ALBERT

Description: The use of reduced intensity conditioning regimens (RIC) has facilitated the allografting of older patients while concurrently reducing the transplant-related mortality associated with allogeneic haematopoietic stem cell transplantation. At present, there is limited data available on the longer-term efficacy and safety of RIC HSCT. We performed a retrospective study on the long term outcomes of patients with haematological malignancies who received RIC HSCT at our center over an 8 year period from Jan 1997 to Dec 2005. A total of 263 adult patients received RIC HSCT, of which 135 patients (51%) survived for 2 or more years and were analysed for long-term outcomes and complications. The median recipient age among our long term survivors at HSCT was 49 years (range: 24–66), with an M: F ratio of 1.6:1 and median follow-up of 51.8 months (range 23.9–100.3). All patients received alemtuzumab (CAMPATH 1H) based RIC regimens with cyclosporin A as post-transplant GvHD prophylaxis. 61 were sibling donor and 74 were volunteer unrelated donor (VUD) transplants. 90 patients (66%) had a myeloid malignancy (mainly AML and MDS), 35 (26%) had lymphoid malignancy and 9 (7%) had myeloma. The stem cell source was PBSC in 98(73%) and bone marrow in 37(27%) cases. Using a 2-year landmark analysis, the actuarial survival at 3 and 5 years was 96% (95% CI: 94.3–97.7) and 91.6% (95% CI: 88.6- 94.6) respectively. There were 8 deaths in the cohort. Four deaths (50%) were due to late relapses, with 4 others due to respiratory failure(1), HBV reactivation with fulminant hepatic failure(1), adenovirus infection(1), chronic GvHD with invasive pulmonary aspergillosis(1). 44 patients had prior acute GvHD (33%). 20(15%) developed chronic GvHD (13 cutaneous involvement, 1 hepatic, 2 hepatic and cutaneous, 5 bronchiolitis obliterans). 18 other patients developed GvHD post donor lymphocytes infusion (DLI). The cumulative incidence of active cGvHD at 3 years and 5 years was 8% and 4% respectively. Significant infectious complications occurred in 38 patients (28%) of which 20 had VZV reactivation most commonly involving the trigeminal nerve. A further 14 had pulmonary problems (9-recurrent chest infections, 2-pneumocystis carinii pneumonia, 2-IPA, 1-TB). Endocrine complications included hyperthyroidism (2 cases) and hypothyroidism (14 cases). In addition, there were 4 cases (8% incidence) of premature menopause and 4 cases (5% incidence) of erectile dysfunction. Secondary malignancy occurred only in 1 patient who developed squamous cell carcinoma of the skin. In addition there were 4 cases of moderate renal impairment, 2 cases of cerebral ischaemic attacks, 8 reports of immune thrombocytopenia/ autoimmune haemolytic anemia. Patients who survive beyond 2 years following alemtuzumab-based RIC HSCT have an excellent overall survival, with a low incidence of chronic GvHD. Nevertheless, late complications of HSCT are still frequent in this cohort. Our data suggests that late effect in patients following RIC HSCT is different from those seen in patients following myeloablative HSCT. Prospective studies are warranted in long-term survivors of RIC HSCT in order to guide appropriate longer-term follow-up.

