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Background & Aim: During the COVID-19 pandemic, we performed HPC-A cryopreservation process validation using the CryoStor CS10 freeze media to replace the current 10% DMSO cryoprotectant (Control), which encountered severe backorder. Methods, Results & Conclusion(s): This process validation included phase I, phase II, and follow-up studies. Ten HPC-A collection cell product samples were cryopreserved in the phase I study using CS10 and Control (1:1) post-plasma depletion. Post-thaw viability tests using the 7-AAD method were performed on the cryopreserved samples for parallel comparison. In phase II, each of three patient HPC-A cell products was split evenly into CS10 and Control cryopreservation. The CS10 cryopreserved HPC-A cell products only were used for infusion. The recipients' engraftment outcomes of white blood cells (WBC), granulocytes (ANC), and platelets (Plts) were monitored. Post-thaw viability test was performed on the quality control samples from both groups. In the follow-up study, engraftment outcomes of WBC, ANC, and Plts were evaluated from ten recipients who received the CS10 cryopreserved HPC-A. In the phase I study, the post-thaw viability of the CS10 group was significantly higher than the Control group (p=0.002). All post-thaw viability results were above 60%, the current lab release criteria. In the phase II study, all cryopreserved cell products met cell product release criteria (> 60%). All engraftment results were within our center-established ranges except for the Pt b's platelet engraftment. Three recipients had not had any cell product infusion-related adverse events post infusion. Both CD34 and CD45 post-thaw viability results in the CS10 group were remarkably higher than the Control group, except for the patient c's CD34 viability. In the follow-up study, the total infused cell product volume ranged from 60 ml to 118 ml, and the WBC concentration in the cryopreserved cell products ranged from 134 to 440 (x10
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Background: The emergence of the COVID-19 pandemic saw an increased use of cryopreserved (cryo) peripheral blood (PB) grafts for allogeneic hematopoietic stem cell transplantation (HSCT). Outcomes of patients receiving either fresh or cryo grafts have yielded heterogeneous results. Herein, we retrospectively compared the outcomes of patients receiving fresh and cryo grafts at a single center.(Table Presented)Methods: Between 2019 and 2021, we reviewed data from 380 patients;167 (44%) received a fresh, and 213 (56%) received a cryo graft. Patients underwent myeloablative or nonmyeloablative HSCT from either matched or mismatched, related or unrelated donors. Cell doses were determined by number of donor cells collected and recipient weight at infusion. Engraftment, disease risk (DR) and acute GVHD were classified based on established criteria. Donor chimerism was collected at approximately day 28 and day 80 after HSCT. Unadjusted and adjusted estimates of overall survival (OS), relapse, and non-relapse mortality (NRM) as a function of time were obtained. The adjusted odds (grades III-IV acute GVHD) and the adjusted cause-specific hazard of failure (all other outcomes) were compared between the 2 groups. with the use of logistic (Figure Presented) or Cox regression, respectively. These models were adjusted for various factors known to be associated with each outcome. Result(s): The characteristics of patients between the 2 groups are shown in Table 1. There was a higher proportion of patients with high/very high DR in the fresh graft group (Table 1). Median time to neutrophil engraftment was 17 and 18 days in fresh vs. cryo, respectively. The adjusted hazard ratio (HR) of neutrophil engraftment (fresh vs. cryo) was 1.07 (95% CI, 0.86-1.34, p=0.54). Median time to platelet engraftment was 13 and 15 days, respectively, and the adjusted HR of platelet engraftment was 1.32 (1.06-1.65, p=0.01). Day 28 chimerism data were available for 272 patients (113 fresh and 159 cryo). At day 28, donor CD3 chimerism was below 50% in 5 out of 113 (4.4%) and 17 out of 159 (10.7%) patients receiving fresh and cryo grafts, respectively (p= 0.06). At day 80, 3 out of 121 (2.5%) patients in the fresh group and 4 out of 165 (2.4%) in the cryo group had CD3 chimerism below 50%. The adjusted HRs (fresh vs. cryo) for death and NRM were 0.83 (0.54-1.28, p=0.40) and 0.71 (0.38-1.33, p=0.29), respectively (Figures 1 and 2). The adjusted HR for relapse was 0.65 (0.42-0.99, p=0.05) (Figure 3). The adjusted odds ratio (fresh vs. cryo) for grades III-IV GVHD was 1.65 (0.94-2.9, p=0.07). Conclusion(s): In this single-center retrospective study we observed numerically better outcomes with fresh grafts relative to cryo grafts for all examined endpoints with the exception of grades III-IV aGVHD, although none of the differences were definitive with the possible exception of relapse and platelet engraftment. Further studies are needed to confirm our observations.Copyright © 2023 American Society for Transplantation and Cellular Therapy
