Received: 16 October 2020 Revised: 31 December 2020 Accepted: 4 January 2021

DOI: 10.1002/pbc.28909 Pediatric

Blood &
Cancer The American Society of
Pediatric Hematology/Oncology
T R A N S P L A N TAT I O N : B R I E F R E P O R T

Pretransplant myeloid and immune suppression, reduced

toxicity conditioning with posttransplant cyclophosphamide:
Initial outcomes of novel approach for matched unrelated
donor hematopoietic stem cell transplant for
hemoglobinopathies

Gaurav Kharya Atish N. Bakane Archana M. Rauthan

Center for Bone Marrow Transplant and

Cellular Therapy, Indraprastha Apollo Abstract
Hospital, New Delhi, India
Hematopoietic stem cell transplant (HSCT) is currently the only curative option for tha-
Correspondence lassemia major (TM) and sickle cell disease (SCD). We report our experience of using
Gaurav Kharya, Clinical Lead, Center for Bone pretransplant immune suppression (PTIS), augmented Johns Hopkins conditioning, and
Marrow Transplant and Cellular Therapy,
Indraprastha Apollo Hospital, Delhi, India. posttransplant cyclophosphamide (PTCy) as graft-versus-host disease (GvHD) prophy-
Email: [email protected] laxis for matched unrelated donor (MUD) transplant in TM/SCD. At a median follow-
up of 307.5 days (range 251-395), all patients (three TM, one SCD) are alive and dis-
ease free. MUD HSCT with PTIS, augmented Johns Hopkins conditioning, and PTCy
as GvHD prophylaxis is a promising way of treating patients with hemoglobinopathies
with low regimen-related toxicity (RRT), no risk of graft failure (GF) and minimal GvHD
rates.

KEYWORDS
hematopoietic stem cell transplant, hemoglobinopathies, matched unrelated donor, posttrans-
plant cyclophosphamide, pretransplant immune suppression

1 INTRODUCTION lated donor (MUD), mismatched family donor (e.g. haploidentical HSCT
[HHSCT]), or cord blood transplant (CBT) expands the donor pool but
Hemoglobinopathies (thalassemia major [TM] and sickle cell dis- comes with risk of regimen-related toxicity (RRT), graft failure (GF),
ease [SCD]) are among the commonest indications for hematopoi- and graft-versus-host disease (GvHD).4–11 In a review on HSCT for
etic stem cell transplant (HSCT) in nonmalignant diseases.1,2 Only 25- SCD, Oshrine and Talano stated that matched sibling donor allogeneic
30% patients have suitable human leukocyte antigen (HLA)-identical HCT after myeloablative conditioning (MAC) offers a cure for SCD
related donor.3 Alternative donor transplants either matched unre- and is accepted as standard of care. They concluded that it should
be offered to all patients with severe SCD prior to developing severe
Abbreviations: aGvHD, acute graft-versus-host disease; ANC, absolute neutrophil count; end organ dysfunction. However, they also mentioned that utilizing
ATG, antithymocyte globulin; CBT, cord blood transplant; cGvHD, chronic graft-versus-host
disease; CMV, cytomegalovirus; DFS, disease-free survival; EF, peri-engraftment fever; ES,
an alternative donor for transplantation and/or reduced intensity con-
engraftment syndrome; GCSF, granulocyte colony-stimulating factor; GF, graft failure; GvHD, ditioning (RIC) for SCD is still under investigation, and clinical tri-
graft-versus-host disease; HLA, human leukocyte antigen; HHSCT, haploidentical HSCT;
als should be performed to optimize the best treatment for these
HSCT, hematopoietic stem cell transplant; IR, immune reconstitution; iv, intravenously; MAC,
myeloablative conditioning; MC, mixed chimerism; MMF, mycophenolate mofetil; MUD, patients.12 Shenoy et al examined the outcomes of MUD HSCT for chil-
matched unrelated donor; OS, overall survival; PTCy, posttransplant cyclophosphamide; PTIS,
dren with severe SCD in BMT CTN phase 2 trial between 2008 and
pretransplant immune and myelosuppression; rBW, recipient body weight; RIC, reduced
intensity conditioning; RRT, regimen-related toxicity; RTC, reduced toxicity conditioning; 2014. They used alemtuzumab, fludarabine, and melphalan based RIC,
SCD, sickle cell disease; TM, thalassemia major.

