scholarly journals Reduced Toxicity Conditioning Is Better Tolerated but Has Higher Graft Failure Compared to Myeloablative Conditioning in Children with Inherited Metabolic Disorders

2019 ◽  
Vol 25 (3) ◽  
pp. S41
Author(s):  
Michael Downey ◽  
Ashish Gupta ◽  
Ryan Shanley ◽  
Weston P. Miller ◽  
Troy C. Lund ◽  
...  
Keyword(s):  
Graft Failure ◽  
Metabolic Disorders ◽  
Myeloablative Conditioning ◽  
Inherited Metabolic Disorders ◽  
Reduced Toxicity

scholarly journals Reduced Toxicity Conditioning for Non-Malignant Hematopoietic Cell Transplants

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4481-4481
Author(s):  
Cristina F Contreras ◽  
Janel R Long-Boyle ◽  
Kristin A. Shimano ◽  
Jasmeen Dara ◽  
James N Huang ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Whole Blood ◽  
Research Funding ◽  
Metabolic Disorders ◽  
Bone Marrow Failure ◽  
Class I ◽  
Myeloablative Conditioning ◽  
Donor Chimerism ◽  
Inherited Metabolic Disorders ◽  
Matched Sibling

Background. Reduced-intensity conditioning (RIC) regimens are commonly used for hematopoietic cell transplantation (HCT) in non-malignant disorders to minimize potential drug-related toxicity from myeloablative conditioning (MAC). However, melphalan-based RIC regimens are associated with poor engraftment and need for second HCT or donor lymphocyte infusions (DLIs). This study expands on our previous experience with targeted busulfan, fludarabine, and intravenous (IV) alemtuzumab as a low-toxicity but myeloablative regimen to achieve sustained donor engraftment. Methods. We conducted a retrospective analysis of patients ≤25 years of age with non-malignant disorders who received targeted busulfan, fludarabine and IV alemtuzumab as conditioning for their first HCT between 2004 and 2018. Graft-versus-host disease (GVHD) prophylaxis included calcineurin inhibitors in all patients, plus methotrexate (n=59), methylprednisolone (n=2), or mycophenolate (n=1). The primary end point was 3-year overall survival (OS). Secondary end points included treatment-related mortality (TRM), event-free survival (EFS) defined as alive without second HCT or disease progression, and incidence of acute and chronic GVHD (aGVHD and cGVHD). Other end points included incidence of graft failure (GF) defined as <5% donor chimerism in whole blood, sinusoidal obstruction syndrome (SOS) and CMV viremia. Analysis was stratified by era of HCT (2004-2011 vs. 2012-2018). Results. We identified 62 patients with a median age of 5.5 years and male:female of 46:16. Diagnoses included primary immune deficiencies (60%), hemoglobinopathies (22%), bone marrow failure disorders (8%) and inherited metabolic disorders (10%). The median busulfan cumulative area-under-the-curve (cAUC) was 70 mg*h/L (range, 57-108 mg*h/L). Donors were matched sibling (MSD) in 27%, 8/8 allele-matched unrelated (MUD) in 50% and Class I allele-mismatched (MM) in 23%. All but 2 of the Class I allele-MM donors were unrelated. The source was bone marrow (BM) in 74% and peripheral blood stem cells (PBSC) in 26%. The cumulative incidence (CI) of GF was 8% (95% CI, 1-16%). In engrafted patients, the median donor chimerism in whole blood, CD3, CD14/15, and CD19 at 1-year was 96%, 90%, 99%, and 99%, respectively. Only 1 patient required DLIs for poor chimerism. T-cell reconstitution (CD4 >200 x 109/L and PHA response >50% control) was achieved at a median of 182 days (range, 76-585 days). Two patients died following disease progression despite 100% donor chimerism. The CI of TRM was 10% (95% CI, 2-17%). Causes of TRM included infectious complications (n=2), hemorrhage (n=1), respiratory failure (n=3 with 2 following subsequent transplants after graft rejection). TRM incidence was significantly higher in patients with Class I MM compared to those with MSD or 8/8 allele-MUD (29% vs 6% vs 3%; p=0.024; Figure 1A). SOS occurred in 5% of patients and all resolved with supportive therapy (n=1) or defibrotide (n=2). Post-transplant CMV viremia occurred in 26% of all patients and in 71% of CMV seropositive patients. None developed CMV disease and all infections resolved with anti-viral therapy. OS and EFS at 3-years were 87% (95% CI, 78-95%) and 80% (95% CI, 70-90%), respectively. HCTs performed in the more recent era showed an OS of 97% compared to 79% in HCTs performed earlier (p=0.057; Figure 1B). OS was 97% in patients with 8/8 allele-MUD compared to 79% in those with MSD and 71% in those with Class I allele-MM (p=0.051). The 6-month CI of grade II-IV aGVHD was 7% (95% CI, 3-13%), while the 3-year CI of cGVHD was 5% (95% CI, 0-11%). GVHD incidence was higher in patients receiving PBSC compared to BM (25% vs 0%; p<0.001) and in patients ≥5 years of age compared to those <5 years of age (13% vs 0%; p=0.043). Patients with inherited metabolic disorders showed significantly worse OS (44%, p=0.016), EFS (33%, p=0.001) and aGVHD (33%, p=0.008) than those in other disease groups. Univariate analysis did not show any significant differences in survival or GVHD incidence by race or sex. Conclusions. Use of targeted busulfan, fludarabine and IV alemtuzumab as myeloablative conditioning in pediatric patients with primary immunodeficiencies, hemoglobinopathies, and bone marrow failure syndromes undergoing matched sibling or well-matched unrelated donor HCT provides a well-tolerated option to achieve sustained engraftment with low incidence of GVHD and toxicities such as SOS. Figure 1 Disclosures Shimano: Pfizer: Research Funding; Daiichi Sankyo: Research Funding; Novartis: Research Funding. Huang:Novartis: Research Funding. Cowan:Homology Medicine: Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Leadiant: Consultancy; California Institute Of Regenerative Medicine: Research Funding; NIH NIAD: Research Funding; Rocket Pharma: Consultancy; UpToDate: Honoraria; bluebird bio: Consultancy. Dvorak:Alexion Inc: Consultancy; Jazz Pharmaceuticals: Consultancy.

