title: Posttransplant autoimmune hemolytic anemia and other autoimmune cytopenias are increased in very young infants undergoing unrelated donor umbilical cord blood transplantation.
abstract: Autoimmune cytopenias are a recognized complication of hematopoietic stem cell transplant (HSCT), and are considered to be a feature of chronic graft-versus-host disease (cGVHD). We report on a cohort of very young infants (< or =3 months of age) receiving HSCT from unrelated donor umbilical cord blood for genetic disorders who developed posttransplant autoimmune cytopenias at an increased rate compared to older aged controls. These infants received a conditioning regimen consisting of busulfan, cyclophosphamide, and antithymocyte globulin (ATG). All infants received HLA mismatched unrelated umbilical cord blood as graft source. GVHD prophylaxis was either cyclosporine + methylprednisolone (n = 16) or cyclosporine + mycophenolate mofetil (n = 3). Engraftment, acute GVHD (aGVHD) and cGVHD, survival, treatment-related mortality (TRM), and deaths were evaluated. Ten patients developed cGVHD manifesting as autoimmune cytopenias at a median 247 days posttransplant with a cumulative incidence of 44% (95% confidence interval [CI] 21%-68%) and 56% (95% CI 32%-80%) at 1 and 2 years, respectively. In 6 of 10 patients developing autoimmune cytopenias, cGVHD presented as autoimmune cytopenia de novo. The cytopenias observed included anemia (n = 4), thrombocytopenia (n = 1), anemia with thrombocytopenia (n = 3), and pancytopenia (n = 2). No graft factors were identified as being significant to development of cGVHD. All patients responded to treatment with methylprednisolone, azithioprine +/- rituximab. One patient required splenectomy. We hypothesize that posttransplant immunosuppression interferes with normal immune ontogeny creating immune dysregulation and graft directed cell destruction. Alternative strategies to prevent GVHD should be considered for this unique patient population.
authors.affiliation: Department of Pediatrics, Division of Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina. Electronic address: kristin.page@duke.edu.
authors.forename: Kristin M
authors.initials: KM
authors.lastname: Page
authors.affiliation: The EMMES Corporation, Rockville, Maryland.
authors.forename: Adam M
authors.initials: AM
authors.lastname: Mendizabal
authors.affiliation: Department of Pediatrics, Division of Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina.
authors.forename: Vinod K
authors.initials: VK
authors.lastname: Prasad
authors.affiliation: Department of Pediatrics, Division of Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Martin
authors.affiliation: Department of Pediatrics, Division of Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina.
authors.forename: Suhag
authors.initials: S
authors.lastname: Parikh
authors.affiliation: Department of Pediatrics, Division of Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina.
authors.forename: Susan
authors.initials: S
authors.lastname: Wood
authors.affiliation: Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Gregory D
authors.initials: GD
authors.lastname: Sempowski
authors.affiliation: Department of Pediatrics, Division of Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina; Department of Immunology, Duke University Medical Center, Durham, North Carolina.
authors.forename: Paul
authors.initials: P
authors.lastname: Szabolcs
authors.affiliation: Department of Pediatrics, Division of Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina.
authors.forename: Joanne
authors.initials: J
authors.lastname: Kurtzberg
mesh_terms: D000740:Anemia / Q000209:etiology; D000744:Anemia, Hemolytic, Autoimmune / Q000209:etiology*; D015331:Cohort Studies; D036101:Cord Blood Stem Cell Transplantation / Q000009:adverse effects* / Q000379:methods; D006086:Graft vs Host Disease / Q000188:drug therapy* / Q000209:etiology / Q000517:prevention & control; D006453:Hemoglobinopathies / Q000150:complications / Q000628:therapy; D006648:Histocompatibility; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016464:Lysosomal Storage Diseases / Q000150:complications / Q000628:therapy; D010198:Pancytopenia / Q000209:etiology; D013921:Thrombocytopenia / Q000209:etiology; D019172:Transplantation Conditioning