Pediatr Blood Cancer. 2021;68:e28909. wileyonlinelibrary.com/journal/pbc © 2021 Wiley Periodicals LLC 1 of 9

https://doi.org/10.1002/pbc.28909
2 of 9 KHARYA ET AL .

and GvHD prophylaxis was with calcineurin inhibitor along with short- col) to treat 25 consecutive patients undergoing haploidentical trans-
course methotrexate and methylprednisolone. At a median follow-up plant for severe SCD with very encouraging results.25 In the current
of 26 months, the overall survival (OS) and disease-free survival (DFS) study, we present our experience with this novel strategy in patients
were 86% and 79%, respectively, with GF rate of 10%. They reported with TM and SCD undergoing MUD HSCT.
day 100 incidence of grade II-IV acute GvHD (aGvHD) as 28% and
1-year incidence of chronic GvHD (cGvHD) as 62%, 38% of which
were extensive.13 In another trial, the URTH trial, Shenoy et al investi- 2 PATIENTS AND METHODS
gated the efficacy of RIC using alemtuzumab, fludarabine, thiotepa and
melphalan based conditioning for patients with TM undergoing MUD 2.1 Patients
HSCT. GvHD prophylaxis was with calcineurin inhibitor and short-
course methotrexate. In their analysis, the OS and DFS at a median Four patients (three TM and one SCD) presenting at our center for
follow-up of 58 months were 82% and 79%, respectively. The cumula- blood and marrow transplant from September 2019 until April 2020
tive incidence of grade II-IV aGvHD rates in their analysis was 24% with for MUD HSCT were enrolled in the trial. All three TM patients were on
bone marrow as source and that of cGvHD was 29% at 2 years.14 In regular transfusions and one with SCD had frequent pain crises, persis-
another recently published prospective multicentric trial, which stud- tent anemia, jaundice, splenic sequestration, splenectomy, and chole-
ied the outcomes of HSCT for adolescents and young adults with SCD cystectomy. All four lacked suitable HLA-matched family donors (Fig-
using busulfan, fludarabine, and thymoglobulin based RIC, Krishna- ure 1). Ethicals approval for this retrospective analysis was granted by
murti et al reported 1-year OS and DFS as 91% and 86%, respectively. our institutional ethics committee (IAH-BMR-021/07-20).
They reported grade II-III aGvHD rates of 18% and cGvHD rates of 27%
in their analysis.15
Transplant physicians have tried to overcome the risk of GF by 2.2 Donors
using MAC, but it increases the risk of RRT and GvHD.16,17 GvHD is
acceptable for leukemias where graft versus leukemia provides bet- In all the cases, donors were MUD (three sourced from DATRI, an
ter disease control, but for nonmalignant diseases, it impairs quality Indian non-governmental organization stem cell registry and one
of life and may defeat the purpose of offering HSCT.18,19 Anurathapan sourced from DKMS, Poland) (Figure 1).
et al demonstrated the use of sequential pretransplant immune and
myelosuppression (PTIS) for Lucarelli class III β-TM undergoing HLA-
identical HSCT. They demonstrated that sequential use of fludarabine 2.3 HLA typing
200 mg/m2 intravenously (iv) over 5 days in combination with dexam-
ethasone 25 mg/m2 /day iv over 5 days, one to two cycles 3 weeks apart All the patients and donors were high-resolution HLA-typed at the A, B,
in association with hydroxyurea, followed by fludarabine and busul- C, DRB1, and DQB1 loci by next-generation sequencing on an Illumina
fan based reduced toxicity conditioning (RTC) is safe and effective pre- MiniSeq platform.
transplant conditioning for patients with high-risk class III TM exhibit-
ing additional comorbidities decreasing the risk of GF and GvHD.20
Bhat et al used a novel pretransplant immunosuppressive prepara- 2.4 PTIS
tive regimen for HHSCT and MUD HSCT in hemoglobinopathies, and
showed it to be a safe and effective approach.21 Two courses of PTIS were given at three-weekly intervals. Dur-
To handle the donor T cells, the posttransplant cyclophosphamide ing each course, patients received fludarabine 150 mg/m2 (Days
(PTCy) platform has evolved over a period of time for T-cell replete 1-5); cyclophosphamide 1000 mg/m2 (Day 1); dexamethasone
haploidentical transplants.10 Using either RIC or myeloablative RTC, 20 mg/m2 /per oral (PO) in two divided doses (Days 1-5). Complete
depending on the underlying disease and performance status of the hemogram and reticulocyte counts were done on a weekly basis,
patient, along with use of calcineurin inhibitor or mTOR based GvHD and an attempt was made to maintain absolute neutrophil count
prophylaxis, both the issues of GF and GvHD have been addressed to >500/mm3 , platelet count >30 000/mm3 , and hemoglobin >10 gm/dL.
a great extent using PTCy platform.22–24 However, its use in combina- Appropriate granulocyte colony-stimulating factor (GCSF), platelet
tion with PTIS for MUD HSCT still remains unexplored in nonmalignant and red cell support was given whenever required. During the entire
settings. period, patients also received hydroxyurea 20 mg/kg/day. Target retic-
We developed a protocol wherein we emphasized on PTIS using flu- ulocyte count was kept between one and two during this period. In case
darabine, cyclophosphamide, and dexamethasone to suppress recip- of febrile neutropenia, patients were admitted and started on broad-
ient T-cell function, followed by augmented Johns Hopkins protocol spectrum antibiotics. During the two cycles of PTIS, patients received
with added thiotepa-based RTC and PTCy along with mTOR inhibitor prophylaxis with penicillin, valaciclovir, fluconazole/voriconazole,
and mycophenolate mofetil (MMF) as GvHD prophylaxis. This adapta- cotrimoxazole +/− antimalarial drugs. Levetiracetam was used for
tion was based on our previous experience of using this strategy with seizure prophylaxis at the start of PTIS and continued at least until Day
added plerixafor for stem cell mobilization in donors (APOLLO proto- +90 posttransplant (Figure 2).
KHARYA ET AL . 3 of 9

