Pediatric Grand Rounds UT Health SA 3/30/2018

Size: px

Start display at page:

Download "Pediatric Grand Rounds UT Health SA 3/30/2018"

Charles Simpson
5 years ago
Views:

Hematopoietic Cell Transplantation for Sickle Cell Disease Disclosures No financial disclosures Discussion of off label use of the CliniMACS device (IND 14045) Michael J.

Health San Antonio March 2018 Objectives Provide overview of sickle cell anemia: Sickle cell disease and complications Review current standard approaches to therapy for SCD

alternative donor transplantation Background Sickle cell disease (SCD) Multisystem disease process affects more than 100,000 individuals in the United States alone

Basis of SCD First disease to be linked to identified gene defect Mutation on chromosome 11 Occurs in beta globin gene of hemoglobin Hydrophillic Image courtesy of: http://

1 Hematopoietic Cell Transplantation for Sickle Cell Disease Disclosures No financial disclosures Discussion of off label use of the CliniMACS device (IND 14045) Michael J. Eckrich, MD MPH Medical Director Pediatric Blood and Marrow Transplant Texas Transplant Institute/Methodist Children s Hospital Adjunct Assistant Professor of Pediatrics UT Health San Antonio March 2018 Objectives Provide overview of sickle cell anemia: Sickle cell disease and complications Review current standard approaches to therapy for SCD Discuss approaches to SCD therapy including matched sibling donor and alternative donor Review data on alternative donor transplantation Discuss future approaches to alternative donor transplantation Background Sickle cell disease (SCD) Multisystem disease process affects more than 100,000 individuals in the United States alone Disproportionally affects African Americans Prevalence of SCD in US: 1/5,000 live births 2,000 newborns born each year in the United States Sickle Cell Disease (SCD) Genetic Basis of SCD First disease to be linked to identified gene defect Mutation on chromosome 11 Occurs in beta globin gene of hemoglobin Hydrophillic Image courtesy of: sickle.bwh.harvard.edu/hbs_mutation.gif Hydrophobic Taliaferro, WH et al. The inheritance of sickle cell anaemia in man. Genetics Image courtesy of: 1

Adhesion of damaged RBCs to the endothelium of the microvasculature is responsible for the phenotype: Vascular occlusion Episodic pain attacks End organ damage from hypoxia Biology of SCD SCD

mutations Variants include: HbS o thalassemia Less severe types of SCD: HgS + thalassemia, HbSC, HbSD and HbSE disease HbSS is most clinically severe phenotype Mortality for HbSS, HbS o thalassemia

Name Hgb MCV Disease Severity s s SS Sickle cell anemia 6 9 nl ++++ s S 0 Sickle 0 thalassemia 6 9 low ++++ s + S + Sickle +thalassemia 10 13 low + s c SC Sickle Hgb C disease 9 12 nl ++ Image

Complications from vascular occlusion include: Early death from infection Dactylitis Pain crisis Acute chest syndrome Stroke (CVA) Infection Pain Crisis At risk from early bacteremia Improvements in:

2 Adhesion of damaged RBCs to the endothelium of the microvasculature is responsible for the phenotype: Vascular occlusion Episodic pain attacks End organ damage from hypoxia Biology of SCD SCD Clinical phenotype varies among subtypes of SCD Most common form of the disease: HbSS Additional variants of SCD : Inheritance of one abnormal beta globin gene in combination with additional mutations Variants include: HbS o thalassemia Less severe types of SCD: HgS + thalassemia, HbSC, HbSD and HbSE disease HbSS is most clinically severe phenotype Mortality for HbSS, HbS o thalassemia is higher Most Common SCD Forms SCD Burden Genotyp e Abbrev. Name Hgb MCV Disease Severity s s SS Sickle cell anemia 6 9 nl ++++ s S 0 Sickle 0 thalassemia 6 9 low ++++ s + S + Sickle +thalassemia low + s c SC Sickle Hgb C disease 9 12 nl ++ Image courtesy of: Frenette et al. Sickle cell disease: old discoveries, new concepts and future promise. Journal of Clinical Investigation Complications from vascular occlusion include: Early death from infection Dactylitis Pain crisis Acute chest syndrome Stroke (CVA) Infection Pain Crisis At risk from early bacteremia Improvements in: Use of antibiotic prophylaxis Pneumococcal vaccines (Prevnar) Monitoring Incidence of death from infection is decreasing in United States Pneumococcus in the blood (Image from of Glaxo SmithKline) Vaso occlusion leads to painful crisis Deoxygenated and sickled RBC impair oxygen transport to tissues Patients suffer from intractable pain Episodes can last hours to days to weeks Frequent cause of hospitalization Battersby et al. Susceptibility to invasive bacterial infections in patients with sickle cell disease. Pediatric Blood and Cancer

Acute Chest Syndrome (ACS) CVA Infarction of pulmonary tissue Associated with both immediate mortality,

all pediatric ischemic stroke is related to SCD Pathophysiology of Stroke in SCD CVA in SCD Stroke risk

, et al. Cerebrovascular accidents in sickle cell disease: rates and risk factors. Blood. 1998.

