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Hematopoietic Stem Cell Transplantation for Sickle Cell Disease: Current Practice and Emerging Trends
Shalini Shenoy1
1Division of Pediatric Hematology/Oncology, Washington University, St Louis Childrens Hospital, St Louis, MO
Allogeneic HSCT controls sickle cell disease (SCD)related organ damage and is currently the only curative therapy available. Over the last 2 decades, HSCT has been limited largely to myeloablative matched sibling donor (MSD) procedures that are feasible only in a minority of patients. As the natural history of the disease has evolved, it is clear that subsets of patients with severe disease are at risk for sudden death, devastating CNS and pulmonary complications, and debilitating vasoocclusive crises. For these patients, the benets of transplantation can outweigh the risks if HSCT can be safely and successfully performed with low early and late toxicities. This review describes advances and ongoing investigation of HSCT for SCD from the perspectives of recipient age and presentation, donor stem cell source, intensity of conditioning, family and medical perspectives, and other variables that inuence outcome. Ultimately, HSCT should be viewed as a viable treatment option for SCD on par with other therapies for select patients who can benet from the procedure.
Introduction
Sickle hemoglobin (HbS) results from an amino acid substitution of glutamine to valine at the sixth position in the beta-globin chain as a result of a single nucleotide mutation. Homozygosity (HbSS) results in sickle cell disease (SCD). HbS can occur in combination with other hemoglobin mutations, resulting in disease variants such as HbSC disease or HbS- thalassemia. Although HbSS and S 0 thalassemia are traditionally implicated in the most severe forms of the disease, other variants are not immune from clinical complications that can be life-threatening or debilitating. Polymerization of HbS in deoxygenated states distorts red cells into sickled shapes, resulting in hemolysis and anemia. The widely variable severity of symptoms and target organ damage even within similar phenotypes depends on the extent of vascular inammation/injury, cellular/ chemokine changes, and the induction of a hypercoagulable state that is blamed on inammatory pathways spurred by nitric oxide depletion, C-reactive protein, inammatory cytokines such as IL-6, and adhesion molecules.1,2 However, the level of contribution of individual pathways is unclear, making targeted pharmacologic intervention complicated.3 Although not curative, there have been signicant advances in supportive care for SCD in the last decade. The most inuential have been symptom control, primarily by hydroxyurea, and increased sophistication in red cell transfusion therapy, such as extended phenotype matching to reduce alloimmunization and erythrocytapheresis to reduce iron overload. Hydroxyurea has provided signicant benet by reducing pain episodes, acute chest syndrome hospitalizations and transfusions, and mortality rates both in adults and children, and has minimal genotoxicity or carcinogenicity despite long-term use.4 Only successful HSCT or gene therapy with transduced autologous hematopoietic stem cells can establish complete or partial normal erythropoiesis that results in a cure. Because gene therapy is still in its early development, HSCT is the only established curative treatment modality. HSCT can establish donor-derived erythropoiesis and, more importantly, can stabilize or restore function in
affected organs and prevent further morbidity. Although the benets of HSCT are well established, complications associated with the procedure require continued investigation to target goals such as determining the population best beneted by the intervention, improving engraftment, reducing post-HSCT toxicities and GVHD, and improving availability (donors). These efforts should proceed in parallel with other intervention and supportive care trials in aficted individuals.
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Table 1. Stringent and extended indications for HSCT by donor availability based on a positive risk-benet ratio Matched sibling donor Stroke Elevated TCD velocity Recurrent acute chest syndrome Recurrent VOC Pulmonary hypertension Tricuspid regurgitation Osteonecrosis/AVN Red cell alloimmunization Silent stroke especially with cognitive impairment Recurrent priapism Sickle nephropathy Stroke Elevated TCD velocity Recurrent acute chest syndrome despite supportive care Recurrent severe VOC despite supportive care Red cell alloimmunization and hemolysis and established indication for chronic transfusion therapy Pulmonary hypertension MUD or minimally mismatched good quality cord product Minimally mismatched donor, double cord product, haploidentical donor Recurrent stroke despite adequate chronic transfusion therapy
TCD indicates transcranial Doppler; VOC, venoocclusive crisis; and AVN, avascular necrosis.
