title: Nonmyeloablative HLA-matched sibling allogeneic hematopoietic stem cell transplantation for severe sickle cell phenotype.
abstract: OBJECTIVE
  Myeloablative allogeneic hematopoietic stem cell transplantation (HSCT) is curative for children with severe sickle cell disease, but toxicity may be prohibitive for adults. Nonmyeloablative transplantation has been attempted with degrees of preparative regimen intensity, but graft rejection and graft-vs-host disease remain significant.
  
  
  OBJECTIVE
  To determine the efficacy, safety, and outcome on end-organ function with this low-intensity regimen for sickle cell phenotype with or without thalassemia.
  
  
  METHODS
  From July 16, 2004, to October 25, 2013, 30 patients aged 16-65 years with severe disease enrolled in this nonmyeloablative transplant study, consisting of alemtuzumab (1 mg/kg in divided doses), total-body irradiation (300 cGy), sirolimus, and infusion of unmanipulated filgrastim mobilized peripheral blood stem cells (5.5-31.7 × 10(6) cells/kg) from human leukocyte antigen-matched siblings.
  
  
  METHODS
  The primary end point was treatment success at 1 year after the transplant, defined as a full donor-type hemoglobin for patients with sickle cell disease and transfusion independence for patients with thalassemia. The secondary end points were the level of donor leukocyte chimerism; incidence of acute and chronic graft-vs-host disease; and sickle cell-thalassemia disease-free survival, immunologic recovery, and changes in organ function, assessed by annual brain imaging, pulmonary function, echocardiographic image, and laboratory testing.
  
  
  RESULTS
  Twenty-nine patients survived a median 3.4 years (range, 1-8.6), with no nonrelapse mortality. One patient died from intracranial bleeding after relapse. As of October 25, 2013, 26 patients (87%) had long-term stable donor engraftment without acute or chronic graft-vs-host disease. The mean donor T-cell level was 48% (95% CI, 34%-62%); the myeloid chimerism levels, 86% (95% CI, 70%-100%). Fifteen engrafted patients discontinued immunosuppression medication with continued stable donor chimerism and no graft-vs-host disease. The normalized hemoglobin and resolution of hemolysis among engrafted patients were accompanied by stabilization in brain imaging, a reduction of echocardiographic estimates of pulmonary pressure, and allowed for phlebotomy to reduce hepatic iron. The mean annual hospitalization rate was 3.23 (95% CI, 1.83-4.63) the year before, 0.63 (95% CI, 0.26-1.01) the first year after, 0.19 (95% CI, 0-0.45) the second year after, and 0.11 (95% CI, 0.04-0.19) the third year after transplant. For patients taking long-term narcotics, the mean use per week was 639 mg (95% CI, 220-1058) of intravenous morphine-equivalent dose the week of their transplants and 140 mg (95% CI, 56-225) 6 months after transplant. There were 38 serious adverse events: pain and related management, infections, abdominal events, and sirolimus related toxic effects.
  
  
  CONCLUSIONS
  Among 30 patients with sickle cell phenotype with or without thalassemia who underwent nonmyeloablative allogeneic HSCT, the rate of stable mixed-donor chimerism was high and allowed for complete replacement with circulating donor red blood cells among engrafted participants. Further accrual and follow-up are required to assess longer-term clinical outcomes, adverse events, and transplant tolerance.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00061568.
authors: Molecular and Clinical Hematology Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland2National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors: Matthew M
authors: MM
authors: Hsieh
authors: Molecular and Clinical Hematology Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland2National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors: Courtney D
authors: CD
authors: Fitzhugh
authors: Molecular and Clinical Hematology Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland2National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors: R Patrick
authors: RP
authors: Weitzel
authors: Molecular and Clinical Hematology Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland2National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors: Mary E
authors: ME
authors: Link
authors: Molecular and Clinical Hematology Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland2National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors: Wynona A
authors: WA
authors: Coles
authors: Office of Clinical Director, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland.
authors: Xiongce
authors: X
authors: Zhao
authors: Molecular and Clinical Hematology Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland2National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors: Griffin P
authors: GP
authors: Rodgers
authors: Sidney Kimmel Cancer Center, Johns Hopkins Medical Institute, Baltimore, Maryland.
authors: Jonathan D
authors: JD
authors: Powell
authors: Molecular and Clinical Hematology Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland2National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors: John F
authors: JF
authors: Tisdale
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000074323:Alemtuzumab; D000755:Anemia, Sickle Cell / Q000150:complications / Q000628:therapy*; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage*; D046528:Chimerism; D004912:Erythrocytes; D005260:Female; D000069585:Filgrastim; D006086:Graft vs Host Disease; D016179:Granulocyte Colony-Stimulating Factor; D006680:HLA Antigens; D019650:Hematopoietic Stem Cell Mobilization; D018380:Hematopoietic Stem Cell Transplantation / Q000009:adverse effects / Q000379:methods; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage*; D007239:Infections / Q000209:etiology; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000209:etiology; D011446:Prospective Studies; D011994:Recombinant Proteins; D020123:Sirolimus / Q000008:administration & dosage* / Q000009:adverse effects; D019172:Transplantation Conditioning; D014184:Transplantation, Homologous; D016896:Treatment Outcome; D014916:Whole-Body Irradiation; D055815:Young Adult; D017086:beta-Thalassemia / Q000150:complications / Q000628:therapy*
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D006680:HLA Antigens; D007166:Immunosuppressive Agents; D011994:Recombinant Proteins; D016179:Granulocyte Colony-Stimulating Factor; D000074323:Alemtuzumab; D000069585:Filgrastim; D020123:Sirolimus