Second Transplant with HLA Haplo-Identical Hematopoietic Stem Cells for Graft Failure after Double Units Cord Blood Transplantation.

Abstract Graft failure (GF) can be a fatal complication following cord blood transplantation (CBT). Up to date, there has not been an ideal treatment for it. Recently, second transplant has been used as a potential therapy for treatment of GF. However, it is unclear which is the best source for donor cells that result successful engraftment and low rate of complications related to transplantation. In this study, we evaluated the outcomes and safety of second transplant with HLA haplo-identical hematopoietic stem cells for graft failure after double units cord blood transplantation in three patients. These patients suffered from myelodysplasia (MDS), acute lymphoblastic leukemia (ALL), severe aplastic anemia (SAA) respectively (median age, 16 years; range, 10–20 years). After myeloablative conditioning, all of them received double umbilical cord blood (UCB) units with at least one 5/6 HLA-matched unit (median infused dose, 6.85×107 nucleated cell [NC]/kg; range, 6.28–7.17×107 NC/kg). The characteristics of these patients and double cord blood transplantation data are detailed in the following Table. The former two patients developed early GF on 30 days after CBT. In the third patient, neutrophil and platelet recovery was observed on +14d and +31d respectively, and sustained hamatopoiesis was derived from a single donor with higher nucleated and CD34+ cells until 4 months after CBT when late GF happened, After reduced-intensity or myeloablative conditioning, all of them subsequently received HLA haplo-identical three-loci mismatched HSCT donated by their mothers (median infused dose, 8.40×108 nucleated cell [NC]/kg; range, 8.02–9.82×107 NC/kg). The time interval from GF to the second transplantation of these patients ranged from 7 to 10 days. Cyclosporine A (CsA) and mycophenolate mofetil (MMF) were ad- ministered for the prophylaxis of graft-versus-host disease (GVHD). Detailed data of the second transplantation were also shown below. Engraftment was achieved on all three patients between the twelfth day and the fourteenth day after the transplantation with a full donor chimaerism. Acute GVHD of grades I–II and slight chronic GVHD occurred in these patients. All three patients survive up till now, and one patient has survived for 15 months after the second transplantation. This is the first report in china using HLA haplo-identical HSCT to rescue the GF after double CBT in China. The results are encouraging though the number of the patients is too small. Patients’characteristics and transplantation data Patients No. 1 No. 2 No. 3 Age(years)/sex 20/F 10/M 16/F Body weight 43.5kg 32kg 40kg Diagnosis MDS ALL(CR1) SAA Conditioning Ara-c/CY/TBI BU/CY CY/ATG Nucleated cells (CB1/CB2) (4.02/2.83)×107/kg (3.92/2.36)×107/kg (2.44/4.73)×107/kg CD34+ cells (CB1/CB2) (0.61/0.28)×105/kg (2.55/0.85)×105/kg (0.53/1.42)×105/kg CD3+ cells (CB1/CB2) (2.26/2.34)×106/kg (0.37/0.16)×106/kg (0.53/0.35)×106/kg HLA-mismatched (CB1; CB2) 2/6; 1/6. 1/6; 0/6 0/6; 1/6 GF 30d 30d 4m Second transplant 37d 38d 4m Conditioning Flu/ATG TBI2GY/ATG Flu/CY/ATG GVHD prhphylaxis CsA+MMF CsA+MMF CsA+MMF Nucleated cells 8.02×108/kg 8.40×108/kg 9.82×108/kg CD34+ cells 4.31×106/kg 3.50×106/kg 7.86×106/kg ANC>0.5×109/L 12d 13d 14d PLT>2×109/L 18d 17d 18d Follow up 15M+ 3M+ 12M+

Download Full-text

Increased Engraftment after Double Cord Blood Transplantation in NOD/SCID Mice.

Blood ◽

10.1182/blood.v104.11.1199.1199 ◽

2004 ◽

Vol 104 (11) ◽

pp. 1199-1199

Author(s):

Alma J. Nauta ◽

Alwine B. Kruisselbrink ◽

Roelof Willemze ◽

Willem E. Fibbe

Keyword(s):

