated whether infused BMC could protect VCA by performing facial VCA without VBM but with donor BMC infusion Briefly, marrow was harvested from the donor lumbar vertebrae immediately following euthanasia and stored overnight using a method adapted from clinical and primate protocols. The infused marrow was analyzed for viability, cell number and percent of CD34+ hematopoietic stem and progenitor cells (HSPCs), and compared to the mandibular marrow compartment excised from the facial segment. Total nucleated cell count of hemimandibles ranged between 42.5 and 56.5 × 106 cells/kg of donor weight. Donor vertebrae yielded between 250 and 341 × 106 cells/kg donor. Viability of HSPCs immediately after processing was greater than 92.4%, with survival to postoperative day (POD) 1 of 94.8%. On POD 1, BMC were infused at a dose of 200 × 106 cells/kg of recipient weight guaranteeing greater than 2 106 HSPCs. Grafts with BMC infusion underwent early significant rejection (Banff grade II), similarly to grafts with no bone marrow component (Figure 1). Alloantibody was positive, although reduced compared to VCA without bone marrow, and in contrast to animals receiving VBM that did not produce alloantibody. One animal in the BMC infusion group progressed to complete rejection and graft loss at POD 28. A second animal progressed to chronic rejection with vessel wall thickening and C4D positivity by POD 50. The third animal resolved rejection but developed posttransplant lymphoproliferative disease (PTLD) likely secondary to LCV-mismatch. No animal with infused BMC demonstrated any evidence of chimerism, in contrast to three of four VCA + VBM animals that demonstrated transient chimerism. These data do have shortcomings, including an N of only 3, comparison to historical controls and the confounding occurrence of PTLD. However, these results suggest that VBM can protect VCA compared to BMC when performed without preconditioning. Minimal preconditioning could lead to further immunologic benefit for VBM that has the benefit of containing both cellular and stromal compartments. These data suggest that compared to infused bone marrow, VBM may improve VCA outcomes by minimizing pretransplant conditioning and chronic immunosuppression requirements, and reducing rejection episodes. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation. This work was performed at the University of Maryland School of Medicine, Baltimore, MD.

SENGSTAKEN-BLAKEMORE tube can prevent whole liver twisting the right hepatic fossa improving venous outflow post-orthotopic liver transplantation

Introduction: Reduced-size liver transplantation in combination with an unusual situation poses an increased risk for venous outflow obstruction. Reduced-size liver transplantation using ex-vivo graft reduction or splitting has become standard procedure in children, with some of these cases described in literature after the successful management use of Sengstaken-Blakemore, although used in orthotopic whole liver transplantation (OLT) has never been described. The aim was to report the successful management of acute venous obstruction after OLT by using a Sengstaken-Blakemore tube within the hepatic fossa in a 51-year-old male patient. Case Report: A 51-year old male patient with hepatitis C cirrhosis and alcoholism, C Child-Pugh, 24 MELD score was submitted to OLT by using the piggy-back technique. The donor and recipient body-weight ratio was 1.38 (65/90kg). The liver recipient weight was 1,152g and the donor liver was 992g. After reperfusion time, the patient showed a venous outflow obstruction in supra-hepatic anastomosis with total resolution after clockwise rotation of the graft, but reduced venous outflow was observed after liver twist to the right hepatic fossa and mean arterial blood pressure (MAP) was reduced to 30 mmHg . After five attempts, a Sengstaken-Blakemore tube was inserted into the right subphrenic space and the gastric and oesophageal balloons were inflated to maintain the graft at the midline position with normalization of the MAP and venous outflow. Although data on hemodynamic measurements were maintained during the ICU period, a Doppler ultrasonography (DUS) was carried out daily to ensure that venous outflow was maintained. On 4th day, the gastric balloon was deflated; after 2 hours the oesophageal balloon was deflated and no systemic abnormality was detected. The Sengstaken-Blakemore tube with deflated balloons was removed on 5th day using slight traction. Later, DUS was carried out after it was shown that venous outflow was maintained and the liver was fixed in a hemodynamically correct position without interfering in the mechanical outflow. The patient was discharged, and he is in good condition. Conclusion: The Sengstaken -Blakemore tube is a good tool to improve liver venous outflow due to mechanical problems such as twist of the right hepatic fossa and preventing re-operations.

Small Kidneys for Large Recipients: Does Size Matter in Renal Transplantation?

