Establishment of Durable Chimerism with Minimal GvHD in Highly Mismatched Recipients Receiving an Investigational Facilitated Allo-HSCT

Abstract Introduction We previously reported the induction of kidney transplant tolerance by the establishment of durable whole blood and T-cell chimerism and withdrawal of immunosuppression (IS) in 26 of 37 highly mismatched recipients of combined stem cell and living donor kidney transplant recipients (KTx) with low risk of graft versus host disease (GvHD), using FCR001, an investigational cell therapy. The focus of the current analysis is to evaluate the impact of degree of bidirectional donor/recipient mismatching using high resolution allele typing at HLA-A, -B, -C, -DRB1, -DQB1 and -DPB1, on the ability to establish durable chimerism, allowing full immunosuppression (IS) withdrawal and the induction of transplant tolerance. Methods In this phase 2 trial, recipients received nonmyeloablative conditioning with fludarabine 30mg/m2 (Days -5, -4, -3), cyclophosphamide 50mg/kg (Days-3 and +3), 200 cGy TBI (Day-1) followed by KTx (Day 0). G-CSF mobilized peripheral blood mononuclear cells were apheresed from the donor >2 weeks prior to KTx, processed to remove GvHD-producing cells yet retain CD34 +cells and tolerogenic CD8+/TCR facilitating cells (FC) and cryopreserved until infusion day+1 after KTx. IS consisted of mycophenolate and tacrolimus. IS was weaned and discontinued in the presence of sustained donor T-cell chimerism (>50%), stable renal function and no evidence of biopsy-proven rejection. Results Samples from 32 of the 37 subject pairs were available for analysis; of these, three subjects did not have sufficient DNA to test for locus DPB1.All 32 recipients, ranging from age 18 - 65 years, have reached at least 4.5 years of follow-up up to 12 years. Two recipients were re-transplants. Of the 29 D/R pairs with data from all 12 alleles, 21 were mismatched between 6 to 12 alleles (6 related, 15 unrelated), 8 were mismatched between 2 and 5 alleles (all related). Of the three D/R pairs missing DP data, one was mismatched 6 of 10, another 10 of 10, and a third 2 of 10 alleles. Despite the high degree of mismatch, durable chimerism allowed for full IS withdrawal in 25 of these 32 subjects (time off IS from 3.5 - 11 years). 12/25 off IS were from unrelated D/R pairs and ≥ 8 HLA mismatches; the majority showed >95% donor whole blood/T cell chimerism. Three have exhibited stable mixed chimerism ranging between 40% - 60%. Of the subjects not off IS, two failed to engraft their cells; four lost chimerism by 4 months, and one developed GVHD. Durably chimeric patients retained chimerism after removal of IS, remain rejection-free without donor-specific antibody (DSA) with up to 12 years following KTx and have not resumed IS. Transiently chimeric subjects resumed endogenous hematopoiesis and are maintained on low dose IS with stable renal function. There have been two cases of GvHD: one grade 2 lower GI acute GvHD that developed during conversion from tacrolimus to sirolimus and responded to steroids; this patient has developed moderate chronic GvHD of the skin. He is off IS with normal renal function. The second presented late following development of severe gastrointestinal symptoms and manifested treatment-resistant lower GI GvHD with associated tissue-invasive CMV colitis that proved fatal at 11 months post-transplant. Conclusions In summary, high levels of durable chimerism and tolerance with a low (5.5%) incidence of GvHD has been achieved in highly mismatched related and unrelated recipients of FCR001 + kidney transplant. Figure 1 Figure 1. Disclosures Krieger: Talaris Therapeutics, Inc.: Current Employment, Current equity holder in publicly-traded company. Tambur: Viela Bio and Sanofi: Consultancy; ThermoFisher: Speakers Bureau. Schneider: Talaris Therapeutics, Inc.: Current Employment. Olsen: Talaris Therapeutics, Inc.: Current Employment. Ildstad: Talaris Therapeutics, Inc.: Current Employment, Current equity holder in publicly-traded company, Membership on an entity's Board of Directors or advisory committees.

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Hematopoietic Mononuclear Cell Transplant with Minimal Gvhd in up to Completely Mismatched Unrelated Recipients

Blood ◽

10.1182/blood-2019-130943 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3243-3243

Author(s):

Suzanne T Ildstad

Keyword(s):

