Nonmyeloablative HLA-matched sibling allogeneic hematopoietic stem cell transplantation for severe sickle cell phenotype

Abstract

Importance: Myeloablative allogeneic hematopoietic stem cell transplantation (HSCT) is curative for children with severe sickle cell disease, but toxicity may be prohibitive for adults. Nonmyeloablative transplantation has been attempted with degrees of preparative regimen intensity, but graft rejection and graft-vs-host disease remain significant.

Objective: To determine the efficacy, safety, and outcome on end-organ function with this low-intensity regimen for sickle cell phenotype with or without thalassemia.

Design, setting, and participants: From July 16, 2004, to October 25, 2013, 30 patients aged 16-65 years with severe disease enrolled in this nonmyeloablative transplant study, consisting of alemtuzumab (1 mg/kg in divided doses), total-body irradiation (300 cGy), sirolimus, and infusion of unmanipulated filgrastim mobilized peripheral blood stem cells (5.5-31.7 × 10(6) cells/kg) from human leukocyte antigen-matched siblings.

Main outcomes and measures: The primary end point was treatment success at 1 year after the transplant, defined as a full donor-type hemoglobin for patients with sickle cell disease and transfusion independence for patients with thalassemia. The secondary end points were the level of donor leukocyte chimerism; incidence of acute and chronic graft-vs-host disease; and sickle cell-thalassemia disease-free survival, immunologic recovery, and changes in organ function, assessed by annual brain imaging, pulmonary function, echocardiographic image, and laboratory testing.

Results: Twenty-nine patients survived a median 3.4 years (range, 1-8.6), with no nonrelapse mortality. One patient died from intracranial bleeding after relapse. As of October 25, 2013, 26 patients (87%) had long-term stable donor engraftment without acute or chronic graft-vs-host disease. The mean donor T-cell level was 48% (95% CI, 34%-62%); the myeloid chimerism levels, 86% (95% CI, 70%-100%). Fifteen engrafted patients discontinued immunosuppression medication with continued stable donor chimerism and no graft-vs-host disease. The normalized hemoglobin and resolution of hemolysis among engrafted patients were accompanied by stabilization in brain imaging, a reduction of echocardiographic estimates of pulmonary pressure, and allowed for phlebotomy to reduce hepatic iron. The mean annual hospitalization rate was 3.23 (95% CI, 1.83-4.63) the year before, 0.63 (95% CI, 0.26-1.01) the first year after, 0.19 (95% CI, 0-0.45) the second year after, and 0.11 (95% CI, 0.04-0.19) the third year after transplant. For patients taking long-term narcotics, the mean use per week was 639 mg (95% CI, 220-1058) of intravenous morphine-equivalent dose the week of their transplants and 140 mg (95% CI, 56-225) 6 months after transplant. There were 38 serious adverse events: pain and related management, infections, abdominal events, and sirolimus related toxic effects.

Conclusions and relevance: Among 30 patients with sickle cell phenotype with or without thalassemia who underwent nonmyeloablative allogeneic HSCT, the rate of stable mixed-donor chimerism was high and allowed for complete replacement with circulating donor red blood cells among engrafted participants. Further accrual and follow-up are required to assess longer-term clinical outcomes, adverse events, and transplant tolerance.

Trial registration: clinicaltrials.gov Identifier: NCT00061568.

Figure 1. Donor Leukocyte Engraftment After Hematopoietic Stem Cell Transplantation (HSCT)

Eleven patients who were still receiving immunosuppression medication (sirolimus) are shown in panels A (myeloid) and C (lymphoid). Fifteen patients who later discontinued immunosuppression medication are shown in panels B and D. The orange lines and data points represent values after patients ceased immunosuppression medication. At the very early time points, eg, 1 month after transplant when patients began to shows signs of white blood cell engraftment, there often were not sufficient numbers of leukocytes for chimerism analysis. Thus not all time points include all 26 data points. At later time point, some patients could not travel back at the half-year marks (eg, 2.5, 3.5, or 4.5 year) for chimerism analysis; thus, there are fewer data points at those times.

Figure 2. Subsets of T-Lymphocytes Recovery After Hematopoietic Stem Cell Transplantation Among Engrafted Patients

Each data point represents data value for that patient at that time point. The black bars represent the means.

Figure 3. Hospitalization Rate and Narcotics Use

A, Median hospital admission rate per patient a year before, 1 year after, 2 years after HSCT, and 3 years after Hematopoietic Stem Cell transplantation (HSCT) and later per year. B, Among 11 participants who took narcotics long-term, median intravenous morphine equivalent doses of narcotics per week are shown with respect to time after HSCT. The boxes refer to 25th and 75th percentile; the whiskers, 10th and 90th percentile; and the dots, values outside the 10th and 90th percentile.