BackgroundImbalance between transplanted renal mass and the metabolic demands of the recipient has been identified as a predictor of renal graft function. Multiple factors have been used to test this influence, but none of them is consensually accepted. The aim of this study is to evaluate the influence of the imbalance between transplanted renal mass and the metabolic needs of the recipient by analyzing the relationship between the ratio of the weight of the renal graft and the body weight of the recipient (Kw/Rw) on transplantation outcomes. MethodsProspective observational study of 236 first and single cadaveric renal transplants in non-hyperimmunized recipients was conducted. Grafts were orthogonally measured and weighed immediately before implantation, and these measures were correlated with donor and recipient data. According to the Kw/Rw ratio, patients were divided into three groups: Kw/Rw < 2.8 (P25), Kw/Rw = 2.8–4.2, and Kw/Rw > 4.2 (P75). After a mean follow-up of 5.2 years, transplant outcomes (delayed graft function; acute rejections; and estimated 1-, 6-, 12-, 36-, and 60-month renal function, graft, and patient survivals) were evaluated and correlated in uni- and multivariate analyses with the Kw/Rw ratio. ResultsMean values for graft dimensions were 109.47 × 61.77 × 40.07 mm and the mean weight was 234.63 g. Mean calculated volume was 145.64 mL. The mean Kw/Rw ratio was 3.65 g/kg. These values were significantly lower for female grafts (3.91 vs 3.24, P < .001). According to the Kw/Rw ratio groups, there were no differences on delayed graft function, acute rejection episodes, and estimated graft function at the defined times. The increase in estimated glomerular filtration rate by a mean of 3.6 mL/min between 1 and 6 months for patients with Kw/Rw < 2.8 was not statistically relevant when compared to the higher ratio group with a mean variation of −0.91 mL/min (P = .222). Graft survival rate at 5 years after transplantation was 79% in the Kw/Rw < 2.8 group and 82% in the Kw/Rw > 4.2 group (P = .538). Patient survival rate at 5 years after transplantation was 85% in the Kw/Rw < 2.8 group and 92% in the high ratio group (P = .381). Kw/Rw ratio was not an independent risk factor for transplant failure at 5.2 years in a multivariate logistic regression analysis. Irrespective of recipient weight, graft survival was significantly higher for grafts with volume or weight above the 50 percentile (vol > 134 mL, P = .011 or weight > 226 g, P = .016). ConclusionThe imbalance between implanted renal mass and recipient metabolic demands does not seem to influence the functional outcomes and graft survival up to 60 months post-transplantation. Nevertheless, irrespective of recipient weight, graft survival is significantly higher for grafts with volume or weight above the 50 percentile.

Clinical outcomes in liver transplantation from donation after cardiac death

Objective To investigate the clinical outcomes in liver transplantation from donation after cardiac death (DCD) . Methods The clinical data of 52 patients with end stage liver disease who received liver transplantation from DCD donors (the age of 21 pediatric recipients <18 years, and the age of 31 adult recipients≥18 years) at the Tianjin First Central Hospital from December 2008 to July 2013 were retrospectively analyzed. The intraoperative, postoperative and prognosis data were analyzed. All patients were regularly followed up in the Transplantation Follow-up Center after discharge till July 31 , 2014. The measurement data with normal distribution were presented as±s. The comparison between groups was evaluated with the repeated measures ANOVA. The cumulative survival rate was done by the Kaplan-Meier method. Results Among the 21 pediatric recipients, 16 received classic orthotopical liver transplantation and 5 received reduced-size liver transplantation from adult donors. The weight of 21 DCD livers, graft to recipient weight ratio (GRWR) , warm ischemia time, cold ischemia time, anhepatic phase, volume of intravenous infusion, operation time and volume of intraoperative blood loss were (338±34) g, 1. 9%±0. 7% , (16±6) minutes, (86±36) minutes, (43±10) minutes, (816±662) mL, (7. 1 ± 1. 5) hours and (329±214) mL, respectively. No peritoneal effusion, acute cellular rejection (ACR) , portal vein thrombosis (PVT) and biliary complications occurred in the pediatric recipients. The duration of hospital stay was (41±23) days. The level of hemoglobin (Hb) and albumin (Alb) to reach the normal level from pre-operation to postoperative day 14 were (101±19) g/ L to (128±23) g/ L and (34±7) g/L to (44±7) g/ L, respectively, with significant differences (F =3.943 , 7.340, P <0.05) . The level of total bilirubin (TBil) , aspartate transaminase (AST) and alanine transaminase (ALT) gradual reducing to the normal level from preoperation to postoperative day 14 were (307±69) μmol/ L to (34±17) μmol/ L, (88±34) U/ L to (36±17) U/ L and (154±51) U/ L to (46±18) U/ L, respectively, with significant differences (F =142.200, 17.060, 31.750, P <0.05) . Thirtyone adult recipients received classic orthotopical liver transplantation form adult donors. The weight of 21 DCD livers, GRWR, warm ischemia time, cold ischemia time, anhepatic phase, volume of intravenous infusion, operation time and volume of blood loss were (1 104 ± 43) g, 1. 7% ± 0. 4%, (16 ± 4) minutes, (89 ± 43) minutes, (47±9) minutes, (2 515±1 803) mL, (7. 9 ± 1.8) hours and (1 208 ± 548) mL, respectively. The complications occurred in 14 adult recipients, including peritoneal effusion in 8 recipients, ACR in 3 recipients, PVT in 2 recipients and biliary complications in 1 recipient. The duration of hospital stay was (44±22) days. The level of Alb to reach the normal level from pre-operation to postoperative day 14 were (31±5) g/ L to (40±5) g/ L, with a significant difference (F =14.930, P <0.05) . The level of TBil, AST and ALT gradual reducing to the nearly normal level from pre-operation to postoperative day 14 were (182 ± 55) μmol/ L to (62 ± 22) μmol/ L, (286 ± 93) U/ L to (79±47) U/ L and (349±111) U/ L to (76±28) U/ L, respectively, with significant differences (F = 34.350, 71.070, 82.680, P <0.05) . All the 52 recipients were followed up for a median time of 544 days (range, 196-1 953 days) , with 1-year survival rate of 90.38%. During the follow-up, 1 pediatric recipient died of pulmonary infection and 1 of massive hemorrhage, and 1 adult recipient died of pulmonary infection, 1 of primary graft dysfunction and 1 of massive hemorrhage. Conclusion Liver transplantation from DCD is a feasible treatment for end-stage liver diseases, with a good short-term clinical outcomes. Key words: End stage liver disease; Donation after cardiac death; Liver transplantation; Short-term outcomes; Clinical analysis