Renal Function ◽

Kidney Transplantation ◽

T Cell ◽

Kidney Transplant ◽

Whole Blood ◽

Peripheral Blood ◽

Chronic Gvhd ◽

Mixed Chimerism ◽

Cell Transplant ◽

Kidney Graft

37 patients have been transplanted in a phase 2 protocol to establish chimerism to induce tolerance in up to 0 of 6 matched related and unrelated recipients of living donor renal allografts (KTx). The protocol is based upon tolerogenic CD8+/TCR- facilitating cells (FC) and nonmyeloablative conditioning. Recipients were conditioned with fludarabine (30mg/m2 days -5,-4,-3), cyclophosphamide (50mg/kg day-3 and+3), 200 cGy TBI (day-1) followed by KTx (day0). G-CSF mobilized peripheral blood mononuclear cells were apheresed from the donor >2 weeks before kidney transplantation, processed to remove graft-versus-host disease (GVHD)-producing cells yet retain CD34 +cells and FC, and cryopreserved until transplantation on day+1 after kidney transplantation. Immunosuppression consisted of mycophenolate mofetil and tacrolimus. 36 patients have reached at least 1 year of follow up (range 12-105 months) and are the focus of this analysis. Patients ranged in age from 18-65 yrs. Enrollment was agnostic to degree of HLA match; 2 were 6/6 and 3 5/6 matched related using high resolution allele level typing, with the remainder 4/6 to 0/6 matched related (n=15) or unrelated (n=16) Two of the recipients were renal re-transplants. Tacrolimus/MMF immunosuppression (IS) was weaned and discontinued at 1 year if chimerism (>50% whole blood and T cell), normal renal function and normal kidney transplant biopsy were noted. 34 of 36 subjects exhibited peripheral blood donor chimerism at one month post KTx. Durable chimerism allowing for full IS withdrawal developed in 26 (time off IS from 1- 88 months); the majority (23/26) showed >95% donor whole blood/T cell chimerism. Three have exhibited stable-mixed chimerism ranging between 40% - 60%. Three patients failed to develop chimerism. Transient chimerism occurred in 8 patients. Durably chimeric patients retained chimerism after removal of IS, remain rejection-free without donor-specific antibody (DSA) and show immunocompetence to vaccinations. None have had to resume immunosuppression. Transiently chimeric subjects resumed endogenous hematopoiesis and are maintained on low-dose IS with stable renal function. There have been two cases of GVHD: one grade 2 lower GI acute GVHD that developed during conversion from tacrolimus to sirolimus that responded to steroids; this patient has developed moderate chronic GVHD of the skin. He is off IS. The second presented late following development of severe gastrointestinal symptoms and manifested treatment-resistant lower GI GVHD with associated tissue-invasive CMV colitis that proved fatal at 11 months post-Tx. There have been two additional kidney graft losses, both related to early infections. A second subject death occurred in a heavy (>100 pack yr) smoker who developed advanced stage lung cancer 4.5 years after Tx. A third subject developed pneumococcal sepsis > 4 years after transplant. He had not undergone the recommended pneumococcal vaccination post HSCT. Overall patient survival is 91.8% and death censored graft survival 94.1%. These rates compare favorably to treatment-related mortality rates after standard of care renal transplant. In summary, high levels of durable chimerism and tolerance with a low (5.5%) incidence of GVHD has been achieved in up to 0 of 6 matched related and unrelated recipients of FCR001 + kidney transplant. Figure Disclosures Ildstad: Talaris Therapeutics Inc: Employment, Equity Ownership, Other: Founder and CSO.

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Impact of donor age and kinship on clinical outcomes after T-cell–replete haploidentical transplantation with PT-Cy

Blood Advances ◽

10.1182/bloodadvances.2020001620 ◽

2020 ◽

Vol 4 (16) ◽

pp. 3900-3912 ◽

Cited By ~ 1

Author(s):

Jacopo Mariotti ◽

Anna Maria Raiola ◽

Andrea Evangelista ◽

Angelo Michele Carella ◽

Massimo Martino ◽

...

Keyword(s):

Stem Cell ◽

T Cell ◽

Clinical Outcomes ◽

Chronic Gvhd ◽

Multivariable Analysis ◽

Cell Transplant ◽

Donor Age ◽

Hematopoietic Cell Transplant ◽

The Impact ◽

Risk Of Relapse

Abstract Donor selection contributes to improve clinical outcomes of T-cell–replete haploidentical stem cell transplantation (haplo-SCT) with posttransplant cyclophosphamide (PT-Cy). The impact of donor age and other non-HLA donor characteristics remains a matter of debate. We performed a multicenter retrospective analysis on 990 haplo-SCTs with PT-Cy. By multivariable analysis, after adjusting for donor/recipient kinship, increasing donor age and peripheral blood stem cell graft were associated with a higher risk of grade 2 to 4 acute graft-versus-host-disease (aGVHD), whereas 2-year cumulative incidence of moderate-to-severe chronic GVHD was higher for transplants from female donors into male recipients and after myeloablative conditioning. Increasing donor age was associated with a trend for higher nonrelapse mortality (NRM) (hazard ratio [HR], 1.05; P = .057) but with a significant reduced risk of disease relapse (HR, 0.92; P = .001) and improved progression-free survival (PFS) (HR, 0.97; P = .036). Increasing recipient age was a predictor of worse overall survival (OS). Risk of relapse was higher (HR, 1.39; P < .001) in patients aged ≤40 years receiving a transplant from a parent as compared with a sibling. Moreover, OS and PFS were lower when the donor was the mother rather than the father. Pretransplant active disease status was an invariably independent predictor of worse clinical outcomes, while recipient positive cytomegalovirus serostatus and hematopoietic cell transplant comorbidity index >3 were associated with worse OS and PFS. Our results suggest that younger donors may reduce the incidence of aGVHD and NRM, though at higher risk of relapse. A parent donor, particularly the mother, is not recommended in recipients ≤40 years.

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Use of Pre-Emptive Donor Lymphocyte Infusions To Achieve Durable Remission Following Alemtuzumab Based Reduced Intensity Conditioning (RIC) Transplantation for AML or MDS.

Blood ◽

10.1182/blood.v106.11.1124.1124 ◽

2005 ◽

Vol 106 (11) ◽

pp. 1124-1124

Author(s):

ZiYi Lim ◽

Laurence Pearce ◽

Wendy Ingram ◽

Rafael Duarte ◽

Stephen Devereux ◽

...

