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Seven patients underwent treatment with mesenchymal stem cells (MSCs), together with allogeneic hematopoietic stem cell transplantation (HSCT). MSCs were given to three patients for graft failure and four patients were included in a pilot study. HSCT donors were three human leukocyte antigen (HLA)-identical siblings, three unrelated donors and one cord blood unit. The conditioning was myeloablative in four patients and reduced in three patients. MSC donors were HLA-identical siblings in three cases and haploidentical in four cases. Neutrophil counts0.5 x 10(9)/l was reached at a median of 12 (range 10-28) days. Platelet counts30 x 10(9)/l was achieved at a median of 12 (8-36) days. Acute graft-versus-host disease (GVHD) grade 0-I was seen in five patients. Two patients developed grade II, which in one patient evolved into chronic GVHD. One severe combined immunodeficiency (SCID) patient died of aspergillosis, the others are alive and well. One patient, diagnosed with aplastic anemia had graft failure after her first transplantation and severe Henoch-Schönlein Purpura (HSP). After retransplantation of MSCs and HSCs, she recovered from both the HSP and aplasia. Thus, co-transplantation of MSC resulted in fast engraftment of absolute neutrophil count (ANC) and platelets and 100% donor chimerism, even in three patients regrafted for graft failure/rejection.

Background. To determine the concentration of cytokines having an immunomodulating effect in the first trimester in women who subsequently developed preeclampsia.Methods. The serum concentrations of IL-10, TNFα, IL-6 and IL-2R were determined in ten women who later developed severe preeclampsia and in ten healthy controls. The groups were compared with the Mann-Whitney U test.Results. The IL-2R concentration was significantly higher in the women who later developed preeclampsia than in normal patients (p = 0.028). No significant differences were detected between the groups with respect to the other evaluated cytokines.Conclusion. Elevated IL-2R concentrations in maternal serum as early as in the first trimester may be a sign of immunological maladaptation and might be associated with a disturbance of trophoblastic invasion.

BACKGROUND: The use of reduced intensity conditioning (RIC) regimens in allogeneic hematopoietic stem cell transplantation (HSCT) has increased over the past five years. PATIENTS: In this study, involving 137 patients, we compared the outcome after RIC in patients receiving grafts from matched unrelated donors (MUD; n=74) and sibling donors (n=63). The MUD and sibling groups were comparable regarding diagnosis, including solid tumors and hematological malignancies, and conditioning regimens. RESULTS: Engraftment was successful in most patients (88%), with no significant difference between MUD and sibling transplants. Cytomegalovirus (CMV) infection was more common in the MUD group (65%) than in the sibling group (46%) (P=0.04). No difference in severe acute graft-versus-host disease (GVHD) was found between the groups. However, the incidence of chronic GVHD was higher after sibling transplants. This was probably due to higher donor age in this group, since this was the only significant risk factor for chronic GVHD in multivariate analysis. The incidence of transplant related mortality (TRM) was significantly higher after MUD transplantation (40%) than after sibling transplantation (16%) (P

It has previously been shown that enteral nutrition has several advantages compared to parenteral nutrition (PN) in critically ill patients. The nutritional history was studied in 231 patients after allogeneic stem cell transplantation (SCT). Parenteral nutrition was given for a median of 10 (0–74) days. Patients with graft-versus-host disease (GVHD) grades III–IV received more PN (median 20, range 0–67) than patients with GVHD grades 0–II (10, 0–74, P=0.016). Eighty-five (37%) patients were not able to eat anything for a median of 4 days (1–37). We found a correlation between the number of days with no oral intake (before the diagnosis of acute GVHD) and the incidence of acute GVHD grades III–IV. In patients with 1–4 days of no oral intake, the incidence of grades III–IV acute GVHD was 6%, in those with 5–9 days it was 17%, and in those with >9 days it was 38%. On multivariate analysis, we found that more than 9 days with no oral intake was associated with acute GVHD grades III–IV (odds ratio 7.66, confidence interval 1.44–40.7, P=0.016). Poor oral intake early after SCT may be associated with an increased risk of developing severe acute GVHD.