FIGURE 1 Donor selection algorithm

F I G U R E 2 Treatment schema. Cy, cyclophosphamide; Dex, dexamethasone; flu, fludarabine; GCSF, granulocyte colony-stimulating factor;
HSCT, hematopoietic stem cell transplant; HYD, hydroxyurea; HT, hypertransfusion; MMF, mycophenolate mofetil; PBSC, peripheral blood stem
cells; PTIS, pre-transplant immune suppression; TBI, total body irradiation; Thymo, rabbit antithymocyte globulin (Thymoglobulin); TT, thiotepa
4 of 9 KHARYA ET AL .

2.5 Conditioning regimen native donor transplant in the absence of HLA-matched sibling donor.
Baseline characteristics of patients and donors are detailed in Table 1.
Patients were admitted on Day −8 and underwent central line inser-
tion. Conditioning included rabbit antithymocyte globulin (ATG; Sanofi-
Genzyme) 1.5 mg/kg/day (Days −7 to −5), thiotepa 10 mg/kg (Day 3.2 Complications experienced during PTIS
−7) in two divided doses, fludarabine 30 mg/m2 /day (Days −7 to −3),
cyclophosphamide 14.5 mg/kg/d (Days −3, −2), total body irradiation All four patients received PTIS along with hydroxyurea, as detailed
2 Gy (Day −1) (Figure 2). above. Four patients received eight courses of PTIS. All courses of PTIS
were well tolerated, and no patient experienced febrile neutropenia
needing admission. Patient 1 did experience neutropenia without fever,
2.6 GvHD prophylaxis which responded to short course of GCSF. There was no episode of
cytomegalovirus (CMV) reactivation post PTIS, and none experienced
GvHD prophylaxis was with cyclophosphamide 50 mg/kg/day (Days fungal pneumonia.
+3, +4), mTOR inhibitor (sirolimus) 2 mg/m2 /day orally once daily
starting from Day +5 and continued until 9 months, with gradual
tapering over 12 weeks if there was no evidence of GvHD, MMF 3.3 Donor
10 mg/kg/dose thrice daily orally starting from Day +5 until Day +35,
halved for next 7 days and then discontinued (Figure 2). Median age of the donors was 30.5 years (range 21-45). Two
donor/recipient pairs had major blood group mismatch and one had
minor. For all the ABO mismatch transplants, antibody titers were done
2.7 Graft and a cutoff of >1:32 was used for neutralization using fresh frozen
plasma. PBSC were harvested after 5 days of GCSF mobilization with
In all the cases, donors were MUD (three sourced from DATRI, an
a target dose of 10 million cells/kg recipient body weight (rBW). All the
Indian stem cell registry and one sourced from DKMS, Poland). All
products were received at the transplant center before the start of con-
four patients received GCSF-mobilized peripheral blood stem cells
ditioning and were cryopreserved.
(PBSC) after 5 days of GCSF 10 mcg/kg given subcutaneous once daily.
Peripherally harvested stem cells were collected with a target CD34
dose of 10 million cells/kg recipient body weight. All the MUD products
3.4 Graft characteristics
were cryopreserved before initiating the conditioning chemotherapy.