Stem Cells ◽

Bone Marrow ◽

Flow Cytometry ◽

Cord Blood ◽

Cord Blood Transplantation ◽

Human Platelets ◽

Hematopoietic Stem ◽

Cell Dose ◽

Blood Transplantation ◽

Cd34 Cells

Abstract Umbilical cord blood (UCB) is considered as an attractive alternative source of hematopoietic stem cells for allogeneic stem cell transplantations in patients who lack HLA-matched donors. However, the low cell dose adversely affects the speed of hematopoietic recovery and therefore limits the application of UCB transplantation in adults. Although ex-vivo expansion of cord blood cells has been explored as a strategy to increase the cell dose, compromised engraftment potential of expanded cells has been demonstrated. Another approach to overcome cell dose limitations is transplantation of multiple, unrelated UCB units. To investigate the effect of multiple cord transplantation on engraftment, NOD/SCID mice were transplanted with human hematopoietic progenitor cells (CD34+) derived from two UCB units with HLA disparity. During the first six weeks after transplantation the number of human platelets in peripheral blood was quantified by flow cytometry. Six weeks after transplantation, the mice were sacrificed and the percentage and donor origin of human CD45+ cells in blood, and in bone marrow was determined by flow cytometry. Transplantation of CD34+ cells derived from two UCB donors resulted in significantly higher number of human platelets in peripheral blood than transplantation of CD34+ cells from either donor alone, ranging from 3.92x106/ml to 10.29x106/ml (mean 6.4x106 ± 2.55x106/ml) and 0.11x106/ml to 3.12.106/ml (mean 1.42x106 ± 1.17x106/ml), respectively. Furthermore, the overall human cell engraftment level in bone marrow after double cord blood transplantation ranged from 7.01% to 64.34% (mean 29.6 ± 21.5%) a nearly 7-fold increase compared to single cord blood transplantation ranging from 0.27% to 13.5% (mean 4.6 ± 3.8%) Although consistently higher engraftment levels were reached after double cord blood transplantation, two different patterns were observed: in 2 out of 4 experiments cells from one donor predominated the engraftment (ratio 3:1), while in two other experiments the two units contributed equally to BM engraftment. The mechanism underlying these effects are <S>is</S> not yet clear. It is not very likely that the single donor predominance results from an unequal amount of hematopoietic stem cells in the cord blood units because each cord blood showed comparable levels of engraftment as a single unit. Alternatively, the unequal engraftment may result from an immunological competition or a graft versus graft stimulatory effect between the cords during the engraftment process and further studies are required to determine if the contribution of both units is dependent on the degree of HLA matching between the two cords. Taken together, these results demonstrate that double cord blood transplantation may represent a means of achieving increased engraftment, making multiple cord blood transplantation a promising strategy to improve the outcome of UCB transplantation. Studies are underway to unravel the mechanisms underlying the enhanced engraftment.

Download Full-text

Reduced Adverse Effects and Improved Engraftment in the Pediatric Transplant Population upon Dilution of HPC, Cord Blood Products Prior to Infusion

Blood ◽

10.1182/blood.v112.11.4137.4137 ◽

2008 ◽

Vol 112 (11) ◽

pp. 4137-4137

Author(s):

Nicole L Prokopishyn ◽

Victor A. Lewis ◽

Susan Berrigan ◽

Debbie Kury ◽

Adnan Mansoor

Keyword(s):