Effect of small donor weight and donor-recipient weight ratio on the outcome of liver transplantation in children.

A small donor weight is a risk factor for HAT with potential for graft loss. To test this hypothesis, we evaluated outcomes of pediatric liver transplants utilizing donors <20 kg using the UNOS database from 01/2003 to 01/2012 (n = 1311). All isolated liver transplants with whole organ grafts were included. Recipients were divided into four groups based on donor weight: group 1, donor weight <5 kg (n = 34 [2%]); group 2, 5-10 kg (431 [33%]); group 3, 10-15 kg (560 [43%]); and group 4, 15-20 kg (286 [22%]). Actuarial patient survival for the first year post-transplant was significantly lower in groups 1 and 2 compared to groups 3 and 4 (p = 0.002), similarly the one-yr graft function (p < 0.0001). The difference was due to graft loss within the first month for groups 1 and 2. HAT was significantly higher in groups 1 and 2 compared to others (p = 0.0006). Logistic regression analysis demonstrated donor weight as the most predictive factor with analysis of the ROC curve showing a cutoff point at 7.8 kg. The donor-recipient weight ratio did, in none of the models, gain statistical significance.

Yield Prediction of Nucleated Cells As Well As CD34+ Progenitors in Allogeneic Bone Marrow Harvests Depends on Differentially Important Biological Donor Variables. A Retrospective Single Center Analysis of 1275 Allogeneic Bone Marrow Collections

Cell requests for allogeneic bone marrow grafts are defined by the amount of total nucleated cells (TNC) according to body weight of the recipient. However, outcome of bone marrow transplantation significantly depends on the amount of infused CD34+ stem and progenitor cells representing around 0.5 to 1.5% of TNC. So far, TNC as well as the CD34+ progenitor yield of marrow harvests cannot be predicted. We retrospectively analyzed donor variables, TNC and progenitor yields of 1275 marrow collections (860 male and 415 female) that have been performed in our collection center - all of those with same experienced staff of physicians. Maximum amount of bone marrow that was allowed to harvest was 20 ml/kg donor weight but limited to a maximum of 1500 ml. The mean TNC count in the final product was analyzed with 16.6 TNC/nl (5.9-46.6) corresponding to 5.6 ± 4.3 TNC/kg body weight of the recipient. The mean CD34+cell concentration in the graft was measured with 111/μl (11-674) corresponding to 4.3 ± 3.9 CD34+cells/kg. We fitted linear regression model for TNC adjusted for harvest volume and recipient weight to identify influential donor variables. Model selection was performed by backward elimination (BE) with the Bayesian information criterion (BIC). Peripheral blood leucocytes of the donor (WBC) before harvest, constitutional donor variables (weight and height), age, platelet count (PLT), smoking status and mononuclear cell count (MNC) before harvest could be identified as predictive donor parameters for TNC-concentration in the bone marrow product – ordered in descending mode by Wald-test statistic. Interestingly, the influence of donor parameters for CD34+ progenitor cell concentration in the marrow was different from TNC. Constitutional parameters of the donor were identified to be most important for CD34+ cell concentration in the marrow product followed by WBC, age and PLT, whereas smoking status and MNC did not influence CD34+ cell harvest. With sex specific centered parameters donor sex was only influential - for both TNC as well as CD34+ cells - through the constitutional parameters weight and height. No significant interactions could be found between harvested volume and the identified donor parameters. Taking also the recipient weight into account we propose a model that allows identification of risk constellations for achieving the designated amount of TNC as well as CD34+ hematopoietic progenitor cells from bone marrow harvests. In addition, this prediction model will enable us to identify additional genetic determinants for collection efficiency in bone marrow.