CD34+ and CD3+ cell counts were done for all the patients (except
patient 1 where CD3+ could not be performed) from the final product
2.8 Supportive care
before cryopreservation. Infusion cutoff of 10 million CD34+ cells/kg
rBW was decided with no capping of CD3+ cells. Median CD34+ cells
All patients received supportive care as per institutional protocol
infused was 10.73 million cells/kg (range 7.67-12.6). Median CD3+
detailed in our previous publication.25
cells infused were 52.0 × 107 /kg rBW (range 23.9-78.7). Stem cell prod-
uct was infused over 2 days in patients 3 and 4 to avoid fluid overload
2.9 Statistical analysis and to minimize dimethylsulfoxide-related toxicity.

All continuous variables were presented as medians and range, and cat-
egorical variables as counts and percentages, using Fisher’s exact test 3.5 Engraftment characteristics
for comparisons. Median follow-up was determined using the reverse
Kaplan-Meier method. The center reports all the transplant outcomes Median time to neutrophil engraftment (first day of absolute neu-
to the European Society for Blood and Marrow Transplantation with trophil count [ANC] >500/mm3 ) was 15 days (range 12-17) and median
CIC number 464. time to platelet engraftment (PC >20 000/mm3 unsupported for more
than 5 days) was 23.5 days (range 12-26).

3 RESULTS
3.6 Complications experienced post HSCT
3.1 Patients (Table 2)

Four patients aged 5-15 years were enrolled in the trial. Three had ∙ Mucositis: Grade III/IV mucositis was not seen in any patient. Enteral
transfusion-dependent β-TM and one had severe SCD. Three were nutrition was maintained in all the patients. None required par-
female; one was male. All patients presented to our center for alter- enteral nutrition (partial or total) in view of decreased oral intake.
TA B L E 1 Baseline characteristics of recipients and donors

Recipient Donor Cell dose

KHARYA ET AL .

Blood
Age Age group CMV IgG HLA ABO CD34 CD3
Pt. No (years) Sex Disease Disease burden (years) Sex Relation (R/D) (R/D) matching incompatibility (106 /kg) (107 /kg)
1 7 F TM Class III, ferritin 1986 ng/mL, 23 M MUD B+/O+ +/+ 10/10 Minor 10 DNA
liver 2-3 cm BCM
2 15 F SCD Frequent VOCs needing 21 F MUD O+/A+ +/+ 10/10 Major 7.67 23.9
hospitalization; frequent
infections, persistent anemia,
and jaundice; frequent blood
transfusions
3 5 M TM Class III, ferritin 3274 ng/mL, 38 M MUD O+/O+ +/+ 10/10 None 12.6 52.04
liver 3 cm BCM
4 6 F TM Class III, ferritin 3147 ng/mL, 45 F MUD O+/B+ +/+ 10/10 Major 11.46 78.75
liver 3 cm BCM

Abbreviations: CMV, cytomegalovirus; HLA, human leukocyte antigen; MUD, matched unrelated donor; R/D, recipient/donor; SCD, sickle cell disease; TM, thalassemia major/transfusion-dependent thalassemia;
VOC, vaso-occlusive crisis.

TA B L E 2 Engraftment, chimerism, and posttransplant details in recipients

Day of Day Chimerism (% donor) Days Status at
neu- of Viral post Other last
Pt. No trophil platelet ES Day Day Day aGvHD reactivation cGvHD IS HSCT complication follow-up
engraftment engraftment +21 +60 +100
1 12 12 No 99.87 99.69 100 Gut Gr1 No No Ongoing 192 None Alive/DF
2 14 22 No 98.37 98.64 100 No No No Ongoing 154 None Alive/DF
3 16 25 No 99.48 98.83 - No Yes (? BK No Ongoing 55 None Alive/DF
virus)
4 17 26 No 99.4 99.16 - No No No Ongoing 48 None Alive/DF

Abbreviations: aGVHD, acute graft versus host disease; cGVHD, chronic graft versus host disease; DF, disease-free; ES, engraftment syndrome; IS, immune suppression.
5 of 9
6 of 9 KHARYA ET AL .

