Aplastic anemia. Immunosuppressive therapy in a multi center trial in Japan

We evaluated the biologic characteristics and effectiveness of immunosuppressive agents in patients with a severe form of aplastic anemia in a multicenter study. Treatment with a bolus of methylprednisolone (mPSL) was associated with a good response and a partial response in 19.4% and 1.4% of the patients, respectively. In contrast, two kinds of antilymphocyte globulin (ALG) were effective for 9.4% and 15.6% of the severe form of aplastic anemia, and two kinds of antithymocytoglobulin (ATG) were effective in 30.8% and 37.2% of the patients, although the difference between ALG and ATG was not statistically significant. We recommend that patients diagnosed as having severe aplastic anemia should be referred as soon as possible for treatment with immunosuppressive agents or bone marrow transplantation, the latter depending on disease severity, age, and potential availability of an HLA-identical sibling donor.     

异基因造血干细胞移植治疗重型再生障碍性贫血

背景：近年来随着造血干细胞移植技术的提高和免疫抑制剂的使用,重型再生障碍性贫血的治疗效果有了明显改善,尤其是亲缘间HLA配型全相合异基因造血干细胞移植,取得了较高的治愈率。 目的：观察异基因造血干细胞移植治疗重型再生障碍性贫血的疗效。 方法：自2009至2011年采用异基因造血干细胞移植治疗重型再生障碍性贫血患者20例,HLA配型全相合12例,不全相合8例。移植预处理采用氟达拉滨+兔抗人胸腺细胞免疫球蛋白+环磷酰胺。除1例为非血缘外周血干细胞移植外,其他患者干细胞来源为动员后的骨髓和外周血干细胞联合移植。HLA全相合移植物抗宿主病预防采用环孢素联合短程甲氨蝶呤,不全相合患者采用环孢素、短程甲氨蝶呤联合吗替麦考酚酸酯。 结果与结论：移植后中性粒细胞恢复> 0.5×109 L-1平均为12.5 d,血小板恢复> 20×109 L-1平均为+18 d。20例患者随访24-60个月,总生存率75%(15例),治愈率70%(14例),死亡5例;12例全相合患者中83%治愈(10例),8例不全相合患者治疗有效率62%(5例),治愈率50%(4例)。20例患者中发生急性及慢性移植物抗宿主病5例,治疗中并发败血症4例,侵袭性真菌感染3例。结果可见异基因干细胞移植是治疗重型再生障碍性贫血的有效方法之一,尤以HLA全相合效果良好,移植后恢复快,移植物抗宿主病发生率低。中国组织工程研究杂志出版内容重点：干细胞;骨髓干细胞;造血干细胞;脂肪干细胞;肿瘤干细胞;胚胎干细胞;脐带脐血干细胞;干细胞诱导;干细胞分化;组织工程全文链接：     

A Case Series of Post-Transplantation Cyclophosphamide in Unrelated Donor Hematopoietic Cell Transplantation for Aplastic Anemia

Patients with severe aplastic anemia (SAA) who fail immunosuppressive therapy have a dismal prognosis. Hematopoietic stem cell transplantation (HSCT) from an unrelated donor (URD) is one of the most effective treatment options. Two institutions have independently adopted a post-transplantation cyclophosphamide (PTCy) approach for patients with SAA undergoing HSCT from a URD. Thirteen patients were included, 11 of whom had been treated with immunosuppressive therapy. Eight patients had a mismatched URD. All patients were conditioned with fludarabine, cyclophosphamide, and total body irradiation, in various dosage combinations. PTCy was given at a dose of 100 mg/kg. Two patients died, and overall survival was 85% at 2 years. All patients engrafted, but 1 patient developed secondary graft failure. Of the 11 patients alive after 2 years, 9 had complete donor chimerism. All surviving patients were transfusion-independent. Ten patients (77%) had cytomegalovirus reactivation, and 2 patients had more than 1 reactivation. No Epstein-Barr virus reactivation or post-transplantation lymphoproliferative disease was observed. Four patients had mild hemorrhagic cystitis. In summary, our findings show that PTCy is a promising treatment for patients with SAA undergoing URD HSCT.     