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Background: The use of cryopreservation for stem cell grafts for both autologous stem cell and allogeneic cord blood transplant has been utilized for years. For other allogeneic stem cell transplant sources, the use of fresh collected grafts has been preferred due to concerns that cryopreservation may result in impaired graft function. With the onset of the COVID-19 pandemic a shift was made at our institution to exclusive use of cryopreservation Methods: In this retrospective single-center analysis a total of 133 patients undergoing allogeneic stem cell transplant at the University of Minnesota between 1/2018-6/2021 for a variety of malignancies were included, with 62 patients receiving fresh stem cell product and 71 patients receiving frozen stem cell product. Univariate statistical analysis was performed. Result(s): There was no significant difference between the two groups with regards to product type, sex, age, diagnosis (acute leukemia vs other), disease risk index, conditioning regimen, Karnofsky score, co-morbidity index, or cell dose (Table 1). Donor type was notably different between the two groups (p<0.01): matched sibling grafts were more commonly used for fresh products than frozen (85% vs. 35%), while matched unrelated donors were used more frequently for frozen than for fresh products (54% vs. 6%). Use of frozen product was associated with delayed neutrophil and platelet engraftment compared to fresh (median days to engraftment 15 vs 12 for neutrophils, 23 vs 17 for platelets, p<0.01 for both). Two-year relapse rates were significantly lower for frozen products (4%) than fresh (24%) (Table 2). This may be partially attributable to differences in follow up between the groups, as fresh products had a total of 910 days of follow up vs 432 for frozen products (P<0.0001). The difference in follow up remained statistically significant if the data was censored at 730 days (P<0.0001). Of note, the use of frozen products was associated with a lower rate of chronic graft-versus-host disease at one year post-transplant (p<0.01). There was no significant difference in the rates of acute GVHD between the groups. There were significant differences in GVHD prophylaxis regimens between the fresh and frozen groups (p<0.01). (Figure Presented)Two-year overall survival did not differ between groups (p=0.96). Conclusion(s): Use of cryopreserved stem cell products is associated with similar efficacy and outcomes as those seen with the use of fresh stem cell products. Although the data presented here suggest novel finding of decreased risk of relapse and chronic GVHD with the use of frozen stem cell products, additional follow up may abrogate these differences. Regardless, the logistical benefits of cryopreservation make this an attractive option for continued use in allogeneic transplants and our data presented here suggests that cryopreserved products remain an appropriate option for allogeneic stem cell transplant.Copyright © 2023 American Society for Transplantation and Cellular Therapy
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Introduction: Wolman disease is a rare genetic disorder with an autosomal recessive inheritance. A mutation in the LIPA gene causes lysosomal acid lipase (LAL) deficiency results in lipid storage and adrenal insufficiency. Death in early infancy is due to liver failure. Patients and methods: We describe the clinical course of a three-month-old infant diagnosed with Wolman disease. A rapid mutational analysis confirmed a LIPA gene defect. Results: He underwent matched unrelated donor peripheral blood stem cell hematopoietic stem cell transplantation (HSCT) at 3 months of age, with a treosulfan-based conditioning, which resulted in engraftment with donor-derived hematopoietic cells. He required supportive care for sinusoidal obstruction syndrome and mucositis. He was administered low dose prednisolone for grade I skin graft versus host disease, and a complete donor chimerism was documented on several occasions. At one year post HSCT, his growth and development were optimal, and there was no hepatosplenomegaly. He is maintained on glucocorticoid and mineralocorticoid supplements for primary hypoaldosteronism. Conclusion: The case emphasizes the timely diagnosis and the potential for successful treatment of Wolman disease by HSCT. © 2022 Pediatric Hematology Oncology Chapter of Indian Academy of Pediatrics
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The Hermanos Ameijeiras Hospital (HAH) in Havana is the only center performing allogeneic hematopoietic stem cell transplantation (HSCT) in adult patients in Cuba. Because transplants from unrelated donors are not possible due to political restrictions and economic embargo, in 2016 HAH and University of Illinois at Chicago (UIC) started a collaboration to support the training of a physician, annual educational programs and exchange of guidelines and protocols to perform haploidentical transplants. The first haploidentical transplant was performed at HAH in 2016. Because of limited resources, disease risk stratification is based on morphologic assessment, as cytogenetic is tested on an irregular basis. Peripheral blood stem cells (PBSC) were infused based on total nucleated cell count (TNC) due to lack of reagents for flow cytometry. Posttransplant chimerism and CMV monitoring cannot be performed. Transplant activity was stopped in 2020 due to high expenses allocated for COVID19 pandemic in Cuba. From 2016 to 2020, 16 haploidentical HSCT in 15 patients (9 males/ 6 females) were completed at HAH. The median age of patients was 34 years (range:21-54). Diagnoses included: acute leukemia, n=12, myelodysplastic syndrome, n=1, Hodgkin disease, n=1, and severe aplastic anemia, n=1. At the time of transplant, 11 patients were in morphologic remission and 5 had active disease. Conditioning regimens utilized were myeloablative (Flu/Bu) in 10 cases and at reduced intensity (Flu/Cy/ TBI200 +/- ATG) in 6 cases, and GVHD prophylaxis was standard PTCy on D3 and 4, CsA and mycophenolate. The donors were mother (n=10), father (n=1), child (1), or sibling (n=3) and the median age was 48 years (range: 26-68). All patients received fresh stem cells from PBSC(n=13) or bone marrow (n=3). Median cell dose infused was 5.5x108 TNC/kg (range: 2.2-8). All patients but 1 engrafted and median time to neutrophil and platelet engraftment was 17 days (range:12-28) and 16 days (range:11-30), respectively. Acute graft-versus-host disease (GVHD) grade 2-3 occurred in 50% of patients and chronic GVHD in 2 out of 8 that were evaluable. Day 100 and 2-year overall survival rates were 73% and 40%, respectively. With a medium follow-up of 18.8 months (range: 0.3-64), 5 of 15 patients (30%) are alive and complete remission. Causes of death in the remaining 10 patients included relapse of original disease, n= 4;bacterial infection, n=2;brain hemorrhage, n=1;VOD, n=1;graft failure, n=1;and multi-organ failure, n=1. Despite significant difficulties, HAH implemented a haploidentical transplant program for adult patients in Cuba. Among future steps, improving access to molecular testing and using younger donors will be pursued to improve on the results. The partnership between HAH and UIC has been instrumental in building clinical and research capacity and continues to support HAH in its mission to provide care to patients in Cuba.