Description: Introduction Reduced-intensity conditioning (RIC) transplants currently comprise 25–30% of allogeneic transplants in Europe. Previously reported data suggested delayed donor erythroid engraftment and isohaemaglutinin disappearance in RIC transplants, Additionally, reduced blood product usage has been reported. We prospectively studiedthe kinetics of donor red cell engraftment;kinetics of recipient- and donor-type isohaemaglutinnins, andusage of blood products, in 100 consecutive patients undergoing haemopoietic cell transplantation (HCT) for haematological malignancy at a single centre: Material and Methods 59 patients had RIC conditioning (37 FB8C (Fludarabine Busulphan 8mg/kg Campath1H), 22 FMC, Melphalan 140mg/m2), and 41 standard (Std) conditioning (13, TBI 14.4Gy BuCyCampath, 4 BuCy200, 16 BEAM-Campath1H, 8 FB16C, Busulphan 16mg/kg). Emergence of donor red cells and isohaemaglutinine titres were detected by Diamed columns (sensitivity approx. 5%). Bone marrow samples on days 28, 56, and 100 post transplant were used for semisolid culture of erythroid progenitors (BFU-E). Results. In 50/100 patients (26 RIC and 24 Std) emergence of donor red cell antigens was detectable by serology (19 major and 8 bidirectional ABO mismatches; 22 patients were informative due to a Rh antigen mismatch (10 D, 8 E, 2 C, and 2 c); One had a M-mismatch). Median time for the appearance of donor red cells was 66 days for Std conditioning and 56 days for RIC (not significant). Within the RIC group, there was no significant difference between ABO vs. Rh - mismatched transplants. Similarly, the kinetics of disappearance of recipient-type isohaemaglutinin was not different between RIC vs. Std conditioning (median 82 days for RIC and 69 days for Std). Appearance of donor-type isohaemaglutinin, followed in patients with minor or bidirectional ABO mismatch, was delayed regardless of the conditioning regime: only 3/24 patients had detectable donor-derived anti-A/B after a median of 336 days post transplant. Patients receiving a RIC regime required significantly less platelet transfusions: 14.4 vs 7.8 units (P= 0.02). There was a trend toward a higher number of RBC units transfused to patients receiving Std than RIC regimes: 14 vs 9 units (P= 0.06), but with substantial variation between different standard regimes. BFU counts showed a linear increase but the mean count was still subnormal by day 100. within the RIC group, BFU-E counts were not significantly different between ABO identical vs. non-ABO identical transplants. DNA from BFU-E colonies from 87 patient- points has been stored, to be compared with serology and blood lymphoid/myeloid chimerism data. There were no cases of Pure Red Cell Aplasia (PRCA) in the RIC patients with major ABO mismatch. Only one case of autoimmune haemolytic anaemia was identified in the entire study group, after a median follow up of 345 days. Conclusions Donor red cell emergence and disappearance of recipient-type anti-A/B are not delayed wit RIC regimes that we use. In keeping with this is the low incidence of post-transplant PRCA. Donor-type anti-A/B production is suppressed, probably due to the effect of Campath 1H, accounting for the absence of severe “passenger lymphocyte” haemolysis. Red cell and platelet usage are markedly decreased in RIC transplants due to reduced myelosuppression.

Description: Bone marrow CD34+ cell apoptosis (annexin V), proliferation (Ki-67), and Bcl-2-related protein expression was evaluated by flow cytometry in 102 patients with myelodysplastic syndrome (MDS) and acute myeloid leukemia secondary to MDS (MDS-AML) and in 30 normal donors (NBM). Apoptosis was significantly increased in refractory anemia (RA)/RA with ringed sideroblasts (RARS) (56.9% [20.4%-93.6%]) and refractory anemia with excess blasts (RAEB) (51.2% [25.2%-76.6%]) compared with NBM (16.7% [3.4%-35.3%],P 

Description: Introduction Autoimmune hemolytic anemia (AIHA) is the most commonly reported autoimmune complication following hematopoietic stem cell transplantation (HSCT) with incidence of 2-6%. The risk factors and pathogenesis remain poorly understood. Treatment often requires multiple therapeutic agents with variable efficacy and outcome. However no study to date has shown whether AIHA directly results in increased mortality. In order to better understand the risk factors, mortality and management of post-HSCT AIHA, we carried out a retrospective analysis of 533 allogeneic HSCTs in adult patients performed at King's College Hospital between 2005-2011. Method The median follow-up period after HSCT was 31 months (range 2.9 – 100 months). The primary endpoint was the onset of AIHA, defined by positive direct agglutinin test (DAT) arising after the HSCT, with biochemical markers of hemolysis (raised serum lactate dehydrogenase (LDH), reduced haptoglobin, or spherocytes on the blood film). Hemolysis was considered significant if the drop in hemoglobin was more than 20 g/l. Cases of DAT positivity due to ABO antibodies, as well as those with history of AIHA or positive DAT prior to HSCT were excluded. Potential risk factors for development of AIHA were calculated with univariate followed by multivariate analysis comparisons of incidence of AIHA for each clinical stratum. Kaplan-Meier method was used to compare mortality caused by AIHA against overall mortality (OM), and transplant-related mortality (TRM). AIHA was modelled as a time-dependent variable when estimating mortality. All patients alive at last follow-up who did not develop AIHA were censored. Results We identified 19 cases of AIHA following HSCT (overall incidence 3.6%). The median time to onset from HSCT to AIHA was 202 days. AIHA was associated with HSCT from unrelated donors (p = 0.026; Hazard Ratio = 5.28, 95% CI = 1.22 – 22.9), and concordant sex between HSCT recipients and donors (p = 0.045; Hazard Ratio = 3.52; 95% CI = 1.03 – 12.1). No significant association was observed between AIHA and the following eight factors: recipient gender; primary hematological disease; source of hematopoietic stem cells; conditioning regimen (alemtuzumab/ATG versus non-alemtuzumab/ATG, and reduced intensity versus myeloablative); HLA mismatch between donor/recipient; ABO mismatch; recipient CMV status; and concurrent chronic GvHD. AIHA patients also exhibited high frequency of simultaneous alloimmunization to Rh antigens coinciding with the onset of AIHA, which was not due to difference in transfusion rates, and not observed in the population who tested negative for DAT. Majority of AIHA patients (14/19; 72%) required multiple agents for treatment, but only 9/19 (47%) cases achieved complete resolution of AIHA (1 with intravenous immunoglobulin; 2 with prednisolone alone; 6 with rituximab in combination with other agents). The median survival from onset of AIHA was 487 days (range 26 – 1977 days). We compared the mortality of the AIHA versus non-AIHA population that survived beyond the median time of onset for AIHA (202 days). Patients with post-transplant AIHA had a higher OM (p = 0.006, Hazard Ratio = 2.37, 95% CI = 1.28 – 4.39), 1-year OM of 22% versus 10% (p = 0.04) and 1-year TRM of 18% versus 4% (p = 0.001), respectively (Figure 1). 36% (4/11 cases) of deaths were attributable to AIHA. Conclusion The overall incidence of AIHA following allogeneic HSCT in our study was 3.6%. The risk factors associated with AIHA were receiving HSCT from unrelated donors, and matched gender between the donor/recipient, which has not been previously reported. We observed an association between allo and autoimmunization in the AIHA patients, suggesting a common immune defect underlying both phenomena. The most effective treatment was a combination regimen of rituximab with prednisolone or other immunosuppressive agents. The overall mortality rate for our AIHA patients was high at 53% (10/19 cases), with AIHA as a cause of death in 36% of deceased patients. We have shown that AIHA following HSCTs indeed leads to increased mortality with over 2 fold higher OM in the patients with AIHA. Figure 1 Figure 1. Disclosures McLornan: Novartis: Research Funding.