Outcomes of 167 healthy sibling donors after peripheral blood stem cell mobilization with G-CSF 16μg/kg/day: efficacy and safety.

Mobilization of peripheral blood stem cells (PBSC) using the granulocyte colony-stimulating factor (G-CSF) has enabled the collection even from older donors and those with comorbidities. Several clinical parameters have been reported to predict the success of PBSC mobilization. The aim of our study was to evaluate the safety of PBSC donation in acohort of 167 sibling donors after mobilization with G-CSF 16 μg/kg/day for 5 days during short- and long term follow-up and to analyse the efficacy, toxicity and factors influencing CD34+ mobilization capacity. All 167 sibling donors completed the established mobilization protocol. The median yield was 7.9x106 CD34 cells/kg per recipient weight. The optimal target dose of CD34 cells ≥ 4.0x106/kg was achieved in 140 donors (84%). Only in 4 donors (2%) was the CD34+ yield < 2x106/kg. No major toxicities occured.Factors associated with higher PBSC yields included age 51/μL (p 45.5 x109/L (p = 0.003). Comorbidity score, performance status and donor weight did not significantly influence PBSC yields. Long-term follow-up was possible in 60% (101/167) of the donors. The median length of follow-up from PBSC donation was 11.9 years. Most of these donors reported good or very good general health (91%), and no hematological malignancies were observed.The mobilization of PBSC in sibling donors with G-CSF 16 μg/kg/day is an effective and safe procedure with no significant short- and long-term toxicities.

Treating morbid obesity in cirrhosis: A quest of holy grail.

The problem of obesity is increasing worldwide in epidemic proportions; the situation is similarly becoming more common in patients with cirrhosis which negatively affect the prognosis of disease and also makes liver transplantation difficult especially in the living donor liver transplantation setting where low graft to recipient weight ratio negatively affects survival. Treatment of obesity is difficult in cirrhosis due to difficulty in implementation of lifestyle measures, limited data on safety of anti-obesity drugs and high risk of surgery. Currently approved anti-obesity drugs have limited data in patients with cirrhosis. Bariatric surgery remains an option in selected compensated cirrhotic patients. Endoscopic interventions for obesity are emerging and are quite promising in patients with cirrhosis as these are minimally invasive. In present review, we briefly discuss various modalities of weight reduction in obese patients and their applicability in patients with cirrhosis.

Single and Multiple Dose MultiStem (Multipotent Adult Progenitor Cell) Therapy Prophylaxis of Acute Graft-versus-Host Disease in Myeloablative Allogeneic Hematopoietic Cell Transplantation: A Phase 1 Trial

We conducted a multicenter, phase 1 dose escalation study evaluating the safety of the allogeneic multipotent adult progenitor cell (MAPC, MultiStem, Athersys, Inc., Cleveland, OH) stromal product administered as an adjunct therapy to 36 patients after myeloablative allogeneic hematopoietic cell transplantation (HCT). Patients received increasing doses of MAPC (1, 5, or 10 million cells per kilogram recipient weight) as a single i.v. dose on day +2 after HCT (n = 18), or once weekly for up to 5 doses (1 or 5 million cells per kilogram; n = 18). Infusional and regimen-related toxicities were assessed for 30 days after the last MAPC dose. Of 36 allogeneic HCT donors (17 related and 19 unrelated), 35 were 6/6 HLA matched. MAPC infusions were well tolerated without associated infusional toxicity, graft failure, or increased incidence of infection. Median times to neutrophil (n = 36) and platelet (n = 31) engraftment were 15 (range, 11 to 25) and 16 (range, 11 to 41) days, respectively. The overall cumulative incidences of grades II to IV and III and IV acute graft-versus-host disease (GVHD) at day 100 were 37% and 14%, respectively (n = 36). In the group that received the highest single MAPC dose (10 million cells/kg), day 100 incidence of grade II to IV GVHD was 11.1% (1 of 9) with no observed cases of grade III and IV GVHD. We found no evidence for MHC class II allogeneic antibody induction, although some patients showed an increase in serum anticlass I titers compared with baseline. MAPC contribution to blood chimerism was negligible. These phase I data support the safety of stromal stem cell therapy and suggest that MAPC should be tested prospectively as a novel therapeutic option for GVHD prophylaxis after HCT.

