scholarly journals Early Myeloid Derived Suppressor Cells (eMDSCs) Are Associated With High Donor Myeloid Chimerism Following Haploidentical HSCT for Sickle Cell Disease

2021 ◽  
Vol 12 ◽  
Author(s):  
Deepali K. Bhat ◽  
Purevdorj B. Olkhanud ◽  
Arunakumar Gangaplara ◽  
Fayaz Seifuddin ◽  
Mehdi Pirooznia ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Graft Rejection ◽  
Immune Cell ◽  
Plasma Concentrations ◽  
Suppressor Cells ◽  
Suppressor Cell ◽  
Cell Disease ◽  
Hematopoietic Stem ◽  
Post Transplant

Haploidentical hematopoietic stem cell transplantation (haplo-HSCT) is a widely available curative option for patients with sickle cell disease (SCD). Our original non-myeloablative haplo-HSCT trial employing post-transplant (PT) cyclophosphamide had a low incidence of GVHD but had high rejection rates. Here, we aimed to evaluate immune reconstitution following haplo-HSCT and identify cytokines and cells associated with graft rejection/engraftment. 50 cytokines and 10 immune cell subsets were screened using multiplex-ELISA and flow cytometry, respectively, at baseline and PT-Days 30, 60, 100, and 180. We observed the most significant differences in cytokine levels between the engrafted and rejected groups at PT-Day 60, corresponding with clinical findings of secondary graft rejection. Of the 44 cytokines evaluated, plasma concentrations of 19 cytokines were different between the two groups at PT-Day 60. Factor analysis suggested two independent factors. The first factor (IL-17A, IL-10, IL-7, G-CSF, IL-2, MIP-1a, VEGF, and TGFb1 contributed significantly) was strongly associated with engraftment with OR = 2.7 (95%CI of 1.4 to 5.4), whereas the second factor (GROa and IL-18 contributed significantly) was not significantly associated with engraftment. Sufficient donor myeloid chimerism (DMC) is critical for the success of HSCT; here, we evaluated immune cells among high (H) DMC (DMC≥20%) and low (L) DMC (DMC<20%) groups along with engrafted and rejected groups. We found that early myeloid-derived suppressor cell (eMDSC) frequencies were elevated in engrafted patients and patients with HDMC at PT-Day 30 (P< 0.04 & P< 0.003, respectively). 9 of 20 patients were evaluated for the source of eMDSCs. The HDMC group had high mixed chimeric eMDSCs as compared to the LDMC group (P< 0.00001). We found a positive correlation between the frequencies of eMDSCs and Tregs at PT-Day 100 (r=0.72, P <0.0007); eMDSCs at BSL and Tregs at PT-Day 100 (r=0.63, P <0.004). Of 10 immune regulatory cells and 50 cytokines, we observed mixed chimeric eMDSCs and IL-17A, IL-10, IL-7, G-CSF, IL-2, MIP-1a, VEGF, TGFb1 as potential hits which could serve as prognostic markers in predicting allograft outcome towards engraftment following haploidentical HSCT employing post-transplant cyclophosphamide. The current findings need to be replicated and further explored in a larger cohort.

Targeting Busulfan to Concentration Steady State of 600–700 ng/Ml Is Associated with Robust Engraftment and Decreased Toxicity in Patients with Sickle Cell Disease Receiving An HLA Identical Donor Transplant

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 1966-1966
Author(s):  
Jennifer Domm ◽  
Elizabeth Yang ◽  
Richard Ho ◽  
Adetola a Kassim ◽  
Haydar Frangoul
Keyword(s):  
Bone Marrow ◽  
Steady State ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Graft Versus Host Disease ◽  
Immune Suppression ◽  
Graft Rejection ◽  
Cell Disease ◽  
Graft Versus Host ◽  
Post Transplant

