Human leukocyte antigen matched sibling fresh cord blood transplantation for beta-thalassaemia major in children

doi:10.12307/2025.095

Abstract

Abstract: BACKGROUND: Allogeneic hematopoietic stem cell transplantation is currently the most effective method for the radical treatment of thalassemia major, but only half of patients can find compatible bone marrow or peripheral blood stem cells. Sib-derived umbilical cord blood stem cells have different characteristics from bone marrow and peripheral blood stem cells, and are a potential alternative source of hematopoietic stem cells for transplantation in patients with thalassemia major.
OBJECTIVE: To investigate the therapeutic effect of human leukocyte antigen matched sibling fresh umbilical cord blood transplantation in the treatment of β-thalassemia major in children.
METHODS: Forty-eight children with β-thalassemia major, including 28 males and 20 females, with a median age of 4 years old, were selected from Nanfang Hospital of Southern Medical University from June 2010 to June 2020. All of them received fresh cord blood transplantation from human leukocyte antigen matched sibling. Transplantation conditioning adopted a myeloablative regiment without anti-thymocyte globulin. A combination of cyclosporine A and mycophenolate mofetil with or without short-range methotrexate was administered for graft-versus-host disease.
RESULTS AND CONCLUSION: (1) The median infused doses of total nucleated cells and CD34+ cells were 8.17×107/kg and 2.40×105/kg, respectively in 48 children. The median follow-up time after cord blood transplantation was 98 months, and 44 cases were successfully engrafted. The median time to neutrophil and platelet engraftment was 28 and 31 days, respectively. Among them, 37 cases were found to be donor-type complete chimerism detected as evidence of implantation after transplantation, 7 cases were found to be stable mixed chimerism. (2) Among the 44 children with successful implantation, four patients developed acute graft-versus-host disease, and were scored as grade I (n=2) and grade II (n=2). All the affected organs were skin, and no chronic graft-versus-host disease occurred. (3) After umbilical cord blood transplantation, cytomegalovirus infection and activation occurred in 5 of the 48 cases, sepsis in 12 cases, invasive fungal disease in 3 cases, stomatitis in 21 cases, hemorrhagic cystitis in 8 cases, and hepatic vein occlusion in 1 case. (4) Among 48 children, 47 patients survived; 1 died of severe pneumonia combined with acute heart failure 28 days after transplantation; 43 survived without disease; 3 had primary implantation failure, and 1 had pancytopenia after transplantation. The 5-year probabilities of overall survival and disease-free survival were 98% and 89%, respectively. The cumulative incidence of transplant-related deaths at 1 year was 2.1%. (5) The above results indicate that human leukocyte antigen matched sibling fresh umbilical cord blood transplantation is effective in the treatment of β-thalassemia major in children with a low incidence of graft-versus-host disease.

Key words: allogeneic hematopoietic stem cell transplantation, fresh cord blood transplantation, β-thalassaemia major, graft-versus-host disease, child

CLC Number:

Wen Jianyun, Chen Libai, He Yuelin, Feng Xiaoqin, Liu Xuan, Xu Xiaoxiao, Li Xiu, Liu Qiujun, Wu Xuedong. Human leukocyte antigen matched sibling fresh cord blood transplantation for beta-thalassaemia major in children[J]. Chinese Journal of Tissue Engineering Research, 2025, 29(23): 4899-4906.