Keyword(s):

T Cell ◽

Advanced Disease ◽

Disease Stage ◽

Mixed Chimerism ◽

Donor Chimerism ◽

Significant Difference ◽

Cell Source ◽

Recipient Age ◽

The Impact

Abstract Use of alemtuzumab in RIC HSCT reduces the incidence of graft rejection and graft vs host disease(GvHD). However, there can be a delay in full T-cell donor engraftment. As a dominant donor T-cell chimerism may be important to achieve a strong graft vs leukaemia effect(GvL), we examined the impact of pre-emptive DLI (pDLI) on patients with falling donor chimerism. 76 patients with AML or MDS were treated with RIC HSCT (fludarabine 150mg/m2, busulphan 8mg/kg, alemtuzumab 100mg). Complete sublineage chimerism data up to day +100 was available on all patients. The underlying diagnoses were AML n=27, MDS n=49. 33 patients had early disease vs 44 advanced disease (advanced disease as defined by AML >CR1, MDS RAEB or AML with multilineage dysplasia). The median recipient age was 51.6 years (range:19–72), with median follow-up of 526 days (range:137–1256). There were 30 sibling and 50 VUD allografts. Stem cell source was 61 PBSC vs 15 BM. 62 patients were fully HLA matched and 14 patients were HLA mismatched. CD15 engraftment occurred rapidly with 95% of patients achieving full donor chimerism(FDC) at day 30 and 96% at day 100. In contrast, CD3 engraftment was significantly delayed, with only 50% of patients FDC at day 30, 47% at day 100. Incremental doses of pDLI were considered for patients with falling donor chimerism (<50% donor) after day 100. Patients had immunosuppresion withdrawn, and had to have no GvHD. 20 patients received a total of 55 doses of pDLI. 10/20 had advanced disease, and 6/20 had unfavourable cytogenetics. Median donor CD3 chimerism at time of pDLI was 31.5%(range:7–59). The median CD3 dose of pDLI was 8.4x106/kg, with the first dose given at a median of day +176 (range:104–494). The median interval between pDLI was 8 weeks(range:4–22). 15 patients had FDC restored at median of 130 days following first doses of pDLI (range:36–523). 8/20 developed acute Gd II-IV GvHD following pDLI, with 2 patients dying of GvHD related complications. 2 patients relapsed with AML following treatment: with 1 death, and 1 patient currently undergoing treatment. 2 patients had not reached FDC at follow-up. A further 9 patients received DLI for cytogenetic or morphological relapse. Time to first dose of DLI was 257 days (range:76–837). The median CD3 dose was 1.67 x 107/kg. 3 patients were FDC and 6 patients MDC at time of relapse. All 3 patients with FDC failed to respond to DLI. Complete remission was seen in 3/6 patients with MDC. 4/9 patients developed acute Gd II-IV GvHD. 5/9 patients have died(all of underlying AML). The outcome of patients receiving pDLI was compared with patients with FDC(n=28), and stable mixed chimerism(defined as donor CD3 chimerism >70%) who did not receive DLI(n=18). There was no significant difference in recipient age, disease, disease stage, HLA type, cell source or cell dose between groups. However, there were more sibling donors in the group receiving pDLI(p=0.02). The 2 year DFS, OS and relapse rate was comparable between patients with FDC, stable chimerism and those receiving pDLI (59% vs 83% vs 67% p=0.22), (62% vs 88% vs 75% p=0.13), (12% vs 17% vs 15% p=0.74) respectively. In summary, pre-emptive DLI is effective in reversing falling donor chimerism, and can induce prolonged remission, even in a sub-group of patients with high risk disease. A dominant donor CD3 chimerism(>70%) may be sufficient to acheive an allo-immune effect in majority of patients.

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Proportions of T-Cell CD8+ Subsets Lacking CD28 Expression at Day 30 after Myeloablative Allogeneic Stem Cell Transplantation Are Predictive for Relapse and Chronic GVHD.

Blood ◽

10.1182/blood.v110.11.2979.2979 ◽

2007 ◽

Vol 110 (11) ◽

pp. 2979-2979

Author(s):

