Study On HLA-haploidentical Allogenic Hematopoietic Stem Cell Transplantation In Treatment Ofβ-thalassemia Major

ObjectiveAllo-hematopoietic stem cell transplantation(allo-HSCT) is the only way to cure β-thalassemia major at present. The human major histocompatibility antigen (HLA) consistent phylogenetic related or unrelated donor allo-HSCT is the most suitable donor. Among patients needing allogeneic HSCT, only20%to30%have an HLA-matched related donor. In unrelated populations found in HLA-matched donor is a probability of1/50000to1/100000,even lower,and need a long time to check. If the HLA-haploidentical hematopoietic stem cell transplantation, there are90%of the patients were able to find a donor, as more are required to undergo transplantation without HLA-matched donor patients brought the gospel. But there are kinds of problem with HLA-haploidentical hematopoietic stem cell transplantation, such as later Hematopoietic Reconstitution、severegraft versus host disease、later immune reconstitution、infection and graft failure. There were less reports with all-hap HSCT in treatment of thalassemia, most in leukemia. This report will be brought a retrospective analysis of HLA-haploidentical transplantation in treatment of β-thalassemia major clinical efficacy. Method21cases of β-thalassemia major received26times of HLA-haploidentical HSCT HSCT in our transplantationg center from Augest,1999to March,2011. Divided into two groups:Pre-2008is11patients, age from3to13(median age is6),9children were male and2children were female. β-thalassemia clinical classification:7cases were categorized as class Ⅰ and classⅡ,4cases were categorized as classⅢ. All of them have HLA1-loci-mismatched. The stem cell were bone marrow, and the median of nucleated cell is2.5×10/kg (1.94～5.4×108/kg).2cases were broughted the second and third time because the first time was lose in the3monthes. After-2008is10patients, age from3toll, median age is5.5,4children were male and6children were female. β-thalassemia clinical classification:9cases were categorized as class Ⅰ and classⅡ,1cases were categorized as classⅢ.8cases have HLA1-loci-mismatched, and2cases were HLA-matched. The stem cell were PBSC, and MNC was8.62(8～9)×108/Kg, and one case was brought donor lymphocyte infusion followsd by heamatopoietic stem cell transplantation for3times1.Conditioning; Pre-2008, patients were condictioned with Bu, Cy and ATG-F, Flu or TBI was used additionly in some cases.1cases was used Bu, Cy, ATG-F and Flu for the second time of transplantation, and Cy, Vp16and TBI for the third time of transplantation.1cases was used Cy and TBI for the second time of tranplantation. After-2008,patients were condictiond with Bu, Cy, Flu, TT and ATG-F.2The prophylaxis of GVHD:Pre-2008,CsA and MMF were used as prophylaxis of GVHD, and short course of MTX, Zenapax, Basiliximab in some cases. After-2008, CsA, MMF and short course MTX were used as prophylaxis of GVHD. Method:Pre-2008, CsA was begin to use at the day of last infusion stem cell, and the serum concentration monitoring between150-250ug/L. MTX was used at1,3,6and11days after transplantation, and the dose was l5mg/m2,10mg/ m2,10mg/m,10mg/m.MMF was begun to use at six houres after infusion stem cell. After-2008, CsA was begun to use at the first day of conditioning with1.5mg/Kg.d, and3mg/Kg.d the day before infusion of stem cells. MTX was used at1,3and6days after transplantation,and the dose was15mg/m2,10mg/m2,10mg/m2. MMF was begun to use at six houres after infusion of stem cells.3. The prophylaxis of HVOD:Pre-2008, heparin(100～150U/Kg.day), lipo-prostaglandin E1(10～30ug/d) were used and begun day1. After-2008, heparin(100U/Kg.day) and Ursodeoxycholic Acid(12mg/kg.d) were begun to use at the firsr day of conditioning, and with the monitor of liver function and APTT, and it would be stop at day20after transplant,if there was no symptom of HVOD.4. The prophylaxis of HC:During precongditioning, hydrantion was applied to maintain a higher60～100ml/m2urinary volume. At the same time, half an hour before using the first dose of Cyclophosphamide, mesna in sodium chloride was intravenously dripped for12hours. Dose of mesna every day=1.25×CY dosage of every day. The treatment is hydrantion+platelet infusion.5.Prevention of infection:All patients were treated in positive-pressure isolationroom and received nonabsorbable oral antibiotic. Ganciclovir were used to