(Figure Presented)Copyright © 2023 American Society for Transplantation and Cellular Therapy
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Background: Allogeneic hematopoietic cell transplantation (HCT) with ex vivo T cell receptor (TCR) alphabeta+ T cell and CD19+ B cell depletion is an effective approach for children with primary immune deficiency disorders (PIDD) as it combines advantages of high CD34+ cell dose facilitating rapid engraftment with low risk of Graft Versus Host Disease (GVHD). The ideal pre-conditioning regimen that facilitates robust donor engraftment without increasing risk of transplant related mortality has not been well defined with this approach. Method(s): We report the outcomes of 4 pediatric subjects: Chronic Granulomatous Disease (CGD) (2), Wiskott Aldrich Syndrome (WAS) (1), and RAC2 deficient Severe Combined Immunodeficiency (1) who underwent haploidentical HCT with TCRalphabeta+ T cell/CD19+ depletion at Johns Hopkins All Children's Hospital/Moffitt Cancer Center from 2020-2022 (NCT04414046). Pre-conditioning regimen consisted of distal thymoglobulin (7.5 mg/kg), fludarabine (175 mg/m2), thiotepa (10 mg/kg) and pharmacokinetic guided busulfan targeting a cumulative area under curve (cAUC) (65-75 mgxhr/L). Rituximab (200 mg/m2) was administered on day +1. Result(s): The median age at HCT was 51 months (range 10-163 months). All patients received mobilized peripheral blood stem cells from HLA- haploidentical donors (paternal=1, maternal=1 sibling=2). Median busulfan cAUC for all patients was 69 mgxhr/L (range 65-76). Median CD34 and TCR alphabeta T cell dose was 9.13x106 cells/kg (range 7.0-18.9x106) and 0.7x105 cells/kg (range 0.09-1.0x105). Median times to neutrophil and platelet engraftment were 11 days (9-12) and 11 days (range 8-15), respectively. All 4 patients are alive with median follow-up of 19.5 months (range 7-24). One patient developed late VOD without organ dysfunction that resolved with defibrotide. At last follow up, peripheral T and myeloid chimerisms exceeded 90% in all 4 patients. Average time to CD4 recovery (> 200x106/L) was 142 days. Pre-existing inflammatory bowel disease in CGD (n=1) and WAS (n=1) patients resolved immediately following transplant. There was no graft failure, and none developed Grade III-IV acute or extensive chronic GVHD. Patient with WAS developed recurrent autoimmune cytopenias requiring corticosteroids, rituximab, sirolimus and daratumumab, and ultimately resolved. Viral reactivations included EBV (n= 1), adeno (n= 1), HHV6 (n= 2), BK (n=1), norovirus (n=1), and late HSV (n=1), all responded to antivirals without disease. All patients acquired SARS-Cov-2 after transplant and recovered without sequelae. Conclusion(s): TCR alphabeta+ and CD19+ depleted haploidentical transplantation using a reduced toxicity conditioning regimen with pharmacokinetic guided busulfan, fludarabine, thiotepa and thymoglobulin is well-tolerated in young children with PIDD that results in rapid, durable engraftment with low likelihood of GVHD and graft rejection.Copyright © 2023 American Society for Transplantation and Cellular Therapy
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Collection of peripheral blood stem cells (PBSCs) for autologous stem cell transplant (ASCT) requires mobilization from the bone marrow. There is variation in mobilization choice;during the COVID-19 pandemic BSBMT&CT guidelines recommended using granulocyte-colony stimulating factor (G-CSF) alone to minimize the use of chemotherapy. We report on the impact of mobilization regimen on stem cell collection, and whether IMiD-containing induction therapy impacts on mobilization and consequently transplant engraftment times for 83 patients undergoing ASCT at Leeds Teaching Hospitals. Cyclophosphamide plus G-CSF (cyclo-G) mobilization yielded more CD34+ cells (8.94 vs. 4.88 x106/kg, p = < 0.0001) over fewer days (1.6 vs. 2.4 days, p = 0.007), and required fewer doses of salvage Plerixafor than G-CSF only (13.6% vs. 35%, p = 0.0407). IMiD-containing induction impaired all of these factors. CD34+ doses > 8x106/kg were more frequent with Cyclo-G (62% vs. 11%, p = 0.0001), including for those receiving IMiD 1st line induction (50% vs. 13.3%, p = 0.0381). Note that 92.6% of those receiving IMiD-free inductions were mobilized with Cyclo-G. The novel agents used in modern induction regimens (e.g Daratumumab) have been shown to impair yields, increasing the importance of optimizing mobilization regimens in the first instance. Furthermore, as cellular therapies become established in the management of multiple myeloma emerging data highlights the potential benefits of stem cell top up in the management of the haematological toxicities of these therapies. Our findings support re-adoption of Cyclo-G as the gold standard for mobilization to optimize PBSC harvesting and ensure sufficient cells for subsequent ASCTs.Copyright © 2023 The Authors. eJHaem published by British Society for Haematology and John Wiley & Sons Ltd.