Figures/Tables 3

2.3.1 植入和植入失败 48例重型地中海贫血患儿回输的总有核细胞中位数为8.17×107/kg，CD34+细胞中位数为2.40×105/kg。48例患儿除去1例移植后不足1个月死亡，其中44例植入成功，中性粒细胞、血小板和红细胞植入中位时间分别为27，30，22 d；3例患儿发生原发性植入失败(7%)，其回输的总有核细胞数分别为5.16×107/kg，5.28×107/kg，6.80×107/kg，回输的CD34+细胞数分别为0.87×105/kg，0.79×105/kg和1.62×105/kg，3例植入失败患儿回输的CD34+细胞数均较少，Logistic回归分析结果显示，CD34+细胞数不是影响移植物排斥的危险因素，这可能是样本数较少的原因，未来需进一步扩大样本量分析。3例植入失败的患儿均存活，1例于2019年3月即与第一次移植间隔43个月接受了同一同胞供者(供者43月龄)的外周血干细胞移植治疗，成功植入供者外周血干细胞，截至随访时患儿无病生存；另外2例患儿恢复重型地中海贫血状态。 48例患儿中，16例预处理方案无塞替哌，发生移植物排斥的3例患儿均未使用塞替哌，无塞替哌组移植物排斥率显著高于有塞替哌组(χ2=6.4，P=0.032)。预处理方案无塞替哌组(n=16)与有塞替哌组(n=32)对比，两组患儿的中位年龄、体质量、回输总有核细胞数和CD34+细胞数比较差异均无显著性意义(P=0.936，P=0.948，P=0.914，P=0.230)。Logistic回归分析结果显示，受者年龄、CD34+细胞数、总有核细胞数及有无使用甲氨蝶呤均不是影响移植物排斥的危险因素，这可能是样本数较少的原因。 44例植入成功的患儿，37例移植后植入证据检测为供者型完全嵌合，7例患儿(16%)在移植后早期检测为供受者稳定混合嵌合(范围：72%-92%的供者细胞)，其中1度混合嵌合3例(7%)，2度混合嵌合3例(7%)，3度混合嵌合1例(2%)。对1度混合嵌合的患儿，每周动态监测植入证据或同时或调整抗排斥药剂量；对2度混合嵌合的患儿，予以减停免疫抑制药物；对于3度混合嵌合的患儿，予以调整抗排斥药和供者淋巴细胞输注2次后，复查植入证据供者细胞比例逐步升高。5例患儿(3例1度混合嵌合和2例2度混合嵌合)转化为完全供者嵌合，其中2例在移植后6个月内，3例在移植后1年内，其余2例儿童(1例2度混合嵌合和1例3度混合嵌合)在停用免疫抑制剂1年或以上后混合嵌合稳定(范围：89%-94%的供者细胞)。截至末次随访时间，最终完全嵌合状态42例，2例混合嵌合状态的患儿脱离输血，7例患儿均未发生原发性或继发性移植物失败。在44例成功植入的患儿中，使用甲氨蝶呤对中性粒细胞恢复(P=0.259)和血小板恢复(P=0.349)均没有显著影响。 2.3.2 移植物抗宿主病在44例植入成功的患儿中，4例发生急性移植物抗宿主病，分为Ⅰ级(n=2)和Ⅱ级(n=2)，受累器官均为皮肤。长期随访后，未发生Ⅲ-Ⅳ级急性和慢性移植物抗宿主病。人类白细胞抗原同胞供者新鲜脐血移植后的急性和慢性移植物抗宿主病累积发生率非常低，分别为9%和0%。 2.3.3 移植相关的并发症 5例发生巨细胞病毒感染及激活，所有患儿经过更昔洛韦抢先治疗均转阴。12例出现败血症，其中6例为革兰阳性细菌感染(其中一半为感染金黄色葡萄球菌)，6例为革兰阴性菌感染(其中4例为感染大肠杆菌)，但没有患儿死于败血症。侵袭性真菌病发生3例，其中2例为真菌性肺部感染，1例为真菌性败血症合并真菌性心内膜炎。口腔炎是移植过程中最常见的不良反应，48例患儿中有21例发生口腔炎。8例发生出血性膀胱炎，1例被诊断为肝静脉闭塞病，血清胆红素升高(> 20 mg/L)。供受者血型不合患儿输注新鲜脐血后均未发生溶血反应。3例患儿发生自身免疫性溶血性贫血，通过Coombs试验阳性确诊，其中2例来自ABO主要不相容供体，1例来自ABO相容供体，发病时间分别为造血干细胞移植后1，3，6个月，均接受了包括糖皮质激素、免疫抑制剂和静脉内注射免疫球蛋白在内的初始治疗，ABO血型相合患儿最初治疗1周后迅速恢复，2例ABO不相合患儿随后每周接受一次抗利妥昔单抗治疗，1例在3周后治愈，而另1例在使用利妥昔单抗治疗4周后反应不佳，在造血干细胞后8个月出现全血细胞减少，在移植1年后接受了来自同一同胞供者的骨髓移植治疗后治愈。 2.3.4 总生存率、无病生存率和移植相关死亡 48例患儿中，47例存活，1例在移植后28 d因重症肺炎合并急性心力衰竭死亡，43例无病存活，3例发生原发性植入失败，1例发生移植后全血细胞减少，5年总生存率和无病生存率分别为98%和89%(图1)。移植后1年时移植相关死亡的发病率为2%。"

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