Post-transplant lymphoproliferative disorder (PTLD) following allogeneic hematopioetic stem cell transplantation (HSCT) is a fulminant disease with high mortality. The objective of this study was to determine risk factors in PTLD following HSCT in order to identify high-risk patients for surveillance, prophylaxis and treatment.Five hundred and fifty-three HSCT patients transplanted at Karolinska University Hospital in Huddinge between 1996 and 2004 were investigated retrospectively and 14 cases of PTLD were identified. Diseased patients were evaluated concerning transplantation procedure, PTLD diagnosis, treatment and outcome. Factors significant in univariate analysis were included in logistic regression multivariate analysis.The incidence of PTLD was 2.5% and the median onset of PTLD was 78 days post-transplantation. Only two PTLD patients survived. The most common therapy was anti-B-lymphocyte antibodies. Statistical analysis showed HLA mismatch (p0.001), mismatch in Epstein-Barr virus (EBV) serology (p0.001) and splenectomy (p = 0.006) to be risk factors associated with PTLD. Indeed, among 387 patients with no risk factors only one developed PTLD (0.26%). Patients with one risk factor had a probability of developing PTLD of 8.2% and those with two risk factors, a probability of 35.7%.We propose a strategy for dealing with PTLD. Patients without risk factors need not be monitored routinely. HSCT patients with one or more risk factors should be monitored weekly by polymerase chain reaction of EBV DNA, and for patients with two or more risk factors EBV-specific cytotoxic T-lymphocytes should be held in readiness before initiating the transplantation procedure.

The influence of BK-viruria, donor background, and conditioning on the development of hemorrhagic cystitis was examined in 90 allogeneic hematopoetic stem cell transplant patients, of whom 15 developed hemorrhagic cystitis. Thirty-two patients had related and 58 had unrelated donors, while 44 received full, and 46 received reduced intensity conditioning (RIC). BK-viruria was more common in patients with hemorrhagic cystitis than in those without (p0.01), and hemorrhagic cystitis was less common in patients with related donors than in those with unrelated donors (p=0.02). Finally, hemorrhagic cystitis and BK-viruria were less common in patients receiving RIC, rather than full conditioning (p0.01 and p0.01, respectively).

Backgrounds: Sex-mismatched hematopoietic cell transplant (HCT), especially HCT of male recipients with female donors (F->M) is known to be associated with a higher incidence of graft-versus-host disease (GVHD) and inferior survival. Total lymphoid irradiation with anti-thymocyte globulin (TLI-ATG) has been reported to reduce GVHD incidences and non-relapse mortality (NRM). We hypothesized that TLI-ATG could reduce adverse effects of sex-mismatched HCT without reducing graft-versus leukemia/lymphoma (GVL) effect. Methods: We reviewed clinical charts of 1041 adult recipients who received peripheral blood stem cell transplant between 2006 and 2013 at Stanford University (n=749) and Karolinska University Hospital (n=292). Primary diseases included acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), lymphoma, chronic lymphocytic leukemia (CLL) and others. Our study excluded indications for which TLI-ATG is not used such as acute lymphoblastic leukemia. Haplo-identical HCT and recipients who received GVHD prophylaxis other than cyclosporine and tacrolimus were also excluded. Impacts of sex-mismatch on clinical outcomes were separately assessed in TLI-ATG (n=437), reduced-intensity conditioning (RIC, n=266), and myeloablative conditioning (MAC, n=345). We also measured allo-antibodies (HY-Ab) against 5 HY-antigens encoded on the Y-chromosome (DBY, UTY, ZFY, EIF1AY, and RPS4Y) at 3 months (3m) post F->M HCT in the Stanford cohort. Results: F->M HCT was significantly associated with an increased risk of acute GVHD grade 2-4 in the RIC group (HR 1.96, P F->M HCT was also associated with an increased risk of NRM only in the MAC group (HR 1.84, P=0.022), while there was no difference in the TLI-ATG or RIC group. In the TLI-ATG group, relapse incidences of sex-mismatched HCT at 2 years post-HCT (40% in F->M HCT and 33 % in M->F HCT) were significantly lower than that of sex-matched HCT (52%, PM and 0.59 in M->F, P We found that the overall survival (OS) of sex-mismatch recipients (69% in F->M and 70% in M->F HCT at 2 years post-HCT) was higher than that of sex-matched HCT (56%, PM HCT (49%) was significantly inferior to those of sex-matched HCT (60%) and M->F HCT (58%, P=0.01). Multivariate analyses confirmed that sex-mismatch was significantly associated with superior OS in the TLI-ATG group (HR 0.69 in F->M, P=0.037; HR 0.61 in M->F, P=0.014), while F->M HCT was significantly associated with inferior OS in the MAC group (HR 1.59, P=0.018). In the TLI-ATG group, the benefit of sex-mismatched HCT on OS seems due to the reduced relapse rate. We previously reported HY-Ab response post-HCT was associated with chronic GVHD as a representative of allo-Ab response (Nakasone et al. ASH 2013). We then hypothesized that HY-Ab response 3m post-HCT could predict reduced relapse in F->M HCT with TLI-ATG. Excluding patients with MDS and CLL because of the absence of GVL benefit by sex-mismatch in TLI-ATG (above), relapse incidence at 2 years post-HCT was higher in the recipients who had no HY-Ab response at 3m post-HCT vs. those who did (49% vs. 26%, P=0.037, Fig 2). Multivariate analysis corroberated that the detection of HY-Ab 3m post-HCT was significantly associated with reduced relapse in F->M HCT with TLI-ATG (HR 0.29, P=0.039). On the other hand, in the MAC group, HY-Ab 3m post-HCT was not significantly associated with reduced relapse. Conclusion: Benefits and risks of sex-mismatch differ according to conditioning intensity. Recipients of TLI-ATG conditioning preferentially benefit from sex-mismatched HCT with significantly reduced relapse rates and improved OS. HY-Ab 3m post-HCT as a representative of allo-Ab demonstrated the association with reduced relapse in the TLI-ATG group. We believe that sex-mismatched HCT should be selected in TLI-ATG, while F->M HCT should be avoided in MAC. Figure 1 Figure 1. Figure 2 Figure 2. Disclosures No relevant conflicts of interest to declare.