Guidelines recommend screening Transcranial Doppler (TCD) TCD measures the blood flow velocity in the

3 Acute Chest Syndrome (ACS) CVA Infarction of pulmonary tissue Associated with both immediate mortality, and long term mortality Can lead to irreversible and often fatal pulmonary hypertension Image courtesy of: Cerebral vascular accident (CVA) is a catastrophic complication Leading cause of morbidity 38% of all pediatric ischemic stroke is related to SCD Pathophysiology of Stroke in SCD CVA in SCD Stroke risk is 0.46 per 100 pt years Estimates for HbSS under age 20, is calculated at 11% Ohene Frempong, K., et al. Cerebrovascular accidents in sickle cell disease: rates and risk factors. Blood What We Know Strokes in SCD are relatively common About 10% Strokes in SCD are preventable National Guidelines recommend screening Transcranial Doppler (TCD) TCD measures the blood flow velocity in the Circle of Willis Velocity of greater than 200cm/sec predicts stroke Adams et al. Long term stroke risk in children with sickle cell disease screened with transcranial doppler. Annals of Neurology

Screening for Stroke in SCA Stroke during STOP trial Observation vs. chronic transfusion HbS <30% Prematurely stopped due to marked benefit in treatment group Eckrich MJ, et al.

4 Screening for Stroke in SCA Stroke during STOP trial Observation vs. chronic transfusion HbS <30% Prematurely stopped due to marked benefit in treatment group Eckrich MJ, et al. Adherence to transcranial Doppler screening guidelines among children with sickle cell disease. Pediatric Blood Cancer Adams, R et al The use of transcranial ultrasonography to predict stroke in sickle cell disease. New England Journal Adams, R et al. Prevention of first stroke by transfusion in children with abnormal results of transcranial doppler ultrasonography. New England Journal Prevention Crisis Prevention Universally accepted approaches include: Penicillin prophylaxis to prevent invasive bacterial infection Educating parents to detect splenomegaly Routine vaccinations, including Prevnar Regular use of TCD to detect patients with increased risk of stroke Prevention Leads to Improvement End Organ Damage Most oscillate between long periods of being asymptomatic and severe vaso occlusive crisis manifesting as ACS or pain crisis Infants as young as 12 months will demonstrate end organ damage Quinn CT, et al.. Improved survival of children and adolescents with sickle cell disease. Blood

Baseline GFR in SCA MRI in Infants MRI examinations of infants with SCA >10% had silent infarcts Silent infarcts occur in small but significant number of infants as early as one year Ware RE, et al.

MRI abnormalities of the brain in one year old children with sickle cell anemia. Pediatric Blood and Cancer. 2008.

Acute silent cerebral ischemic events in children with sickle cell anemia. JAMA Neurology. 2013 Baseline 10 months later Quinn CT, et al.

5 Baseline GFR in SCA MRI in Infants MRI examinations of infants with SCA >10% had silent infarcts Silent infarcts occur in small but significant number of infants as early as one year Ware RE, et al. Renal function in infants with sickle cell anemia: baseline data from the BABY HUG trial. Journal of Pediatrics Axial FLAIR of asymptomatic 16 month old Wang et al. MRI abnormalities of the brain in one year old children with sickle cell anemia. Pediatric Blood and Cancer Acute Silent Cerebral Events Acute Silent Cerebral Events Produce no motor or sensory deficits Associated with neurocognitive impairment Quinn CT, et al. Acute silent cerebral ischemic events in children with sickle cell anemia. JAMA Neurology Baseline 10 months later Quinn CT, et al. Acute silent cerebral ischemic events in children with sickle cell anemia. JAMA Neurology Hemolysis Chronic ongoing hemolysis Associated with decreased survival Pulmonary Hypertension Resulting from intravascular hemolysis Associated with elevated cardiac output Independently correlates with survival Nouraie M, Lee JS, Zhang Y, et al. The relationship between the severity of hemolysis, clinical manifestations and risk of death in 415 patients with sickle cell anemia in the US and Europe. Haematologica Cabrita IZ, et al. The association between tricuspid regurgitation velocity and 5 year survival in a North West London population of patients with sickle cell disease in the United Kingdom. British Journal of Haematology

Cardiac Arrythmias Summary of SCD and Complications Associated with increased TRV Independently associated with increased mortality Upadhya B, et al.

Factors Associated with Survival in a Contemporary Adult Sickle Cell Disease Cohort. American Journal Hematology. 2014.

6 Cardiac Arrythmias Summary of SCD and Complications Associated with increased TRV Independently associated with increased mortality Upadhya B, et al. Prolongation of QTc intervals and risk of death among patients with sickle cell disease. European Journal Haematology Elmariah H, Garrett ME, De Castro LM, et al. Factors Associated with Survival in a Contemporary Adult Sickle Cell Disease Cohort. American Journal Hematology Clinically severe and evident events Accumulation of end organ disease leads to increased mortality in adults with SCD Objectives Therapy for SCD Provide overview of sickle cell anemia: Sickle cell disease and complications Review current standard approaches to therapy for SCD Discuss approaches to SCD therapy including matched sibling donor and alternative donor Review data on alternative donor transplantation Discuss future approaches to alternative donor transplantation Acute medical management: O2 Morphine Fluids Exchange or simple transfusions Chronic management: Hydroxyurea Chronic transfusion Eckrich Medical school notes on SCD management, circa 2003 Hydroxyurea BABY HUG Trial Platt et al. Mortality in Sickle Cell Disease Life Expectancy & Risk Factors for Early Death. NEJM Increase fetal hemoglobin production Cost effective Large multi center randomized trial for infants 9 to 17 months Randomized between hydroxyurea and placebo x24 months Endpoints: Renal and splenic function Assessed by spleen uptake 99mTc sulpher colloid and quantitative GFR 6

Results of BABY HUG Trial SWiTCH Trial Lobo et al. The effect of hydroxycarbamide on survival of children with sickle cell disease. British Journal of Hematology.

