Treatment of Donor-Specific Antibody-Mediated Graft Rejection by Immunochemotherapy, Third-Party DLI, Plasmapheresis and Immunoa

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LETTER TO THE EDITOR Treatment of donor-speciﬁc antibody-mediated graft rejection by immunochemotherapy, third-party DLI, plasmapheresis and immunoadsorption

Bone Marrow Transplantation (2015) 50, 613–614; doi:10.1038/ B cells, we first administered immunochemotherapy according to bmt.2014.321; published online 26 January 2015 a modified fludarabine, cytarabine, rituximab (FCR) scheme (rituximab 3 × 375 mg/m2 days +27 to +30, cyclophosphamide 2 fl 2 fi 3 × 300 mg/m and udarabine 3 × 30 mg/m both days +30 to In allogenic SCT, patient-derived donor-speci c HLA antibody +32). Most prophylactic desensitization protocols used irradiated (DSA)-mediated graft rejection is a rare, but serious complication. 1 lymphocyte infusions (DLI) or platelet infusions from the original Gergis et al. recently described a new therapeutic approach to donor or infusion of surrogate platelets.2 In our patient, no DLI or reduce pre-existing DSA before allogeneic transplantation to donor platelets were available, as this donor was prepared for the enhance the likelihood of engraftment in 10 patients. They second donation. In this special situation, we took advantage of combined pretransplant extracorporeal antibody elimination by the fact that the haploidentical son carried the same mismatched plasmapheresis with immunochemotherapy (rituximab, bortezo- A2 antigen as the donor (Table 1). We hence isolated a total of mib and/or intravenous immunglobuline (i.v.IG)) and thereby 1.9 × 108 CD3+ lymphocytes/kg from the haploidentical son and achieved substantial reduction in DSA titers with sustained infused these cells after irradiation in three fractions on days +32 engraftment in nine patients. and +33 (MFI 9846 before the first and MFI 7894 after last We here report the case of a patient suffering from primary application, respectively). However, both the pharmacological graft failure due to elevated DSA titers. Although a combination of intervention and third-party DLI failed to substantially decrease pretransplant immunochemotherapy and third-party DLI with the DSA titers (Figure 1). Therefore, the patient received a high- fi plasmapheresis seemed to be inef cient in reducing DSA titers dose i.v.IG (1 g/kg bodyweight) on day +33, followed by alone, immunoadsorption additionally performed in the post- extracorporeal DSA elimination using plasmapheresis (exchange fi transplant period might have helped to achieve suf cient DSA of 1, 5 plasma volumes against fresh frozen plasma) on days +34 titer reduction, thereby facilitating sustained engraftment. and +35 (MFI 9538 before the first and MFI 6581 after last A 44-year-old female with the diagnosis of AML with plasmapheresis). We observed a transient decrease in the DSA myelodysplastic syndrome-related changes was referred to our titers after each treatment, which was rapidly followed by a transplant unit in January 2014 after failing two induction cycles rebound of antibody titers the following day —a well-described including one course of high-dose cytarabine. Following an phenomenon2 (Supplementary Table S1). extensive donor search, we identified an unrelated donor with a In the presence of still elevated DSA (MFI 5905), we performed 10/10 match in the graft-versus-host (GvH) direction, but only a the second transplant (7.8 × 106 CD34+ cells/kg bodyweight) on 9/10 match in the host-versus-graft direction (Table 1). At that day +35 without any additional conditioning regimen apart of the time, HLA class one and class two antibodies were identified, FCR immunochemotherapy. This time we infused the second including a donor-specific anti-A2. As we did not type HLA-DP, we transplant directly into the BM. The DSA titers remained high do not know whether there were additional DSA against after transplantation. We switched from plasmapheresis to mismatched DP. Because of refractory leukemia, the patient was immunoadsorption (IA) with regenerable protein A adsorber treated with a sequential high-dose conditioning therapy consist- columns (Immunosorba, Fresenius Medical Care, Bad Homburg, ing of fludarabine, amsacrine, cytarabine, i.v. busulfan and Germany), for extracorporeal DSA elimination, as IA allowed an melphalan followed by transplantation of an unmanipulated intensified daily treatment of three plasma volumes without the peripheral blood stem cell graft containing 7.9 × 106/kg CD34+ necessity for substitution of exchanged clotting factors with fresh cells. Rabbit-ATG 40 mg/kg, tacrolimus and mycophenolate frozen plasma as a potential additional source of anti-A2 mofetil were used for GvHD prophylaxis. No additional action antibodies. IA was performed three times on days +40 (MFI was taken to reduce the pretransplant DSA titers. Until day+20, no 4314) to +42, until the DSA titers were reduced to o600 MFI. As hematological reconstitution was observed. BM biopsy showed an indicated in Figure 1, after the three sessions of IA no further acellular marrow without maturing hematopoiesis and donor rebound of DSA titers was detected during the next months. We chimerism of 40.5%, indicating primary graft failure. In parallel, a observed sustained neutrophil and platelet engraftment on day single antigen bead assay revealed increasing fluorescence +48 (that is, day +12 after the second transplant). BM biopsy on intensities of the anti-A2 antibody (MFI 4529), suggesting this day +28 after the second transplant showed maturing hematopoi- DSA as the primary cause for the graft failure. esis and 98.8% donor chimerism (MFI 654). After 6 months the To maximize the likelihood of engraftment of the second patient still remains in remission with a full, donor-derived transplant by the elimination of the resident DSA-producing hematopoietic reconstitution and a low DSA titer.