Ibrahim Yakoub-Agha ◽

Pasquine Saule ◽

Leonardo Magro ◽

Pascale Cracco ◽

Valerie Coiteux ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

Chronic Gvhd ◽

Immunosuppressive Treatment ◽

Cd8 T Cell ◽

T Cell Subsets ◽

Mixed Chimerism ◽

Effector Memory ◽

Myeloablative Conditioning ◽

Risk Of Relapse

Abstract The curative potential of allo-SCT for malignancies derives from the progressive reconstitution of the immune system and the development of effective anti-tumor immunity, but GVHD and disease relapse remain considerable obstacles to improvement in overall outcomes. Because in recipients target antigens are persisting, donor-derived T-cell responses may be expected to lead to the accumulation of a sizable proportion of differentiated T-cells, as happens following infection with persisting pathogens. A few cross-sectional studies have pointed to the preponderance of certain memory T-cell subsets associated with chronic GVHD (cGVHD), but the subset identified differed between studies. Inasmuch as qualitative T-cell recovery takes months to years to complete and there is substantial variability in time to development of GVHD or relapse, serial analysis might be more suitable to unveil early changes in T-cell subset composition attributable to transplantation-related events. From October 2003 on, 55 pts who underwent an allo-SCT after myeloablative conditioning were monitored prospectively in terms of clinical post-graft complications, including graft rejection, infections, GVHD and relapse. Blood samples were obtained on days 30±2, 60±3, 90±5, 180±10 and 365±15 post-transplant. Naive (CD45RA+CCR7+), central memory (TCM, CD45RAnegCCR7+), effector memory (TEM, CD45RAnegCCR7neg), and terminally differentiated effector (TTD, CD45RA+CCR7neg) were enumerated within the CD4+ and CD8+ pools, and the percentage of cells coexpressing CD28 was calculated within each eight subsets. The degree of donor-derived T-cell chimerism was assessed by real time PCR (sensitivity ≤ 1%). Median follow-up was 733 d (404–1251). Dynamics of CD4+ and CD8+ naive, TCM, TEM, and TTD were similar between the pts who developed cGVHD (n=15) and those who did not and between pts who relapsed and those who did not. However, costaining to detect CD28 demonstrated contrasting differences between cGVHD and relapse. At day 30, pts who subsequently relapsed (n=17) had elevated percentages of cells keeping CD28 expression within CD8+ T-cell subsets (TCM, p=.001; TCM, p=.021; and TTD, p=.007). Conversely, pts who subsequently developed cGVHD (n=15; only one relapsed) had diminished percentages of CD28+ cells within the two CD8+CCR7+ subsets at day 30 (p=.002 and p=.034, respectively). Loss of CD28 expression is known to be a hallmark of CMV infection but multivariate analysis ruled out, however, a confounding effect of CMV. Adjusted hazard ratios were 0.10 (95% CI, 0.01-0.76; p=.026) and 5.56 (95% CI, 1.16-25.00; p=.032) with CD28neg cells 16.7% of all CD8+ TCM at day 30 for relapse and cGVHD, respectively. Furthermore, pts with relapse had more often mixed chimerism at day 30 while those with cGVHD had more often full-donor chimerism (p=.042 and p=.023, respectively). CONCLUSION: This prospective study is the first to associate an early contrasting change in CD8+CD28neg T-cells with the risk of relapse and cGVHD after a myeloablative conditioning. Determination at day 30 of the proportions of CD8+ T-cell subsets expressing CD28 and of the level of T-cell chimerism could assist in predicting risk of relapse and cGVHD and help build an algorithm for the management of immunosuppressive treatment.

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Long Term Follow-up of Recipients of Combined HLA-Matched Nonmyeloablative Bone Marrow and Kidney Transplantation for Multiple Myeloma with End-Stage Renal Disease.

Blood ◽

10.1182/blood.v114.22.3368.3368 ◽

2009 ◽

Vol 114 (22) ◽

pp. 3368-3368

Author(s):

Thomas R Spitzer ◽

Megan Sykes ◽

Nina Tolkoff Rubin ◽

Tatsuo Kawai ◽

Steven L McAfee ◽

...

Keyword(s):

Multiple Myeloma ◽

Renal Function ◽

Normal Renal Function ◽

End Stage Renal Disease ◽

Renal Allograft ◽

Chronic Gvhd ◽

Mixed Chimerism ◽

Stage Renal Disease ◽

End Stage

Abstract Abstract 3368 Poster Board III-256 Specific tolerance following combined kidney and bone marrow transplantation (Kd/BMT)for patients with end stage renal disease (ESRD) with or without an underlying malignancy has been accomplished, as evidenced by prolonged normal renal function without ongoing immunosuppression (IS)and the demonstration of in vitro donor specific hyporesponsiveness (N Engl J Med 2008; 358:353-361; Am J Transplant 2006;6:2121-2133). In order to achieve potent anti-myeloma responses and induce tolerance through the induction of mixed chimerism (MC) for the renal allograft, 7 patients (median age 48 (34-55) yrs with multiple myeloma (MM) and ESRD received a combined HLA-matched Kd/BMT, with longest follow-up time of almost 11 years. An eighth pt developed cyclophosphamide (CY) cardiotoxicity on day -5 and did not receive a transplant. Preparative therapy for the transplants consisted of CY 60 mg/kg (days -5, -4) with hemodialysis 14 hrs after each CY dose, equine anti-thymocyte globulin, 15-20 mg/kg on days -1, +1, +3, and +5 and thymic irradiation (700 cGy) on day -1. Cyclosporine (CSP) was begun on day -1, with combined Kd/BMT on day 0. Nine additional donor lymphocyte infusions were given to 5 pts (5 for chimerism conversion, 4 for persistent/progressive disease (PD)). Acute (A) and chronic (C) GVHD developed in one patient following DLI for early PD, while chronic GVHD developed in two pts (one after a second stem cell transplant). Characteristics and outcomes of the 7 combined Kd/BMT recipients are as follows: # after 2nd transplant (myeloablative) from the same donor ; FDC: full donor chimerism In summary, 5 of 7 pts are alive, 4 without evidence of MM from 2.7 to 10.9 yrs post-Kd /BMT. Three pts have normal renal function without IS, while two pts have normal renal function on IS for chronic GVHD. Sustained renal allograft tolerance and prolonged anti-myeloma responses are achievable following nonmyeloablative HLA-matched kidney and BMT and the induction of mixed chimerism. This study was supported by the Immune Tolerance Network, National Institute of Allergy and Infectious Diseases. Disclosures: Off Label Use: Equine anti-thymocyte globulin: in vivo T cell depletion Cyclophosphamide:conditioning therapy for transplantation.

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Targeted Lymphocyte Depletion Prior to Reduced Intensity Allogeneic Stem Cell Transplantation: A Personalized Approach to Facilitate Engraftment.

Blood ◽

10.1182/blood.v114.22.865.865 ◽

2009 ◽

Vol 114 (22) ◽

pp. 865-865

Author(s):

Rachel B. Salit ◽

Seth Steinberg ◽

Daniel H. Fowler ◽

Jeanne Odom ◽

Kelly Bryant ◽

...