7 Results of BABY HUG Trial SWiTCH Trial Lobo et al. The effect of hydroxycarbamide on survival of children with sickle cell disease. British Journal of Hematology HU demonstrates reduction: Fewer pain crises Less ACS Fewer hospitalizations Improved urine concentrating ability and less renal hypertrophy No strokes in transfusion group 7 strokes in HU group Study closed Ware RE, et al. Stroke With Transfusions Changing to Hydroxyurea (SWiTCH): a phase III randomized clinical trial for treatment of children with sickle cell anemia, stroke, and iron overload. Pediatric Blood and Cancer TWiTCH Trial Recommendations Transition patients to HU after a period of chronic transfusion if they meet the following: Completion of 2 years with stable HbS levels Normalization of TCD No evidence of vasculopathy on MRI Demonstrate HU compliance Demonstrate WBC response to HU Complications of RBC Therapy RBC allo immunization Results in modern era improving: 14% of chronically transfused develop new antibody Most common against C, E, Kell Extended RBC matching is standard of care Iron overload Thompson et al. Allo immunization in sickle cell anemia in the era of extended red cell typing. Pediatric Blood and Cancer Iron Accumulation Iron stores increase Iron Overload Capacity of transferrin exceeded Unbound iron accumulates Toxicity: hepatic, endocrine, cardiac IRON OVERLOAD Courtesy of: Cardiothoracic and vascular atlas, meduweb.com Kwiatkowski et al. Transfusional iron overload in children with sickle cell anemia on chronic transfusion therapy for secondary stroke prevention. American Journal of Hematology

Iron Overload Causes of Death in SCD Deposition of iron in tissue Liver failure Endocrine

and vascular atlas, meduweb.com Kaushik N, Eckrich, MJ et al.

for better therapy Survival in SCD Platt et al.

The Pediatrician s view Survival in SCD SCD Therapy In a chronic disease where symptomatology

8 Iron Overload Causes of Death in SCD Deposition of iron in tissue Liver failure Endocrine toxicity Cardiac toxicity Cardiac tissue may be relatively spared Courtesy of: Cardiothoracic and vascular atlas, meduweb.com Kaushik N, Eckrich, MJ et al. Chronically transfused pediatric sickle cell patients are protected from cardiac iron overload. Pediatric Hematology Oncology Pediatric Adult Survival Improving Chronic transfusion: Alloimmunization Iron overload Need for better therapy Survival in SCD Platt et al. Mortality in Sickle Cell Disease Life Expectancy & Risk Factors for Early Death. NEJM The Pediatrician s view Survival in SCD SCD Therapy In a chronic disease where symptomatology does not always mirror pathology: Do pediatricians need to consider offering intervention with curative therapy? Platt et al. Mortality in Sickle Cell Disease Life Expectancy & Risk Factors for Early Death. NEJM The longer view 8

Objectives Provide overview of sickle cell anemia: Sickle cell disease and complications Review current standard approaches to

donor transplantation Discuss future approaches to alternative donor transplantation HCT for SCD HCT = Only readily available

immune system Tolerant to recipient HLA antigens MOM PT A A B B DR DR A A B B DR DR A A B B DR DR X A B DR A B DR A B DR A B DR A B

Health and HCT for SCD 2,000 born in US each year with SCD Estimated 6,000 could be eligible 1137 * US patients have been

9 Objectives Provide overview of sickle cell anemia: Sickle cell disease and complications Review current standard approaches to therapy for SCD Discuss approaches to SCD therapy including matched sibling donor and alternative donor Review data on alternative donor transplantation Discuss future approaches to alternative donor transplantation HCT for SCD HCT = Only readily available curative therapy Goal of Transplant Inheritance of HLA Haplotypes Create a Chimera Donor derived hematopoietic system Donor derived immune system Tolerant to recipient HLA antigens MOM PT A A B B DR DR A A B B DR DR A A B B DR DR X A B DR A B DR A B DR A B DR A B DR DAD A B DR A B DR A B DR Match History of HCT for SCA First HCT for SCA performed for AML Cured AML but also cured SCA Public Health and HCT for SCD 2,000 born in US each year with SCD Estimated 6,000 could be eligible 1137 * US patients have been transplanted for SCD (~600 in Europe) * Data obtained from Statistical Center of the Center for International Blood and Marrow Transplant Research in The data presented here are preliminary and were obtained from the Coordinating Center of the Center for International Blood and Marrow Transplant Research. The analysis has not been reviewed or approved by the Statistical or Scientific Committees of the CIBMTR. 9

Indications for HCT Stroke/elevated flow on TCD Recurrent VOC Recurrent ACS Significant end organ damage Allo immunization Infers chronic transfusion therapy Seizures, CVA, PRES Mucositis SHORT TERM

Infertility Chronic Graftversus host disease Endocrine abnormalities, Thyroid, Growth Walters et al. Bone Marrow Transplantation in Sickle Cell Anemia. NEJM 1996.