Description: Background: Blood transfusion is a key intervention in the management of sickle cell disease (SCD), and is being increasingly used. Nonetheless, transfusion is not without risks; alloimmunisation to red blood cell antigens is a major complication, and can sometimes precipitate a delayed haemolytic transfusion reaction (DHTR), a potentially life-threatening event. Objectives: We describe the prevalence, risk factors and experience of DHTR in a large cohort of adult patients with SCD. Methods: Medical records of the 637 adult patients (all of African descent) regularly attending the SCD specialist clinic at King’s College Hospital, London, were retrospectively reviewed to identify DHTR cases. 362 (57%) were female, with 401 HbSS, 202 HbSC, 29 HbSβ+-thalassaemia (thal), 4 HbSβ0-thal, and 1 HbSSHPFH patients, mean age 36 ± 12 years. Between 1st August 2008 and 31st December 2013, 219 of the 637 patients received red blood cell transfusion, either as simple or exchange transfusion. 123 /219 (56%) of those who received transfusion were female, 84% HbSS genotype. Their Electronic Patient Records were examined, looking for a sharp drop in haemoglobin (Hb) after transfusion. If this was observed, laboratory data were combined with the clinical notes to detect evidence of a DHTR. Results: We identified 25 DHTR episodes (1.2% of all transfusion episodes) in 16 patients (table 1). Six patients had repeat DHTR episodes – 4 twice, one thrice, and one 4 times. Mean age at transfusion was 35.5 ± 14.8 years. Indications for the transfusion that triggered the DHTR, included 20 acute pain episodes (some with acute chest syndrome), 3 pre-operative and 2 chronic exchange program. Mean interval from transfusion to DHTR onset was 11 ± 7 days. Typical presentations of DHTR were fever, pain and hemoglobinuria. Blood results at DHTR diagnosis showed evidence of active haemolysis (mean LDH 1330 IU/L), and Hb drop (mean drop 40.4g/L, range 7 – 88g/L). 84% of episodes showed a severe haemolysis with nadir Hb lower than the pre-transfusion Hb. Mean reticulocyte count at peak haemolysis was 291 x109/L ± 121 x109/L. Eleven of the 25 episodes (44%) resulted in new red cell antibodies; 8 alloantibodies and 3 autoantibodies (table 1). DAT was positive in 16 of 19 (84%) cases where performed. 56% (14/25) of DHTR episodes were not diagnosed during admission, most often they were misdiagnosed as an acute pain crisis. Four of the 11 recognised DHTRs were treated with immunosuppression that included methylprednisolone, immunoglobulin, and, in one case, rituximab. All four of these uneventfully received further blood transfusions. The mean length of hospital stay was 15.9 days. 2/16 patients died, one of stroke, one of multi organ failure, giving a 13% mortality. Discussion: Our data suggest that DHTRs are a severe but uncommon complication of blood transfusion. They are poorly recognised, possibly as their presentation mimics an acute painful crisis. Notably, most of the DHTRs are triggered by RBC transfusions in the acute setting. We recommend a high index of suspicion for DHTR in any SCD patient who has been transfused in the past month and presents acutely to clinicians, as early intervention can be life-saving. Table 1. Table 1. *Exchange Disclosures No relevant conflicts of interest to declare.