Fludarabine,Campath, and Low-Dose Cyclophosphamide (FCClow) with or without TBI Conditioning Results in Excellent Transplant Outcomes in Children with Severe Aplastic Anemia

Various reduced-intensity conditioning regimens are in use for allogeneic hematopoietic cell transplant (HSCT) in patients with idiopathic severe aplastic anemia (SAA). We describe the use of fludarabine, Campath, and low-dose cyclophosphamide (FCC^low) conditioning in 15 children undergoing related or unrelated donor transplants. Total body irradiation (TBI) of 2 Gy was added for unrelated donor HSCT. At a median follow-up of 2.3 years, the failure-free survival was 100%, with low rates of infection and toxicity. There was no occurrence of grade III to IV acute graft-versus-host disease (GVHD). All patients had full donor myeloid chimerism post-HSCT, even with mixed chimerism in the T cell lineage. The absence of chronic GVHD and long-term stable mixed donor T cell chimerism confirms immune tolerance following FCC^low (± TBI) conditioned transplantation in children with SAA.     

Umbilical Cord Blood Transplantation Using Reduced-Intensity Conditioning without Antithymocyte Globulin in Adult Patients with Severe Aplastic Anemia

Umbilical cord blood transplantation (UCBT) is a possible option for patients with aplastic anemia (AA) without a related or unrelated HLA-matched donor, particularly if immunosuppressive therapy (IST) has failed or transplantation is urgently needed. However, a higher rate of graft failure after UCBT remains a major problem, and the optimal conditioning regimen for stable engraftment after UCBT has not been established. Here we investigated 6 adult patients with AA who underwent UCBT using a reduced-intensity conditioning (RIC) regimen comprising fludarabine 125 mg/m², cyclophosphamide 120 mg/kg, and 4 Gy of total body irradiation (Flu/CY/TBI4Gy) without antithymocyte globulin (ATG). Five patients underwent UCBT after IST failure, and 1 patient underwent UCBT as a first-line treatment due to a fulminant clinical finding of a neutrophil count of 0, despite granulocyte colony-stimulating factor administration. Regarding graft-versus-host disease (GVHD) prophylaxis, 2 patients received tacrolimus plus short-term methotrexate and 4 patients received tacrolimus plus mycophenolate mofetil, and all patients achieved sustained engraftment of both neutrophils and platelets, at a median of 17.5 days (range, 14 to 37 days) and 38.5 days (range, 31 to 86 days), respectively, with complete donor chimerism confirmed in all patients at a median of 14 days (range, 14 to 32 days). Three patients developed grade II acute GVHD (aGVHD), but grade III/IV aGVHD was not observed, whereas 4 patients developed chronic GVHD involving only skin. At the time of this report, all 6 patients were alive without the need for blood transfusion, at a median follow-up of 16 months (range, 12 to 131 months). Although further study is needed, our findings suggest that conditioning with Flu/CY/TBI4Gy without ATG might allow stable engraftment in UCBT for adults with AA.     

Comparable outcomes of matched-related and alternative donor stem cell transplantation for pediatric severe aplastic anemia.

Matched sibling donor (MSD) bone marrow transplantation is the treatment of choice for pediatric patients with severe aplastic anemia (SAA); however, only about 33% of patients will have an HLA-identical sibling. Alternative donor (AD) transplants may be an option for these patients, but such therapies have been associated with greater incidence of graft failure and graft-versus-host disease (GVHD). We retrospectively analyzed 36 pediatric patients who received 38 bone marrow or peripheral blood stem cell transplants (15 MSD and 23 AD) for SAA at our institution from April 1997 to October 2005. Nineteen AD recipients received reduced intensity conditioning with cyclophosphamide, low-dose total body irradiation, and antithymocyte globulin (ATG) or Campath. The 4-year overall survival for MSD recipients was 93% versus 89% for AD recipients treated with reduced intensity conditioning regimens at a median follow-up of 52 months (range, 6-99 months). No patient receiving Campath, compared with 3 of 9 patients receiving ATG, developed extensive, chronic GVHD. We conclude that, for children with SAA, AD transplantation is as effective as MSD transplantation. Further, compared with ATG, preparatory regimens containing Campath may be associated with a lower incidence of extensive, chronic GHVD.     