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Introduction: Use of hematopoietic cell transplantation (HCT) in patients with trisomy 21 (+21) is infrequent given concerns about increased toxicity with cytotoxic chemotherapy.1 Due to increasing evidence of benefit from post-HCT cyclophosphamide (PTCy) for graft-vs.-host disease (GVHD) prophylaxis and lack of prior descriptions in patients with +21,2-4 we report on 2 patients with +21 and acute lymphoblastic leukemia (ALL) who underwent HCT with PTCy. Method(s): Retrospective data were collected from 2 patients with ALL and +21 who underwent allogeneic HCT with PTCybased GVHD prophylaxis from 2019 to 2021. Data collected included age, disease risk, HCT-CI, GVHD incidence, and survival. Result(s): Patient 1 is a 22-year-old male and patient 2 a 25-year-old female. Both had Ph-negative, B-cell ALL. Patient 1 had ETV6/RUNX1 rearrangement, del 12p, gain of X, and he had recurrence of measurable residual disease (MRD) after initial MRD-negative CR with two lines of therapy pre-HCT. Patient 2 had normal cytogenetics and relapsed disease with 4 prior lines of therapy. Both achieved MRD-negativity pre-HCT. Both received fludarabine and melphalan conditioning, and patient 1 also received thiotepa 2.5 mg/kg. PTCy was given on days +3 and 4 at 50 mg/kg with sirolimus and tacrolimus for GVHD prophylaxis. Patient 1 had a haploidentical donor and received one dose of rabbit ATG (1 mg/kg) on day +5. Patient 2 had a matched unrelated donor. There was no significant delay in engraftment of ANC (day 16-19) or platelets (day 15-16). Patient 2 developed acute GVHD at day 30 (stage I skin, stage II GI) that resolved with steroids which were tapered off by day 96 without recurrence. Sirolimus stopped at day 79 (pt 1) and 103 (pt 2) and tacrolimus was stopped at day 274 (pt 1) and 469 (pt 2). Patient 1 developed a sirolimus-induced pericardial effusion at day 84 which did not recur after sirolimus discontinuation. Patient 2 developed moyamoya 8 months post-HCT during tacrolimus taper without other GVHD symptoms. Response to steroids was noted, so tacrolimus was restarted for residual neurological deficit. Neither patient developed chronic GVHD or left ventricular ejection fraction decline, and neither patient had disease relapse at follow-up of 30 and 16 months respectively. Patient 2 developed COVID pneumonia 16 months post-HCT and died while in CR. Patient 1 remains alive, in CR, and off immunosuppression nearly 3 years post HCT. Conclusion(s): Allogeneic HCT with PTCy at standard doses did not appear prohibitively toxic in patients with +21 when administered after reduced-intensity conditioning. In this case series, GVHD rates seemed consistent with larger series in patients without +21. Moyamoya development is associated with autoimmunity in patients with +21 and hence may have been GVHD-related5. Trisomy 21 should not be a barrier to patients otherwise eligible for HCT, even with PTCy prophylaxis.Copyright © 2023 American Society for Transplantation and Cellular Therapy
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The World Health Organization (WHO) declared COVID-19 a pandemic in March 2020. Since then, logistical challenges arose regarding the procurement of allogeneic (allo) hematopoietic stem cell (HSC) donor grafts. Little data was available on transplant outcomes using cryo haploidentical (haplo) HSC grafts with post-transplant cyclophosphamide (PTCy) for GVHD prophylaxis. We retrospectively analyzed patients who received a first PTCy-based haplo hematopoietic stem cell transplant (Haplo HCT) at a single outpatient transplant center between January 2015 and December 2021. We identified 294 patients, 179 received a fresh graft and 115 received a cryo graft (Table 1). Both cohorts were similar in terms of median age, diagnoses, HCT-CI score and DRI. Out of 179 fresh haplo grafts, 160 (89.4%) were from peripheral blood stem cells (PBSC) and 19 (10.6%) were bone marrow grafts (BM). There were no cryo BM grafts used. Conditioning intensity were similar amongst both cohorts, with 43% myeloablative, 41.9% non-myeloablative and 15.1% RIC regimens used for fresh Haplo HCT and 39.1% myeloablative, 42.6% non-myeloablative and 18.3% RIC cryo Haplo HCT. Median time to engraftment was 16 days for fresh Haplo HCT and 17 days for cryo HCT (p=0.18). Median time to platelet engraftment was 27 days for fresh Haplo HCT and 27.5 days for cryo HCT (p=0.96). Since March 2020, only 8 transplants performed at our institution were from fresh haplo HSC grafts. Cryo grafts performed after March 2020 accounted for 73 (63.5%) of 115 total cryo Haplo HCT performed in the period reviewed. Using a Cox model to evaluate the effect of graft type and adjusting for significant variables, we found no difference in overall survival (OS), disease free survival (DFS), non-relapse mortality (NRM) and relapse rates between fresh and cryo Haplo HCT performed (Figure 1). While we found no difference in grades III-IV aGVHD (Table Presented) (Figure Presented) between fresh vs cryo Haplo HCT, we found a statistically significant higher incidence of grades II-IV aGVHD (p=0.033). There was no difference in all-grade cGVHD (p=0.53) or moderate- severe cGVHD (p=0.86) (Figure 2).(Figure Presented) The National Marrow Donor Program (NMDP) released a statement requiring cryopreservation of unrelated donor grafts at the start of the COVID-19 pandemic. The cryopreservation of all types of allo HSC grafts has been adopted by many transplant programs including ours. Our results mimic a CIBMTR analysis published at the start of the pandemic, where survival outcomes using fresh vs cryo haplo HSC grafts with PTCy as GVHD prophylaxis were similar. Contrary to other reports, we did not see differences in graft failure or rates of cGVHD between fresh and cryo Haplo HCT. The use of cryopreserved HSC grafts for Haplo HCT with PTCy results in favorable outcomes in an outpatient transplant setting. Further studies are needed to determine the cost-effectiveness of this practice in the post-pandemic era.Copyright © 2023 American Society for Transplantation and Cellular Therapy
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With increasing evidence of the success of hematopoietic progenitor cell (HPC) transplantation in the cure of many benign and malignant diseases, such interventions have been performed at increasing rates for the past several years. Due to myelosuppression caused by the conditioning and graft-versus-host disease (GVHD) prophylaxis regimens, blood component transfusions are almost inevitably needed. During transplantation, patient's hematopoietic lineages reconstitute to the HPC donor's progenitor cell types. Therefore, specific immunoserologic and hemotherapeutic aspects need to be considered for the selection of blood components during different phases of transplantation for successful outcomes. Those considerations include but are not limited to ABO and human leucocyte antigen (HLA) compatibility of the transfused blood components with either or both the patient and the HPC donor according to the particular phase of transplantation, and the special blood component processing to reduce the risk of transfusion associated graft-versus-host disease (TA-GVHD), cytomegalovirus (CMV) transmission in CMV seronegative patients and immune mediated platelets refractoriness. Complications may still arise, particularly in major, minor, or bidirectional ABO mismatched transplantations and/or due to the HLA mismatch and alloimmunization. Here we discuss the indications, immunoserologic considerations and the special component processing of red blood cells (RBCs), platelets, granulocytes, and plasma transfusions, based upon the current evidence and describe the prevention and management of salient, pertinent complications.Copyright © 2022 The authors.