Description: Bone marrow CD34+ cell apoptosis (annexin V), proliferation (Ki-67), and Bcl-2-related protein expression was evaluated by flow cytometry in 102 patients with myelodysplastic syndrome (MDS) and acute myeloid leukemia secondary to MDS (MDS-AML) and in 30 normal donors (NBM). Apoptosis was significantly increased in refractory anemia (RA)/RA with ringed sideroblasts (RARS) (56.9% [20.4%-93.6%]) and refractory anemia with excess blasts (RAEB) (51.2% [25.2%-76.6%]) compared with NBM (16.7% [3.4%-35.3%],P 

Description: Reduced-intensity conditioned (RIC) hematopoietic stem cell transplantation (HSCT) has improved the accessibility of transplantation in patients previously ineligible. We report the results of allografting following conditioning with fludarabine, busulphan, and alemtuzumab in 62 patients with myelodysplastic syndromes (MDSs) (matched sibling donors [24] or volunteer unrelated donors [VUDs, 38]). The median age for sibling recipients was 56 years (range, 41-70 years) and for VUD recipients, 52 years (range, 22-65 years), with a median follow-up (survivors) of 524 days (range, 93-1392 days) and 420 days (range, 53-1495 days), respectively. The nonrelapse mortality (NRM) at days 100, 200, and 360 was 0%, 5%, and 5%, respectively, for siblings and 11%, 17%, and 21%, respectively, for VUD. The overall survival at one year was 73% for siblings and 71% for VUDs, with a disease-free survival (DFS) of 61% and 59%, respectively. The prognostic significance of the International Prognostic Scoring System (IPSS) was preserved. Of recipients, 86% achieved full-donor chimerism. The cumulative incidence at day 100 of grades III to IV graft-versus-host disease (GVHD) for VUD recipients was 9% and for sibling recipients, 0%. There were 26 patients (16 sibling and 10 VUD) who received donor lymphocyte infusion (DLI) at a median of 273 days (range, 126-1323 days). RIC allogeneic HSCT using this protocol appears to be safe and permits durable donor engraftment. Longer follow-up is required to confirm any potential survival advantage. (Blood. 2004;104:1616-1623)

Description: Platelet transfusion refractoriness results in adverse outcomes and increased healthcare costs. Managing refractoriness due to HLA alloimmunization necessitates the use of HLA antigen matched platelets, but requires a large platelet donor pool, and does not guarantee full matching. We report the first ever randomized, double-blind, non-inferiority, cross-over trial comparing HLA epitope-matched (HEM) platelets with HLA standard antigen-matched (HSM) platelet transfusions. Eligibility criteria were alloimmunized, platelet refractory, thrombocytopenic patients with aplastic anemia, myelodysplastic syndrome or acute myeloid leukemia. HEM platelets were selected using HLAMatchMaker epitope (specifically eplet) matching. Patients received up to eight prophylactic HEM and HSM transfusions provided in random order. Primary outcome was one-hour post transfusion platelet count increment (PCI). 49 patients were randomized at 14 UK hospitals. For intention-to-treat, number of evaluable transfusions was 107 and 112 for HEM and HSM, respectively. Unadjusted mean (SD) PCI for HEM and HSM was 23.9 (15) and 23.5 (14.1) respectively (adjusted mean difference -0.1, 95% CI -2.9, 2.8). As the lower limit of 95% CI was not greater than pre-defined non-inferiority limit, HEM was declared non-inferior to HSM. There were no differences in secondary outcomes of platelet counts, transfusion requirements and bleeding events. Adequate one-hour PCI was more frequently observed with a mean number of 3.2 of epitope mismatches compared to 5.5 epitope mismatches for inadequate one-hour increments. For every additional one epitope mismatch, the likelihood of an adequate PCI decreased by 15%. Epitope matched platelets should be considered to support HLA alloimmunized patients. Funded by NHS Blood and Transplant, ISRCTN23996532.