Keyword(s):

Stem Cell ◽

T Cell ◽

Whole Blood ◽

Graft Rejection ◽

Th2 Cells ◽

Mixed Chimerism ◽

Lymphocyte Depletion ◽

Gvhd Prophylaxis ◽

Personalized Approach ◽

Reduced Intensity

Abstract Abstract 865 Reduced intensity allogeneic stem cell transplantation (RIST) is associated with decreased transplant-related mortality (TRM), broadening the pool of patients who could potentially benefit from allogeneic cellular therapy. However, RIST is typically associated with higher rates of mixed chimerism and graft rejection compared to myeloablative conditioning. Data from clinical studies have shown that the number of therapies prior to transplant, which inversely correlates with host T-cell immunity, is a statistically important predictor of graft rejection and mixed chimerism. In order to compensate for variability in host immune status and facilitate early full-donor chimerism (>95%), we developed a strategy of targeted lymphocyte depletion (TLD) which uses repetitive cycles of disease-specific conventional-dose chemotherapy to provide both tumor cytoreduction and lymphocyte depletion prior to RIST. The number of TLD cycles (0-3 maximum) was based on reaching a target CD4+ count <100 cells/μl; patients with higher pre-TLD CD4+ count required more cycles. We employed the TLD approach in 111 patients (mean age = 49 years, (19-71) with advanced hematologic malignancies. Median CD3+, CD4+, and CD8+counts at enrollment were: 673 cells/μl (5-3953), 286 cells/μl (5-3888), and 277 cells/μl (1-1763) respectively. Following TLD chemotherapy, median CD3+, CD4+, and CD8+ counts were: 164 cells/μl (1-1496), 82 cells/μl (0-508), and 52 cells/μl (1-1195) respectively. All patients then received an identical reduced intensity conditioning regimen (fludarabine/cyclophosphamide) followed by HLA-matched sibling peripheral blood stem cell allografts. All patients received cyclosporine as graft versus host disease (GVHD) prophylaxis (1) alone, (2) with methotrexate, (3) with TH2 cells, (4) with sirolimus or (5) with TH2 cells and sirolimus. Immediately prior to stem cell infusion (Day 0) median host CD3+, CD4+, and CD8+ counts were 4 cells/μl (0-69), 3 cells/μl (0-65) , and 1 cell/μl (0-44) respectively. 109 evaluable patients demonstrated 100% engraftment; there were no graft failures. At Day +14, median lymphocyte chimerism was 99% and median myeloid and whole blood chimerism were 100%. Patients were able to maintain chimerism as evidenced by median 100% chimerism in the myeloid, lymphoid and whole blood compartments at Day +28 and median 100% whole blood chimerism at Day +100. Full donor lymphocyte chimerism at Day +14 was associated with lower post-TLD CD4+ counts (p=0.012) and Day 0 CD3+, CD4+, and CD8+ counts (p<0.0005). Full donor myeloid chimerism at Day+14 and Day+28 was associated with lower Day 0 CD3+, CD4+, CD8+ counts (p<0.05). Full donor whole blood chimerism at Day +14, Day +28 and Day+100 was associated with lower Day 0 CD3+, CD4+, and CD8+ counts (p<0.05). The CD3+ and CD34+ dose contained in the allograft was associated with Day +14 lymphoid chimerism (p=0.04) and with Day +28 myeloid chimerism (p=0.03) respectively. CMV status was associated with both lymphoid and whole blood chimerism at Day +14 (p<0.05). Only lymphoid chimerism at Day+28 was associated with GVHD prophylaxis regimen (p<0.05). Patients with acute GVHD II-IV had significantly lower CD4+ counts post-TLD (p=0.01). Patients with acute GVHD III-IV had significantly lower CD4+ and CD3+ counts at Day 0 (p<0.05). These data demonstrate the tremendous variability in pre-transplant host T-cell numbers. By using the strategy of TLD, we were able to compensate for this variability while achieving levels of T-cell depletion comparable to myeloablative conditioning. We conclude that TLD provides a personalized approach to pre-transplant host immune status resulting in absence of graft rejection and rapid and full donor chimerism following RIST. Disclosures: No relevant conflicts of interest to declare.

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Favorable Outcomes in Patients with High Donor-Derived T Cell Count Following In Vivo T Cell Depleted Reduced Intensity Allogeneic Stem Cell Transplantation

Blood ◽

10.1182/blood.v118.21.3043.3043 ◽

2011 ◽

Vol 118 (21) ◽

pp. 3043-3043

Author(s):

Amir A Toor ◽

Roy T Sabo ◽

Harold M Chung ◽

Catherine H Roberts ◽

Rose H Manjili ◽

...