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The current COVID-19 pandemic has placed unprecedented stress on the healthcare system, including HSCT. Several international organizations have created guidelines for managing different aspects of HSCT in the context of the pandemic. Comparing 2019 and 2020, our transplant center performed the same number of transplants. In both periods, transplants were mainly for patients with acute leukemia; thus, the urgency criteria was respected in light of pandemic restraints. Transplants by sibling donors and cord blood units remained the same, while transplants by unrelated donors were increased, in particular from European registries, and transplants by haploidentical donors were decreased. This change was made in light of the necessity of cryopreserving all apheresis products. We decided against cryopreserving bone marrow products due to the greater risk of drastic reduction in CD34 + cell count during the process. For urgent cases with only a haploidentical donor available, we opted for the use of PBSC following stimulation with G-CSF. GvHD prophylaxis was performed with PTCY on days + 3 + 5, cyclosporine with tapering from day + 100, and mycophenolic acid until day + 90 post-HSCT. Post-transplant outcomes such as graft failure, sepsis, and GVHD were not affected by the changes implemented. As a result of logistic difficulties, we halted our Car-T program from the start of the lockdown in March 2020 until September 2020. In accord with international guidelines, we were able to continue our HSCT program in the order to ensure a lifesaving treatment for patients with hematologic diseases for whom this procedure cannot be postponed.
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BACKGROUND/OBJECTIVE: Cryopreservation of grafts is not common practice in allogeneic hematopoietic stem cell transplant (HSCT) recipients. However, our center had to use cryopreserved cells for allogeneic HSCT during the COVID-19 pandemic to avoid delays in transplantation due to uncertainty regarding patient and donor exposures. STUDY DESIGN: We retrospectively evaluated post-transplant engraftment and survival outcomes of adult patients who received cryopreserved versus fresh allografts during the COVID-19 pandemic. RESULTS: Fifty-five patients with hematologic malignancies received either cryopreserved (n = 34) or fresh (n = 21) allogeneic HSCT using peripheral blood stem cells between January 2020 and December 2020. At a median follow-up time of 15 months, cryopreserved allograft recipients had significantly lower overall survival (OS) (p = 0.02). They also experienced significantly delayed neutrophil (p = 0.01) and platelet engraftments (p < 0.0001), as well as higher red blood cell transfusion-dependence after day + 60 (67.6% vs. 28.6%; p = 0.01). Significantly more cryopreserved allograft recipients received donor lymphocyte infusion than fresh allograft recipients (35.3% vs. 4.8%, p = 0.01). Neither relapse-free survival nor non-relapse mortality differed significantly between the two groups. CONCLUSION: Cryopreservation of allografts in combination with post-transplant cyclophosphamide may negatively affect engraftment and OS outcomes in HSCT recipients.
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Endothelial dysfunction underlies many of the major complications following hematopoietic cell transplantation (HCT), including transplant-associated thrombotic microangiopathy (TA-TMA), veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS), and engraftment syndrome (ES). Emerging evidence similarly implicates endothelitis and microangiopathy in severe COVID-19-related multi-system organ dysfunction. Given the overlap in these two illness states, we hypothesize that prior COVID-19 infection may increase risk for HCT-related endotheliopathies. This retrospective, multicenter study included patients aged 0-25 years who underwent autologous or allogeneic HCT for any indication between January 1, 2020 and September 21, 2021, with close attention to those infected with COVID-19 in either the six months prior to transplant or twelve months following transplant. Incidences of TA-TMA, VOD/SOS, and ES were compared among patients with COVID-19 infection pre-HCT and post-HCT, as well as with historical controls who were never infected with SARS-CoV-2. Those who underwent HCT following COVID-19 infection displayed significantly increased rates of TA-TMA compared to those who were never infected. Additionally, our data suggests a similar trend for increased VOD/SOS and ES rates, although this did not reach statistical significance. Therefore, a history of COVID-19 infection prior to undergoing HCT may be a nonmodifiable risk factor for endothelial-related complications following HCT. Further studies are warranted to better clarify this relationship among larger cohorts and in the era of the Omicron SARS-CoV-2 variants.