10 Indications for HCT Stroke/elevated flow on TCD Recurrent VOC Recurrent ACS Significant end organ damage Allo immunization Infers chronic transfusion therapy Seizures, CVA, PRES Mucositis SHORT TERM Veno occlusive disease of the liver Acute Graft Versus Host Disease Transplant Toxicities Infections Learning Disability Bronchiolitis LONG TERM Obliterans Cardiac Dysfunction Liver Dysfunction Infertility Chronic Graftversus host disease Endocrine abnormalities, Thyroid, Growth Walters et al. Bone Marrow Transplantation in Sickle Cell Anemia. NEJM Transplant Balance Engraftment Finding a Donor Intensity Engraftment MAC: Myeloablative RIC: Reduced Intensity HLA identical sibling or family member Vs. Alternative donor Unrelated donors Partially matched family member Intensity HCT Strategy for SCD HLA matched sibling HCT for SCD Transplant risk reduction: Ideal donor Reduce toxicity of conditioning Lower mortality No GVHD Infection Graft rejection Good engraftment Low rates of GVHD Stable mixed chimerism cures SCD Walters et al. Stable Mixed Chimerism after Bone Marrow Transplantation for Sickle Cell Anemia. Biology Blood and Marrow Transplant

11 HLA matched sibling HCT for SCD Outcomes of 67 patients with SCD w/ HLAmatched sibling donors reported to CIBMTR Most common indications: Stroke 38% Vaso occlusive pain 37% Poor performance scores 27% Busulfan Cyclophosphamide +/ ATG Bone marrow HLA matched sibling HCT for SCD Most had hematopoietic recovery No deaths in early post transplant period Rates of: Acute GVHD: 10% Chronic GVHD: 22% 9 patients had graft failure with autologous recovery Panepinto et al. Matched related donor transplantation for sickle cell disease: Report from the CIBMTR. British Journal of Hematology Panepinto et al. Matched related donor transplantation for sickle cell disease: Report from the CIBMTR. British Journal of Hematology Survival in SCD after MRD Panepinto et al. Matched related donor transplantation for sickle cell disease: Report from the CIBMTR. British Journal of Hematology European experience in HLA matched sibling HCT in SCD 87 patients with SCD Most marrow; few sibling cord blood transplants OS and 93% EFS rates 86% 10 consecutive SCA patients: HCT by EBMT 90% survival 90% SCA disease free survival 10% transplant related mortality Bernaudin et al. Long term results of related myeloablative stem cell transplantation to cure sickle cell disease. Blood Lucarelli et al. Allogeneic cellular gene therapy in hemoglobinopathies evaluation of hematopoietic SCT in sickle cell anemia. Biology Blood and Marrow Transplant Summary of HLA matched sibling HCT Large retrospective cohort from US and Europe Myeloablative (n=873) Reduced intensity (n=125) 84% bone marrow grafts 5 year EFS was 91% 5 year OS 93% Summary of HLA matched sibling HCT 92 94% overall survival, 82 91% EFS Graft rejection 7 10% Graft versus host disease (GVHD) Acute grade II IV 15 20%, Chronic 12 20% Transplant related mortality 6 7% Gluckman et al. Sickle Cell Disease: An international survey of results of HLA identical sibling hematopoietic stem cell transplantation. Blood Vermylen et al, 1998; Walters et al, 2000; Bernaudin et al, 2007, Lucarelli et al 2014; Dedeken et al 2014, Bhatia et al, 2014, McPherson et al 2011; Gluckman et al

Survival in SCD Late Effects of Myeloablative BMT No Transplant With Transplant Bu/Cy ATG follow up of 10 years 95% survival Pulmonary function tests: FEV1 pre BMT 88%+10%, post BMT 86%+11% (p=0.

12 Survival in SCD Late Effects of Myeloablative BMT No Transplant With Transplant Bu/Cy ATG follow up of 10 years 95% survival Pulmonary function tests: FEV1 pre BMT 88%+10%, post BMT 86%+11% (p=0.6) FVC pre BMT 78%+16%, post BMT 81%+12% (p=0.4) Gondal toxicity: Males <25% had normal testosterone Females >50% had primary ovarian failure Quinn CT et al. Improved survival of children and adolescents with sickle cell disease. Blood Michlitsch et al. Recent advances in bone marrow transplantation in hemoglobinopathies. Current Molecular Medicine Walters MC, Hardy K, Edwards S, et al. Pulmonary, gonadal, and central nervous system status after bone marrow transplantation for sickle cell disease. Biology of Blood Marrow Transplant Non myeloablative Conditioning HLA matched PBSC Conditioning: Alemtuzumab (Campath) + low dose TBI (total body irradiation) GVHD prophylaxis with Rapamycin Outcomes in adults: No transplant related mortality (TRM) Mixed donor chimerism only with continued immune suppression Pediatric Experiences with Reduced Intensity/NMA Conditioning Trial (n=1) Bu/Flu +ATG 1 death, GVHD Trial (n=6) TBI/Flu 6, transient engraftment in 5 Trial (n=2) Flu/Mel +ATG none remain alive without SCD Trial (n=7) Bu/Flu +ATG 6 of 7 alive without SCD Hsieh MM, et al. Allogeneic hematopoietic stem cell transplantation for sickle cell disease. New England Journal of Medicine Jacobsohn et al 2004, Iannone et al 2003, van Besein et al 2000, Krishnamurthi et al 2008 Reduced Intensity Matched Sibling Campath, Fludarabine, Melphalan MSD OS 94% EFS 92% agvhd 23% cgvhd 13% Reduced Intensity Matched Sibling N=13 Six patients with severe SCD Amongst matched sibling: OS 100% agvhd <20% King et al. Successful matched sibling donor marrow transplantation following reduced intensity conditioning in children with hemoglobinopathies. American Journal of Hematology Eckrich et al. Reduced Intensity allogeneic stem cell transplant for sickle cell disease in pediatrics: A single institution experience. Biology of Blood and Marrow Transplantation. March