Few and Nonsevere Adverse Infusion Events Using an Automated Method for Diluting and Washing before Unrelated Single Cord Blood Transplantation

Graft dilution and DMSO washing before cord blood (CB) administration using an automated system may offer low incidence of adverse infusion events (AIE), ensuring reproducible cell yields. Hence, we analyzed the incidences and significance of immediate AIE, cellular yield, and engraftment after single CB infusion. One hundred and fifty-seven patients (median age, 20 years; range, 1 to 60) received a single CB unit for treatment of hematologic and nonhematologic malignancies with myeloablative conditioning after graft dilution and washing. The median total nucleated cell (TNC) doses was 3.4 × 107/kg (range, 2 to 26) and the median post-thaw recovery was 84% (range, 45 to 178). The cumulative incidence of neutrophil engraftment at 50 days was 84% (95% confidence interval [CI], 83 to 93). A total of 118 immediate AIE were observed in fifty-two (33%) patients. All reported AIE were transient, graded from 1 to 2 by Common Terminology Adverse Events version 4. The most frequent toxicity was cardiovascular but without any life-threatening reaction. Infused TNC, recipient's weight, and rate of infusion per kilogram were risk factors associated with cardiovascular AIE in multivariate analysis (odds ratio [OR], 1.2 (95% CI, 1.1 to 1.4); P < .001; OR, .94 (95% CI, .9 to .97); P < .001; and OR, 1.5 (95% CI, 1.2 to 1.8); P < .001; respectively). In summary, use of an automated method for graft washing before CB administration showed low incidence of AIE without compromising cell yields and engraftment. Infused TNC dose, recipient's weight, and rate of infusion per kilogram were risk factors associated with infusion reactions.

Prediction of Hematopoietic Stem Cell Yield after Mobilization with GCSF in Healthy Unrelated Donors

Introduction:The collection of hematopoietic stem cells from the peripheral blood in healthy donors has been established as a highly efficient method in clinical practice. Nevertheless, there are some donors who mobilize poorly despite adequate mobilization regimes. Several factors influencing the process of stem cell mobilization have previously been discussed in the literature.Methods:In total, the data of 7.216 unrelated donors who underwent GCSF-induced stem cell mobilization and collection in two German apheresis centers between July 1997 and August 2012 were retrospectively reviewed. We systematically analyzed more than 30 factors with potential influence on the mobilization process and established a statistically stable model in order to predict the mobilization efficacy and the harvest success in unrelated stem cell donors.Based on empirical data and standard values, we created three model donors of each gender with different donor profiles (favorable/average/unfavorable). In those model donors we calculated the corresponding likelihood of a successful stem cell harvest dependent on the recipient’s weight.Results:Overall, ten variables with high statistical significance were included in the prediction model. Body mass index, platelet count, absolute lymphocyte count and the relative monocyte count correlated positively with the CD34+ count in the peripheral blood after five days of GCSF use (p < 0.0001 in a multivariate analysis). In contrast, female sex, age, smoking, lactate dehydrogenase (ldh), relative monocyte count, and the relative large unstained cell count were associated negatively with the CD34+ count on day five (p < 0.0001 in a multivariate analysis).In order to predict the harvest success (collection of > 2 x 10^6 CD34+ cells/kg recipient weight after first apheresis) three different models were compared in a ROC-analysis. The first model was purely based on female sex and recipient weight. The second model additionally contained the predicted CD34+ counts. Finally, in the third model the actual observed CD34+ counts were included.By adding the predicted CD34+ counts to the simple model, a significant improvement of the predictability of a harvest success could be viewed although a considerable difference comparing these results to the model with the observed CD34+ counts remained (figure 1).Furthermore, the prediction of harvest success in model donors (figure 2) revealed that donors with a favorable donor profile (covariates set to the most favorable values within the normal range) showed a particular high likelihood for a successful harvest (100 % likelihood, irrespective to donor’s gender or recipient’s weight). The likelihood for a successful harvest in male donors with an average distribution of covariates (covariates set to the empirical mean value) was nearly 100% as well even in donations for heavy recipients. Contrary, the likelihood for an average female donor was high in normal weight recipients (97 %; 60 kg recipient) but decreased with rising recipient weight (78 %; 140 kg recipient).In donors with an unfavorable profile (covariates set to the worst values within the normal range), especially in females, the chance for a successful stem cell collection was poor even when donating for light recipients (54 % in males, 10 % in females; 60 kg recipient).Conclusions:In conclusion, multiple factors with influence on the CD34+ count after GCSF mobilization in healthy donors have been identified. With the prediction model a significant gain in the predictability of a harvest success could be achieved though a certain amount of unexplained variance still remains.Model donors with a favorable or average donor profile had a high likelihood for a successful stem cell collection. In donors with an unfavorable profile, especially in females, the chance for a harvest success was very low. [Display omitted] Abb.: AUC – area under the curve [Display omitted] DisclosuresSchmidt:Cellex GmbH: Employment. Ehninger:Cellex GmbH: Equity Ownership. Off Label Use: G-CSF.