∙ Peri-engraftment fever (EF)/engraftment syndrome (ES): EF was noticed

in patients 1, 3, and 4. Along with clinical parameters, we also per-

CD56
formed interleukin 6 levels in symptomatic patients close to engraft-

N/A
202

139

145
100
IgA

12
53

34
ment as a part of our ongoing trial on interleukin 6 and cytokine-
release syndrome to assess the clinical utility of early administra-

CD19
tion of tocilizumab. The values were 202 ng/mL in patient 1 and

Immune reconstitution at Day 100

111
309

225
244
27.37 ng/mL in patient 4 at day 14 and 11, respectively; it could not

Immune reconstitution at Day 100

be done on patient 3 due to COVID-mediated lockdown. None of

IgM
N/A
32

29
the patients fulfilled the criteria of ES. GCSF was discontinued in

1023
2983
CD8
948
535
patients 1 and 3, and short course of steroids was given with opti-
mal response. Patient 4 received single-dose tocilizumab at 4 mg/kg
subsequent to which fever settled.

CD4
282
959

618
391
∙ Bacterial/fungal infection: Culture-positive bacterial infection was

1267
N/A

428
380
IgG
not seen in any patient.
∙ CMV reactivation was not seen in any of the patients.

1251
1592

1637
3433
CD3
∙ BK polyoma virus and Epstein Barr virus reactivation: Hemorrhagic cys-
titis was seen in patient 3 at day 30. Urine culture was negative; urine
BK viral load could not be done. He responded to two doses of cido-

CD56

236

213
fovir along with supportive care. Epstein Barr virus reactivation was

<33

30

32
217
IgA
74

44
not seen in any of our patients.
∙ aGvHD: Grade III/IV aGvHD was not seen in any of our patients.

CD19
Patient 1 developed grade I acute gut GvHD, which resolved with

282
189
17

2
Immune reconstitution at Day 60
short course of steroids.
∙ cGvHD: cGvHD (limited or extensive) was not seen in any of our

Immune reconstitution at Day 60

<20.6
<20

<21
patients until last follow-up. IgM

1790
31

CD8
973
268

884
3.7 Chimerism analysis

CD4
138
469
214
929
Sixteen STR loci and one ameloginin locus were used to identify infor-
1214
560

652
431
IgG

mative loci between donor and recipient. The amplicon was resolved by

1116

2043
1811
CD3

746
capillary electrophoresis on Dx 3500 platform. Chimerism was sent at
the time of engraftment and then at Days +30, +60, +100, +180, +270,
and +365 using peripheral blood. At a median follow-up of 307.5 days
CD56

on December 29, 2020 (range 251-395), all four patients had ≥95%
626
130
45

84
118
294

119
IgA

donor chimerism in whole blood (Table 2).

24
Immune reconstitution at Days 30, 60, and 100

CD19

130

3.8 Immune reconstitution (IR)

3
4

6
Immune reconstitution at Day 30

Immune reconstitution at Day 30

IR is always a challenge with alternative donor transplants. Delayed

IgM

316

1936

2798
1048
CD8
21
41

223
7

IR leads to increased risk of secondary infection. For all our patients,

we assessed immunoglobulin levels (G, M, A) and IR panels (CD3, 4, 8,
19 and 56) at Days +30, +60, +100, +180, +270, and +365. Median
2075
CD4
434
116
262

IgG level at Day 100 was 428 mg/dL (range 380-1267). The pattern
of IR is shown in Table 3. Median CD4+ count at Day +100 was
1581
964

645
881
IgG

504.5 cells/mm3 (range 282-959); CD8+ was 985.5 cells/mm3 (range

2382

3098
3108

535-2983); CD19+ was 234.5 cells/mm3 (range 111-309), and CD56+

CD3

336

was 119.5 cells/mm3 (range 34-145).

TA B L E 3

Patient

Patient
No.

