Durable Engraftment of Cryopreserved CD3+/CD19+ Depleted Cadaveric Vertebral Bone Marrow Grafts in Primary Immunodeficiency Patients Undergoing Sequential Bilateral Orthotopic Lung Transplant (BOLT) and Bone Marrow Transplant (BMT)
Year: 2025
Type: article
Abstract: Introduction Patients with primary immune-deficiency who have missed curative bone marrow transplant (BMT) may develop pulmonary complications and become ineligible for either or lung transplant (LTX) or BMT alone due to futility. We are conducting a first in human prospective trial (NCT01852370) where PID patients in lung failure may enroll as long as 2 of 6 HLA antigen-matched cadaveric donor is identified and 8 weeks passed after BOLT before cryopreserved BMT. RIC regimen is based on Ritux/ATG/Campath, Thiotepa and TBI 200-250cGy. Patient #4 with WAS mutation and MDS/RAEB received 500cGY TBI in 2 fractions + Fludarabine . Hematopoietic stem cells from organ donor vertebral bodies (VB) yielded greater CD34+ cell doses compared to prior iliac crest aspirates. With the inherent logistical barriers of iliac crest marrow recovery, we hypothesized that cryopreserved vertebral marrow could generate durable hematopoiesis and immunity. Here we present 8 consecutive cases of vertebral bone marrow (VBM) processing experiences and subsequent CD3+/CD19+ cell depletion on the CliniMACS® device infused into 7 eligible patients. Methods With a threshold 7AAD viability of 70% pre-cryopreservation, the CD3/CD19-depleted product must contain 1 × 10E+6/kg CD34+ cells and 1 × 10E+5/kg CD3+ T cells to achieve durable engraftment and minimize GVHD risks respectively besides continued FK506 for at least 6 months post-BMT. In 2017 we introduced a cavity wash saline-betadine mix and scrubbing T9/11-L4VB logs with chlora-prep that has eliminated bacterial contamination . The prior 2 were infused with no adverse events following IRB&FDA approved antibiotic prophylaxis . We also replaced the manual processing of the VBs with electrical saw freeing up one tech. The entire process (dissection, crushing, filtering, depletion and cryopreservation) can be completed in 12 hours with 3 technologists. For details of processing, see Table. Results Engraftment with donor cells was achieved in 6/7 transplanted patients (ANC >500 @ D+12) and (PLT>50K @ D+20), however, patient #5 had immune rejection -after multiple lung rejections- while 5 of 7 patients had mixed chimerism at Day +100. For 30- and 100-day chimerism details, see Table. We have developed a complex sequence of procedures exceeding 2E+06 CD34/kg pre-cryo dose (mean: 5.06E+06) leading to prompt and multilineage engraftment in 5 of the first 7 analyzable patients and 3 of our patients are maintaining full or mixed donor chimerism 19 months, 6 and 8 years post-BMT. Long term survival (>1 yr post-BMT appears to be associated with attaining platelets>50K. Summary We present the first cases of cadaveric vertebral bone marrow transplant with durable engraftment attainable despite multiple HLA-mismatches and RIC conditioning with implications in SOT and BMT independently. Patient #1 has been off immunosuppression in tolerant state > 5years.
Authors: Heather Stanczak, Nikolette Long, Xiaohua Chen, Shawna Mcintyre, Paul Szabolcs
Language: English
Subfield: Hematology
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $3,650
OpenAlex ID: W4407976646