Longer Procedure Duration and Large Volume Harvests Reduce the Likelihood of Achieving the Requested Cell Dose from Unrelated Bone Marrow Donors

IntroductionThe factors influencing the quality of bone marrow (BM) harvests and total nucleated cell count (TNC) achieved are poorly understood. As the number of BM harvest procedures falls (due to an increasing proportion of harvest requests for peripheral blood stem cells), concerns are raised around maintaining expertise in this area. We investigate, in four Anthony Nolan collection centers, the procedure- and donor -related factors influencing the quality of harvests, and likelihood of achieving the requested TNC.Materials & Method110 consecutive BM harvests of healthy unrelated donors (UD)s were performed according to standard Anthony Nolan protocols. Harvest quality was defined as TNC/ml volume collected. Univariate analyses of factors influencing the TNC and harvest quality were performed using Chi squared or Fisher’s test where appropriate.Results110 BM harvests were performed in 80 male and 30 female donors. The median donor age was 28 years (range 18-56 years).The median TNC requested was 4x108/kg, and median harvested TNC 4.2x108/kg recipient weight, with the requested TNC dose achieved in 50% of harvests. Higher volume harvests (greater than the median volume 1200 mls) were significantly less likely to achieve TNC> 4x108/kg recipient weight (38% vs 70% p=0.001), as were harvests with a procedure time greater than 30 minutes (p=0.037). We investigated donor factors influencing the harvest yield and found that donor/recipient weight discrepancy significantly impacted the TNC achieved: with only 18% of BM harvests from donors who weighed less than their recipient achieving TNC >4x108/kg compared to 62% harvests from donors who were heavier than their recipient (p=0.001). No other donor factor had a significant influence on the TNC.The median TNC/ml collected was 18.2x10^6/ml and harvests in donors>40 years were more likely to be of lower quality (p=0.036). No other donor factors affected harvest quality, however a significant variation between the 4 collection centers was observed: both the harvest quality (p=0.014) and volume collected (p=0.035) varied significantly between centers.ConclusionsDonor weight is a strong determinant of bone marrow harvest yield; we recommend that when multiple matched UDs are available, a donor with high body weight should be selected for BM harvest. Procedure factors including large volume harvests and long procedure times reduce the likelihood of achieving the requested TNC, and significant variation was seen between centers. Given the declining number of requests for BM harvests, it is crucial these are performed by the most experienced centers and that systems exist to ensure operators retain their expertise. DisclosuresNo relevant conflicts of interest to declare.

Remobilization with G-CSF Is Less Effective Than the Initial Mobilization in Healthy Donors Undergoing Peripheral Blood Stem Cell Collection for Allogeneic Transplantation