干细胞移植治疗重型再生障碍性贫血：研究应用与进展

文题释义：获得性再生障碍性贫血：是一种免疫介导的骨髓衰竭性疾病,主要表现为骨髓有核细胞增生低下、一系或多系血细胞减少及其所致的贫血、出血和感染。获得性再生障碍性贫血的发病机制尚未完全阐明,目前认为T淋巴细胞异常活化、功能亢进造成骨髓造血功能衰竭在获得性再生障碍性贫血发病机制中占主要地位。 人类白细胞抗原：即HLA,是人类主要组织相容性复合体的表达产物,HLA的研究最初是在器官移植研究推动下开展起来的,因此HLA又称移植抗原。在遗传学中,主要组织相容性复合体是作为一个单位孟德尔式传递的。因此,同胞之间可有HLA相同、半相同和不同3种情况。 背景：异基因造血干细胞移植仍然是获得性重型再生障碍性贫血患者的唯一治愈方法,如何选择适合移植的重型再生障碍性贫血患者进行治疗成为近年的研究热点。 目的：从HLA全相合无关供者造血干细胞移植、非血缘脐血移植和单倍体相合造血干细胞移植3个方面进行综述,阐述异基因造血干细胞移植的研究进展。 方法：检索2000至2018年期间收录在PubMed、中国知网期刊全文数据库及万方数据库中异基因造血干细胞移植治疗重型再生障碍性贫血的相关文献,检索词为“unrelated donor,haploidentical,unrelated cord blood,severe aplastic anemia”及“无关供者,单倍体相合,无血缘脐血,重型再生障碍性贫血”。 结果与结论：①HLA全相合同胞供者造血干细胞移植是治疗重型再生障碍性贫血的一线治疗方案,但鉴于HLA相合同胞供者不易寻找,HLA全相合无关供者造血干细胞移植作为重要的替代治疗手段,目前疗效已接近HLA全相合同胞供者造血干细胞移植,但移植物抗宿主病、严重感染的发生率仍高于HLA全相合同胞供者造血干细胞移植,在选择HLA全相合无关供者造血干细胞移植治疗时仍然需要多因素综合考虑;②脐血造血干细胞来源丰富且配型成功率高,使得非血缘脐血移植的应用变得普遍,预冻存总有核细胞量>3.9×10⁷/kg时非血缘脐血植入概率较高,但鉴于非血缘脐血植入延迟、免疫功能重建延迟等因素,临床治疗重型再生障碍性贫血时只有在其他移植方式不可行且第1个疗程免疫抑制治疗失败后才应考虑非血缘脐血移植;③单倍体相合造血干细胞移植具有供者易获得且依从性好等优点,疗效接近全相合移植,现已成为一种重要的替代移植选择;巴利昔单抗和(或)抗胸腺细胞球蛋白的使用有望降低移植物抗宿主病的发生率以拓展单倍体相合造血干细胞移植的临床应用范围。 ORCID: 0000-0003-3509-920X(丁宇斌) 中国组织工程研究杂志出版内容重点：干细胞;骨髓干细胞;造血干细胞;脂肪干细胞;肿瘤干细胞;胚胎干细胞;脐带脐血干细胞;干细胞诱导;干细胞分化;组织工程     

Rapid and complete donor chimerism after unrelated mismatched cord blood transplantation in 5 children with beta-thalassemia major.