No.
1
2
3
4

1
2
3
4
KHARYA ET AL . 7 of 9

4 DISCUSSION transplant for severe SCD with very encouraging results.25 In the cur-
rent study, we used a combination of PTIS and PTCy to reduce the risk
HLA-identical related donor transplant has been standard of care for of both GF and GvHD in MUD HSCT setting. PTIS in the current study
transfusion-dependent TM or severe SCD with very good outcomes; was different as the dose of fludarabine was reduced to 150 mg/m2 ,
however, this option is available only to 25-30% of the patients in thus making a cumulative dose of fludarabine 300 mg/m2 in compari-
need.1–3 Alternative donor transplantation methods such as MUD, son to Anurathapan et al, where a dose of 400 mg/m2 was used over
CBT, or haploidentical donor have increased the donor pool, making two courses. We also added cyclophosphamide at 1000 mg/m2 during
transplant an option for all transplant-eligible patients but RRT, GF, each course of PTIS. Our conditioning platform was a reduced toxicity
and GvHD remain risks.4–11 Bernaudin et al reported a GF rate of augmented Johns Hopkins protocol with added thiotepa. Thiotepa is
22.6% in SCD patients who received busulfan with cyclophosphamide known to be an excellent immune- and myelosuppressive agent, with a
as compared to 2.9% in patients who received additional ATG.26 Out- gradually increasing role in HSCT.23
comes of MUD transplants have improved over the years primarily The PTCy platform championed by the Johns Hopkins group has
involving MAC in combination to serotherapy.27 Various groups have been found to be effective GvHD control strategy in haploidentical
tried to reduce the intensity of chemo-conditioning, but experienced donor setting; however, it remains less explored in HLA-identical
mixed chimerism and GF. Shenoy et al reported GF in 10% of chil- donor settings. By the virtue of causing immune tolerance, it is known
dren undergoing MUD HSCT for severe SCD in the BMT CTN phase to reduce the risk of aGvHD and cGvHD more effectively than the
2 trial between 2008 and 2014. The OS and DFS were 86% and 79%, conventional GvHD strategies alone.10 Persistence of recipient
respectively, at a median follow-up of 26 months. They reported Day antigen-presenting cells in the post-HSCT period is known to increase
100 incidence of grade II-IV aGvHD as 28% and 1-year incidence of the risk of GvHD by reacting to alloreactive donor T cells. Our PTIS
cGvHD as 62%, 38% of which were extensive.13 In the URTH trial, and PTCy platform ameliorated this risk in two ways. Sequential PTIS
which studied outcomes of MUD BMT for patients of TM using RIC, helped to suppress recipient T-cell function, whereas PTCy in combina-
the OS and DFS at a median follow-up of 58 months were 82% and tion with mTOR inhibitor and MMF addressed the alloreactive donor
79%, respectively. The cumulative incidence of grade II-IV aGvHD rates T cells and achieved better immune tolerance, thus minimizing the risk
in their analysis was 24% and that of cGvHD was 29% at 2 years.14 of GvHD.33 PTIS-mediated recipient T-cell suppression also helped
In another multicentric trial, which studied the outcomes of BMT for reduce the risk of GF. Addition of cyclophosphamide in PTIS was a
adolescents and young adults with SCD using RIC, Krishnamurti et al novel approach that helped reduce the cumulative dose of fludarabine
reported 1-year OS and DFS as 91% and 86%, respectively. They to 300 mg/m2 . This also helped reduce the RRT by using RTC, which