Abstract Abstract 1966 Sickle cell disease is a chronic illness with significant morbidity and mortality. The most frequent adverse events are painful vaso-occlusive crises (VOC) that often require hospitalization. VOC are recurrent and unpredictable and associated with higher mortality. Adults frequently suffer from the consequences of cumulative organ damage. The life expectancy of patients with sickle cell disease is still in the 40s by the most recent evaluation. The only curative therapy is allogeneic hematopoietic stem cell transplant. The major complication related to transplant includes transplant related mortality and graft rejection. We used the previously described regimen of busulfan, cyclophosphamide and ATG. Concentration steady state (CSS) of busulfan <600 ng/ml has been associated wth graft rejection and a CSS >900 ng/ml is associated with increased risk of regimen related toxicity. We targeted busulfan to a CSS of 600–700 ng/ml in an attempt to decrease regimen related toxicity and achieve donor engraftment. Between 2004 and 2011 14 patients underwent allogeneic bone marrow transplant from HLA identical siblings. Preparative regimen consisted of intravenous busulfan 0.8–1 mg/kg/dose for 16 doses, cyclophosphamide of 50 mg /kg daily for 4 doses, and equine ATG 30 mg/kg daily for 3 doses. Busulfan levels were measured after the first dose busulfan and subsequent doses were adjusted to provide a total exposure of concentration steady state of 600–700 ng/ml. Graft versus host disease prophylaxis was with cyclosporine starting on day −3 and short course methotrexate. Indications for transplantation included stoke or abnormal transcranial doppler (n=2), acute chest syndrome (n=1), renal disease (n=1), history of vaso-occlusive crisis in (n=10) and availability of HLA identical donor. The median age at time of transplant was 6.1 years (range 1.2–19 years). All patients received anti-seizure prophylaxis and antihypertensive therapy until all immune suppression was discontinued. All patients received a bone marrow graft from HLA identical siblings. The median busulfan steady state exposure was 648 ng/ml (range 607–670). Only 3 patients (21%) developed mucositis requiring parentral nutrition and none of the patients developed sinusoidal obstructive syndrome post transplant. All patient achieved neutrophil and platelet engraftment at a median of 18 and 22 days respectively. Grade II acute graft versus host disease developed in 2 patients (14%) and none of the 13 evaluable patients developed chronic GVHD (one patient is <100 days from transplant). Median donor engraftment is 100% (range 85–100) and all patients have achieved a hemoglobin profile identical to their donor's. None of the patients experienced sickle cell related complications post transplant. With a median follow up of 600 days (range 70–2644), the event free and overall survival are both 100%. All patients who are beyond one year post transplant are off all immune suppression. We conclude that targeting of busulfan between 600 and 700 ng/ml in combination with cyclophosphamide and ATG can result in excellent and sustained engraftment with low risk of toxicity in young patients with sickle cell disease. Disclosures: No relevant conflicts of interest to declare.

A Novel Allogeneic Transplant Conditioning Regimen Designed for Tolerance Induction in Patients with Severe Sickle Cell Disease.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 5429-5429
Author(s):  
Elizabeth M. Kang ◽  
Matthew Hsieh ◽  
Jonathan D. Powell ◽  
Beth Link ◽  
Theresa Donohue ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Nutritional Support ◽  
Chronic Gvhd ◽  
Conditioning Regimen ◽  
Cell Disease ◽  
Hematopoietic Stem ◽  
Post Transplant