Hematopoietic stem cell transplantation is currently the only curative therapy for beta-thalassemia major. However, <30% of patients have unaffected HLA-identical siblings to serve as donors. We investigated the feasibility of using umbilical cord blood transplants from unrelated HLA mismatched donors and a myeloablative preparative regimen that did not involve total body irradiation. Between October 2003 and November 2004, 5 children with beta-thalassemia major received busulfan, cyclophosphamide, and antithymocyte globulin before cord blood transplantation (median dose, 8.8 x 10(7) cells per kilogram of body weight) from unrelated donors (1 or 2 of 6 HLA antigens were mismatched) and were then evaluated for engraftment, adverse effects, and treatment outcome. The median times to neutrophil engraftment, red blood cell transfusion independence, and platelet engraftment were 12, 34, and 46 days after transplantation, respectively. All patients showed grade II or III acute graft-versus-host disease; none developed extensive chronic graft-versus-host disease until the date of last contact. All patients were alive at a median follow-up of 303 days after transplantation, with complete donor chimerism and transfusion independence. These results are encouraging and clearly show the feasibility of unrelated mismatched umbilical cord blood transplantation in the treatment of children with beta-thalassemia major.     

造血干细胞移植治疗再生障碍性贫血的现状

文题释义：预处理：指在移植前对患者进行的放、化疗和免疫抑制治疗。再生障碍性贫血预处理的重点为免疫抑制,常采用非清髓和减低剂量预处理。 移植物抗宿主病：是异基因造血干细胞移植最常见的并发症,分为急性和慢性2种类型。目前认为移植物含有免疫活性细胞、供受者之间存在组织不相容性、受者不排斥植入的细胞是发生移植物抗宿主病3个必备条件。 背景：异基因造血干细胞移植治疗再生障碍性贫血的研究近年来取得很大的进步,但是移植后移植物抗宿主病、移植失败等仍是患者非复发死亡的主要原因,严重影响患者生存。 目的：总结异基因造血干细胞移植治疗再生障碍性贫血的现状及进展。 方法：中文检索词为“再生障碍性贫血,同胞全合异基因造血干细胞移植,无关供者造血干细胞移植,单倍体造血干细胞移植,脐血造血干细胞移植”,英文检索词为“aplastic anemia,matched sibling donor hematopoietic stem cell transplantation,unrelated donor hematopoietic stem cell transplantation,haploidentical hematopoietic stem cell transplantation,cord blood transplantation”,由第一作者检索1990年1月至2019年9月在PubMed、中国知网、万方、维普等数据库中发表的与造血干细胞移植治疗再生障碍性贫血相关的文献,最终选择55篇文献进行分析。 结果与结论：同胞全合异基因造血干细胞移植仍是目前首选的移植方式;对于无同胞全合供者的重型再生障碍性贫血患儿,一线治疗可以选择无关供者相合异基因造血干细胞移植;缺乏全合供者时,单倍体移植和脐血移植亦为不错的选择。 ORCID: 0000-0003-3931-8385(黄东平) 中国组织工程研究杂志出版内容重点：干细胞;骨髓干细胞;造血干细胞;脂肪干细胞;肿瘤干细胞;胚胎干细胞;脐带脐血干细胞;干细胞诱导;干细胞分化;组织工程     

Nonmyeloablative Allogeneic Hematopoietic Stem Cell Transplantation for GATA2 Deficiency

We treated 14 patients with GATA2 deficiency using a nonmyeloablative allogeneic hematopoietic stem cell transplantation regimen. Four patients received peripheral blood stem cells from matched related donors (MRD), 4 patients received peripheral blood stem cells from matched unrelated donors (URD), 4 patients received hematopoietic stem cells from umbilical cord blood donors (UCB), and 2 patients received bone marrow cells from haploidentical related donors. MRD and URD recipients received conditioning with 3 days of fludarabine and 200 cGy total body irradiation (TBI). Haploidentical related donor recipients and UCB recipients received cyclophosphamide and 2 additional days of fludarabine along with 200 cGY TBI. MRD, URD, and UCB recipients received tacrolimus and sirolimus for post-transplantation immunosuppression, whereas haploidentical recipients received high-dose cyclophosphamide followed by tacrolimus and mycophenolate mofetil. Eight patients are alive with reconstitution of the severely deficient monocyte, B cell, and natural killer cell populations and reversal of the clinical phenotype at a median follow-up of 3.5 years. Two patients (1 URD recipient and 1 UCB recipient) rejected the donor graft and 1 MRD recipient relapsed with myelodysplastic syndrome after transplantation. We are currently using a high-dose conditioning regimen with busulfan and fludarabine in patients with GATA2 deficiency to achieve more consistent engraftment and eradication of the malignant myeloid clones.     

