Alternative donor sources in pediatric bone marrow transplantation.

Every year 2,800 children are diagnosed with leukemia and between 30% and 60% will relapse and need a bone marrow transplant. In addition, children with hematologic, genetic, or immunologic diseases may also require a transplant to be cured. Unfortunately, only 30% of these children will have a human leukocyte antigen-matched sibling donor. The current options for alternative donor sources include matched unrelated donor, mismatched related donor, and unrelated cord blood donor. Compared to a matched sibling donor, each of these options has an increased risk for graft failure and graft-versus-host disease (GVHD). For patients who receive stem cells from matched unrelated donors or mismatched related donors, the risk of graft failure is 5% to 10% and the risk of GVHD approaches 80%. After unrelated cord blood transplants, the graft failure rate is 8%, but this is potentially offset by less severe GVHD. Challenges for nurses include providing anticipatory guidance for patients and families undergoing these novel therapies and devising treatment strategies to manage the complications. Graft failure, GVHD, and infections pose the most significant risks associated with alternative donor transplants.

Steroid-refractory cutaneous graft-versus-host disease after transplantation of haploidentical parental CD34+ cells in children with Down's syndrome and recurrent acute leukemia.

PURPOSE: This study evaluated the feasibility of performing haploidentical CD34+ selected transplants for children with Down's syndrome (DS) and recurrent leukemia. PATIENTS AND METHODS: Within a cohort of 15 children, two patients had DS. Transplantation of CD34+ cells from haploidentical parents was performed after the children were conditioned with fractionated total body irradiation, cyclophosphamide, and antithymocyte globulin (ATG). Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine and a short course of methotrexate. RESULTS: The preparative regimen was well tolerated, and engraftment of polymorphonuclear cells and platelets took place promptly (by day 20) in both patients with DS. However, both patients with DS experienced severe grade IV GVHD that was limited to the skin and was refractory to salvage with high-dose methylprednisolone therapy. In one patient, GVHD responded to second-line salvage therapy with ATG, but the patient died on day 234 from leukemic relapse. The second patient had GVHD that did not respond to ATG and died of multisystem organ failure and refractory GVHD on day 44. Two of two DS patients had steroid refractory severe acute GVHD of the skin, while only one of 11 evaluated and identically treated non-DS patients had severe GVHD (p < 0.05). CONCLUSION: These observations in patients who underwent mismatched bone marrow transplantation suggests that patients with DS have an increased risk of severe acute GVHD of the skin in this context.