High-Exposure, Targeted Daily Busulfan and Fludarabine-Based Conditioning for Children Undergoing Hematopoietic Stem Cell Transplantation for Inherited Metabolic Disorders: Outcomes at a Single Center

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2191-2191
Author(s):  
Weston P Miller ◽  
Melisa Kay Stricherz ◽  
Cathryn Jennissen ◽  
Nicole Sando ◽  
Jennifer Danielson ◽  
...  
Keyword(s):  
Stem Cell ◽  
Hematopoietic Stem Cell Transplantation ◽  
Stem Cell Transplantation ◽  
Cell Transplantation ◽  
Graft Failure ◽  
Metabolic Disorders ◽  
High Exposure ◽  
Hematopoietic Stem ◽  
Once Daily ◽  
Inherited Metabolic Disorders

Abstract Allogeneic hematopoietic stem cell transplantation (HSCT) has emerged as standard therapy for children suffering from various life-threatening inherited metabolic disorders (IMD). Historically, successful outcomes have been limited by high rates of both graft failure and regimen-related toxicity. Real-time busulfan pharmacokinetic monitoring, combined with once daily dosing, has allowed for more precise delivery of targeted exposures during transplant conditioning. Recently, the Utrecht group reported highly favorable outcomes following a high-dose busulfan and fludarabine-based preparative regimen in patients with a variety of diagnoses, particularly in comparison to historical regimens that employ two or more alkylating agents. We report our experience using the same regimen specifically in patients with IMD. Since July 2014, 24 children undergoing first HSCT for IMD were conditioned with once daily IV busulfan (4 days; total regimen exposure of 90 mg x h/L) and once daily IV fludarabine (40 mg/m2/day x 4 days). Busulfan pharmacokinetic monitoring was performed on each of the first 3 doses (days); subsequent doses were altered to achieve the desired total regimen exposure. Serotherapy use was donor-dependent: HLA-matched related donor (MRD, n = 5), none; unrelated UCB (n = 16), thymoglobulin (2.5 mg/kg/day, days - 8 to -5); HLA-matched unrelated donor (MUD, n = 1), thymoglobulin (2.5 mg/kg/day, days - 5 -to -2); and, related HLA haploidentical marrow (n = 2), alemtuzumab (0.5 mg/kg divided days -11 and -10), +/- rituximab (375 mg/m2, day -12). All patients received CSA for GvHD prophylaxis. Additional GvH prophylaxis depended upon the allograft source: UCB, prednisolone; MRD/MUD, MMF; related haploidentical, MMF and post-transplant cyclophosphamide. Growth factor support was administered to recipients of UCB or haploidentical grafts. IMD diagnoses were as follows: Hurler syndrome (n = 10); cerebral adrenoleukodystrophy (n = 9); metachromatic leukodystrophy (n = 1); osteopetrosis (n = 1); fucosidosis (n = 1); alpha-mannosidosis (n = 1); and, beta-mannosidosis (n = 1). At a median follow-up of 229 days (range, 15 - 743), 22 of 24 patients survive, with a Kaplan Meier estimate of survival at one year of 86%. Causes of death were pulmonary bronchiolitis obliterans (BOS, n = 1) and graft failure (n = 1). Twenty-two patients had initial donor neutrophil recovery at a median day +14 (range, +11 to +21); for these patients, the median duration of severe neutropenia (ANC < 500/μL) was 7.5 days (range, 4 to 16 days). Of 20 patients who at the time of analysis are ≥ 30 days from HSCT, 18 had platelet engraftment (≥20,000/μL, transfusion unsupported) at a median day +22.5 (range, +10 to +94). One patient developed Grade II aGvHD (haploidentical marrow graft) which was successfully treated; no patients developed Grade III-IV aGvHD. One patient developed chronic GvHD with fatal BOS (UCB). Regimen-related complications were as follows: veno-occlusive disease, n = 0; hemorrhagic cystitis, n = 1; diffuse alveolar hemorrhage n = 1; idiopathic pneumonia syndrome, n = 1; immune-mediated cytopenias, n = 2; CMV viremia, n = 3; and, adenovirus infection, n = 1. Twenty patients (83%) have demonstrated durable, complete donor myeloid engraftment following the regimen. Of these, all have demonstrated mixed donor-recipient T-cell chimerism. Four patients, (all UCB grafts), have experienced graft failure: aplastic graft failure, n = 3, and autologous hematopoietic recovery, n = 1. Three of these patients underwent second HSCT and 2 are alive and engrafted while the other died of complications following second transplant. One patient awaits second transplant. In summary, this regimen of high-exposure, targeted daily busulfan and fludarabine in children with IMD provides favorable engrafted survival with minimal toxicities. Disclosures No relevant conflicts of interest to declare.

Ketogenic diets in patients with inherited metabolic disorders

2015 ◽  
Vol 38 (4) ◽  
pp. 765-773 ◽  
Author(s):  
S. Scholl-Bürgi ◽  
A. Höller ◽  
K. Pichler ◽  
M. Michel ◽  
E. Haberlandt ◽  
...  
Keyword(s):  
Metabolic Disorders ◽  
Ketogenic Diets ◽  
Inherited Metabolic Disorders

INHERITED METABOLIC DISORDERS AND HEART DISEASES

2019 ◽  
Author(s):  
Vjekoslav Krželj ◽  
Ivana Čulo Čagalj
Keyword(s):  
Metabolic Disorders ◽  
Metabolic Diseases ◽  
Technological Development ◽  
Heart Diseases ◽  
Glycogen Storage ◽  
Acid Oxidation ◽  
Lysosomal Storage ◽  
Glycogen Storage Diseases ◽  
Coronary Diseases ◽  
Inherited Metabolic Disorders

Inherited metabolic disorders can cause heart diseases, cardiomyopathy in particular, as well as cardiac arrhythmias, valvular and coronary diseases. More than 40 different inherited metabolic disorders can provoke cardiomyopathy, including lysosomal storage disorders, fatty acid oxidation defects, organic acidemias, amino acidopathies, glycogen storage diseases, congenital disorders of glycosylation as well as peroxisomal and mitochondrial disorders. If identified and diagnosed on time, some of congenital metabolic diseases could be successfully treated. It is important to assume them in cases when heart diseases are etiologically undefined. Rapid technological development has made it easier to establish the diagnosis of these diseases. This article will focus on common inherited metabolic disorders that cause heart diseases, as well as on diseases that might be possible to treat.

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