Nonmyeloablative Peripheral Blood Haploidentical Stem Cell Transplantation for Refractory Severe Aplastic Anemia

New transplant approaches are urgently needed for patients with refractory severe aplastic anemia (SAA) who lack a matched sibling or unrelated donor (UD) or who have failed UD or cord blood transplant. Patients with refractory SAA are at risk of later clonal evolution to myelodysplastic syndrome and acute leukemia. We report our pilot findings with haploidentical hematopoietic stem cell transplantation (haploHSCT) using uniform reduced-intensity conditioning with postgraft high-dose cyclophosphamide in 8 patients with refractory SAA or patients who rejected a prior UD or cord blood transplant. Six of 8 patients engrafted. Graft failure was associated with donor-directed HLA antibodies, despite intensive pre-HSCT desensitization with plasma exchange and rituximab. There was only 1 case of grade II skin graft-versus-host disease. We show that haploHSCT can successfully rescue refractory SAA patients who lack donor-directed HLA antibodies but not in the presence of donor-directed HLA antibodies. This novel protocol for haploHSCT for SAA has been adopted by the European Group for Blood and Marrow Transplantation Severe Aplastic Anaemia Working Party for a future noninterventional, observational study to further evaluate its efficacy.     

Marrow transplantation for treatment of aplastic anemia. An analysis of factors associated with graft rejection.

Seventy-three consecutive patients with severe aplastic anemia were treated by marrow grafts from normal, HLA-identical siblings, and 68 lived long enough to demonstrate engraftment. In 21 patients the garft was rejected, and 19 of these patients died. This analysis, using a binary logistic regression model, was aimed at identifying factors that predicted marrow-graft rejection. Of the 24 factors entered into the analysis, only two strongly correlated with graft rejection: a positive relative response index in mixed leukocyte culture indicating sensitization of patient against donor (P less than 0.01); and a low number of marrow cells ( less than 3 X 10(8) cells per kilogram) used for transplantation (P less than 0.01). These findings suggest that more powerful immunosuppressive conditioning regimens should be used in patients who are sensitized, and that the greatest possible amount of donor marrow, perhaps supplemented by stem cells derived from the peripheral blood, should be obtained.     

Haploidentical Bone Marrow Transplantation with Post-Transplantation Cyclophosphamide Plus Thiotepa Improves Donor Engraftment in Patients with Sickle Cell Anemia: Results of an International Learning Collaborative

Curative therapy for individuals with severe sickle cell disease (SCD) who lack an HLA-identical sibling donor has been frustratingly elusive. In with the goal of improving engraftment while minimizing transplantation-related morbidity, a multi-institutional learning collaborative was developed in the context of a Phase II clinical trial of nonmyeloablative, related HLA-haploidentical (haplo) bone marrow transplantation (BMT) with post-transplantation cyclophosphamide. All eligible participants had hemoglobin SS, and 89% (16 of 18) had an identifiable donor. The median patient age was 20.9 years (IQR, 12.1 to 26.0 years), and the most common indication for transplantation was overt stroke (in 69%; 11 of 16). In the first 3 patients, the conditioning regimen consisted of antithymocyte globulin, fludarabine, cyclophosphamide, and low-dose total body irradiation. Graft-versus-host disease (GVHD) prophylaxis included post-transplantation cyclophosphamide, mycophenolate mofetil, and sirolimus. Primary graft rejection occurred in 2 of the 3 patients (67%), which triggered the study-stopping rule. To reduce graft rejection risk, thiotepa was added to the conditioning regimen, and then 15 patients (including 2 with previous graft rejection) underwent haplo-BMT with this thiotepa-augmented conditioning regimen. At a median follow-up of 13.3 months (interquartile range [IQR], 3.8 to 23.1 months), 93% (14 of 15) had >95% stable donor engraftment at 6 months, with 100% overall survival. The median time to neutrophil engraftment (>500) was 22 days (IQR, 19 to 27 days), and that for platelet engraftment (>50 x 10^9/L) was 28 days (IQR, 27 days to not reached). Two patients had grade III-IV acute GVHD, 1 patient had mild chronic GVHD, and 86% of patients (6 of 7) were off immunosuppression therapy by 1-year post-transplantation. Our data suggest that haplo-BMT with post-transplantation cyclophosphamide and thiotepa improves donor engraftment without significantly increasing morbidity or mortality and could dramatically expand curative options for individuals with SCD.     