Objective Treosulfan is a prodrug with a specific clinical activity in ovarian carcinoma and other solid tumors. Due to its myeloablative and immunosuppressive effects, its use in conditioning regimens prior to allogeneic stem cell treatment (SCT) has been proposed. In the present preclinical study, myeloablative as well as immunosuppressive properties of treosulfan were compared with those of busulfan and cyclophosphamide. Methods Three groups of BALB/c mice were treated with treosulfan, cyclophosphamide, or busulfan at sublethal doses that maintained survival without bone marrow support. The control group was left untreated. At different intervals, colony-forming unit granulocyte macrophage assay was performed on marrow cells. Additionally, immunological analyses were performed using spleen cells. Results We found that treosulfan and busulfan induced a high and persisting degree of myeloablation, as compared with cyclophosphamide. Moreover, treosulfan was more effective in depletion of splenic B and T cells in comparison with busulfan and cyclophosphamide. Furthermore, T cells isolated from the spleens of treosulfan- or busulfan-treated mice were not responsive to allogeneic cells compared with that observed in controls and cyclophosphamide-treated mice. Treatment with treosulfan induced only interleukin-2 production in spleen cells for a short time and had no significant effect on synthesis of tumor necrosis factor-α and/or interferon-γ as compared with that observed in splenic T cells isolated from mice treated with either busulfan or cyclophosphamide. Conclusion Our findings suggest that treosulfan possesses both myeloablative and immunosuppressive properties and may be used as a single agent for conditioning prior to bone marrow transplantation.

Mixed chimerism (MC) within CD4+ and CD8+ T cell days 7 and 10 after allogeneic stem cell transplantation (SCT) was compared with the occurrence of acute graft-vs.-host disease (GVHD) in 34 patients after SCT. Acute GVHD was diagnosed in 22 patients within the first 3 months after SCT, 15 of these developed acute GVHD grades II-IV. The difference in the clearance rate of host T cell between the two days were compared. We found a significantly higher risk (p = 0.005) for developing acute GVHD grades II-IV in patients with complete donor CD4+ T-cell chimerism day 7 after SCT together with patients who increased 50% or more in donor CD4+ T cells between days 7 and 10 after SCT. Our data suggest that molecular monitoring of MC early after transplantation may be useful as a diagnostic tool in predicting the occurrence of moderate to severe acute GVHD after SCT.

