Matched Sibling Donor Hematopoietic Cell Transplantation for Sickle Cell Disease Using a Reduced Intensity Conditioning Regimen Can Lead To Stable Long Term Engraftment.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 3172-3172 ◽  
Author(s):  
Lakshmanan Krishnamurti ◽  
Catherine Wu ◽  
K. Scott Baker ◽  
John E. Wagner
Keyword(s):  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Hematopoietic Cell Transplantation ◽  
Conditioning Regimen ◽  
Cell Disease ◽  
Reduced Intensity Conditioning ◽  
Sibling Donor ◽  
Matched Sibling ◽  
Reduced Intensity

Abstract Hematopoietic Cell Transplantation (HCT) from sibling donors has been demonstrated to cure sickle cell disease. Concerns about high regimen related toxicity particularly in older patients and in those with advanced organ damage and the potential for late sequelae such as chronic graft-versus-host disease (GVHD) and infertility have limited the applicability of HCT. HCT following a reduced intensity conditioning (RIC) regimen has the potential for reducing toxicity and making this curative therapy more acceptable and applicable to this group of patients. We report preliminary results on the first five patients enrolled on a pilot study to evaluate the safety and efficacy of HCT following a RIC regimen for patients with high risk sickle cell disease. All patients received bone marrow from a matched sibling donor. The conditioning regimen consisted of Busulfan 2 mg/kg orally q12 hr x 2 days (0.8mg/kg IV q 6 hr x 2 days for patient#3, 4, 5), Fludarabine 35 mg/m2/dose IV daily x 5 days, anti-thymocyte globulin 30 mg/kg/dose IV daily x 5 days and total lymphoid irradiation 500 cGy with shielding of the liver, lungs, heart, and gonads. GVHD prophylaxis consisted of cyclosporine A and Mycophenolate mofetil. Clinical characteristics, outcomes and donor chimerism in peripheral blood genomic DNA and of subjects are summarized in the Table.1 The preparative regimen was well tolerated with no serious infections or mucositis in any patient. No patient has had recurrence of previous sickle cell related symptoms. Lineage-specific chimerism analysis (patients # 3, 4, 5), reveal predominance of donor erythropoiesis (Table 2). These findings indicate that HCT for sickle cell disease following a RIC regimen is well tolerated and can lead to stable long term engraftment. Clinical Characteristics of patients with sickle cell disease undergoing HCT from a matched sibling donor following a reduced intensity conditioning regimen PIN. Age, Indication Follow-up (days) Regimen Related Toxicity ANC<500(days) GVHD Acute or Chronic % Engraftment Day 100 % Engraftment Day180 % Engraftment Day 365 1. 8 yrs. Stroke, allosensitization 2100 None 7 None 89 100 100 2. 8 yrs. Repeated ACS 1800 None 8 Grad II Skin 75 81 81 3. 6yrs. Repeated ACS 750 None 9 None 75 85 81 4. 8 years Repeated ACS 295 None 14 None 79 71 - 5.18 yrs. Stroke, allosensitization 288 Mild 13 None 100 100 - Lineage Specific Chimerism PIN, Genotype Donor Genotype % donor erythroid day 100 % donor erythroid day 180 % Donor Lymphoid day 100 % Donor Lymphoid day 180 % Hemoglobin S Day 100 % Hemoglobin S Day 180 3. Hb SS Sickle trait 100 100 30 35 30 34 4. HbS/β Thalassemia β Thalassemia trait 100 81 33 58 4 3 5. HbSS Sickle trait 100 100 100 100 32 34

scholarly journals Stable Long-Term Donor Engraftment following Reduced-Intensity Hematopoietic Cell Transplantation for Sickle Cell Disease

2008 ◽  
Vol 14 (11) ◽  
pp. 1270-1278 ◽  
Author(s):  
Lakshmanan Krishnamurti ◽  
Sandhya Kharbanda ◽  
Melinda A. Biernacki ◽  
Wandi Zhang ◽  
K. Scott Baker ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Cell Transplantation ◽  
Sickle Cell ◽  
Hematopoietic Cell Transplantation ◽  
Hematopoietic Cell ◽  
Cell Disease ◽  
Reduced Intensity

Correction of Sickle Cell Anemia with γ-Globin Gene Delivered by Lentivirus Vector in the Setting of Myeloablative or Reduced Intensity Conditioning, and Establishing Critical Determinants for Successful Gene Therapy for Sickle Cell Disease.

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 2354-2354
Author(s):  
Ajay Perumbeti ◽  
Tomoyasu Higashimoto ◽  
Fabrizia Urbinati ◽  
Kristy Lauderback ◽  
Anastacia Loberg ◽  
...  
Keyword(s):  
Gene Therapy ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Cell Disease ◽  
Lentivirus Vector ◽  
Reduced Intensity Conditioning ◽  
F Cells ◽  
Transplant Model ◽  
Reduced Intensity