Unrelated Cord Blood Transplantation for Severe Aplastic Anemia

In the present study we evaluated the feasibility of unrelated cord blood transplantation (UCBT) in patients with severe aplastic anemia (SAA). The outcome of 31 SAA patients (median age 28; range: 0.9-72.3 years old) who received UCBT was analyzed. The cumulative incidences of the neutrophil and platelet recovery after UCBT were 54.8 and 72.2%, respectively (95% confidence interval [CI] = 36.0%-70.3% and 51.3%-85.3%, respectively). The cumulative incidences of grade ≥II acute and chronic graft-versus-host disease (aGVHD, cGVHD) were 17.1% (95% CI = 6.2%-32.8%) and 19.7% (95% CI = 6.2%-38.8%), respectively. Currently, 13 patients are alive, having survived for 33.7 months (median; range: 6-77 months) after UCBT. The probability of overall survival (OS) at 2 years was 41.1% (95% CI = 23.8%-57.7%). A conditioning regimen that included low-dose total body irradiation (TBI) (2-5 Gy), fludarabine, and cyclophosphamide resulted in a favorable OS (80%; 95% CI = 20.4%-96.9%). This result suggests that UCBT using the optimal conditioning regimen can be a salvage treatment for patients without a suitable bone marrow donor and warrants evaluation in further prospective studies.     

异基因造血干细胞移植治疗24例重型再生障碍性贫血北大核心

背景:重型再生障碍性贫血病情重、病死率高,需快速恢复造血功能,目前异基因造血干细胞移植为一线治疗方案,同胞全相合异基因造血干细胞移植为首选,单倍体相合造血干细胞移植作为替代治疗方案也取得了较好的效果。目的:探讨异基因造血干细胞移植(包括同胞全相合造血干细胞移植及单倍体相合造血干细胞移植)治疗重型再生障碍性贫血的临床疗效。方法:回顾性分析2015年4月至2021年7月于徐州市中心医院接受异基因造血干细胞移植治疗24例重型再生障碍性贫血患者的临床资料,其中接受同胞全相合造血干细胞移植8例,接受单倍体相合造血干细胞移植16例。24例重型再生障碍性贫血患者预处理方案为氟达拉滨、环磷酰胺、抗淋巴细胞球蛋白方案。同胞全相合造血干细胞移植采用环孢素联合短程甲氨蝶呤预防移植物抗宿主病,单倍体相合造血干细胞移植在此基础上增加吗替麦考酚酯。结果与结论:①24例重型再生障碍性贫血患者中有2例患者预处理期间死于严重感染,其余22例均达造血重建;中性粒细胞植入中位时间为12.5(10-18)d,血小板植入中位时间为14.5(10-26)d;②22例植入成功患者发生急性移植物抗宿主病8例(36%),Ⅲ/Ⅳ度急性移植物抗宿主病2例,慢性移植物抗宿主病累计发生4例(18%),Ⅲ/Ⅳ度慢性移植物抗宿主病1例;③18例患者存活,6例患者死亡,5年预计总生存率为74%;④结果表明,异基因造血干细胞移植为重型再生障碍性贫血的有效治疗手段,同胞全合供者作为首选,无同胞全相合供者时可选择单倍体相合供者作为替代。     

Comparable Outcome with a Faster Engraftment of Optimized Haploidentical Hematopoietic Stem Cell Transplantation Compared with Transplantations from Other Donor Types in Pediatric Acquired Aplastic Anemia

