T-Cell Depleted (TCD) Hematopoietic Stem Cell (HSC) Boosts From the Original Donor without Conditioning for Poor Graft Function (PGF) Following Allogeneic Hematopoietic Stem Cell Transplants (HSCT)

Poor graft function without immune rejection, defined as persistent cytopenias with a hypocellular marrow and full donor chimerism, is a life-threatening complication after allogeneic HSCT. Treatment options include supportive therapy with transfusions and growth factors, vs administration of additional HSCs from the same donor without any conditioning (stem cell boost). The use of unmanipulated boosts increases the risk of development or worsening of GvHD by virtue of infusing mature T cells. The aim of this retrospective study was to evaluate the efficacy and safety of TCD boosts in patients with PGF.

PATIENT AND METHODS: Between January 1992 and December 2007, 35 patients from a single center with PGF following either an unmanipulated (10) or a TCD (25) allogeneic HCST received a TCD HSC boost collected from the original donor. T cells were removed ex-vivo from marrow grafts with soybean lectin agglutinin and sheep red blood cells (sRBC) rosetting and from peripheral blood stem cell grafts by positive selection with a CD34 antibody (Isolex) followed by sRBC rosetting. HSC donors were matched related (21), mismatched related (5) and unrelated (9). Indication for first transplant included: aplastic anemia (2), non-Hodgkin's lymphoma (5) and myeloid malignancies (28). The preparative regimen was myeloablative for all recipients of unmanipulated grafts and for 22 of 25 recipients of TCD grafts. With the exception of one patient, the cell dose as measured by total nucleated cell dose/kg or CD34 cells/kg was adequate. Following the initial transplant, all patients had partial or complete recovery of blood counts and full donor chimerism documented by karyotype, FISH analysis or DNA polymorphism.

The median time from first transplant to the diagnosis of PGF was 4.5 months (0.72-90.7). Etiologies of PGF included: viral infection and anti-virals (10), bacterial sepsis (3), Mycobacterial infection (4), low cell dose (1), GvHD 12, and idiopathic (5). None of the patients had evidence of relapse or progression of their underlying disease. All patients received a TCD boost from the original donor; with 21 patients receiving bone marrow and 14 receiving PB HSC.

Seven patients died before day 21 post boost and were not evaluable for blood count improvement. Improvement (PLT>50,000/μL, ANC>500/μL) occurred in 20 of the 28 evaluable patients (71.4 %) at a median time of 3.2 months; 17 of them (60.7%) had a more substantial improvement (PLT ≥100,000/μL and ANC³1000/μL) at a median of 8.81 months. TCD boost infusions were well tolerated with no significant adverse events. Also, no new onset GvHD occurred after TCD boosts; although two patients with preexisting GvHD flared. The median survival for all patients following TCD boosts was 21.47 months (range: 1.84–208.45). The 2-year and 5-year survivals were 48.6% and 37.1% respectively. The 2-year survival for patients who had improvement of their counts was 90% and for those who remained pancytopenic despite the boost was 18%. The 2-year survival according to etiology was 52.9% for the infection group, 50% for the idiopathic and low cell dose, and 33.3% for the GvHD group. Patients were also analyzed according to their medical condition prior to receiving the boost and were separated into four groups based on organ function (serum creatinine ≥ 2; total bilirubin ≥ 2; need for mechanical ventilation) and infection status. Group A: outpatient with no infection and no organ dysfunction (9); group B: hospitalized but afebrile with no infection or organ dysfunction (7); group C: febrile or documented infection but preserved organ function (8); group D: organ dysfunction with or without a concurrent infection (11). The 2-year survival for each group was 55.6%, 85.7%, 50%, and 9%, respectively. Patients with organ dysfunction with or without concurrent infection had the lowest survival. Causes of death included: GvHD (10), infection (5), relapse (4), organ failure (3), and poor graft function (1).

Treatment of PGF with a TCD HSC boost from the original donor is safe and effective with minimal risk of GvHD. Medical status at the time of the boost infusion had a significant impact on outcome. A TCD boost should be considered early in the course of PGF as once complications of persistently low blood counts occur the potential for benefit sharply declines.

Small:Pfizer, Inc: Equity Ownership, family member employed by Pfizer, Inc. Perales:Pfizer, Inc: Equity Ownership.