Acute graft-versus-host disease (GVHD) is still a major complication after allogeneic stem cell transplantation. It is initiated by infiltrating donor T cells specific against the host antigens. Because T-cell migration is largely controlled by the expression of chemokines and chemokine receptors, we investigated the relation of acute GVHD and chemokine receptor expression in peripheral blood in 50 patients after allogeneic stem cell transplantation. The gene expression of the chemokine receptors CCR1, CCR2, CCR5, and CXCR3 was monitored by using quantitative real-time polymerase chain reaction. Among the 36 patients diagnosed with acute GVHD, 10 developed a second episode of acute GVHD. Therefore, gene-expression levels could be analyzed in 46 occasions of acute GVHD. When all 4 markers were evaluated at the same time, increased gene-expression levels of at least 1 of the 4 markers were seen in 44 of 46 episodes of acute GVHD. The median increase of the 4 markers ranged from 3× to 12× in connection with acute GVHD. It is interesting to note that we saw increasing gene-expression levels a few days before acute GVHD was diagnosed clinically at 17, 15, 22, and 19 occasions for CCR5, CXCR3, CCR1, and CCR2, respectively. The median number of days before diagnosis ranged from 3 to 5. Although they are not specific for acute GVHD, quantitative monitoring of the gene expression of chemokine receptors may be a valuable molecular method to monitor and diagnose acute GVHD.

T cells play an important role in the adaptive immune system. After haematopoietic stem cell transplantation (HSCT), T-cell function is impaired. This is reflected by the emergence of opportunistic infections, infections that are often difficult to treat because of the patient's insufficient immune function. T-cell receptor reconstitution was studied using CDR3 spectratyping to analyze the diversity of the T-cell repertoire at 3, 6 and 12 months after myeloablative and reduced intensity conditioning (RIC) HSCT in 23 patients. Immune function in vitro was tested by lymphocyte stimulation at 3, 6 and 12 months after HSCT. Lower diversity in the CDR3 repertoire was demonstrated in CD4+ cells after RIC HSCT at 3 and 6 months and in CD8+ cells at 3 months compared with healthy donors. After myeloablative HSCT, lower diversity was seen at 3, 6 and 12 months in CD4+ cells and at 6 and 12 months in CD8+ cells after HSCT. Acute and chronic graft-versus-host-disease (GVHD) did not affect diversity. Responses to phytohaemagglutinin (PHA), Concanavalin A (Con A) and Staphylococcus aureus protein A were significantly lower compared with healthy donors during the first 6 months after RIC HSCT. After myeloablative HSCT, lymphocyte response to Con A was significantly lower at 3 months compared with healthy donors. Decreased responses to cytomegalovirus and varicella zoster virus antigens were seen in patients suffering from acute GVHD grade II or chronic GVHD. The T-cell repertoire is skewed under the first year after HSCT, and immune reconstitution after HSCT with myeloablative and RIC conditioning seems to be comparable. GVHD, infections and age are more important for immune reconstitution than type of conditioning.

Soluble interleukin-2 receptor (sIL-2R) levels were analyzed in 127 stem-cell transplant recipients. Granulocyte-colony stimulating factor (G-CSF) was given to 57 patients after transplantation. We found an association between G-CSF and increased sIL-2R levels. This indicates increased T-cell activation and may be one reason for the previously found increased incidence of acute graft-versus-host disease in G-CSF-treated patients.

KIR-ligand mismatch in the graft-versus-host (GVH) direction between donor and recipient in allogeneic stem cell transplantation (ASCT) may trigger NK cell alloreactivity. Such KIR-ligand mismatch has been associated with improved survival after haploidentical ASCT for acute myeloid leukemia (AML). Its role in unrelated ASCT has been more controversial. In an analysis of 190 unrelated ASCTs for hematological malignancies, we observed that KIR-ligand mismatch was associated with increased transplantation related mortality (TRM) and decreased overall survival. The increased TRM was a consequence of a higher rate of infections. Thus, the presence of alloreactive NK cells can potentially interfere with effective immunity to infections in the early post-transplantation period. Here, we review the discrepancies in published reports on KIR-ligand mismatch in unrelated ASCT.