Haploidentical family donors have been used as an alternative source in hematopoietic cell transplantation for patients with severe aplastic anemia. We evaluated and compared the outcomes of transplantation in pediatric acquired severe aplastic anemia based on donor type. Sixty-seven patients who underwent transplantation between 1998 and 2017 were included. Fourteen patients received grafts from matched sibling donors, 21 from suitable unrelated donors, and 32 from haploidentical family donors. Ex vivo CD3⁺ or αβ⁺ T cell–depleted grafts were used for haploidentical transplantation. Sixty-five patients (97.0%) achieved neutrophil engraftment at a median of 11 days. Haploidentical transplantation resulted in significantly faster neutrophil engraftment at a median of 10 days, compared with 14 days in cases of matched sibling donors and 12 days in cases of unrelated donor recipients. Nine patients experienced graft failure, and 5 of 7 who underwent a second transplantation are alive. There was no difference in the incidence of acute or chronic graft-versus-host disease based on donor type. The 5-year overall survival and failure-free survival rates were 93.8% ± 3.0% and 83.3% ± 4.6%, respectively, and there was no significant survival difference based on donor type. The survival outcomes of haploidentical transplantation in patients were comparable with those of matched sibling or unrelated donor transplantation. Optimized haploidentical transplantation using selective T cell depletion and conditioning regimens including low-dose total body irradiation for enhancing engraftment may be a realistic therapeutic option for pediatric patients with severe aplastic anemia.     

单倍体相合造血干细胞移植治疗儿童重型再生障碍性贫血

背景：目前治疗儿童再生障碍性贫血的主要方法为强化免疫抑制治疗或干细胞移植,后者由于供者来源少而受到限制,HLA单倍体相合的异基因造血干细胞在白血病治疗中常见应用,在再生障碍性贫血治疗中较少应用。目的：探讨单倍体相合的造血干细胞移植联合胎盘来源的间充质干细胞移植治疗重型儿童再生障碍性贫血的疗效。方法：患儿,女,7岁,确诊重型再生障碍性贫血1年半,2012-07-09接受HLA单倍体相合的异基因骨髓及外周血单个核细胞联合胎盘来源间充质干细胞移植,供者为母亲。预处理采用氟达拉滨联合环磷酰胺和抗胸腺细胞球蛋白方案。结果与结论：移植后+9 d中性粒细胞>0.5×10⁹ L^-1,+12 d完成造血重建,+100 d查STR提示植入完成。移植后+8个月停用免疫抑制药物,未发生急、慢性移植物抗宿主病。患儿随访18个月,无病生存。结果表明,HLA单倍体相合的造血干细胞联合胎盘来源间充质细胞移植治疗儿童重型再生障碍性贫血是一种安全有效、值得探索的方法。中国组织工程研究杂志出版内容重点：干细胞;骨髓干细胞;造血干细胞;脂肪干细胞;肿瘤干细胞;胚胎干细胞;脐带脐血干细胞;干细胞诱导;干细胞分化;组织工程全文链接：     

Marrow transplantation from unrelated donors for patients with severe aplastic anemia who have failed immunosuppressive therapy.