Keyword(s):

Decision Making ◽

Overall Survival ◽

Stem Cell ◽

T Cell ◽

Stem Cell Transplantation ◽

Cell Count ◽

Cell Transplantation ◽

Whole Blood ◽

Mixed Chimerism ◽

Cell Counts

Abstract Abstract 3043 In patients undergoing T cell depleted stem cell transplantation (SCT) a high rate of mixed chimerism is seen. Further, chimerism analysis does not consistently predict risks of GVHD or relapse upon withdrawal of immunosuppression (IS) in these patients. Thus, a reliable predictor for the expected evolution of mixed T cell chimerism is needed to help in clinical decision-making for withdrawal of IS and donor lymphocyte infusion (DLI). An alternative immune parameter is T cell recovery post-transplant. We combined this measure with T cell chimerism and examined the predictive value of a calculated donor-derived T cell count for clinical outcomes following SCT. Patients were enrolled in a randomized clinical trial examining two different doses of rabbit anti-thymocyte globulin (ATG 2.5 or 1.7 mg/kg/day; Thymoglobulin®, Genzyme, Cambridge, MA) given IV on day –9 through –7, followed by total body irradiation (4.5 Gray), administered in 3 doses on day –1 and 0 (NCT00709592). Donor engraftment was measured by PCR of short tandem repeat alleles in each donor and patient at 4, 8, 12, and 24 weeks following SCT on whole blood, granulocytes, and total T cells. Between 2008 and 2011, 25 patients were enrolled in this trial, and 22 patients were eligible for this analysis. Nine of the 22 patients had mixed T cell chimerism (≥5% recipient DNA) at 8 weeks post-transplant, and of these 33% (n=3) became fully donor T cell chimeric after withdrawal of IS over the ensuing weeks. One of the 9 patients had improved donor chimerism after DLI. Of the 13 patients who were full donor chimeric in T cells, one patient reverted from full donor to mixed chimerism. Donor-derived CD3+ T cell count (dd CD3) was calculated from T cell chimerism and absolute blood CD3+ T cell count. Median dd CD3+ cell count at 8 weeks following SCT was 433 ƒýL (range: 3–2464). After calculating the sum of receiver operating characteristic area under the curves (AUC), a dd CD3 of 110ƒýL was found to be the optimal cut-off value with both the highest AUC sum and the highest AUC for each measure (cumulative acute and chronic GVHD: 0.79, remission: 0.74, whole blood chimerism: 0.88), and was subsequently used to distinguish between low (<110; n=8) and high (>110; n=14) values of dd CD3. A significant correlation was found between this single dd CD3 level discriminator and higher rates of cumulative GVHD (Fishers Exact Test: p = 0.024), remission (p = 0.0524) and full donor whole blood chimerism at ≥12 weeks following SCT (p < 0.0001) in patients with high-dd CD3 cell counts. Furthermore, Bayesian analysis showed higher whole blood mixed chimerism rates (Posterior Probability = 0.99), lower GVHD rates (PP = 0.99), and lower remission rates (PP = 0.99) in the low-dd CD3 group. Both overall survival and time to relapse favored the high-dd CD3 group (vs. low-dd CD3 group). However, while the relationship was significant for relapse (p = 0.028), it was only marginally significant for overall survival (p = 0.07). When measured after withdrawal of IS, declining donor or persistent mixed T cell chimerism was observed in patients who had mixed T cell chimerism and low- dd CD3 at eight weeks post SCT (Fig 1A), whereas those with high- dd CD3 had increasing donor T cell chimerism (Fig 1B). Granulocyte chimerism too was modulated by dd CD3 in patients with mixed chimerism and early DLI arrested the decline of donor hematopoiesis in a patient with low-dd CD3. NK cell counts were significantly higher in the high-dd CD3 group than in the low-dd CD3 group at 8 weeks (p = 0.044; PP = 0.99). No significant relationships were found between dd CD3 levels and donor age, donor type, total ATG dose, and infused graft CD34+ or CD3+ cell dose.Figure 1AFigure 1A. In conclusion, we report the effect of an easily calculable measure of donor T cell reconstitution on clinical outcomes following SCT (particularly GVHD), stability of engraftment and disease relapse. Donor-derived CD3+ cell count may help in the decision-making regarding IS withdrawal and DLI timing in allogeneic SCT recipients. We will be confirming the optimal dd CD3 cell count parameter in larger patient cohorts with comparable disease biology for validation in regimens of varying myeloablative intensities. Disclosures: Toor: Genzyme: Research Funding. Off Label Use: ATG in stem cell transplantation.

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Donor Genetic Determinant of Thymopoiesis rs2204985 Impacts Clinical Outcome after Single HLA Mismatched HSCT

Blood ◽

10.1182/blood-2021-144748 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 3903-3903

Author(s):

Chrysanthi Tsamadou ◽

Sowmya Gowdavally ◽

Uwe Platzbecker ◽

Elisa Sala ◽

Thomas Valerius ◽

...

Keyword(s):