Abstract Allogeneic transplantation of hematopoietic stem cells remains the only curative approach for patients with sickle cell disease (SCD), yet procedural toxicities and graft-versus-host disease limit this approach to children. We chose a low-dose radiation approach utilizing rapamycin based upon its unique ability to promote T cell tolerance even when T cells are stimulated in the presence of costimulation (Powell, et al, J Immunol. 1999). We confirmed this approach in vivo in a murine bone marrow transplantation model comparing a short course of conventional immunosuppression with cyclosporine to that with rapamycin, with long-term, high-level chimerism attained only in mice treated with rapamycin (Powell et al., manuscript submitted). We have now begun accrual to an IRB approved clinical trial testing this approach in adults with SCD and herein report the results in our first two subjects. Protocol entry criteria include those previously reported (Walters, et al, NEJM, 1996) with the addition of pulmonary hypertension defined as a tricuspid-regurgitant jet velocity (TRV) &gt; 2.5 m/s (Gladwin et al, NEJM, 2004). Additionally, patients must have failed a 6-month course of hydroxyurea. The conditioning regimen consists of a single radiation dose of 300cGy, alemtuzumab (1mg/kg total), and oral rapamycin targeting trough levels between 10–20 ng/ml. The graft consists of unmanipulated mobilized peripheral blood progenitors obtained from an HLA-matched sibling. The first patient is a 24-year-old female referred due to recurrent transient ischemic attacks and strokes despite chronic exchange transfusions. Her initial evaluation was notable for evidence of significant hemolysis with a total bilirubin of 9.8 mg/dl, an LDH 1,172 units/L (range 113–226), an absolute reticulocyte count of 318,000/uL and an undetectable haptoglobin. Cardiac doppler-echocardiogram revealed a TRV of 3.7 m/s, consistent with severe pulmonary hypertension. The conditioning was well tolerated and the patient did not require parenteral antibiotics or nutritional support. Assessment of donor chimerism, measured by microsatellite PCR and hemoglobin electrophoresis, revealed an early peak of myeloid chimerism which has stabilized at approximately 60%, with lower levels of lymphoid chimerism at approximately 5–10% now more than 300 days post-transplant. Hemoglobin levels stabilized at 11–12 g/dL, without detectable sickle hemoglobin, now allowing for therapeutic phlebotomy. Remarkably, the LDH and TRV fell concurrently toward the normal range. Patient 2 is a 26 year old male with frequent crises requiring hospitalization twice monthly. At one month post-transplant, myeloid chimerism is 97%, with lymphoid chimerism currently unmeasurable due to lymphopenia, and similar to that seen in patient 1 at the same time point. Patient 2 also required neither parenteral antibiotics nor nutritional support. Finally, neither patient to date has developed any symptoms or signs of either acute or chronic GVHD. Thus with two patients accrued to date, we have demonstrated the ability of allogeneic HSC transplantation to achieve mixed hematopoietic chimerism without the development of GVHD and for the first time, established the reversibility of the associated pulmonary hypertension.

scholarly journals Sickle Cell Disease Post-Transplant Care Challenges in Nigeria: Systematic Institutional Neglect of Medical Tourism

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4568-4568
Author(s):  
Adeseye Michael Akinsete ◽  
Michael R. DeBaun ◽  
Adetola A. Kassim
Keyword(s):  
Stem Cell ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Medical Tourism ◽  
Graft Function ◽  
Cell Disease ◽  
Term Survival ◽  
Hematopoietic Stem ◽  
Post Transplant