reported grade II-III aGvHD rates of 18% and cGvHD rates of 27% is known to be better tolerated. None of our patients experienced
in their analysis.15 Oshrine et al reported mixed chimerism of 66.7% grade III/IV mucositis, and we could maintain enteral nutrition during
and GF of 22.2% using RIC with alemtuzumab.28 Other groups also the entire transplant period. None of our patients developed CMV
raised similar concerns with RIC. Subsequently, the emphasis moved to reactivation, and only one had hemorrhagic cystitis possibly due to BK
pretransplant preparative strategies. Therapies including hydroxyurea virus (BK virus estimation not done), which responded to supportive
and azathioprine along with hypertransfusion to suppress hyperactive care and two courses of cidofovir.
marrow and suppress endogenous erythropoiesis have achieved some IR post HSCT has been less studied and reported. Due to fewer
success.27,29,30 alternative donor transplants, the data on IR post alternative-donor
Initial studies reported DFS of 50-80% post HSCT in high-risk class HSCT are sparse. We previously described our experience of IR post
III TM.6,9,31 Anurathapan et al reported 5-year OS and DFS of 89% HHSCT for SCD in 25 consecutive patients treated on APOLLO
in high-risk class 3 TM patients undergoing HLA-identical transplant protocol.25 In comparison to HHSCT for SCD, CD4+, CD8+, and
using a combination of fludarabine and dexamethasone based PTIS, fol- CD19+ recovery was better at Day +100 following MUD HSCT; how-
lowed by fludarabine and busulfan based conditioning and calcineurin ever, no significant difference was noticed in CD56+ cells. Due to small
inhibitor in combination with MMF as GvHD prophylaxis. The con- sample size, it is difficult to draw any statistically significant conclusion,
cept was based on a nucleoside analog-alkylating agent platform that and we propose that IR patterns should be studied in larger cohorts
aimed at achieving initial immune suppression by giving nucleoside assessing various parameters such as type of donor, source of stem cell,
analog and subsequently stable engraftment by giving alkylating agent- conditioning chemotherapy (MAC/RIC), choice and dose of serother-
based conditioning chemotherapy.32 They reported mild reversible apy, and posttransplant complications warranting need of steroids for
veno-occlusive disease in 16% patients, CMV reactivation in 16%, and >7-10 days.
other viral reactivation in another 16% of patients. Thirty-three per- We feel addition of PTCy in the current study helped minimize
cent (6/17) of patients in their study developed grade II-IV aGvHD, the risk of grade III/IV aGvHD and also cGvHD, which were not seen
and limited cGvHD was seen in 28% (5/18) patients.20 Our group used in any of our patients at the last follow-up, although the number
a novel strategy of adding cyclophosphamide to PTIS with 25% dose of follow-up days is small to assess the risk of cGvHD. The current
reduction in fludarabine with added plerixafor for stem cell mobiliza- protocol was adopted from our haploidentical transplant protocol for
tion in donors and post-PTCy platform for GvHD prophylaxis (APOLLO SCD, where the OS and DFS were 88%.25 However, unlikethe APOLLO
protocol) to treat 25 consecutive patients undergoing haploidentical protocol, upfront plerixafor was not used for mobilization of healthy
8 of 9 KHARYA ET AL .