Background: The need to repeat peripheral blood stem cell (PBSC) mobilization and collection arises infrequently in healthy donors, but may be required due to insufficient initial collection, graft failure, or relapse of the recipient’s disease. Currently no published data exists on the efficacy of remobilization of healthy PBSC donors. Studies of remobilization in patients undergoing autologous transplantation (ASCT) have largely focused on the use of alternative mobilization agents such as chemotherapy or plerixafor. Boeve et al (Bone Marrow Transplant, 2004) reported that remobilization with G-CSF in patients undergoing ASCT who failed initial mobilization with G-CSF, resulted in higher numbers of CD34+ cells collected than the initial collection, though this required a doubling of the dose of G-CSF.Patients/Methods: We performed retrospective chart review of 977 consecutive adult (>18 yrs) donors who underwent apheresis for PBSC donation at Washington University School of Medicine from 1995 through 2013. We identified 66 donors who had undergone more than one mobilization. Two cohorts of donors were identified for analysis: Group 1 included donors mobilized initially and again subsequently with G-CSF (10 ug/kg/day), or GM-CSF (5 ug/kg/day) + G-CSF (10 ug/kg/day). Group 2 consisted of donors mobilized with a CXCR4 antagonist, plerixafor (240-320 ug/kg) or POL6326 (1000-2500 ug/kg), and subsequently were remobilized with G-CSF (10 ug/kg/day).Statistical Analysis: Spearman correlations were performed to analyze the relationship between peak peripheral blood (PB) CD34+/uL level; the number of CD34+ cells collected per kg (recipient weight); and the number of CD34+ cells per L of apheresis collected during initial mobilization (MOB1) and remobilization (MOB2); and the interval (days) between MOB1 and MOB2. One-way ANOVA with repeated measures analyses were performed to determine the relationship of PB CD34+/uL, CD34+/kg and CD34+/L during MOB1 and MOB2.Results: Group 1 included 30 donors. The median age was 49 years (range 18-75) and 15 were male. The median number of days between MOB1 and MOB2 was 140 (range 26-2238). All 30 donors were remobilized due to graft failure or relapse of the recipient’s disease. PB CD34+/uL, CD34+/kg and CD34+/L all correlated between MOB1 and MOB2. The mean PB CD34/uL at MOB1 was 69 compared to 37 at MOB2 (p= 0.029); the mean CD34/kg collected at MOB1 was 5.6x106 compared to 3.3x106 at MOB2 (p= 0.002); and the mean CD34/L collected at MOB1 was 24.0x106 compared to 17.6x106at MOB2 (p= 0.023). The interval between MOB1 and MOB2 did not correlate with any of the MOB2 variables. Results from the analysis are summarized in Table 1.Group 2 included 32 donors. The median age was 51 years (range 21-67) and 18 were male. The median number of days between MOB1 and MOB2 was 20 (range 4-1123). 18 donors were remobilized due to mobilization failure, while 14 were remobilized due to graft failure or relapse of the recipient’s disease. The mean PB CD34/uL at MOB1 was 15 compared to 68 at MOB2 (p< 0.001); the mean CD34/kg collected at MOB1 was 2.5x106 compared to 7.1x106 at MOB2 (p< 0.001); and the mean CD34/L collected at MOB1 was 10.6x106 compared to 30.1x106at MOB2 (p< 0.001). The interval between MOB1 and MOB2 did not correlate with any of the MOB2 variables. Results from the analysis are summarized in Table 2.Conclusion: Remobilization with G-CSF or GM-CSF and G-CSF after initial successful mobilization with the same regimen results in poorer mobilization while remobilization with G-CSF after initial mobilization with a CXCR4 antagonist results in dramatically improved mobilization. The reason for this remains unclear, but in this study the interval between collections was not associated with successful remobilization.Abstract 850. Table 1Group 1MOB 1MOB 2One-way ANOVASpearman CorrelationPB CD34/ul69 (13-417)37 (1-115)F(1.0, 29.0) = 5.26, p= 0.029r= 0.615, p< 0.001CD34/kg (x106)5.6 (0.8-13.8)3.3 (0.3-10.6)F(1.0, 29.0) = 11.77, p= 0.002r= 0.483, p= 0.007CD34/L (x106)24.0 (4.5-72.0)17.6 (2.8-41.3)F(1.0, 29.0) = 5.74, p= 0.023r= 0.566, p< 0.001Abstract 850. Table 2Group 2MOB 1MOB 2One-way ANOVASpearman CorrelationPB CD34/ul15 (2-54)68 (14-358)F(1.0, 31.0) = 23.16, p< 0.001r= 0.433, p= 0.013CD34/kg (x106)2.5 (0.2-19.7)7.1 (1.7-42.4)F(1.0, 31.0) = 33.84, p< 0.001r= 0.769, p< 0.001CD34/L (x106)10.6 (1.4-67.1)30.1 (6.0-165.0)F(1.0, 31.0) = 34.70, p< 0.001r= 0.774, p< 0.001 DisclosuresNo relevant conflicts of interest to declare.

Preliminary Results of a Phase 1/2 Clinical Trial of Cndo-109-Activated Allogeneic Natural Killer Cells in High Risk Acute Myelogenous Leukemia Patients in First Complete Remission