Barriers to HCT in SCD Only 14 18% with matched sibling Lack of HLA matched donor: 85% do NOT have donor available Only 40% had HLA typing performed Lack of psychosocial support 10% Parental

SCD Discuss approaches to SCD therapy including matched sibling donor Review data on alternative donor transplantation Discuss future approaches to alternative donor transplantation Walters et al.

1996 Alternative donor: Unrelated donors Partially matched family member Alternative Options for SCD Alternative Donor: Unrelated cord blood 50% 5/6 cords with cell doses of 5 x10 cells/kg 46%

13 Barriers to HCT in SCD Only 14 18% with matched sibling Lack of HLA matched donor: 85% do NOT have donor available Only 40% had HLA typing performed Lack of psychosocial support 10% Parental refusal 10% Physician referral to transplant refusal 4% Objectives Provide overview of sickle cell anemia: Sickle cell disease and complications Review current standard approaches to therapy for SCD Discuss approaches to SCD therapy including matched sibling donor Review data on alternative donor transplantation Discuss future approaches to alternative donor transplantation Walters et al. Barriers to bone marrow transplantation for sickle cell anemia. Biology of Blood and Marrow Transplant Alternative donor: Unrelated donors Partially matched family member Alternative Options for SCD Alternative Donor: Unrelated cord blood 50% 5/6 cords with cell doses of 5 x10 cells/kg 46% 5/6 cords (Stevens ASH abstract 2012) Approximately 50% will have suitable cord unit available Adamkiewicz, TV et al. Identification of unrelated cord blood units for hematopoietic cell transplantation in children with sickle cell disease. Journal of Pediatric Hematology and Oncology

14 Alternative donor HCT for SCD Preliminary data: Conditioning: Campath/Fludarabine/Melphalan Used related or unrelated marrow n=14 OS of 95%, EFS 79% S.C.U.R.T. trial S.C.U.R.T. Trial (Including Cord) Sickle Cell Unrelated Donor Transplant n=8 5 patients with autologous recovery Only 3/8 alive without graft failure or disease recurrence Unrelated cord transplant arm closed due to increased graft rejection Kamani NR, et al. Unrelated donor cord blood transplantation for children with severe sickle cell disease: results of one cohort from the phase II study from the Blood and Marrow Transplant Clinical Trials Network (BMT CTN). Biology of Blood and Marrow Transplant European Conditioning (Cord) Myeloablative conditioning in 9/16 with SCD Busulfan and cyclophosphamide with or without ATG most common 7 patients received reduced intensity (RIC) All received calcineurin inhibitor GVHD prophylaxis (CSA most common) Median follow up of 2 years Engraftment Outcomes (Cord) 9 SCD achieved hematopoietic recovery No patients experienced secondary graft failure Multivariate analysis: Engraftment higher in cell doses >5x10 7 (nucleated cells/kg) Cumulative incidence of engraftment: 63% for units > 5x10 7 (nucleated cells/kg) 32% for units < 5x10 7 (nucleated cells/kg) Ruggeri et al. Umbilical cord blood transplantation for children with thalassemia and sickle cell disease. BBMT Outcomes (Cord) Disease free survival (DFS): 50% for SCD DFS higher in CB units >5x10 7 /kg Effect of TNC on DFS: Independent of disease Historically, cords matched at three alleles Increased TRM unless matched at four alleles Further reduces suitable cord units Cord Barriers Eapen et al. Impact of allele level HLA matching on outcomes after myeloablative single unit umbilical cord blood transplantation for hematologic malignancy. Blood