donors, which possibly led to slightly delayed neutrophil and platelet 2. Hsieh MM, Kang EM, Fitzhugh CD, et al. Allogeneic hematopoi-
engraftment in the current study. etic stem-cell transplantation for sickle cell disease. N Engl J Med.
2009;361(24):2309-2317.
To summarize, our study suggests, based on a small number of
3. Ballen KK, King RJ, Chitphakdithai P, et al. The national marrow donor
patients, that MUD transplant can safely be offered to patients suf- program 20 years of unrelated donor hematopoietic cell transplanta-
fering from high-risk TM or severe SCD with no risk of GF and tion. Biol Blood Marrow Transplant. 2008;14(9 Suppl):2-7.
minimal risk of GvHD. The use of fludarabine-, cyclophosphamide-, 4. Sodani P, Gaziev D, Polchi P, et al. New approach for bone marrow
transplantation in patients with class 3 thalassemia aged younger than
dexamethasone-based PTIS for recipients and PTCy in combination
17 years. Blood. 2004;104(4):1201-1203.
with mTOR inhibitor-based GvHD prophylaxis helps to minimize risk of 5. Shenoy S, Grossman WJ, DiPersio J, et al. A novel reduced-intensity
GF and GvHD. It also helps to modify the conditioning from myeloab- stem cell transplant regimen for non-malignant disorders. Bone Mar-
lative to RTC, thus decreasing RRT. The good outcomes make this row Transplant. 2005;35(4):345-352.
6. Bernardo ME, Piras E, Vacca A, et al. Allogeneic hematopoietic
approach feasible and may be preferred over routine management for
stem cell transplantation in thalassemia major: results of a reduced-
patients with TM and SCD. Previous investigators have either focused
toxicity conditioning regimen based on the use of treosulfan. Blood.
on PTIS to target recipient T-cell suppression, or in rare occasions on 2012;120(2):473-476.
PTCy in cases where GvHD was a major concern in MUD settings. We 7. La Nasa G, Giardini C, Argiolu F, et al. Unrelated donor bone marrow
believe this is the first attempt to combine both approaches for MUD transplantation for thalassemia: the effect of extended haplotypes.
Blood. 2002;99(12):4350-4356.
HSCT for TM or SCD. If substantiated in larger groups of patients, we
8. Jaing TH, Yang CP, Hung IJ, Chen SH, Sun CF, Chow R. Transplantation
believe this approach can be further extended to high-risk TM and SCD of unrelated donor umbilical cord blood utilizing double-unit grafts for
patients and can also be used in HLA-identical related donor settings. five teenagers with transfusion-dependent thalassemia. Bone Marrow
Although the results of the current approach are encouraging, the Transplant. 2007;40(4):307-311.
9. Choudhary D, Sharma SK, Gupta N, et al. Treosulfan-thiotepa-
study has a few limitations, small sample size being one of them. In view
fludarabine-based conditioning regimen for allogeneic transplantation
of the short follow-up, relatively longer follow-up will be required to in patients with thalassemia major: a single-center experience from
better assess the risk of cGvHD with the current approach. Feasibility north India. Biol Blood Marrow Transplant. 2013;19(3):492-495.
also needs to be explored in highest risk TM, which is expected to have 10. Bolaños-Meade J, Fuchs EJ, Luznik L, et al. HLA-haploidentical
bone marrow transplantation with posttransplant cyclophosphamide
even higher complications with the standard approach while undergo-
expands the donor pool for patients with sickle cell disease. Blood.
ing MUD HSCT. 2012;120(22):4285-4291.
11. Kamani NR, Walters MC, Carter S, et al. Unrelated donor cord blood
transplantation for children with severe sickle cell disease: results of
ACKNOWLEDGMENTS one cohort from the phase II study from the Blood and Marrow Trans-
Authors would like to acknowledge Ms Manju Joseph and the entire plant Clinical Trials Network (BMT CTN). Biol Blood Marrow Transplant.
nursing team for the excellent execution of the protocol and state of 2012;18(8):1265-1272.
12. Oshrine B, Talano J. Curative treatment for severe sickle cell disease:
art clinical care given to the patients, and to Ms Himshikha Yadav who
allogenic transplantation. Clin Adv Hematol Oncol. 2015;13(4):249-
fulfilled the job of BMT coordinator. Ms Bharti Sharma, senior data ana-
256.
lyst helped in maintenance and compilation of the entire data and also 13. Shenoy S, Eapen M, Panepinto JA, et al. A trial of unrelated donor mar-
in statistical analysis. row transplantation for children with severe sickle cell disease. Blood.
2016;128(21):2561-2567.
14. Shenoy S, Walters MC, Ngwube A, et al. Unrelated donor transplanta-
CONFLICT OF INTEREST tion in children with thalassemia using reduced-intensity conditioning:
The authors declare that there is no conflict of interest. the URTH trial. Biol Blood Marrow Transplant. 2018;24(6):1216-1222.
15. Krishnamurti L, Neuberg DS, Sullivan KM, et al. Bone marrow trans-
plantation for adolescents and young adults with sickle cell dis-
AUTHOR CONTRIBUTIONS ease: results of a prospective multicenter pilot study. Am J Hematol.
2019;94(4):446-454.
Gaurav Kharya conceptualized the protocol and drafted the paper.
16. McDonald GB, Slattery JT, Bouvier ME, et al. Cyclophosphamide
Atish N. Bakane and Archana M. Rauthan compiled the data and did metabolism, liver toxicity, and mortality following hematopoietic stem
the statistical analysis (in association with the senior data analyst). All cell transplantation. Blood. 2003;101(5):2043-2048.
the authors contributed, read, and approved the final version of the 17. Gaziev J, Sodani P, Polchi P, Andreani M, Lucarelli G. Bone marrow
transplantation in adults with thalassemia: treatment and long-term
manuscript.
follow-up. Ann N Y Acad Sci. 2005;1054:196-205.
18. Pai SY, Logan BR, Griffith LM, et al. Transplantation outcomes
ORCID for severe combined immunodeficiency, 2000-2009. N Engl J Med.
Gaurav Kharya https://orcid.org/0000-0003-2181-1825 2014;371(5):434-446.
19. Vermylen C, Cornu G, Ferster A, et al. Haematopoietic stem cell trans-
Atish N. Bakane https://orcid.org/0000-0001-6403-2309
plantation for sickle cell anaemia: the first 50 patients transplanted in
Belgium. Bone Marrow Transplant. 1998;22(1):1-6.
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