BACKGROUNDWe previously reported that resting human peripheral blood NK cells can be primed to kill NK-resistant tumor cells by co-incubation with a lysate of the leukemia cell line CTV-1. CNDO-109 is a clinical-grade CTV-1 lysate that primes NK cells ex-vivo to kill NK-resistant acute myeloid leukemia (AML) cells. CNDO-109-activated NK cells can be cryopreserved and remain primed when thawed. Incubation or treatment with IL-2 is not required. We report preliminary safety, outcome and NK chimerism data from an ongoing Phase 1/2 transitional clinical trial of CNDO-109-NK cells.METHODSA 3x3 dose escalation phase 1 trial was opened in 2013 for patients with AML in 1st CR with high-risk disease and no conventional treatment options. Patients were given preparative chemotherapy of cyclophosphamide and fludarabine on Study Days -6 to -2, followed on day 0 by a single dose of CNDO-109-activated NK cells at the following doses; cohort 1 = 3×105, cohort 2 = 1×106, cohort 3 = up to 3×106 cells/kg recipient body weight. The MTD will set the dose for the transitional phase 2 trial.CNDO-109-NK cells were generated from a single apheresis collection from HLA-haploidentical related donors. NK cells were isolated with anti-CD56 microbeads (CliniMACS, Miltenyi Biotec) and co-incubated with CNDO-109 lysate (Coronado Biosciences) overnight under cGMP conditions. After lysate removal cells were cryopreserved in dosed aliquots and released for infusion. Exogenous IL-2 was not used. Quality control testing of the final product included NK purity (>50%), viability (> 70%), potency, sterility, mycoplasma and endotoxin. Residual T cell contamination (<104 cells/kg patient body weight) was a lot release safety criterion. Patients were assessed for safety and efficacy whilst expansion, proliferation and persistence of donor NK cells were assayed by molecular-based chimerism techniques, and by flow cytometry, where informative markers were available. Pre- and post-treatment samples from cohort 3 patients are being tested for flow cytometric and molecular MRD (University of Washington - Walter, R.B.2013 and NextGene Sequencing).RESULTSSeven eligible patients have been enrolled. All products met lot release and contained activated NK cells as determined by killing of NK resistant Raji cells as well as increased expression of CD69 & CD25: TableBaseline(Resting NK Cells)Activated NK CellsChangep-valueRaji Cell Lysis15.2%+/- 10.0%29.7% +/- 13.9%0.008CD69+ Expression5.9% +/- 2.9%42.6% +/- 12.5%0.008CD25+ Expression3.1% +/- 1.8%5.8% +/- 1.9%0.008No infusional toxicity, adverse events attributed to NK therapy, GvHD nor deaths have been reported. As expected, all patients experienced transient myelosuppression (approx. 2 weeks). 3 patients suffered early relapse post-treatment (2 in cohort 1, 1 in cohort 2; average time to relapse from CR1 for these 3 patients was 104 days).In 5 of 7 evaluable patients, persistence of donor activated NK cells was observed from Day +7 post-infusion (chimerism = 1%-84%) to as late as day +56 in one patient. Flow cytometric comparison of donor NK cells and patient NK cells in the same sample by selective gating on the mismatched HLA allele showed that circulating donor NK cells typically differed from recipient NK cell in higher expression of NKG2A (e.g. 63.5% vs 2.7%), CD57 (e.g. 80.5% vs 13.2%) and CD69 (e.g. 11.6% vs 2.52%) suggesting a more normal, mature and activated phenotype than the endogenous host NK population.Even after loss of circulating donor primed NK cells, 2 of the 3 patients tested showed persistence of low levels of activated autologous NK cells (~10-20% of circulating NK) exceeding the numbers circulating pre-CNDO-109 NK treatment, out to Day +56, suggesting that the therapy may induce endogenous NK activation to enhance the patients’ innate immunity to AML.CONCLUSIONSThis establishes proof of concept that CNDO-109-NK can persist transiently in patients with lasting microchimerism for > 1 month and can induce activation of endogenous NK cells in patients treated without cytokine administration. To date 4 of the 7 patients enrolled remain relapse free (max. = 410 days post CR1 date). These results highlight the potential of CNDO-109-NK cells in the treatment of AML and other malignancies. DisclosuresMiller:Coronado Biosciences: Consultancy. Hillman:Coronado Biosciences: Employment. Silver:Coronado Biosciences: Employment. Szarek:Coronado Biosciences: Consultancy. Lowdell:Coronado Biosciences: Consultancy, Patents & Royalties. Gorelik:Coronado Biosciences: Employment. Rowinsky:Coronado Biosciences: Equity Ownership, Membership on an entity’s Board of Directors or advisory committees.

The Cell Loss after Thawing in Cord Blood Units

Umbilical cord blood (CB) are increasingly used for allogeneic transplantation as an alternative source to bone marrow or peripheral stem cell for patients who lack a human leucocyte antigen (HLA)-matched donor. Cell dose is one of the main determinant factor for selection of the unit and it has been shown to correlate with time and probability of engraftment. Cell doses available for selection of the unit are the ones evaluated before cryopreservation. Processing of the graft either with cryopreservation and/or thawing inevitably lead to cell loss but the data showing to what extent is very limited although this has great importance especially for the units with critical cell counts. To evaluate the extent of the cell loss after thawing and the effect of preservation duration on cell loss and the viability, we retrospectively analyzed our single center experience in a cohort of patients receivingunrelated CBT.Sixty cord blood units used for unrelated CBT in fifty-eight patients in our Pediatric Stem Cell Transplantation Unit were included in the study. One of the patient was transplanted with double cord blood unit and one had recurrent CBT because of previous graft failure.Median number of declared TNC per kilogram of recipient body weight was 16x107/kg (range: 3,16-59,1). After thawing the median TNC dose decreased to 11,1x107/kg (range:1,5-34), with median cell viability at 80%. The median TNC recovery was found as 70%. Median CD 34+ cell count declared by the banks per kilogram body weight of recipient was 6,0x105/kg (range: 0,5-37). The CD 34 cell count of one of the units used in a patient having double cord blood infusion was not available. The CD34 cell count of the other complementary unit was 0,48x105/kg. Since the total cell counts received bu the recipient was given, the CD34 cell count of the patient having double CB infusion was not included in statistical analysis. The median postthawed CD 34 cell count was 3,4 x105/kg (range: 0-21)and median CD34 cell recovery was %58.The storage duration of the CB units in liquid nitrogen was available for 59 units and that was 52±30 months (range:3-130 months). Correlation analysis did not show any significant correlation between CB unit storage duration and viability (r=-0,2 p=0.07). Also any correlation between storage time and also TNC and CD34 cell recovery were not identified.Our study indicated that approximately 30% of cell loss is expectable in cord blood transplantation because of either cryopreservation or thawing. It should be kept in mind while assessing acceptibility of cord blood units with limited cell counts DisclosuresNo relevant conflicts of interest to declare.