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Cord Blood Stem Cells Umbilical Cord Blood Transplant for Adult Patients Bone Marrow Transplantation (2004) 33, 33–38 & 2004 Nature Publishing Group All rights reserved 0268-3369/04 $25.00 www.nature.com/bmt Cord blood stem cells Umbilical cord blood transplant for adult patients with severe aplastic anemia using anti-lymphocyte globulin and cyclophosphamide as conditioning therapy P Mao, S Wang, S Wang, Z Zhu, Q Liv, Y Xuv, W Mo and Y Ying Department of Haematology, First Municipal People’s Hospital, Guangzhou, China Summary: therapy with immunosuppressive agents.1 For patients without a sibling donor having no response to one or Allo-CBSCT (cord blood stem cell transplant) has more courses of immunosuppressive therapy a fully been applied in sixadult patients with severe aplastic matched unrelated donor BMT should be considered anemia (SAA). Anti-lymphocyte globulin (ALG) asalternative salvagetherapy. Finding related or unrelated 40 mg kgÀ1 dÀ1 Â 3 days combined with cyclophosphamide individualswho are HLA-identical to some (CTX) 20 mg kgÀ1 dÀ1 Â 3 days constituted a lower patients, however, is difficult and time consuming because intensive conditioning regimen. The prophylaxis of of the extreme polymorphism of most HLA GVHD consisted of standard CsA and MTX. Patients loci. Umbilical cord blood isanother alternative sources are all male having a mean age of 26.5 years (range 22– of stem cells that improves donor availability for trans- 38), and a median weight of 55.6 kg (range 52–60 kg). plantation because frozen and stored UCB can be Cord blood searches were all conducted at Guangzhou made available on demand. Infectiousagents,particularly Cord Blood Bank. Three of sixpatients in our study cytomegalovirus(CMV), are rarely seenin the new received one unit of cord blood in a procedure, whereas for born than in adults. Furthermore, UCBT may have a another three patients, two units of cord blood (double lower incidence and severity of GVHD than conventional units) were infused at the same time in a transplant BMT, allowing successful transplantation in the HLA- protocol. The nine units of umbilical cord blood (UCB) mismatched recipient. Recently, investigators have ex- infused contained 1.6–10.7 Â 107 nucleated cells/kg body plored the applicability of UCB stem cells as a rescue weight of the recipient after thawing. HLA antigens were therapy for both malignant and non-malignant hematolo- identical in one unit, 1 antigen mismatched in seven, 2 gical diseases with some promising results.2,3 We first antigens mismatched in 1. As of February 2003, after a reported in 2000 an UCB transplantation from unrelated median follow up of 20 months (range 7–50), four patients donor in an adult with SAA4 and now report additional are alive and disease free. Five patients engrafted with experience. molecular biology analyses showing donor-recipient mixed chimerism post transplant which is stable and persistent. One patient died of severe infection in the third month from transplant and another patient died in the early stage Patients and methods post transplant of serious aspergillus infection without evidence of engraftment. Patients Bone Marrow Transplantation (2004) 33, 33–38. Six adult patientswith SAA on our studyreceived allo- doi:10.1038/sj.bmt.1704295 CBSCT from December 1998 to January 2002. All patients Keywords: umbilical cord blood; stem cell transplanta- had previously failed immunosuppressive therapy and had tion; severe aplastic anemia no HLA-matched sibling donor. They were all male with the average age of 26.5(22–38) at the time of transplant. Mean interval from diagnosis to CBSCT was 4.6 months (range 2–10 months) and all remained transfu- BMT remainsthe firstchoice in children and young adults sion-dependent when transplanted. All patients were with SAA. Full matched sibling BMT may also considered transfused before transplant and all but one had more in older patients if there is no response to the first-line than four transfusions. Bone marrow smears and biopsy showed failure of hematopoiesis and increased nonhema- topoietic cells and fat cells. Hemolytic screening tests were negative for acidified-serum hemolysis, sucrose lysis test Correspondence: Dr P Mao, First Municipal Peoples Hospital of Guangzhou, Haematology Department, 602, Renmin road, Guangzhou, and venom hemolysis test. In all patients, severe aplastic 5 510180, China; E-mail: [email protected] anemia was diagnosed by standard criteria with the Received 08 April 2003; accepted 05 July 2003 exclusion of MDS. Umbilical cord blood transplant for adult patients P Mao et al 34 Umbilical cord blood according to blood CsA level and MTX 15 mg/m2 (day 1) and 12 