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Background: We have previously described AUTO1, a CD19 CAR with a fast off-rate CD19 binding domain, designed to reduce CAR T-cell immune toxicity and improve engraftment. Its clinical activity has been tested in r/r paediatric and adult B-ALL (Ghorashian S et al., Nat Med 2019;Roddie C et al., JCO 2021). This data confirms the intended function of the receptor, with low levels of CRS/ICANS and long-term engraftment of CAR T-cells observed in both patient groups. Aims: We have initiated testing of AUTO1 in the setting of B-NHL and CLL/SLL (NCT02935257). Methods: Manufacturing: CAR T-cell products were generated using a semi-automated closed process from non-mobilised patient leukapheresate. Study design: Subjects ≥ 16y underwent lymphodepletion with fludarabine (30mg/m x3) and cyclophosphamide (60mg/kg x1) prior to AUTO1 infusion, with the exception of the DLBCL cohort who additionally received a single dose of pembrolizumab (200mg) on day -1 to potentiate CAR-T expansion. AUTO1 dose varies based on the indication. Split dosing of 230 x106 CD19 CAR T-cells at day 0 and day 9 is employed in the CLL cohort. A single dose of 200 x106 CD19 CAR T-cells is delivered to patients with B-NHL. Study endpoints include feasibility of manufacture, grade 3-5 toxicity and remission rates at 1 and 3 months. Results: As of 8th February 2022, we enrolled 23 patients: 11 low grade NHL (LG-NHL:7 with FL and 3 with MCL), 7 DLBCL and 5 CLL. Apheresis was successful in all 23 patients and product manufacture was successful in 22 (pending in the last). 19 patients were infused: 10 with LG-NHL, 6 with DLBCL and 3 with CLL. 1 CLL patient was pending infusion at time of data cut-off and 2 patients died pre-infusion: 1 MCL patient, from COVID-19 and 1 CLL patient, from intracerebral haemorrhage. Patients treated with AUTO1 had a median age of 60 years (range 39-79), had received a median of 3 prior lines of treatment (range 2-8). Grade 1 CRS was reported in 6/19 and Grade 2 CRS in 3/19. No ICANS was observed in the B-NHL and CLL cohorts. CAR engraftment was observed in 13/13 patients evaluated by qPCR with ongoing persistence in 12/13 patients at last follow-up. In the LG-NHL and DLBCL cohorts 10/10 and 4/5 evaluable patients respectively were in CMR by 18FDG PET-CT post-treatment. Responses were ongoing in 9/10 LG-NHL at 12 months and in 4/4 DLBCL at months 1, 3, 3 and 6. In the CLL cohort, 2/3 evaluable patients achieved MRD negative remission in the bone marrow with residual small volume lymph nodes by CT at 6 and 3 months of follow-up respectively. 1 CLL patient did not engraft and had SD at month 1. Summary/Conclusion: AUTO1 has a tolerable safety profile in patients with r/r B-NHL and CLL despite high disease burden. Early data shows excellent complete remission rates and excellent CAR engraftment/expansion. Additional patients, updated data and longer follow up will be presented.
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Background: Gemtuzumab ozogamicin (GO), an anti-CD33 immunoconjugate Antibody is currently approved in combination with 7 + 3 in low- and intermediate risk acute myeloid leukaemia (AML). These patients are candidate for consolidation with autologous stem cell transplantation (ASCT) particularly when MRD- is obtained. GO can improve the rate of MRD negativity. There are limited data on the effect of its addition on the mobilization of Hemopoietic Stem Cells (HSC). Aims: To assess the feasibility of mobilization of HSC after re-introduction into market of GO at 3mg/m2 in 2019. Methods: We retrospectively studied AML patients undergoing 3+7 + GO induction and Ara-C + Daunorubicine + GO, consolidation (doses are derived from label instructions and ALFA0701 study) and mobilization on day +20 using GCSF 10μg/kg. CD34+ were monitored, and patients were harvested when a threshold of 20 cells/μL was reached in peripheral blood. Results: In 2020 and 2021, also considering constrains caused by COVID-19 pandemics, we attempted mobilization in our 3 Italian centres of 14 patients with a diagnosis of CD33+ de novo-AML. The median age was 52 years (range 29-65 yrs.), 4 were males and 10 females;11 patients carried a mutation of NPM1 and all had a normal karyotype except one with t(10p12;11q14) (Table 1). All received 3+7+GO induction and achieved a CR. Therefore, we started consolidation (total ARA-C 8g/m2) + GO as inpatient. Ten patients (71%) reached the established threshold of 20 CD34+ /μL and were successfully harvested, while 4 patients (29%) failed mobilization. The median day of apheresis was D+26 from the start to chemotherapy (range 22- 39). The median number of circulating CD34+ cells on the day of collection was 35.9 cells/μL (range 20-2153 cells/μL). The median CD34+ harvested was 4.65 x 106/kg (range 1.8- 44.6 x 106/kg). In our cohort, 4 patients (28% of the entire cohort and 40% of the harvested patients) underwent ASCT, 3 achieved favourable engraftment, while in the last patient ASCT is ongoing. Several reasons prevented ASCT in the remaining 6 patients: 3 patients underwent allogeneic SCT (2 had positive MRD on harvested apheresis;1 was reclassified as high-risk ELN2017 due to RUNX1 mutation resulting from NGS panel), 2 refused ASCT and one suffered early relapse. Summary/Conclusion: In our patients, the addition of GO did not impair HSC mobilization and harvesting that was reached in about 71% of cases, similarly to the AML-10 trial of the EORTC and GIMEMA Leukemia Groups where 70% of patients were successfully harvested. Our data are particularly interesting because in the pivotal ALFA0701 study, only one patient underwent Autologous- SCT, but in the control arm. An important limit of our case-series is that only 4 patients were auto-transplanted, so we have scant data on engraftment. In particular, evaluating day to engraftment of platelets would be interesting, given the known increase of thrombocytopaenia in patients treated with GO. In conclusion, mobilization with GO is feasible and further studies are warranted to evaluate the effects of fractioned doses of GO on HSC mobilization and ASCT outcome;the ongoing trial GIMEMA AML1819 - EudraCT number 2019-003871-20 - will prospectively assess the effect of GO, but with lower doses of ARA-C (total ARA-C 6 g/m2). (Table Presented).