Table 1. HLA-phenotype of the patient, the stem cell donor and the patient’s son

HLA-A HLA-B HLA-Cw HLA-DRB1 HLA-DQB1

Patient 24:02,24:02 15:01, 27:02 02:02, 03:03 03:01, 16:01 02:MS, 05:02 Donor 02:01,24:02 15:01, 27:02 02:02, 03:03 03:01, 16:01 02:MS, 05:02 Patient's son 02:01,24:02 15:01, 44:02 03:03, 05:01 03:01, 04:01 02:MS, 03:SAK Letter to the Editor 614 FCR ivIG PP IA

10000 10000

2nd Tx Platelet count x10 / nl Leukocytes / nl 8000 Anti-A2 / MF1 8000

DLI Platelet count [x10/nl] 6000 6000 leukocytes [/nl]

4000 4000 Anti-A2 antibody [MFI]

2000 2000

0 0

23 25 27 29 31 32 33 34 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 84 days post 1st allo TX Figure 1. The figure shows the anti-A2 DAS titers (dashed line) as well as the numbers of leukocytes (dotted line) and thrombocytes (continuous line). In the upper part, arrows mark the use of DSA reducing procedures such as immunochemotherapy (FCR = fludarabine, cytarabine, rituximab), PP = plasmapheresis, ivIG = intravenous immunglobulin substitution and IA = immunoadsorption. Platelet transfusions are not marked in the figure.

Awareness of pretransplant DSA and the associated risk of graft stem cells could have had a beneficial effect. Prospective studies failure increased during the last years, as the number of are definitively needed to evaluate the impact of IA on reduction mismatched and alternative donor transplants such as haploiden- of the DSA titers and the associated risk of graft failure. tical and cord blood transplants is growing. Published strategies to decrease DSA titers consist of plasmapheresis, i.v.IG, rituximab, bortezomib, donor platelet or DLI infusion so far. We used an CONFLICT OF INTEREST alternative approach to circumvent DSA-associated graft rejection: The authors declare no conflict of interest. (1) we administered for the first time third-party DLI of the haploidentical son, who shares the same HLA-A2 mismatch CM Wilk1, JC Fischer2, G Schieren3, JM Rox2, R Haas1, LC Rump3, probably having caused humoral sensitization during pregnancy. G Kobbe1 and T Schroeder1 (2) To prevent exposure of the transplant to the high DSA titers in 1Department of Hematology, Oncology and Clinical Immunology, serum, we injected the second transplant directly into the BM. University Hospital Düsseldorf, Medical Faculty, Düsseldorf, Germany; So far, intrabone injection of blood stem cells has not been reported 2Institute for Transplantation Diagnostics and Cell in the context of DSA, but is an option for cord blood transplantation Therapeutics, University Hospital Düsseldorf, Medical Faculty, to hasten hematopoietic recovery,3 (3) We applied post-transplant-IA Düsseldorf, Germany and to achieve a sustained DSA titer reduction. IA has previously been 3Department of Nephrology, University Hospital Düsseldorf, Medical used almost exclusively in solid organ transplantation to manage Faculty, Düsseldorf, Germany ABO incompatibility or allosensitization. In the context of alloSCT, E-mail: [email protected] only one patient has been reported so far in whom DSA were significantly reduced by protein A immunoadsorption.4 REFERENCES In summary, our time to manage DSA-mediated graft failure was limited and we therefore sequentially applied a number of 1 Gergis U, Mayer S, Gordon B, Mark T, Pearse R, Shore T et al. A strategy to reduce potentially effective actions. Thus, it is difficult to ascertain a donor-specific HLA Abs before allogeneic transplantation. Bone Marrow Transplant 49 – definitive role of the employed intervention, and we also cannot 2014; :722 724. exclude that more conventional treatment with immunochem- 2 Zachary AA, Leffell MS. Desensitization for solid organ and hematopoietic stem cell transplantation. Immunol Rev 2014; 258: 183–207. otherapy, plasmapheresis and i.v.IG had a delayed effect on DSA fi 3 Rocha V, Labopin M, Ruggeri A, Podestà M, Gallamini A, Bonifazi F et al. Trans- titer, thereby contributing to nal engraftment. However, the plantation 2013; 951284–1291. clinical course and the course of DSA level reduction argue in 4 Braun N, Faul C, Wernet D, Schnaidt M, Stuhler G, Kanz L. Successful transplantation favor that IA may have contributed to decrease DSA in our patient, of highly selected CD34+ peripheral blood stem cells in a HLA-sensitized patient facilitating engraftment. In addition, intra-marrow injection of treated with immunoadsorption onto protein A. Transplantation 2000; 69:1742–1744.

Supplementary Information accompanies this paper on Bone Marrow Transplantation website (http://www.nature.com/bmt)