adults with SCD.13,14 Stability of pulmonary function is achieved with HSCT. Tricuspid regurgitation measured as a precursor to pulmonary hypertension was noted in more than 20% of children at a mean age of 6.2 years.15 The debilitation of recurrent vasoocclusive crises is harder to dene precisely for a transplantation threshold, but they signicantly impair quality of life.16 Other severe complications include sickle nephropathy, avascular necrosis, silent stroke with cognitive impairment, priapism, and red cell alloimmunization. HSCT needs to be weighed in the context of the risk-benet ratio for each of these indications. Similarly, stringency regarding indications is advisable in the absence of HLA-matched sibling donors (MSDs) given the difference in expected outcomes especially from the perspective of morbidity/mortality and GVHD. HSCT indications should remain a uid paradigm revisited intermittently based on changing transplantation protocols and outcomes (Table 1). With stringent severity criteria (CNS and pulmonary), approximately 16% of patients would qualify for transplantation; approximately 38% would t extended criteria.17 A case could be made for consideration of extended criteria for related donor HSCT, reserving unrelated donor (URD) transplantations only for those patients with severe disease based on stringent criteria. Donor availability and transplantation indications (Table 1) need to be further balanced with recipient age because increased morbidity and mortality is expected with young adult patients compared with HSCT in children with SCD. This is attributable to established organ dysfunction and comorbidities expected with age. Because the validity of expanding HSCT indications are dened by outcomes to dene risk-benet ratios, expansion of transplantation options and donor options from the sibling to the URD setting should only be undertaken in a trial setting.
less than 16 years of age. Disease and age-related comorbidities result in higher morbidity and mortality rates in older patients undergoing HSCT.20,21 Management of disease-related organ damage exacerbated by HSCT-related conditioning and other events is complex and SCD transplantations have unique complications that need to be managed to prevent excess morbidity and mortality; these include hypertension, stroke, seizures, and renal dysfunction. Because transplantation is generally undertaken after an established complication predicts severe disease, almost all recipients are higher risk. Myeloablative transplantation outcomes are good in the young ( 16 years) likely due to the absence of comorbid conditions and organ decompensation.22-24 This age bar could potentially be pushed higher into the second decade with a reduced-intensity treatment (RIT) conditioning approach that could be better tolerated in the presence of organ toxicity. Trials of RIT HSCT that include older patients with SCD using matched related, unrelated, and haploidentical donors are under way and in early stages of enrollment at the National Institutes of Health, Blood and Marrow TransplantRelated Clinical Trials Network (BMT CTN) Sickle Cell Unrelated Transplant (SCURT), the NIH, and at the Johns Hopkins School of Medicine. Acceptability of transplantation in the pediatric age group is a parent-dependent decision that can be a difcult even with adequate information and education. When SCD parents were polled by questionnaire, 37% of parents were willing to accept HSCT as a treatment modality given a 15% mortality risk, but acceptance dropped to 13% if the mortality risk was 15% and GVHD risk was 15%.25 The acceptability of transplantation is higher in adult SCD patients, presumably because of experience with complications of the disease. In 2 adult surveys, 63% of adult SCD patients were willing to accept a mortality risk of 10% and 60% were willing to accept a RIT transplantation trial, but only 20% would accept chronic GVHD and only 50% would accept infertility.26,27
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Figure 1. Algorithm for consideration to expand donor selection on experimental HSCT trials for SCD. The efcacy of MSD transplantations and the paucity of sibling donors requires continued careful evaluation in trial settings of alternative donor transplantations; options are listed in this algorithm.
toxicity and mortality risks, but is now more acceptable with RIT regimens that are better tolerated.28 The paucity of minority donors in the registry often limits nding a suitable MUD in this population.29 The probability of nding a matched marrow or cord product for SCD patients depends on the level of mismatching that is considered acceptable. Restricting donor searches to 8 of 8 highresolution HLA matching for BM and 5-6 of 6 intermediateresolution (class I) and high-resolution (class II) for cords with an adequate cell dose ( 5 105 CD34/kg) limits availability to approximately 30%-40%.30-32 Upon identication, donor withdrawal has also been a problem. Donor solicitation and retention are critical for the success of HSCT in minority populations irrespective of disease indication. As treatment strategies continue to improve, single allele mismatched marrow transplantations and matched or minimally mismatched single and double cord transplantations with optimized cell dose requirements may be considered acceptable, especially if HSCT methods provide more safety. As an example, strategies such as immunoablative regimens with alemtuzumab that can partially deplete immunoreactive graft T cells or posttransplantation cyclophosphamide as GVHD prophylaxis are under evaluation.33,34 Mobilized peripheral blood products have a higher risk of chronic GVHD and mortality, especially in children. For this reason, pediatric transplantation protocols that use unmanipulated stem cell products have preferred to use BM, especially in nonmalignant disorders whenever feasible. Although chronic GVHD rates are no different, adult patients have had higher mortality after related donor peripheral blood stem cell transplantations for severe aplastic
anemia, and may also benet from marrow as the stem cell source.35 Haploidentical transplantations (preferably from the mother due to the possibility of tolerance to maternal antigens) are under investigation with CD34 selected products and early success has been reported.33 With trials continuing to investigate and dene outcomes in a controlled manner, a future reality will be the ability to offer HSCT to eligible patients based on a selection algorithm (Figure 1).