15 Cord Conclusions Only UCB units containing >5 x10 7 /kg should be considered for transplantation of hemoglobinpathy Associated with 50% DFS Associated with high rates of graft rejection Largest U.S. trial of unrelated cord transplant for SCD was closed Recent Cord for SCD Recent experience with novel reduced intensity regimen (phase I) (n=9) age 3 10 years, with CVA complications received Campath, Fludarabine, Melphalan, Thiotepa 7/9 engrafted, 2 autologous recovery Disease free survival of 78% Acute GVHD in 3 (33%) Chronic GVHD in 3 (33%) Abraham, A et al Unrelated Umbilical Cord Blood Transplantation for Sickle Cell Disease Following Reduced intensity conditioning: Results of a Phase I trial. Biology of Blood and Marrow Transplant Results of Phase II MUD N=29 One and 2 year EFS were 76% and 69%, respectively Overall survival (OS) was 86% and 79% The day 100 incidence of grade II IV acute GVHD was 28%; 1 year incidence of chronic GVHD was 62%; 38% classified as extensive There were 7 GVHD related deaths Results of Phase II MUD Shenoy et al A BMT CTN phase II trial of unrelated donor marrow transplantation for children with severe sickle cell disease. Blood Shenoy et al A BMT CTN phase II trial of unrelated donor marrow transplantation for children with severe sickle cell disease. Blood Summary of Phase II MUD Cannot be considered sufficiently safe for widespread adoption without modifications to achieve more effective GVHD prophylaxis Other Alternative Donor Trials Conditioning: Fludarabine, Melphalan, Campath 2 marrow (7/8 allele matched) 6 cord (4/6 cord) Addition of mesenchymal cells (MSC) Shenoy et al A BMT CTN phase II trial of unrelated donor marrow transplantation for children with severe sickle cell disease. Blood Kharbanda S et al. Unrelated donor allogeneic hematopoietic stem cell transplantation for patients with hemoglobinopathies using a reduced intensity conditioning regimen and third party mesenchymal stromal cells. Biology of Blood and Marrow Transplant

Other Alternative Donor Trials Only 3/6 patients engrafted 2/3 engrafted patients developed GVHD 4/6 patients died 2 infectious (CMV, toxoplasmosis) GVHD Intra ventricular hemorrhage Result: Pilot

16 Other Alternative Donor Trials Only 3/6 patients engrafted 2/3 engrafted patients developed GVHD 4/6 patients died 2 infectious (CMV, toxoplasmosis) GVHD Intra ventricular hemorrhage Result: Pilot study prematurely terminated Kharbanda S, et al. Unrelated donor allogeneic hematopoietic stem cell transplantation for patients with hemoglobinopathies using a reduced intensity conditioning regimen and third party mesenchymal stromal cells. Biology of Blood Marrow Transplant Alternative Donor Transplant Engraftment, No GVHD, low regimen related toxicity 1. In vivo graft manipulation 2. Graft Engineering Mismatched Related (Haploidentical) Donor Transplant Almost every child will have a donor Rapid engraftment short hospital stay High risk of GVHD and graft rejection can potentially be overcome Major challenge is delayed immune recovery and infection after transplant T Cells Coordinate response to infection Fight viral and fungal infection Cause Graft Versus Host disease For patients needing alternative donor transplant Alternative Donor Transplant HLA matching In vivograft manipulation Vs. T depletion Engraftment, No GVHD, low regimen related toxicity 1. Graft Engineering 2.In vivo graft manipulation 16

Leukapheresis (1x10 11 ) T cell depletion (CliniMACS ) NK B T SC cells + magnetic microbeads with anti CD34 Conditioning Regimen Fludarabine T celldepleted PBSC Target cells (1x10 8 10 9 ) Magnet SC

17 Leukapheresis (1x10 11 ) T cell depletion (CliniMACS ) NK B T SC cells + magnetic microbeads with anti CD34 Conditioning Regimen Fludarabine T celldepleted PBSC Target cells (1x ) Magnet SC Magnet CD34+ cells (graft) Melphalan Thiotepa ratg Rituximab B T Waste No GVHD prophylaxis Age (y) Se x Patient Characteristics Indications Donor (match) 13 F Recurrent VOC, ACS Father (7/10) 15 F Recurrent VOC, alloimmunized Half brother (5/10) 13 M Recurrent VOC Unrelated (10/10) 8 F Conditional TCD Sister (9/10, A) 5 F Stroke Unrelated (9/10) 17 M Recurrent VOC, ACS Mother (5/10) 19 M Stroke Sister (6/10) 18 M Recurrent VOC Half-sister (6/10) 12 M ACS Uncle (5/10) Recurrent VOC, 23 F Brother (6/10) osteonecrosis Gilman, Eckrich et al. Alternative Donor Transplant for Sickle Cell Disease. Blood Advances Age (y) BMT Day to ANC > 500 Chimerism Donor % 30 days Donor % 90 days Donor % 12 months Follow-up (mo) * * Required second transplant from a second haploidentical donor SCD Outcomes Post HCT Hemoglobin Show data Show graph Outcomes Recovery of donor CD4+ T Cells CD4+ less than 200 requires anti viral and anti fungal prophylaxis Prolonged immune suppression Pre HCT Day100 1 year >1 year Gilman, Eckrich et al. Alternative Donor Transplant for Sickle Cell Disease. Blood Advances. Dec

Complications Graft failure in one; engrafted after second SCT 2 pts developed PRES (posterior reversible encephalopathy); one seizure PRES resolved by four weeks in both 4 PTLD (post transplant