Background. Nonmyeloablative (NM) conditioning and reduced-intensity conditioning (RIC) are increasingly used for allogeneic hematopoietic stem-cell transplantation. Such regimens have not been compared. Methods. The primary endpoint was graft-versus-host disease (GVHD). Secondary endpoints included transfusions, engraftment, and transplant-related mortality (TRM). NM conditioning (n=24) consisted of fludarabine and 2-Gy total-body irradiation followed by immunosuppression with cyclosporine A (CsA) combined with mycophenolate mofetil (MMF). The RIC (n=34) protocol consisted of fludarabine combined with busulfan or cyclophosphamide, antithymocyte globulin, and posttransplant immunosuppression CsA plus methotrexate. Diagnoses included hematologic malignancies and solid tumors. Donors were 34 human leukocyte antigen-identical siblings and 24 unrelated donors. Chimerism was analyzed by polymerase chain reaction of minisatellites. Results. Graft failure occurred in 6 of 24 in the NM group and in I of 34 in the RIC group, which was a significant difference (odds ratio [OR], 22.6; P=0.02). The NM group also had less leukopenia and required fesser erythrocyte and platelet transfusions than the RIC group. The time to and proportion of CD3, CD19, and CD45 donor chimerism were similar in both groups. The cumulative incidence of grades II to IV acute GVHD was higher in the NM group (59% vs. 12%; OR, 26.9; P

In patients with metastatic solid cancer, antitumor effects occur after allogeneic stem-cell transplantation (SCT). However, this treatment is not as effective in the liver as against pulmonary and lymph-node metastases. To intensify the effect of donor-lymphocyte infusions (DLI) against liver metastases, intra-arterial (IA) cell injection by way of the hepatic artery (HA) can be used.To trace infused cells, three patients with colorectal, three with renal, and one with breast carcinoma were treated with Indium-111 (111-In)-oxinate-labeled lymphocytes. Four patients received the DLI IA, all after radio-frequency ablation (RFA) of liver metastases. Three patients with other metastases received 111-In DLI intravenously (IV). One of them had RFA before SCT.Localization of the IA 111-In DLI activity on scintigrams homed to the liver. After IA injection, the liver to sternum ratio of radioactivity was higher compared with IV injection. Cells (CD3+, 19+, and 56+) of donor origin in biopsies of liver metastasis in two patients treated with IA injection increased to 80% to 100%. Two of four patients treated using the IA DLI showed stable size and number of liver metastases for 5 and 21 months, respectively. Both are alive 18 and 34 months after SCT. Two of three patients receiving DLI IV are doing well, with a stable metastatic disease or still without metastases 21 and 20 months after cell infusions (26 and 34 months after SCT), respectively. Three patients died because of progressive disease.When infused by way of the HA, 111-In-labeled lymphocytes home to the liver and its metastases. The liver metastasis infiltrating cells of donor origin increased. DLI by way of the HA combined with RFA may be used to treat liver metastases after SCT.

To investigate which factors impact on survival, relapse, relapse free survival, transplant-related mortality (TRM) and graft-versus-host disease (GVHD) in children who undergo allogeneic stem cell transplantation, we included all 181 children transplanted due to leukemia at our unit. At the end of follow up 54% of the patients were alive, 27% had died due to relapse while 19% had died of other causes. Survival was similar in recipients of related (55%) and unrelated grafts (48%). Risk factors identified in univariate analysis were brought into a multivariable analysis. However, an unrelated donor was not identified as a risk factor for any of the five end-points analysed. A donor positive for three to four herpes viruses increased the risk of acute GVHD, TRM and death. A female to male transplant increased the risk of TRM, particularly if combined with a mismatch. Early stage of disease as well as human leukocyte antigen (HLA)-matching independently predicted survival. The risk of relapse increased after 1992. Chronic GVHD independently decreased the risk of relapse (relative risk RR, 0.39) and death (RR 0.42). We conclude that in children with leukemia other specific donor characteristics such as HLA-matching, gender, parity, and exposure to herpes viruses were more important for outcome than relationship.