Stem Cells ◽

Cord Blood ◽

Adverse Reactions ◽

Pediatric Patients ◽

Cord Blood Transplantation ◽

Experimental Studies ◽

Patient Specific ◽

Cellular Cytotoxicity ◽

Hematopoietic Stem ◽

Cd34 Cells

Abstract Patient specific adverse reactions are common when HPC, Cord Blood (HPC-C) units, cryopreserved in dimethylsulfoxide (DMSO) are warmed to 37°C and infused into pediatric patients. Adverse reactions, including hemodynamic instability, fever, chills, nausea, cardiomyopathy, unconsciousness, and even death have been described in the pediatric population. Additionally, hematopoietic stem cells (HSC) cryopreserved in DMSO have limited viability upon thawing due to the cellular cytotoxicity of DMSO, resulting in the potential for significant loss of cells available for transplantation and subsequent engraftment. Although DMSO is essential as a cryoprotectant for long-term preservation of hematopoeitic stem cells, standardized techniques are required to mitigate the cellular cytotoxicity and acute onset adverse events witnessed in unwashed/undiluted cord blood transplantation. Immediate mixing of thawed cord blood units with a hypertonic reconstitution solution can ameliorate many of these problems by restoring the osmolarity of the suspension, promoting colloidal-osmotic intracellular equilibrium, and reducing DMSO concentration in the infused product. In general, studies examining the benefits of dilution and/or washing of HPC-C prior to infusion have largely been confined to adult populations with varying results. Since pediatric patients often experience more significant adverse reactions, even when DMSO concentrations in the infused unit are well below the recommended maximum of 5 mL of 20% DMSO/kg body weight, examination of effective and robust techniques for minimizing these effects in the pediatric patient is crucial. The studies presented demonstrate successful utilization of diluted HPC-C products in HSC transplants in pediatric patients. HPC-C products were either infused immediately after thaw or infused after dilution with a solution of 8% Gentran-40 and 5% HSA (ReCon solution). Dilution of HPC-C products immediately after thaw appears to ensure maximal HSC recovery and viability--essential for transplant and engraftment. In experimental studies, improved HPC recovery and viability was observed in all diluted HPC-C products as compared to undiluted products. As well, the number and viability of CD34+ cells remains constant for >24 hours post thaw when HPC-C products are diluted in ReCon solution. In contrast, thawed and undiluted HPC-C units experience a significant reduction in number and viability of CD34+ cells 15–30 minutes post-thaw. Most importantly, pediatric patients displayed reduced adverse reactions when infused with diluted HPC-C products as compared to undiluted products. Dilution of HPC-C products with ReCon solution did not affect engraftment of neutrophils and/or platelets in these patients. In a specific case study, a diluted HPC-C product resulted in engraftment when a double-cord transplant with undiluted HPC-C products did not. As well, the negative adverse reaction experienced by the patient following infusion of undiluted product was not experienced when the diluted HPC-C product was infused. In the pediatric HSC transplant population it is essential not only to ensure optimal recovery and potency of HSCs in the transplant graft but also to alleviate adverse reactions. Application of HPC-C dilution protocols employing a solution of Gentran-40 and HSA provide an effective, safe, and efficient strategy for diminishing DMSO related toxicities in the pediatric HSCT patient.

Download Full-text

Phase II Multicenter Study of Busulfan-Fludarabine Conditioning Regimen for cord Blood transplantation in Pediatric Acute Myeloid Leukemia

Blood ◽

10.1182/blood.v120.21.1928.1928 ◽

2012 ◽

Vol 120 (21) ◽

pp. 1928-1928

Author(s):

Hee Young Ju ◽

Hyoung Jin Kang ◽

Ji Won Lee ◽

Hyery Kim ◽

Kyung Duk Park ◽

...

Keyword(s):

Cord Blood ◽

Myeloid Leukemia ◽

Graft Failure ◽

Cord Blood Transplantation ◽

Chronic Gvhd ◽

Conditioning Regimen ◽

Myeloablative Conditioning ◽

Once Daily ◽

Pediatric Acute Myeloid Leukemia ◽

Blood Transplantation

Abstract Abstract 1928 Introduction. Cord blood transplantation (CBT) has become an alternative transplantation for various diseases. CBT has comparable efficacy with unrelated transplantation, but higher transplantation related mortality (TRM) rate upto 50% in early results has been a major obstacle. To reduce TRM, we studied reduced toxicity myeloablative conditioning regimen with busulfan and fludarabine for CBT in pediatric acute myeloid leukemia (AML) patients. Patients and methods. This study was a phase II prospective multicenter clinical trial (NCT01274195) and 27 patients were enrolled who underwent CBT with upto 2 HLA mismatch cord blood. Conditioning regimen was composed of fludarabine (40 mg/m2 once daily iv on days -8 ∼ -3), busulfan (0.8 mg/kg every 6 hours iv on days -6 ∼ -3) and rabbit thymoglobulin (2.5 mg/kg once daily iv on days -8 ∼ -6). For GVHD prophylaxis, cyclosporine and MMF were used. Results. Nine patients received single unit cord blood, and 18 patients received double unit cord blood. Median dose of nucleated cells and CD34+ cells were 4.23×107/kg (0.5–16.4) and 2.58×105/kg (0.33–6.77), respectively. Primary graft failure developed in 5 patients, and secondary graft failure occurred in 1 patient. Acute and chronic GVHD occurred in 16 patients (59.3%) and 10 patients (37%), respectively. TRM developed in 5 patients (cumulative incidence 22.2%), which included chronic GVHD-associated complication (n=1), post-transplantation lymphoproliferative disease (n=2), pneumonia (n=2), and diastolic cardiomyopathy (n=1). Relapse incidence was 30.9%. The 5-year overall and event-free survival were 46.3% and 40.0%, respectively. Patients who received single unit cord blood showed survival rate of 44.4%, and those who received double unit cord blood showed survival rate of 50%. Univariate analysis revealed that low nucleated cell count (P=0.011), low CD34+ cell count (P=0.002) were independent prognostic factor for survival. Conclusion. Reduced intensity conditioning regimen containing fludarabine and iv busulfan showed lower TRM rate than previous studies with myeloablative conditioning regimens. However graft failure and relapse rate were not satisfactory, and further study for optimization of conditioning regimen is warranted. Disclosures: No relevant conflicts of interest to declare.