ABSTRACT
Background & Aim: During the COVID pandemic the National Marrow Donor Program® (NMDP)/Be The Match® required cryopreservation of unrelated hematopoietic stem cell (HPSC) products prior to initiation of recipient conditioning to minimize risks associated with logistical complications. Transplant centers are still evaluating cryopreservation associated risk factors due to reported concerns on poor postthaw graft quality compared to fresh products. We evaluated the effect of cryopreservation on engraftment outcomes. Methods, Results & Conclusion: Data from patients receiving either unrelated HPSC fresh or cryopreserved products obtained through the NMDP were included in this study. There were 43 fresh infusions during (Table Presented) during 2019 and 54 cryopreserved infusions between January 2020 and January 2022. Neutrophil and platelet engraftments were our primary endpoints. Absolute neutrophil count (ANC) recovery was defined as an ANC of ≥ 0.5×109/L for three consecutive laboratory values obtained on different days. While platelet engraftment was determined as the first day of three consecutive measurements, obtained on different days, where the platelet count is ≥ 20×109/L without a platelet transfusion in the previous seven days. Medians for two unpaired groups were compared by using Mann-Whitney U test. Two-sided p-values < 0.05 were considered statistically significant. Of the total of fresh transplants, 62.8% of patients underwent reduced intensity conditioning (RIC) while 37.2% underwent myeloablative conditioning (MAC). Regardless of the diagnosis category and in accordance with the American Society of Blood and Marrow Transplantation (ASBMT) Standardized Request for Information (RFI), 11.6% of recipients were classified as a high risk, 20.9% as an intermediated risk, 41.9% as a low risk and 25.6% unclassified. Whereas 52.8% of patients who received cryopreserved products underwent RIC and 47.2% underwent MAC;according to ASBMT-RFI classification, 18.9% were considered as a high risk, 24.5% as an intermediated risk, 41.5% as a low risk and 15.1% unclassified. Engraftment characteristics for both groups of patients is summarized in Table I. No statistically significant differences in engraftment were observed. Our analysis suggests that compared to outcomes of fresh product transplantation, cryopreservation does not negatively effect allograft quality in terms of neutrophil and platelet engraftment.
ABSTRACT
Background & Aim: Prior to the COVID-19 pandemic, allogeneic transplants were typically performed with fresh hematopoietic stem cell (HPSC) products. Unrelated donor (UD) cells are obtained through the National Marrow Donor Program (NMDP). The logistics for coordinating collection, transport, and delivery of fresh products with preconditioning of recipients is complicated under the best circumstances. The pandemic created uncertainty and disruptions in the UD HPSC process. In March 2020 the NMDP required cryopreservation of UD HPSC products, with rare exceptions, prior to patient conditioning. The impacts of cryopreservation on allogeneic HPSC engraftment are not well defined and conflicting outcomes based on transport time and cell concentration have been published. We aimed to determine if cryopreservation, transport time and pre-processing cell concentration negatively impacted patient engraftment. Methods, Results & Conclusion: Methods: Between July 2021 and January 2022, we analyzed UD HPSC products from 24 patients for CD34+ pre- and post-thaw cell recovery and viability based on transit time and pre-processing cell concentration. Transit time, defined as the interval from end of collection to start of processing, was divided into 3 cohorts: 1-20 h, 21-40 h, and >40 h. Pre-processing nucleated cell counts were divided into 2 cohorts: <200 x106 cells/mL and >200 x106 cells/mL. Neutrophil and platelet engraftment data were obtained from the patients’ medical record. Medians for 2 unpaired groups were compared by using Mann-Whitney U test. Three or more unpaired groups were compared using one-way ANOVA with Tukey’s multiple comparisons or Kruskal Wallis non-parametric test with Dunn’s test for post hoc analysis, as appropriate. For paired data a mixed model ANOVA with Geisser-Greenhouse correction was applied. Results: Information regarding patient diseases and product characteristics are shown in Table I. There were no statistically significant differences between the nucleated cell count in the product bag reported by the collection center and those measured at the time of processing. When these parameters were evaluated based on transit time and pre-processing cell concentration, no statistically significant differences were observed. Conclusion: Although our data set is small, the results suggest that transit time and cell concentration of the HPSC product bag does not negatively impact allograft quality and engraftment. (Table Presented)
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Background & Aim: Background: Traditionally, ‘fresh’ Hematopoietic progenitors cell (HPC) infusions have been preferred over cryopreserved HPC in Allo-HCT because cryopreservation and thawing leads to cell loss, besides DMSO-related adverse reactions in patients. Emergence of COVID-19 pandemic has severely affected fresh HPC infusions and most professional bodies recommend cryopreservation of HPC products before initiating conditioning chemotherapy. Although some western studies suggest no significant impact of graft manipulation on patient outcome, there is no available data from the developing world.Aim: We compare neutrophil and platelet engraftment in patients undergoing Allo-HCT with fresh and cryopreserved HPC products. Methods, Results & Conclusion: Material and Method: Allo-HCT data from October 2018 to October 2021 were analyzed. Cryopreservation was performed by controlled-rate freezing using 10% DMSO, plasmalyte- A and human albumin ( 1:2:1) as cryoprotectant. Cryopreserved products were stored in vapour-phase of Liquid nitrogen tank. CD34+ enumeration and viablity( by 7-AAD) was done on Flow-cytometry on fresh and post-thaw HPC samples. Neutrophil engraftment was defined as absolute neutrophil count >0.5 ×109/L for 3 days. Platelet engraftment was defined as independence from platelet transfusion for at least 7 days with a platelet count >20 × 109/L. Statistical analysis using Wilcoxon Rank Sum test. Results: Ninety-six patients underwent allo-HCT (46 received fresh and 50 received cryopreserved HPC products) (Table 1). There was no significant difference in neutrophil engraftment with fresh and cryopreserved grafts (p>0.05) in different types of transplants( Matched related/unrelated and haploidentical). 