T Cell ◽

Research Funding ◽

Genetic Variant ◽

Chronic Gvhd ◽

Disease Free Survival ◽

Multivariate Models ◽

Common Genetic Variant ◽

Hematopoietic Stem ◽

Genotype Frequencies ◽

The Impact

Abstract Introduction: A common genetic variant within the TCRA-TCRD locus has been recently identified as a predictive factor of thymic function and T cell repertoire diversity (Clave et al., 2018). Specifically it was shown in a mouse model that transplantation of rs2204985 AA human hematopoietic stem cells (HSC) into immunodeficient mice led to lower thymocyte counts and poorer TCR diversity. T cell mediated pathways are known to play a significant role in immunological processes affecting HSCT outcome like GvL, GvH and infection. Aim of this study was to investigate the potential impact of donor rs2204985 genotype on patient's outcome after unrelated HSCT. Methods: The study included 2,016 adult patients with hematologic malignancies who received their first unrelated (10/10 or 9/10 HLA matched) graft between 2000 and 2013 in a German transplant center. Patients with refractory disease at time of transplantation were excluded from the analysis. Both donors and patients were retrospectively genotyped for the TCRA-TCRD rs2204985 polymorphism by next generation sequencing using a validated protocol on an Illumina Miseq platform. Overall survival (OS), disease free survival (DFS), relapse (RI), non-relapse mortality (NRM), acute GvHD (aGvHD) and chronic GvHD (cGvHD) were evaluated; p<0.05 was considered significant and donor rs2204985 GG/AG genotype was set as reference vs the AA genotype. Stratification for diagnosis was performed and a backward stepwise model finding approach was used to select variables related to a given outcome with a threshold of 0.10 for retention in the model. Results: The rs2204985 genotype frequencies found in both patients and donors were in line with those previously reported for Caucasian populations indicating a codominance of the two alleles (i.e. A and G). Regarding the impact of this genetic variation on outcome, multivariate analysis of the combined cohort indicated different risk estimates in 10/10 and 9/10 HLA matched transplantations, therefore subanalysis on account of HLA incompatibility was performed. Analysis in the subgroup of single HLA mismatched cases (n=624) revealed that donor AA genotype associated with markedly inferior OS (55.1% vs 70.6%, p=0.004, Fig. 1) and DFS (47.6% vs 63.4%, p=0.002, Fig. 2) one year after HSCT as compared to the donor AG/GG genotypes. These results were confirmed in the corresponding multivariate models (OS HR: 1.48, p=0.003; DFS HR: 1.50, p=0.001) which are visually displayed as forest plots in Fig. 3 and Fig 4, respectively. The adverse effect of donor AA genotype on survival appears to be driven by a combined higher risk of RI (1Y after HSCT: 29.3% vs 18.3%, p=0.048; HR: 1.38, p=0.035) and NRM (1Y after HSCT: 28.6% vs 19.9%, p=0.043; HR: 1.38, p=0.042) as shown by both the univariate and multivariate analyses for the two respective endpoints. No association was found between donor rs2204985 genotype and risk of acute or chronic GvHD. The donor rs2204985 genotype had also no significant impact on any outcome endpoint in the 10/10 HLA matched subgroup. Last, no significant interactions were observed between this variable and the other adjusted covariates in the multivariate models. Conclusion: To our knowledge this is the first study to date investigating the potential effect of donor's genotype regarding a common genetic variant within the TCRA-TCRD locus on the outcome of patients receiving unrelated HSC grafts. Our data suggest that donor rs2204985 AA genotype in combination with single HLA mismatches may adversely affect the outcome of HSC transplanted patients and should therefore be avoided. It is of note that one in four unrelated donors of Caucasian origin is expected to carry the AA genotype. A weaker relapse and -presumably- infection control, especially in the early post-transplantation period, due to compromised T cell reconstitution as a result of the unfavorable donor AA genotype may account for these findings. Confirmatory studies in larger independent cohorts are warranted before final conclusions are drawn. Figure 1 Figure 1. Disclosures Platzbecker: Geron: Honoraria; Janssen: Honoraria; Takeda: Honoraria; AbbVie: Honoraria; Novartis: Honoraria; Celgene/BMS: Honoraria. Sala: Celgene/BMS: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Gilead: Consultancy, Honoraria; Jazz: Consultancy, Honoraria. Wulf: Gilead: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; Clinigen: Consultancy, Honoraria. Kroeger: Celgene: Honoraria, Research Funding; Riemser: Honoraria, Research Funding; Gilead/Kite: Honoraria; AOP Pharma: Honoraria; Novartis: Honoraria; Jazz: Honoraria, Research Funding; Sanofi: Honoraria; Neovii: Honoraria, Research Funding. Einsele: Janssen, Celgene/BMS, Amgen, GSK, Sanofi: Consultancy, Honoraria, Research Funding. Hertenstein: Novartis: Honoraria; Sanofi: Honoraria; Celgene: Honoraria; BMS: Honoraria. Schrezenmeier: Alexion, AstraZeneca Rare Disease: Honoraria, Other: Travel support, Research Funding; Roche: Honoraria; Novartis: Honoraria; Apellis: Honoraria; Sanofi: Honoraria.

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Non-Myeloablative Allogeneic Transplantation (NMT) with T-Cell Replete Graft for Relapsed Chemosensitive Follicular Lymphoma (FL): Donor Lymphocyte Infusion (DLI) To Convert Stable Mixed Chimerism to Full Donor Chimerism Is Not Necessary in the Absence of Disease Progression.

Blood ◽

10.1182/blood.v106.11.3659.3659 ◽

2005 ◽

Vol 106 (11) ◽

pp. 3659-3659 ◽

Cited By ~ 2

Author(s):

Issa F. Khouri ◽

Ming-Sheng Lee ◽

Rima M. Saliba ◽

Sandra A. Acholonu ◽

Rosamar Valverde ◽

...