mg/m2 (days3, 6, 11). They alsoreceived UCBswere found in Guangzhou cord blood bank. They methyprednisolone 1.0 mg kgÀ1 dayÀ1 p.o. from day 1 to were collected after delivery and cryopreserved in 10% 14, 0.5 mg kgÀ1 dayÀ1 from day 15 to day 28. DMSO in a programmed cell freezer to avoid cell loss which might impair engraftment. Syphilisand viral testsincluding HIV, hepatitisB and C and CMV were performed on both Supportive care mothers’ blood and cord blood units. Tests for genetic diseases such as thalassemia were also performed. Each cord Prophylaxisof infectionsincluded acyclovir, fluconazole, blood waskept in liquid nitrogen below À1921C. Trypan ofloxacin, metronidazole and SMZ. CMV-seropositive blue test to determine the viable cell frequency, flow patients(patients1, 2, and 5) received prophylactic cytometry to count CD34 þ cellsand cell culture for ganciclovir. All blood productswere irradiated and filtered. CFU-GM were done immediately after the cellswere Red blood cell and platelet transfusions were performed to thawed. UCBsrecovery rate were 79–93.5% after thawing. maintain a hemoglobin of 470g/l, platelet count 9 All UCBsand related patientsdata were listedin Table 1. 420 Â 10 /l. Patientswere given a combination of G-CSF 5ugkgÀ1 dayÀ1 and EPO 6000 IU every other day from day 0 until recovery from aplasia. All patients received Preparative conditioning regimen intravenousimmunoglobulin prophylaxisand hyperali- Patients in our study received a pretransplant regimen of mentation when needed. both CTX 20 mg/kg/day i.v. on days-6, -5, -4, and ALG À1 À1 40 mg kg day i.v. on days-3, -2, -1. CTX wasgiven Assessment of engraftment daily as a 2 h infusion. Mesna was administered for uroprotection before the first dose of CTX to 24 h after Hematopoietic chimerism was evaluated by cytogenetic the last dose of CTX. ALG was given daily by continuous methodsasmicrosatelliteDNA fingerprinting for detection i.v. infusion over 6 h. of multiple short tandem repeat loci. The DNA samples were extracted from bone marrow and /or peripheral white GVHD prophylaxis blood cells. ABO-mismatched pairs were usually tested to find conversion of the blood group. All patients received GVHD prophylaxis consisting of CsA The immunoreconstitution evaluation was carried out 4 mg/kg/day (days1-5) followed by regulated dosage prior to and 1, 2, 3, 6, 9, 12 monthsafter transplantation Table 1 Characteristics of patients, donors, and cord blood data after thawing Patient Age Weight HLA-mismatched loci Sex ABO group MNC Â 107/kg CD34+ Â 105/kg CFU-GM Â 104/kg no. (kg) (donor/recipient) (donor/recipient) (donor/recipient) 1 23 60 — M/M AB/B 1.89 1.70 1.80 2 25 59 B13,DR1202/ M/M B/A 10.7 17.20 13.50 B61(40),DR0402 3 26 60 A11/A30(19) M/M O/B 1.60 1.22 1.63 4 37 50.5 A24/A1102 M/M O/B 2.43 1.80 2.96 DR03/DR0403 M/M O/B 3.26 4.43 3.20 5 22 56 B13(Donor1)/B75(15) F/M A/O 2.56 2.94 1.69 B46(Donor2)/B39(16) F/M AB/O 2.18 1.16 1.96 6 24 52.5 B38(16)/B51(5) M/M B/A 4.42 6.74 8.16 B38(16)/B46 F/M A/A 2.20 1.49 2.14 M ¼ male; F ¼ female. Patients 4–6 receiving double-unit transfusion. Table 2 Consecutive observations for recipient’s peripheral blood The month WBC( Â 109/L) BPC( Â 109/L) Hb(g/L) post transplant Patient1 Patient 2 Patient 4 Patient 5 Patient 1 Patient 2 Patient43 Patient54 Patient 1 Patient 2 Patient43 Patient54 0.5 2.6 0.8 1.0 1.2 31 19 16 18 73 62 36 46 1 3.7 2.1 2.1 1.8 62 13 46 20 89 65 32 78 3 4.0 2.4 3.2 2.7 131 21 80 49 123 58 66 126 6 4.1 2.5 3.0 3.6 125 28 82 42 119 86 76 120 9 3.9 4.0 4.2 3.7 161 36 118 68 143 107 90 152 12 4.4 5.8 5.0 5.2 147 88 196 102 135 145 116 159 24 4.8 5.5 186 261 146 142 36 4.6 154 141 48 6.2 184 148 Bone Marrow Transplantation Umbilical cord blood transplant for adult patients P Mao et al 35 and subsequently every 6 months for those longer surviving cytes, T-lymphocytes recovered to normal levels after 6 patients. The investigated immunological parameters in- months. CD4 þ T-lymphocytes were decreased signifi- cluded lymphocyte count, B-lymphocytes, T3-, T4-, T8- cantly during the first 150 days posttransplant while lymphocytes, T4/T8 ratio, natural killer cell (CD3À CD16 þ CD56 þ ) activity and serum-IgG, -IgA, IgM. Results Engraftment and outcome Evidence of engraftment wasfound in five patientsby molecular biology analyses showing donor-recipient mixed chimerism post transplant which is stable and persistent. Median time to ANC 40.5 Â 109/L was18.4 days(range 15–25 days); the median time for platelets counts 420 Â 109/L was37.7 days(range 15–79 days).One patient died of severe infection (both staphylococcemia and trichomycosis nigra) in the third month from transplant though there wasevidence of engraftment.
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