prevent infection of CMV for7days before transplant.6.Supporting therepy; Blood transfusion was based on the day’s blood routine result. Products of blood were irradiated. Pay attention to supplement water, electrolyte, glucose fat, emulsions amino acid,such as maittain cital signs.7.Engraftment test; Successful transplant was defined as NCU was moer than0.5, the bood platelet was over20and the Hb was above90g/L without transfusion. Approximately1month after the transplant, tested the FISH between different sexes, and DNA tested between same sex.8.Statistical method; SPSS13.0statistical software. The measurement data with t test, Fisher exact test with count data. Binary logistic regression was used in multivariate analysis, survival analysis was Kaplan-Meier method and Cox regression analysis model was used in death risk factors. Ap value of<0.05was considered statistically singnificant difference.Results:1. Results of GVHDPre-2008,3cases had GVHD in5evaluable patients, and all of them w ereaGVHD, grade Ⅰ, Ⅱ, and Ⅳ was1case, and1case was died of GVH D. After-2008,2cases had GVHD in10evaluable patients, and1was were aGVHD(I°), and1were cGVHD, they were cured after anti-rejiection treat ment.2. Results of HVODPre-2008,5cases had HVOD in11evaluable patients. According to the classification of HVOD, the incidence of mild to moderate was60%, an d the incidence of serious HVOD was40%. Among4cases who were young er5, there was none patient appeared HVOD, and among7cases who were older5, there was5patients appeared HVOD, in and2cases was died of HVOD. All HVOD symptom appeared within twenty five days after transplan t. After-2008, there were none patients appeared HVOD in9cases.3. Results of HCPre-2008,3cases developed HC in11evaluable patients. After-2008, t here was one patients appeared HC in10cases.4. Results of IFI, CMV infection and oral mucositisPre-2008, the incidence of IFI、CMV infection and oral mucositis is18.2%(2/11)、9.1%(1/11) and63.6%(7/11). After-2008,the incidence of IFI and oral mucositis is10%(1/10)、10%(1/10) and50%(5/10).5. Results of engraftment Pre-2008, hematological recovery was prompt in8evaluable patients wit h an absolute neutrophil count of more than0.5×109/L on day16(rang:12～19days), and a platelet count of more than20×109/L without platelet support o btained on day32(rang:11～56days), and no uesed to infusion Hb on day38(rang:14～57days). After-2008, hematological recovery was prompt in10eva luable patients with an absolute neutrophil count of more than0.5×109/L on d ay19.5(rang:17～24days), and a platelet count of more than20×109/L witho ut platelet support obtained on day16.5(rang:9～60days), and no uesed to in fusion Hb on day27(rang:9-60days). Pre-2008, five patients were independe nt implanted, and six patients died of infection or heart failure. After-2008,9patients were independent implanted, and one case FISH test was [XX]2/[XY]498on day28then after3times DLI the latest FISH test was [XX]3/[XY]497, and no need of infusion RBC.Conclusion1、HLA-haploidentical HSCT could be effective in treatment of β-thalassemia major. Especially, there wes a stationary engraftment of stem cell, low rates of aGVHD, low rates of infection, low rates of transplant related mortality in PBSC.2、The condition of engraftment of stem cell was a risk fator to death after HSCT, and no engraftment was higher risk than a engrafement, so make sure to engeftment was important factor to HSCT.3、The condicioning after-2008can effectively vacated the bone marrow, and to provide a good environment to ensure donor implant. Furthermore, the complications are fewer because of side effects of the drugs, and there is a good physical condition for transplantation. 4、It was effectively to reduce mortality if there was no use of whole body radiation and with Ursodeoxycholic Acid to prevent HVOD in allo-hematopoitic stem cell transplantation in children.5、In our results, the age older than ten、class Ⅲ of β-thalassemia major、 TBI were risk factors of hepatic vein occlusion disease, so that it was important to tranplant as early as possible. Ursodesoxycholic acid was effectively prevent hepatic vein occlusion. There was no signifacant difference in aGVHD、HC and infection after HSCT.6、HLA-haploidentical HSCT could greatly solve the questions that transplant matches, and brings the hope for more recipients. We can infusion donor lymphocyte to prevent failure engraftment...