Download Full-text

Comparison of haploidentical and umbilical cord blood transplantation after myeloablative conditioning

Blood Advances ◽

10.1182/bloodadvances.2021004462 ◽

2021 ◽

Author(s):

John E. Wagner ◽

Karen Kuhn Ballen ◽

Mei-Jie Zhang ◽

Mariam Allbee-Johnson ◽

Chatchada Karanes ◽

...

Keyword(s):

Cord Blood ◽

Umbilical Cord ◽

Umbilical Cord Blood ◽

Lymphoblastic Leukemia ◽

Cord Blood Transplantation ◽

Hla Antigens ◽

Myeloablative Conditioning ◽

Hematopoietic Stem ◽

Blood Transplantation ◽

Co Morbidity

Haploidentical hematopoietic stem cell transplantation (haplo HSCT) has emerged as an important treatment modality. Most reports comparing haplo HSCT with post-transplant cyclophosphamide (PTCy) and other donor sources have focused on outcomes in older adults treated with reduced intensity conditioning. Therefore, in the current study, we evaluated outcomes in patients with hematological malignancy treated with myeloablative conditioning prior to haplo (n=375) or umbilical cord blood (UCB, n=333) HSCT. All haplo recipients received a 4 of 8 HLA matched graft while recipients of UCB were matched at 6-8/8 (n=145) or ≤5/8 (n=188) HLA antigens. Recipients of 6-8/8 UCB transplants were younger (14 years vs. 21 and 29 years) and more likely to have lower co-morbidity scores compared to recipients of ≤5/8 UCB and haplo HSCT (81% vs. 69% and 63%, respectively). UCB recipients were more likely to have acute lymphoblastic leukemia and transplanted in second complete remission (CR) whereas haplo HSCT recipients were more likely to have acute myeloid leukemia in first CR. Other characteristics, including cytogenetic risk were similar. Survival at 3 years was similar for the donor sources (66% haplo and 61% after ≤5/8 and 58% after 6-8/8 UCB). Notably, relapse at 3 years was lower in recipients of ≤5/8 UCB (21%, p=0.03) compared to haplo (36%) and 6-8/8 UCB (30%). However, non-relapse mortality was higher in ≤5/8 UCB (21%) compared to other groups (p<0.0001). These data suggest that haplo HSCT with PTCy after myeloablative conditioning provides an overall survival outcome comparable to that after UCB regardless HLA match group.

Download Full-text

Phenotype and Function of Placenta Derived Stem Cells (PDSC).

Blood ◽

10.1182/blood.v108.11.4182.4182 ◽

2006 ◽

Vol 108 (11) ◽

pp. 4182-4182

Author(s):

James Edinger ◽

Qian Ye ◽

Ajai Pal ◽

Andy Zeitlin ◽

Wolfgang Hofgartner ◽

...

Keyword(s):