Introduction: Allogeneic hematopoietic stem cell transplantation (Allo-HCT) is potentially curative in eligible patients with sickle cell disease (SCD). Long term survival remains a challenge following allo-HCT and factors that predict for longer term complications and late mortality include increased hospitalization within the first 100 days, low socioeconomic status and poor access to healthcare. A new cottage industry of medical tourism associated with allo-HCT has emerged where children and adults with SCD living in Africa are traveling to countries that provide allo-HCT. Recent advances in improved disease-free survival and overall survival has resulted in families seeking curative options outside of their low resource-setting. The decision for allo-HCT is heavily weighed to family preference without regards to post-transplant care in their local environment. Unfortunately, the long-term care required for many children following an allo-HCT transplant is usually not available in their home country. Thus, the family desiring an allo-HCT is put in an awkward situation where they may need to have follow-up care in their primary country at a medical facility where neither the expertise nor the resources are available to manage long-term complications of allo-HCT. To explore the relationship between transplant medical tourism and patients with SCD, we report a case series of children who received their allo-HCT in another country only to return back to Nigeria. Methods: We recently established a post-transplant care clinic at the Lagos University Teaching Hospital, Idi-Araba, Nigeria. This includes a multidisciplinary team of providers, physicians and nurses with expertise in transplant care, and collaboration from Vanderbilt University Medical Center, USA. All cases described received allo-HCT outside Nigeria and returned within 60-100 days post-transplant. Parental preference for curative option was main indication for seeking allo-HCT. Records were obtained through electronic and paper medical records. Results: All the four cases reported had sickle cell anemia (Hb SS). Cases 1-3 received reduced intensity haploidentical HCT with post-transplant cyclophosphamide (Haplo-HCT), using G-mobilized peripheral blood stem cell grafts from parental donors with sickle cell trait. They all received preconditioning with hydroxycarbamide, azacytidine, and hypertransfusion (Table). Case-1 was 2years old, initially evaluated at day +135 post-transplant, complications included grade-II acute GI graft-versus-host disease (GVHD) at day+37 post-transplant, febrile illness and pseudo-membranous colitis requiring repeat endoscopies and prolonged steroid therapy. Case 2 was 5-years-old, seen day+395 post-transplant self-discontinued immunosuppression and antimicrobial prophylaxis with no guidance (despite the original haplo-HCT required a minimum of 12 months of immunosuppression therapy). Similarly, Case 3 was 7-years-old, off immunosuppression prematurely, and yet to commence routine post-transplant immunizations. Case 4 was 5-year-old who received matched related myeloablative bone marrow transplant. He was seen at day +138 post-transplant. He had poor graft function, EBV reactivation requiring Rituximab chemotherapy. Other management challenges encountered by patient's post-transplant include timely monitoring of immunosuppression and graft function, provision of irradiated blood component transfusion support, provision of anti-malaria and anti-helminthic prophylaxis which are endemic locally. Further, no physician to physician contact was made to transfer the patient back to a hematologist or oncologist with knowledge about post-transplant medical care. Discussion: The argument for performing the allo-HCT in children moving back to a low-income country has to be weighed against the availability of a strategy for management of late complications of allo-HCT, such as chronic GVHD, infectious complications related to immune reconstitution, as well as endocrine and chronic metabolic syndromes. Ultimately, the decision to perform an allo-HCT in such situations must be done on a case-by-case basis with a clear contingency plan to manage transplant-related complications for at least 2 years after the procedure at a hospital with adequate transplant expertise and support measures. Disclosures No relevant conflicts of interest to declare.

scholarly journals RH genotyping in a sickle cell disease patient contributing to hematopoietic stem cell transplantation donor selection and management

Blood ◽  
2010 ◽  
Vol 116 (15) ◽  
pp. 2836-2838 ◽  
Author(s):  
Ross M. Fasano ◽  
Alessandro Monaco ◽  
Emily Riehm Meier ◽  
Philippe Pary ◽  
A. Hallie Lee-Stroka ◽  
...  
Keyword(s):  
Stem Cell ◽  
Sickle Cell Disease ◽  
Stem Cell Transplantation ◽  
Cell Transplantation ◽  
Blood Group ◽  
Sickle Cell ◽  
Disease Patient ◽  
Nucleotide Sequencing ◽  
Cell Disease ◽  
Hematopoietic Stem

Abstract African individuals harbor molecular RH variants, which permit alloantibody formation to high-prevalence Rh antigens after transfusions. Genotyping identifies such RH variants, which are often missed by serologic blood group typing. Comprehensive molecular blood group analysis using 3 genotyping platforms, nucleotide sequencing, and serologic evaluation was performed on a 7-year-old African male with sickle cell disease who developed an “e-like” antibody shortly after initiating monthly red blood cell (RBC) transfusions for silent stroke. Genotyping of the RH variant predicted a severe shortage of compatible RBCs for long-term transfusion support, which contributed to the decision for hematopoetic stem cell transplantation. RH genotyping confirmed the RH variant in the human leukocyte antigen–matched sibling donor. The patient's (C)ces type 1 haplotype occurs in up to 11% of African American sickle cell disease patients; however, haplotype-matched RBCs were serologically incompatible. This case documents that blood unit selection should be based on genotype rather than one matching haplotype.