Keyword(s):

T Cell ◽

Median Time ◽

Chronic Gvhd ◽

Disease Free Survival ◽

Study Entry ◽

Mixed Chimerism ◽

Pcr Analysis ◽

High Dose ◽

Donor Cells ◽

Active Disease

Abstract DLI is commonly provided for mixed chimerism post NMT, even in the absence of measurable disease. This is with a high risk for graft-versus-host disease (GVHD) and a major cause of mortality and morbidity after NMT. We hypothesized that this practice may not be routinely needed in pts with indolent diseases, such as FL, and who continue to have stable mixed chimera (SMC) after NMT. We defined SMC as presence 50% to 99% donor cells by PCR analysis, and without any significant decrease of > 20% on two consecutive analysis. We treated prospectively 47 pts with relapsed FL with a NMT after conditioning with fludarabine, cyclophosphamide and high-dose rituximab as previously described (Blood89:3595, 2001). ATG was added for 2 pts receiving unrelated transplants. Tacrolimus and methotrexate were used for GVHD prophylaxis. All pts received a non-manipulated graft, from peripheral blood (45 pts) or marrow (2 unrelated donors). At the time the first analysis was undertaken post NMT (median 30 days), 13 of 18 pts (72%) in clinical complete remission (CR) and 24 of 29 pts (83%) who had evidence of active disease at study entry had mixed chimera (P = 0.2). The % of donor cells were 93% and 75%, respectively. When the subsequent PCR analysis to assess engraftment was undertaken (median time, 89 days post NMT), median % donor cells were 100% and 95%, respectively, for the pts who were in CR or had active disease at study entry. All pts achieved CR post NST. Median time to achieve CR for pts who had active disease at study entry was 5.5 months after transplant. Twelve pts in CR continue to have SMC at the time of their last PCR analysis, undertaken at a median of 12 months (range, 6 to 55 months) post NMT. Nineteen pts were tested for the amplification of bcl-2 rearrangement from the marrow by PCR. They all had evidence of clonal disease prior study entry. All converted to PCR-negativity. Sixteen of these 19 pts had mixed chimera when they were first tested to be PCR (−) at a median time of 3 mos (range, 1–6 months) post NMT. At a median time follow-up time of 34 months, overall survival and disease-free survival of all 47 pts at 3-year were 88 and 85%, respectively. Only one relapse occurred. This occurred in a pt who had 60% donor at 3 months post NMT; it then decreased to 42% at 9 months. This was followed by graft failure and relapse. DLI was provided to only one pt with decreasing chimerism. This resulted to conversion to full donor after the infusion of to 1 x 105 CD3+ cells/kg, from the HLA-identical sibling donor. The incidence of acute grade II–IV and chronic (extensive and limited) GVHD in the study was 17% and 51%, respectively. These data suggest that DLI may not be needed for SMC after non-T cell depleted NMT for pts with FL who do not have evidence of progression. This strategy resulted in lower than expected acute and chronic GVHD and improved survival.

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A Comparison of Stem Cell Source in Recipients of T-Cell Depleted Myeloablative Transplants for Leukaemia: No Difference in Mortality Using BM or PBSC.

Blood ◽

10.1182/blood.v110.11.46.46 ◽

2007 ◽

Vol 110 (11) ◽

pp. 46-46

Author(s):

B.E. Shaw ◽

Nigel H. Russell ◽

A. Pagliuca ◽

J. Apperley ◽

G. Cook ◽

...

Keyword(s):

Stem Cell ◽

T Cell ◽

Acute Gvhd ◽

Chronic Gvhd ◽

Unrelated Donor ◽

Stem Cell Source ◽

Increased Risk ◽

Significant Difference ◽

Cell Source ◽

The Impact

Abstract The use of GSCF-mobilised Peripheral Blood Stem Cells (PBSC) for unrelated donor (UD) transplantation has increased dramatically since 2000. The association of PBSC with more rapid engraftment and with an increase in chronic Graft versus Host Disease (GvHD), compared to bone marrow (BM) has been reported in a number of studies. More recently the use of PBSC has been associated with an increase in transplant related mortality (TRM) and decrease in survival (OS) in T-cell replete transplants. We sought to analyse the impact of PBSC compared to BM in a cohort of UD transplant recipients, where T-cell depleting agents (in-vivo campath in >90%) were included in the transplant conditioning. The study included 145 patients transplanted between January 2000 and March 2006: CML- 35 in 1CP; acute leukaemia (AML in 61, ALL in 49)-110 in CR1 or 2. All had myeloablative conditioning regimens and received grafts with 9–10/10 matched HLA alleles. 86 patients received BM and 59 PBSC. There were no associations between the stem cell source and any transplant variable (including disease and stage). There was a trend to an increased use of PBSC in patients with a single antigen mismatch (p=0.052). All evaluable patients achieved neutrophil engraftment, with a significantly faster time to engraft in recipients of PBSC compared to BM (16 vs 20 days; p=0.0003). The incidence of acute GvHD was 46% (grade I in 50%, II in 41%, III in 8%, IV in 2%). This was significantly higher in recipients of PBSC (60%) compared to BM (36%; p=0.006), however there was no increase in either II/IV (p=0.69) or III/IV (p=0.18) disease in PBSC recipients. In univariate analysis, the presence of a single HLA mismatch (p=0.026) was the only other variable to be associated with an increase in acute GvHD. In a logistic regression model including both these variables, the use of PBSC remained significantly associated with an increase in aGvHD (OR=2.3; 95% CI 1.1,4.7;p=0.020). The TRM was 14%, 27% and 39% at 100 days, 1 and 5 years respectively. At none of these time points was the stem cell source associated with a significant difference in TRM. The 5-year incidence of chronic GvHD was 58% (BM 55%, PBSC 60%; NS), extensive disease in one third, and of relapse was 61% (BM 60%, PBSC 62%; NS). The 5-years OS was 41% with a median follow-up of 3.4 years (0.5–7.1). This was 44% using PBSC and 40% using BM (NS). In conclusion, although we observed an increase in acute GVHD with PBSC this was only of grade 1 disease. We found no association between the use of PBSC and an increased risk of chronic GVHD or of a worse transplant outcome, when compared to BM, in recipients of T-cell depleted myeloablative transplants for leukaemia.

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