18 Complications Graft failure in one; engrafted after second SCT 2 pts developed PRES (posterior reversible encephalopathy); one seizure PRES resolved by four weeks in both 4 PTLD (post transplant lymphoproliferative disorder) One treated XRT and with EBV specific T cells and low dose TBI 2 treated with 4 doses of IV rituximab resolved One died as consequence of treatment for PTLD Outcomes OS 90% EFS 90% agvhd 20% cgvhd 10% Gilman, Eckrich et al. Alternative Donor Transplant for Sickle Cell Disease. Blood Advances Gilman, Eckrich et al. Alternative Donor Transplant for Sickle Cell Disease. Blood Advances. Dec Alternative Donor Transplant In vivo Graft Manipulation HLA haploidentical bone marrow transplantation with post transplant cyclophosphamide Engraftment, No GVHD, low regimen related toxicity 1. Graft Engineering 2. In vivo graft manipulation Bolanos Meade J, Fuchs EJ, Luznik L, et al. HLA haploidentical bone marrow transplantation with posttransplant cyclophosphamide expands the donor pool for patients with sickle cell disease. Blood Post HCT Cyclophosphamide Outcomes 11/17 Durable engraftment 10/17 Remain asymptomatic 1/17 Developed GVHD (skin only) 5/11 Remain on immune suppression 6/17 Graft rejection Limitations Graft failure Many need prolonged or indefinite immune suppression Bolanos Meade J, Fuchs EJ, Luznik L, et al. HLA haploidentical bone marrow transplantation with posttransplant cyclophosphamide expands the donor pool for patients with sickle cell disease. Blood

The Future of HCT Trials for SCD Stride II Trial: Eligibility will be determined on the biological assignment of HLA identical siblings or well matched unrelated donors Those lacking an eligible

19 The Future of HCT Trials for SCD Stride II Trial: Eligibility will be determined on the biological assignment of HLA identical siblings or well matched unrelated donors Those lacking an eligible donor for HCT serving as a comparison group BMT 1507: Alternative donor SCT for SCD using reduced intensity conditioning and haploidentical donors Gene Therapy Lentiviral vector gene insertion Phase III expected to open in 2018 CRISPR single nucleotide mutagenesis Phase I opening soon Summary Moving Beyond SCD HLA matched sibling donor transplant may be considered standard of care for SCD Alternative donor transplant options are available A reduced intensity conditioning regimen followed by T cell depleted transplant provides: Reliable engraftment Low GVHD Low transplant related mortality Haploidentical transplant expands the donor pool References References Hsieh MM, Kang EM, Fitzhugh CD, et al. Allogeneic hematopoietic stem cell transplantation for sickle cell disease. N Engl J Med 2009;361: Gluckman E. Allogeneic transplantation strategies including haploidentical transplantation in sickle cell disease. Hematology Am Soc Hematol Educ Program 2013;2013: Matthes Martin S, Lawitschka A, Fritsch G, et al. Stem cell transplantation after reduced intensity conditioning for sickle cell disease. Eur J Haematol 2013;90: Shenoy S. Hematopoietic stem cell transplantation for sickle cell disease: current evidence and opinions. Ther Adv Hematol 2013;4: Quinn CT, Rogers ZR, McCavit TL, Buchanan GR. Improved survival of children and adolescents with sickle cell disease. Blood 2010;115: Shenoy S. Umbilical cord blood: an evolving stem cell source for sickle cell disease transplants. Stem Cells Transl Med 2013;2: Booth C, Lawson S, Veys P. The current role of T cell depletion in paediatric stem cell transplantation. Br J Haematol2013;162: Omondi NA, Ferguson SE, Majhail NS, et al. Barriers to hematopoietic cell transplantation clinical trial participation of african american and black youth with sickle cell disease and their parents. J Pediatr Hematol Oncol 2013;35: Frenette et al. Sickle cell disease: old discoveries, new concepts and future promise. Journal of Clinical Investigation. 2007, Vol. 117; Ohene Frempong, K., et al. Cerebrovascular accidents in sickle cell disease: rates and risk factors. Blood, (1): p Platt et al. Mortality in Sickle Cell Disease Life Expectancy & Risk Factors for Early Death. NEJM Vol 330; Panepinto et al. Matched related donor transplantation for sickle cell disease: Report from the CIBMTR. British Journal of Hematology vol 137; Ruggeri et al. Umbilical cord blood transplantation for children with Thalassemia and Sickle cell disease. BBMT. Vol 17; Adamkiewicz, TV et al. Identification of unrelated cord blood units for hematopoietic cell transplantation in children with sickle cell disease Vol. 28; Walters et al. Barriers to bone marrow transplantation for sickle cell anemia. BBMT Vol. 2; Walters MC, Hardy K, Edwards S, et al. Pulmonary, gonadal, and central nervous system status after bone marrow transplantation for sickle cell disease. Biol Blood Marrow Transplant 2010;16:

20 References Voskaridou E, Christoulas D, Terpos E. Sickle cell disease and the heart: review of the current literature. Br J Haematol 2012;157: Nouraie M, Lee JS, Zhang Y, et al. The relationship between the severity of hemolysis, clinical manifestations and risk of death in 415 patients with sickle cell anemia in the US and Europe. Haematologica 2013;98: Cabrita IZ, Mohammed A, Layton M, et al. The association between tricuspid regurgitation velocity and 5 year survival in a North West London population of patients with sickle cell disease in the United Kingdom. Br J Haematol 2013;162: Upadhya B, Ntim W, Brandon Stacey R, et al. Prolongation of QTc intervals and risk of death among patients with sickle cell disease. Eur J Haematol 2013;91: Kassim AA, DeBaun MR. The case for and against initiating either hydroxyurea therapy, blood transfusion therapy or hematopoietic stem cell transplant in asymptomatic children with sickle cell disease. Expert Opin Pharmacother 2014;15: Aydinok Y, Kattamis A, Viprakasit V. Current approach to iron chelation in children. Br J Haematol Bunn HF, Nathan DG, Dover GJ, et al. Pulmonary hypertension and nitric oxide depletion in sickle cell disease. Blood 2010;116: Elmariah H, Garrett ME, De Castro LM, et al. Factors Associated with Survival in a Contemporary Adult Sickle Cell Disease Cohort. Am J Hematol O'Suoji C, Liem RI, Mack AK, Kingsberry P, Ramsey G, Thompson AA. Alloimmunization in sickle cell anemia in the era of extended red cell typing. Pediatr Blood Cancer 2013;60: References Ware RE, Helms RW. Stroke With Transfusions Changing to Hydroxyurea (SWiTCH). Blood 2012;119: Alvarez O, Yovetich NA, Scott JP, et al. Pain and other non neurological adverse events in children with sickle cell anemia and previous stroke who received hydroxyurea and phlebotomy or chronic transfusions and chelation: results from the SWiTCH clinical trial. Am J Hematol 2013;88: Wang WC, Pavlakis SG, Helton KJ, et al. MRI abnormalities of the brain in one year old children with sickle cell anemia. Pediatr Blood Cancer 2008;51: Jordan LC, Casella JF, DeBaun MR. Prospects for primary stroke prevention in children with sickle cell anaemia. Br J Haematol 2012;157: Bolanos Meade J, Fuchs EJ, Luznik L, et al. HLA haploidentical bone marrow transplantation with posttransplant cyclophosphamide expands the donor pool for patients with sickle cell disease. Blood 2012;120: Freed J, Talano J, Small T, Ricci A, Cairo MS. Allogeneic cellular and autologous stem cell therapy for sickle cell disease: 'whom, when and how'. Bone Marrow Transplant 2012;47: Dallas MH, Triplett B, Shook DR, et al. Long term outcome and evaluation of organ function in pediatric patients undergoing haploidentical and matched related hematopoietic cell transplantation for sickle cell disease. Biol Blood Marrow Transplant 2013;19: Hsieh MM, Fitzhugh CD, Tisdale JF. Allogeneic hematopoietic stem cell transplantation for sickle cell disease: the time is now. Blood 2011;118: References References Kharbanda S, Smith AR, Hutchinson SK, et al. Unrelated donor allogeneic hematopoietic stem cell transplantation for patients with hemoglobinopathies using a reduced intensity conditioning regimen and third party mesenchymal stromal cells. Biol Blood Marrow Transplant 2014;20: Lucarelli G, Isgro A, Sodani P, Gaziev J. Hematopoietic stem cell transplantation in thalassemia and sickle cell anemia. Cold Spring Harb Perspect Med 2012;2:a Kamani NR, Walters MC, Carter S, et al. Unrelated donor cord blood transplantation for children with severe sickle cell disease: results of one cohort from the phase II study from the Blood and Marrow Transplant Clinical Trials Network (BMT CTN). Biol Blood Marrow Transplant 2012;18: Isgro A, Marziali M, Sodani P, et al. Immunohematologic reconstitution in pediatric patients after T cell depleted HLA haploidentical stem cell transplantation for thalassemia. Biol Blood Marrow Transplant 2010;16: Eckrich MJ, Wang WC, Yang E, et al. Adherence to transcranial Doppler screening guidelines among children with sickle cell disease. Pediatr Blood Cancer 2013;60: Kaushik N, Eckrich MJ, Parra D, Yang E. Chronically transfused pediatric sickle cell patients are protected from cardiac iron overload. Pediatr Hematol Oncol 2012;29: Eckrich MJ, Ahn KW, Champlin RE, et al. Effect of race on outcomes after allogeneic hematopoietic cell transplantation for severe aplastic anemia. Am J Hematol 2014;89: Michlitsch JG, Walters MC. Recent advances in bone marrow transplantation in hemoglobinopathies. Curr Mol Med 2008;8: Kanter J, Kruse Jarres R. Management of sickle cell disease from childhood through adulthood. Blood Rev 2013;27: Hansbury EN, Schultz WH, Ware RE, Aygun B. Bone marrow transplant options and preferences in a sickle cell anemia cohort on chronic transfusions. Pediatr Blood Cancer 2012;58: Darbari DS, Onyekwere O, Nouraie M, et al. Markers of severe vaso occlusive painful episode frequency in children and adolescents with sickle cell anemia. J Pediatr 2012;160: Thompson AA. Ideal donors, imperfect results in sickle cell disease. Blood 2013;122: Quinn CT, McKinstry RC, Dowling MM, et al. Acute silent cerebral ischemic events in children with sickle cell anemia. JAMA Neurol 2013;70: Kwiatkowski JL, Cohen AR, Garro J, et al. Transfusional iron overload in children with sickle cell anemia on chronic transfusion therapy for secondary stroke prevention. Am J Hematol 2012; 87: Quinn CT, Rogers ZR, Buchanan GR. Survival of children with sickle cell disease. Blood 2004;103:

1 Kattamis et al. Growth of Children with Thalassemia: Effect of Different Transfusion Regimens. Archives of

1 Kattamis et al. Growth of Children with Thalassemia: Effect of Different Transfusion Regimens. Archives of Objectives Sickle Cell Anemia and Thalassemia: Transplantation Provide overview of hemoglobinopathies: Sickle cell disease and Thalassemia Discuss approaches to therapy Review recent registry collaboration