Abstract While genetic delivery of recombinant anti-sickling β-globin genes have been shown to correct murine sickle cell anemia (SCA), correction of SCA by delivery of a natural hemoglobin, fetal hemoglobin (HbF), the proportion of genetically modified hematopoietic stem cells (HSC), or amount of HbF necessary to correct the disease is unknown. We designed a lentivirus vector carrying γ-globin exons with β-globin regulatory elements and non-coding sequences, GbG. First, GbG or mock transduced Berkeley sickle HSC were transplanted using a myeloablative (lethal irradiation) transplant model, to acheive full donor chimerism. GbG mice showed high HbF expression (HbF 41 ± 5% measured by HPLC) that was sustained in primary (6 mo) and secondary (7.5 mo) transplant recipients, and resulted in effective correction of hematological and functional RBC parameters, and reduction of inflammation that results from sickle cell disease. We found significantly reduced irreversibly sickled cells (2.3 ± 0.7% in GbG versus 10.2 ± 0.3% in mock mice; p<0.001), minimal sickling of RBC when exposed to graded hypoxia using tonometry, improved RBC deformability (performed by ektacytometry), and a four-fold increase in RBC half-life (by in vivo biotin labeling) in the GbG group of mice. There was correction of anemia, and reduction in hemolysis (measured by LDH levels), reticulocytes, and leukocytosis (Table 1). This was accompanied by a dramatic improvement in chronic organ damage that is seen in untransplanted Berkeley/mock group of mice: there was a significant reduction in spleen weights and normalization of splenic follicular architecture, correction in bone marrow myeloid:erythroid ratios, and a notable absence of kidney infarction and atrophy, and liver infarction and extramedullary hematopoiesis that was observed in mock mice. Untransplanted Berkeley and mock mice showed shortened survival consistent with a severe SCA phenotype. Genetic correction with GbG improved survival to 100% compared to a 20% survival in the mock transplanted. Notably, in our proof-of principle studies, comparable functional sickle RBC correction was also seen in the Townes knock-in sickle mice (Wu et al, Blood 2006) transduced with GbG. Myeloablative conditioning in this setting allowed non-competitive repopulation of donor genetically modified HSC, resulting in high HbF and correction of disease. However, myeloablation in SCA is associated with peri-transplant mortality and long-term effects, and may not be necessary for achieving correction of phenotype. To address this, we used a unique reduced-intensity conditioning transplant model. We transplanted GbG-modified Berkeley HSC into sub-lethally irradiated Berkeley mice. In this model, when HbF was <10%, there was a small and variable improvement in hematological and functional sickle RBC parameters. However, when HbF was γ10%, there was consistent long-term correction in RBC sickling, deformability, RBC survival, and improvement in hematological parameters for 10–11 months (Table 1). Impressively, when HbF was γ10%, there was a significant reduction in splenomegaly, absence of liver and kidney pathology, and a dramatically improved overall survival of the mice, comparable to that seen in the myeloablative model. Comparison of the proportion of F-cells (HbF containing RBC) and HbF/F-cell to the assays showing correction of SCA revealed that >30% HbF/F-cell and >60% F-cells consistently corrected SCA. The mean HSC transduction (assessed by secondary HbF+ CFU-S at 6 months post transplant) was 50% and 30% in the myeloablative and reduced intensity transplant models, respectively, with 1–3 GbG copies/ cell. Furthermore, three GbG mice showed correction of SCA with 20% HSC transduction, a clinically achievable goal. Taken together, this study is the first demonstration of correction of SCA with gene therapy using γ-globin, and defines critical determinants for effective gene therapy of this disease. Mouse Model Hb (g/dl) RBC 106/ul) Reticulocyte (%) WBC (K/ul) *p<0.05; ** p<0.001 Mock Myeloablative 7.6±0.7 5.8±0.4 40.0±3.0 29.7±1.4 GbG Myeloablative 10±0.8* 9.4±0.8** 15.8±3.2** 10.6±3.1** GbG, HbF ≥ 10% Reduced intensity 9.3±0.6* 8.1±0.5** 21.2±1.9** 13.4±1.1**

scholarly journals Allogeneic hematopoietic stem cell transplantation for sickle cell disease: the time is now

Blood ◽  
2011 ◽  
Vol 118 (5) ◽  
pp. 1197-1207 ◽  
Author(s):  
Matthew M. Hsieh ◽  
Courtney D. Fitzhugh ◽  
John F. Tisdale
Keyword(s):  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Disease Burden ◽  
Conditioning Regimen ◽  
Adult Patients ◽  
Cell Disease ◽  
Hematopoietic Stem ◽  
Alternative Donor ◽  
Hematopoietic Chimerism ◽  
Matched Sibling

Abstract Although sickle cell disease (SCD) has a variable clinical course, many patients develop end-organ complications that are associated with significant morbidity and early mortality. Myeloablative allogeneic HSCT (allo-HSCT) is curative but has been historically performed only in children younger than 16 years of age. Modest modifications in the conditioning regimen and supportive care have improved outcome such that the majority of children with a suitable HLA-matched sibling donor can expect a cure from this approach. However, adult patients have been excluded from myeloablative allo-HSCT because of anticipated excess toxicity resulting from accumulated disease burden. Efforts to use nonmyeloablative transplantation strategies in adults logically followed but were initially met with largely disappointing results. Recent results, however, indicate that nonmyeloablative allo-HSCT in adult patients with SCD allows for stable mixed hematopoietic chimerism with associated full-donor erythroid engraftment and normalization of blood counts, and persistence in some without continued immunosuppression suggests immunologic tolerance. The attainment of tolerance should allow extension of these potentially curative approaches to alternative donor sources. Efforts to build on these experiences should increase the use of allo-HSCT in patients with SCD while minimizing morbidity and mortality.

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