Demands and challenges for patients with sickle-cell disease requiring hematopoietic stem cell transplantation in Saudi Arabia

2016 ◽  
Vol 20 (6) ◽  
pp. 831-835 ◽  
Author(s):  
Abdulrahman Alsultan ◽  
Wasil Jastaniah ◽  
Sameera Al Afghani ◽  
Muneer H. Al Bagshi ◽  
Zaki Nasserullah ◽  
...  
Keyword(s):  
Saudi Arabia ◽  
Stem Cell ◽  
Sickle Cell Disease ◽  
Hematopoietic Stem Cell Transplantation ◽  
Stem Cell Transplantation ◽  
Cell Transplantation ◽  
Hematopoietic Stem Cell ◽  
Sickle Cell ◽  
Cell Disease ◽  
Hematopoietic Stem

scholarly journals 115. Correction of the Sickle-Cell Disease Mutation in Human Hematopoietic Stem/Progenitor Cells

2015 ◽  
Vol 23 ◽  
pp. S48
Author(s):  
Megan D. Hoban ◽  
Matthew C. Mendel ◽  
Zulema Romero ◽  
Michael L. Kaufman ◽  
Alok V. Joglekar ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Progenitor Cells ◽  
Sickle Cell ◽  
Cell Disease ◽  
Hematopoietic Stem ◽  
Disease Mutation

Sickle Cell Disease Hematopoietic Stem Cell gene therapy with globin gene addition is promising

2021 ◽  
Author(s):  
Moataz Dowaidar
Keyword(s):  
Gene Therapy ◽  
Stem Cell ◽  
Sickle Cell Disease ◽  
Hematopoietic Stem Cell ◽  
Sickle Cell ◽  
Globin Gene ◽  
Autologous Transplantation ◽  
Gene Repair ◽  
Cell Disease ◽  
Hematopoietic Stem

Autologous transplantation of gene-modified HSCs might be used to treat Sickle Cell Disease (SCD) once and for all. Hematopoietic Stem Cell (HSC) gene therapy with lentiviral-globin gene addition was optimized by HSC collection, vector constructs, lentiviral transduction, and conditioning in the current gene therapy experiment for SCD, resulting in higher gene marking and phenotypic correction. Further advancements over the next decade should allow for a widely approved gene-addition therapy. Long-term engraftment is crucial for gene-corrected CD34+ HSCs, which might be addressed in the coming years, and gene repair of the SCD mutation in the-globin gene can be achieved in vitro using genome editing in CD34+ cells. Because of breakthroughs in efficacy, safety, and delivery strategies, in vivo gene addition and gene correction in BM HSCs is advancing. Overall, further research is needed, but HSC-targeted gene addition/gene editing therapy is a promising SCD therapy with curative potential that might be widely available soon.

scholarly journals Genome editing using CRISPR-Cas9 to create the HPFH genotype in HSPCs: An approach for treating sickle cell disease and β-thalassemia

2016 ◽  
Vol 113 (38) ◽  
pp. 10661-10665 ◽  
Author(s):  
Lin Ye ◽  
Jiaming Wang ◽  
Yuting Tan ◽  
Ashley I. Beyer ◽  
Fei Xie ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Genome Editing ◽  
Sickle Cell ◽  
Globin Gene ◽  
Autologous Transplantation ◽  
Clinical Manifestations ◽  
Fetal Hemoglobin ◽  
Compound Heterozygous ◽  
Cell Disease ◽  
Hematopoietic Stem

Hereditary persistence of fetal hemoglobin (HPFH) is a condition in some individuals who have a high level of fetal hemoglobin throughout life. Individuals with compound heterozygous β-thalassemia or sickle cell disease (SCD) and HPFH have milder clinical manifestations. Using RNA-guided clustered regularly interspaced short palindromic repeats-associated Cas9 (CRISPR-Cas9) genome-editing technology, we deleted, in normal hematopoietic stem and progenitor cells (HSPCs), 13 kb of the β-globin locus to mimic the naturally occurring Sicilian HPFH mutation. The efficiency of targeting deletion reached 31% in cells with the delivery of both upstream and downstream breakpoint guide RNA (gRNA)-guided Staphylococcus aureus Cas9 nuclease (SaCas9). The erythroid colonies differentiated from HSPCs with HPFH deletion showed significantly higher γ-globin gene expression compared with the colonies without deletion. By T7 endonuclease 1 assay, we did not detect any off-target effects in the colonies with deletion. We propose that this strategy of using nonhomologous end joining (NHEJ) to modify the genome may provide an efficient approach toward the development of a safe autologous transplantation for patients with homozygous β-thalassemia and SCD.

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