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Nonablative (MSD)42,44 Number Age, y Conditioning agents OS EFS Graft rejection Death 9 3.8-30 Flu, TBI, ATG 9 1 8 0
(MSD
RIT URD)28,43
Myeloablative (MSD)22-24 179 0.3-22 Bu, Cy, ATG/ALG, TLI/Al 90%-100% 79%-92% 2%-10% GVHD, infection, ARDS
Cord blood (URD)51,52 16 Median 6 y Bu, Cy, ATG/ALG, Flu, TLI/Al, TBI 94% 50% 7 1 1
Haploidentical33
Flu indicates udarabine; Bu, busulfan; Al, alemtuzumab; Mel, melphalan; Cy, cyclophosphamide; TLI, total lymphoid irradiation; ATG, anti-thymocyte globulin; ALG, anti-lymphocyte globulin; TBI, total body radiation; OS, overall survival; EFS, event-free survival; and TT, thiotepa.
and eligibility for transplantation, conditioning strategy, management of SCD patients after HSCT, and tailoring transplantation strategies based on donor availability and recipient status are the focus of newer transplantation trials and worthy of investigation. Previous trials have been instrumental in proving the benet of transplantation in SCD. Deterrents to HSCT include the risk of immediate mortality, graft rejection, infections, GVHD, and later sterility, ovarian failure, and poor spermatogenesis. Supportive care strategies such as hydroxyurea and erythrocytapheresis/iron chelation therapy have been perfected to support reasonable longevity into middle adulthood, but the patients course will be difcult due to the medical and psychosocial complications of chronic disorders such as iron overload, infection risk, alloimmunization, narcotic dependence, poor compliance, and poor quality of life. The cost and availability of medical resources for lifelong medical care has to be considered. Hospital admissions cost $1000/day and outpatient visits for transfusions cost $350 each (based on 2009 data). Further, disease progression, organ involvement, and sudden death can occur despite these measures. Before embarking on HSCT, it is essential that both conservative therapy options and HSCT pros and cons are discussed in detail and in a balanced fashion by a combined hematologist-transplantation team for informed decision making. Like supportive care measures, transplantation efforts targeting newer interventions are directed at improving the safety and efcacy of HSCT to minimize areas of risk and make a curative intervention available to the majority of patients.
was noted in 74% and 34% of recipients at 1 and 6 months, respectively; the incidence of secondary (late) graft rejection at 1 year after transplantation was only 8%.41 Murine models of SCD suggest that normal erythrocytes have a survival advantage that may be based both on normal red cell longevity and effective erythropoiesis.
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Figure 2. Conceptual projection of acceptable transplantation toxicities based on known risks from URD transplantation.
success without evidence of GVHD.33 Continued success with this approach opens yet another transplantation avenue for SCD. Taking host factors (disease severity) and donor availability into consideration, a donor selection algorithmic process with optimized individual transplantation approaches for each source is a necessary future direction that will allow the best use of an available stem cell source (Figure 1). A single transplantation approach will not t all. Similarly, the acceptability of adverse outcomes such as treatmentrelated mortality, graft rejection, and chronic GVHD will need to vary between groups. Figure 2 shows anticipated differences in HSCT outcomes after URD transplantations based on host factors. The BMT CTN is conducting a trial of URD BM RIT transplantation, the SCURT trial, for children less than 20 years of age with severe SCD. This trial accepts only fully (8 of 8 at A, B, C, and DRB1) matched marrow donors to optimize outcomes. Stopping rules are designed to detect unacceptable outcomes of death, GVHD, and graft rejection in a timely fashion. This is an important trial designed to answer questions regarding the benets of URD HSCT for SCD. Our current strategy in children is to use an RIT regimen (alemtuzumab, udarabine, and melphalan) for patients with matched marrow donors and to enroll eligible patients in the SCURT trial. This trial was closed to unrelated cord transplantation recipients due to increased graft rejection. Patients with severe disease with unrelated, well-matched cord/ double cord/allele mismatched marrow options can be enrolled in other experimental multicenter trials of intensied RIT conditioning, with requisites for cord size and matching. Haploidentical CD34-selected stem cell transplantation trials are in development or under way at several centers, as are RIT transplantations for young adults. Ultimately, the cooperative goal of the sickle cell transplantation community is to design safe and benecial transplantation approaches that can cure this devastating disease. These need to be evaluated in a trial setting so that outcomes can be clearly dened.
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Disclosures
Conict-of-interest disclosure: The author declares no competing nancial interests. Off-label drug use: None disclosed.
Correspondence
Shalini Shenoy, MD, Division of Pediatric Hematology/Oncology, Box 8116, Washington University, St Louis Childrens Hospital, 1 Childrens Place, St Louis, MO 63110; Phone: (314) 454-6018; Fax: (314) 454-2780, e-mail: shenoy@wustl.edu.
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