Allogeneic marrow transplantation offers curative therapy for patients with aplastic anemia. We analyzed retrospective results in 141 patients with severe aplastic anemia who received transplants between 1988 and 1995 from an unrelated volunteer donor identified through the National Marrow Donor Program (NMDP). All patients had failed one or more courses of immunosuppressive therapy. Of the patients, 121 (86%) received a radiation-containing conditioning regimen, and 20 (14%) were given chemotherapy only. Based on serologic human leukocyte antigen (HLA) typing (class I and II), 105 patients (74%) received HLA-matched marrow, and 36 (26%) received marrow mismatched for at least one HLA-A, -B, or -DR antigen. Allele-level (molecular) typing for HLA-DRB1 was available in 108 donor-recipient pairs; 77 patients received DRB -matched and 31 DRB1-mismatched transplants. All but 13% of patients were given a cyclosporine-containing regimen for graft-vs.-host disease (GVHD) prophylaxis, and 45 patients (32%) received marrow that was T cell-depleted. Among 131 evaluable patients, 116 (89%) achieved sustained engraftment and 15 (11%) did not. Among patients with engraftment, acute GVHD of grades II-IV developed in 60 patients (52%) and extensive chronic GVHD in 24 patients at risk (31%). Currently, 51 patients (36%) are surviving at 11-94 months (median 36) after transplantation. All but five have Karnofsky scores > or =80. Patients who received a serologically matched transplant fared somewhat better than did patients given a serologically mismatched transplant p = 0.03). Patients with donors matched by both serology and allele-level DRB1 typing had significantly better survival than DRB1-mismatched patients with 56 vs. 15% surviving at 3 years p = 0.001). Outcome in patients transplanted within 3 years of diagnosis was superior to that among patients transplanted with greater delay. Major causes of death were graft failure, GVHD, and infections. These data suggest that unrelated marrow transplantation offers successful therapy for a proportion of patients who have failed immunosuppressive therapy.     

Cyclophosphamide and antithymocyte globulin to condition patients with aplastic anemia for allogeneic marrow transplantations: the experience in four centers.

This report summarizes the experience with a conditioning regimen of cyclophosphamide and antithymocyte globulin in patients with severe aplastic anemia given HLA-matched related marrow grafts at 4 transplantation centers. Enrolled were 94 consecutive patients, of whom 87 had received multiple transfusions and 38 had failed immunosuppressive therapy. Their ages ranged from 2 to 59 years. After transplantation, 89 patients received a methotrexate/cyclosporine regimen for graft-versus-host disease (GVHD) prevention. Cyclosporine with or without prednisone was given in 4 patients, and no immunosuppression was given in 1 patient. Ninety-six percent of patients had sustained grafts, whereas 4% rejected grafts between 2 and 7 months after transplantation. Of the 4 rejecting patients, 3 are alive with successful second engraftments. Acute grade II GVHD was seen in 21% of patients, grade III in 7%, and grade IV in 1% of patients. Chronic GVHD was seen in 32% of patients, most of whom responded completely to immunosuppressive therapy. With a median follow-up of 6.0 years (range, 0.5-11.6 years), the survival rate was 88%. No unusual long-term side effects have been seen with the regimen. We conclude that the cyclophosphamide/antithymocyte globulin regimen combined with methotrexate/cyclosporine after transplantation is well tolerated and effective in heavily pretreated patients with aplastic anemia.     

Outcomes of Haploidentical Stem Cell Transplantation using Total Body Irradiation (600 cGy) and Fludarabine with Antithymocyte Globulin in Adult Patients with Severe Aplastic Anemia: A Prospective Phase II Study

The aim of this study was to verify the feasibility of rabbit antithymocyte globulin (ATG; 5 mg/kg) in combination with 600 cGy of fractionated total body irradiation (fTBI; 3 doses of 200 cGy) and fludarabine (Flu; 150 mg/m²) as a conditioning regimen for haploidentical stem cell transplantation from a related mismatched donor (haplo-SCT) in adult patients with severe aplastic anemia (SAA). We analyzed 47 consecutive patients who underwent haplo-SCT, including 24 patients from our previous pilot report. The median age was 36.0 years (range, 17 to 61 years), and 25 patients (53%) were very severe aplastic anemia (VSAA) at transplantation. All patients achieved primary engraftment. The cumulative incidence of grade ≥II acute graft-versus-host disease (GVHD) and chronic moderate or greater GVHD was 27.7% at 100 days and 13.5% at 3 years, respectively. With a median follow-up of 32.3 months, the 3-year probability of overall survival and failure-free survival was 91.0% and 88.6%, respectively. The 3-year GVHD- and failure-free survival (GFFS) was 71.6%. Offspring donor and lower comorbidity index were independent factors correlated with higher GFFS in multivariate analysis. In conclusion, the outcomes of haplo-SCT with fTBI 600 cGy/Flu/ATG-5 indicate that haplo-SCT can be an effective alternative option when a fully matched donor is not available or a patient with VSAA needs an urgent transplantation.