22% (11/50) of cryopreserved graft infusions were associated with Grade-1 DMSO-related adverse reactions, which were managed with symptomatic treatment. Cryopreservation increased the cost of related allogeneic transplants by USD1100. No cryopreserved HPC product was culture positive on microbiological assessment. Conclusion: In our experience, the engraftment kinetics were similar with fresh and cryopreserved HPC products as CD34+cell dose administered was almost the same. Cryopreserved grafts had a median 7% CD34+cell loss, associated with mild DMSO-related adverse reactions and cost increment. Even though, graft cryopreservation is a feasible alternative during the pandemic, it is crucial to ensure graft quality and promptly manage DMSO-related adverse reactions.(Table Presented) Table 1 Comparison of Fresh and cryopreserved HPC products in Allo-HCT
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Background & Aim: Hematopoietic progenitor cells (HPCs) are infused for hematopoietic reconstitution in the setting of malignancy and inherited or acquired hematological deficiencies. Given the global COVID-19 pandemic, the recommendation was made to cryopreserve all allogeneic HPCs to protect recipients by allowing for subclinical cases of infection to present prior to infusion. As such, consideration of HPC stability programs (SP) and their rigor has risen. The goal of a SP is to prove the rigor of a transplant program’s cryopreservation and storage standard operating procedures so that sufficient HPC viability and potency are maintained for engraftment. SPs are also required by accreditation agencies such as AABB and FACT. Many HPC SP have validated product expirations out to 10 years. Here we share our SP to 20 years with ongoing validation for 30-year expiration. Methods, Results & Conclusion: Program Design: Current testing frequency of our SP is within the first year, and then at three-year intervals (3, 6, 9, 12, 15, 19, 21). Our rolling SP includes 2 additional (Figure Presented) Fig. 1.Current vs proposed HPC product testing and cryopreseveration schema. samples tested at 0, 5, & 9 years, then at 3-year intervals (12, 15, 19, 21, 24, 27, 30). SP samples are collected from donors requiring additional days to reach their goal but are in excess at the conclusion of collection (e.g., Day 1 collection 4.5e6 CD34+ cells/Kg, goal 5e6 CD34+ cells/ Kg). Samples are collected on a quarterly basis with ten 1mL cryovials being drawn (Figure 1). CD3+ and CD34+ viabilities are tested after cryopreservation with an acceptable threshold set at ≥75% for both. Conclusion: We are validating our SP up to 20 years with intention to validate to 30 years. Thus far, our SP reveals product age has no to low correlation with engraftment, suggesting maintenance of potency over time in a cryopreservative of 10% DMSO, 10% plasma, and 30% PlasmaLyte-A with a final cell concentration of ≤3×108 NC/mL (Figure 2). Successful engraftment has been seen in all recipients. Transplant programs should modify testing frequency, acceptance criteria, and product expiration to meet individual need while working towards standardization in the field. Given the frequency of DLIs and 2nd/3rd transplants at the Mayo Clinic, a 30-year SP reflects the need of our transplant program.(Figure Presented)Fig. 2 . ANC and platelet engraftment dates for ≥10-year-old HPC products
ABSTRACT
Background Dysbiosis of the gut microbiota may be responsible for the pathogenesis of ulcerative colitis (UC). Restoration of gut microbiota diversity by means of faecal microbiota transplantation (FMT) is of increasing interest as a therapeutic option in the management of UC. The aims of this phase II feasibility study are to estimate the magnitude of treatment response to FMT in treatment-naïve patients with newly diagnosed UC, evaluate donor and patient recruitment rates and determine optimal study conditions for phase III study (ISRCTN 58082603). Methods Treatment-naïve patients with histologically confirmed UC below the sigmoid were recruited. Subjects were randomised to single FMT enema, five daily enemas and control group. All groups received antibiotic for 10 days and bowel preparation 48 hours before the interventions. They were followed up for 12 weeks with quality of life (QOL) scores (IBDex, CUCQ-32) and 16S RNA study on faecal samples. Endoscopic (Mayo score) and histological assessments were performed at the baseline and week 12. The primary endpoints were endoscopic remission of UC and rate of persistent microbial engraftment at 12 weeks. Secondary endpoints included QoL and mucosal cytokine profiling with IL-10. Clinical remission was defined as Mayo score ≤ 2 with an endoscopic Mayo score of 0. Results Eighteen UC patients were recruited between July 2016 and February 2020 until the COVID-19 pandemic, of those five achieved clinical remission. One subject from the control group withdrew at week 4 due to worsening symptoms. 72% improved Mayo and QOL scores, and 44% avoided medical treatment. Clinical remission was more observed among subjects with lower baseline QoL and mild-moderate disease, although this did not reach statistical significance (P=0.173). No correlation between FMT dose, frequency and clinical remission were observed. The 16S evaluation of the faecal samples demonstrated successful engraftment of FMT and showed a similar faecal microbiota profile amongst the intervention groups, which was markedly different from the control group. Coprococcus was found to be much more abundant amongst subjects who responded to the FMT intervention. This study also suggested an inverse correlation between IL-10 and the severity of UC. Conclusions FMT intervention protocols were well adhered and 94% completion rate, though the recruitment period was much longer than the original plan due to some unforeseen interruptions. Yet, this feasibility study demonstrated potential for employing this method for a larger multicentre RCT to further evaluate FMT dose and frequency effects. The correlation between IL-10 and IL-10 producing microorganisms should be sought in the future study.