Stem Cells ◽

Cord Blood ◽

Clinical Investigation ◽

Cord Blood Transplantation ◽

Multiparameter Flow Cytometry ◽

Human Umbilical Cord Blood ◽

Human Umbilical Cord ◽

Blood Transplantation ◽

Cd34 Cells ◽

And Function

Abstract We developed a proprietary procedure to recover ethical and non-controversial stem cells from full term, postpartum human placentas (Placenta Derived Stem Cells, PDSC). In this work, we describe the phenotype and function of PDSC as compared to Human Umbilical Cord Blood, (HUCB) derived stem cells. As compared to HUCB, PDSC contains a high percentage of live, post thaw CD34+ cells (2.3% ± 3.5 %, N = 83 versus an average pre-freeze CD34% in HUCB at our bank of 0.3% ± 0.2%; N=220). Notably, 85 to 90% of the CD34+ cells in PDSC but not HUCB were CD45 negative. CD34+ cells derived from PDSC were flow sorted into CD34+CD45+ and CD34+CD45− and colony forming assays performed. Both CD34+CD45− and CD34+CD45+ cells gave rise to hematopoietic colonies including CFU-E, CFU-GM and CFU-GEMM, suggesting that CD34+CD45− cells derived from PDSC were lineage negative, immature stem cells that differentiate into hematopoietic progenitor cells. Using multiparameter flow cytometry, we demonstrated that these cells were CD133+ and CD38−. To determine the hematopoietic repopulating ability of PDSC and to examine if PDSC can augment HUCB engraftment in vivo, sub lethally irradiated NOD/SCID mice were infused with freshly thawed, non-sorted PDSC alone, HUCB alone, or a mixture of PDSC and HUCB. Overall human engraftment was determined by assessment of human CD45+ in the bone marrow of recipient mice at four (short-term engraftment) and 12 weeks. Mice were considered engrafted if the percentage of huCD45 was >0.5%. Human engraftment (>0.5% CD45) was observed in all groups 4 weeks post infusion, including PDSC alone, with 2 out of 6 mice positive for engraftment in the HUCB group (mean CD45% of 0.62%), 2 out of 8 mice in the PDSC group (mean CD45% of 0.52%), and 8 out of 9 mice in the group that received both HUCB and PDSC (mean CD45% of 2.84%). There was a significant increase in human engraftment observed when comparing either the PDSC group alone to the HUCB+PDSC group (p=0.006) and the HUCB group to the HUCB+PDSC group (p=0.02). At 12 weeks post transplant, sustained engraftment in the PDSC group alone was not observed with only 1 out of 8 animals engrafted at >0.5% CD45. In contrast, although there was no statistical difference observed in the overall level of human engraftment between mice that received HUCB alone versus the HUCB+PDSC group (mean CD45% of 15.1% and 13.1%, respectively; p=0.82), only 3 out of 6 mice were engrafted in the HUCB group as compared to 9 out of 9 mice in the HUCB+PDSC group. These data indicate that co-infusion of PDSC and HUCB results in significant enhancement of both short-and longer-term human engraftment as compared to PDSC or HUCB alone. Although it remains unclear whether the observed enhanced engraftment is due to an increased number of repopulating cells or the presence of facilitator cells provided by the PDSC, Studies are ongoing and aimed at investigating the mechanism(s) by which PDSC enhances HUCB engraftment. Delayed engraftment following cord blood transplantation remains a significant clinical problem, even in the case of double unit myeloablative cord blood transplantation, where the median time to neutrophil engraftment is 23 days (Barker et al, Blood.2005; 105:1343–1347). These results also suggest clinical investigation of co-infusion of PDSC with either single or double cord blood units for transplantation as a potential method to facilitate more rapid engraftment.

Download Full-text

Cytokine-Induced Killer Cells Facilitate Immune Reconstitution After Allogeneic BMT In Mice.

Blood ◽

10.1182/blood.v116.21.3719.3719 ◽

2010 ◽

Vol 116 (21) ◽

pp. 3719-3719

Author(s):

Shintaro Mase ◽

Ryosei Nishimura ◽

Rie Kuroda ◽

Hideaki Maeba ◽

Kazuhito Naka ◽

...

Keyword(s):

Cord Blood ◽

Graft Failure ◽

Immune Reconstitution ◽

Conflicts Of Interest ◽

Ex Vivo ◽

Cord Blood Transplantation ◽

Early Time ◽

Hematopoietic Stem ◽

Cik Cells ◽

Blood Transplantation

Abstract Abstract 3719 Cytokine-induced killer (CIK) cells are ex vivo–expanded T lymphocytes expressing both natural killer (NK)– and T-cell markers. We have reported that adoptive transfer of allogeneic CIK cells in a murine model caused minimal graft versus host disease (GVHD) with retention of antitumor activity mediated by NKG2D, which is an activating receptor expressed on NK cells. With the purpose of potential application of CIK cells in a clinical hematopoietic stem cell transplantation, the problem we have to consider next is whether CIK cells could promote an engraftment and facilitate an immune reconstitution. To this end, lethally irradiated BALB/c mice were injected with minimal number of MHC incompatible C57BL/6 bone marrow (BM) cells alone, in which almost half of mice died because of graft failure, or with CIK concurrently. The mice receiving BM plus CIK cells survived with 93% without GVHD, demonstrating that CIK cells significantly promote an engraftment (P<0.05). In particular, recovery of CD3+ T-cells was significantly faster (p<0.05) in the mice receiving BM plus CIK cells than those receiving BM cells alone. Next we further evaluated whether CIK cells also promote an engraftment in the mice receiving non-myeloablative conditioning using low dose total body irradiation. As expected, CIK cells promoted an engraftment and favored immunoreconstitution, especially from the early time point after BMT. In conclusion, our study clearly demonstrated that CIK cells promote an engraftment and facilitate an immure reconstitution without GVHD. As recent studies demonstrated that sufficient number of CIK cells could be expanded even from washouts of cord blood units bags, infusion of CIK cells would be a potent strategy for preventing a graft-failure in clinical settings, especially after cord blood transplantation. Disclosures: No relevant conflicts of interest to declare.

Download Full-text