Peripheral blood stem cell transplantation (PBSCT) with in vivo lymphodepletion can provide faster neutrophil recovery with limited risk of severe graft-versus-host disease (GVHD) in children with... Show morePeripheral blood stem cell transplantation (PBSCT) with in vivo lymphodepletion can provide faster neutrophil recovery with limited risk of severe graft-versus-host disease (GVHD) in children with nonmalignant disorders (NMDs). We aimed to provide an historical comparison of these 2 strategies regarding the prevalence of GVHD, viral reactivation, timing of immune reconstitution, and final outcomes. Data on 98 children undergoing PBSCT were collected from 5 European pediatric transplantation centers. Only patients with NMDs receiving treosulfan or myeloablative busulfan conditioning and 9-10/10 HLA-matched transplant were included. The patients were divided into 2 groups according to in vivo lymphodepletion with antithymocyte globulin (ATG) or with alemtuzumab. We compared rates of acute and chronic GVHD; Epstein-Barr virus, cytomegalovirus, and adenovirus reactivation; chimerism; lymphocyte recovery; overall survival (OS) and event-free survival (EFS) between the 2 groups. The rate of severe acute GVHD (grade III-IV) was significantly higher in patients receiving ATG (26% vs 10% in alemtuzumab recipients; P <.05), whereas viral reactivations occurred with a similar rate in the 2 groups (alemtuzumab, 56%; ATG, 57%). Alemtuzumab was the major risk factor for delayed T cell immune reconstitution in the first 3 months after transplantation (odds ratio [OR], 6.0; 95% confidence interval [CI], 1.8 to 19; P <.005). Extended chronic GVHD, ADV reactivation, slower CD3(+) cell recovery, and HLA-mismatch reduced the probability of survival. Infections were the main cause of mortality in our cohort, and delayed T cell recovery was significantly associated with mortality in multivariate analysis (OR, 12; 95% CI, 1.2 to 114; P <.05). Ultimately, no differences in OS and EFS survival were seen between the ATG and alemtuzumab groups. ATG and alemtuzumab showed similar impacts on outcomes of children undergoing PBSCT for NMDs. The 2 strategies of in vivo lymphodepletion showed specific drawbacks that were counterbalanced by benefits that ultimately led to a comparable survival rate. A patient-centered lymphodepletion strategy can be advised in children undergoing PBSCT for NMDs, by favoring T cell recovery in the presence of invasive infection or GVHD prevention in high-risk mismatched donor transplantation. (C) 2021 The American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc. All rights reserved. Show less
Oostenbrink, L.V.E.; Jol-van der Zijde, C.M.; Kielsen, K.; Jansen-Hoogendijk, A.M.; Ifversen, M.; Muller, K.G.; ... ; Tol, M.J.D. van 2019
Anti-thymocyte globulin (ATG) and alemtuzumab are both used in hematopoietic cell transplantation (HCT) to prevent graft-versus-host-disease (GvHD) and graft failure. Main toxicities include... Show moreAnti-thymocyte globulin (ATG) and alemtuzumab are both used in hematopoietic cell transplantation (HCT) to prevent graft-versus-host-disease (GvHD) and graft failure. Main toxicities include absent or slow immune reconstitution. This thesis aims to develop evidence based dosing regimens for both agents. We found that current weight-based dosing of ATG and alemtuzumab lead to highly biased exposures across the different age groups in the pediatric population. Furthermore, ATG clearance was not found to increase with increasing body weight in patients over 50 kg (i.e. adolescents and adults). Timely CD4+ T-cell immune reconstitution after HCT is essential for reducing viral reactivations and relapse following HCT, and thereby improves survival chances. High exposure to ATG after infusion of the graft diminishes chances for CD4+ T-cell reconstitution. Therefore, exposure to ATG has a major impact on the clinical outcomes including survival following HCT in children and adults. We conclude that individualizing dosing and timing of ATG potentially makes HCT a safer and more effective treatment option, and will lead to improved survival chances. Individualized dosing regimens for ATG in children have been designed based on the results in this thesis, and are currently being evaluated in prospective clinical trials for efficacy and safety. Show less