Purpose The role of unrelated allogeneic stem-cell transplantation in acute lymphoblastic leukemia (ALL) patients is still not clear, and only limited data are available from the literature. We analyzed factors affecting clinical outcome of ALL patients receiving a related or unrelated stem-cell graft from matched donors. Patients and Methods The total study population was 264 adult patients receiving a myeloablative allogeneic stem-cell transplant for ALL at nine bone marrow transplantation centers between 1990 and 2002. Of these, 221 patients receiving a matched related or unrelated graft were analyzed. One hundred forty-eight patients received transplantation in complete remission; 62 patients were in relapse; and 11 patients were refractory to chemotherapy before transplant. Fifty percent of patients received bone marrow, and 50% received peripheral blood stem cell from a human leukocyte antigen–identical related (n = 103), or matched unrelated (n = 118) donor. Results Disease-free survival (DFS) at 5 years was 28%, with 76 patients (34%) still alive (2.2 to 103 months post-transplantation), and 145 deceased (65 relapses, transplant-related mortality, 45%). We observed an advantage regarding DFS in favor of patients receiving transplantation during their first complete remission (CR) in comparison with patients receiving transplantation in or after second CR (P = .014) or who relapsed (P < .001). We observed a clear trend toward improved survival in favor of B-lineage ALL patients compared with T-lineage ALL patients (P = .052), and Philadelphia chromosome–positive patients had no poorer outcome than Philadelphia chromosome–negative patients. Total-body irradiation–based conditioning improved DFS in comparison with busulfan (P = .041). Conclusion Myeloablative matched related or matched unrelated allogeneic hematopoietic stem-cell transplantation in ALL patients should be performed in first CR.

The aim of this study was to elucidate the effect of the type of chemo-radio therapy given before allogeneic hematopoietic stem-cell transplantation (HSCT) on cytokine release.We analyzed serum cytokine levels during pre-transplant therapy in 178 HSCT recipients. Samples were drawn daily during the treatment and serum levels of tumor necrosis factor-alpha (TNF-alpha) were analyzed by automated chemo-luminescence immunoassay. Conventional high-dose myeloablative therapy was given to 119 patients, while 59 patients received reduced intensity therapy (RIC). Most patients had a hematologic malignancy: their median age was 37 years (range 1-67). Anti-thymocyte globulin (ATG) was given to 126 patients as part of the pre-transplant treatment.The use of ATG significantly increased the TNF-alpha levels in the last four days before transplantation. We found significantly higher TNF-alpha levels, days -4 to -2 before transplant, in patients given RIC compared to myeloablative therapy independently of ATG treatment. No effect of age or disease stage was found. In patients not given ATG, we found a correlation between high TNF-alpha levels on day -2 and moderate-to-severe acute graft-versus-host disease (GVHD).To conclude, during the pre-transplant treatment for HSCT, patients receiving RIC and those treated with ATG had increased levels of TNF-alpha.

The purpose of this study was to determine whether body mass index (BMI, kg body weight/height (in m2) is related to survival in recipients of allogeneic stem cell transplantation (ASCT).Since 1977, 544 adult patients (age ranging from 18 to 64 years) diagnosed with hematologic malignancies; 172 acute myeloid leukemia, 83 acute lymphocytic leukemia, 190 chronic myeloid leukemia and 99 others, underwent myeloablative conditioning and ASCT. Low BMI (20) was seen in 88 patients, normal BMI (20-25) in 290 and high BMI (25) in 166 patients. The donors were 348 HLA-identical siblings, 157 matched unrelated donors and 39 HLA major mismatched donors. We assessed BMI as a risk-factor controlling for other risk-factors regarding transplant-related mortality, survival and relapse-free survival using the Cox regression model.Patients with a low BMI more often had ALL, were younger, were more often conditioned with total body irradiation and more often received monotherapy as immunosuppression against graft-versus-host disease. BMI had no effect on engraftment, transfusions and acute or chronic GVHD. Patients with BMI20 had a higher incidence of a-streptococcal septicemia (p=0.005) than did patients with BMIor = 20, but both groups had a similar incidence of overall bacteremia. Five-year survival was 36% in those with low BMI, 47% in those with normal BMI and 55% in those with high BMI. In multivariate analysis, death was associated with BMI20 (p=0.023). Other significant factors adjusted for were: diagnosis of acute lymphoblastic leukemia, donors other than HLA-identical siblings, disease stage beyond first complete remission or 1st chronic phase, transplantation before 1993 and total body irradiation vs. busulfan conditioning.A low BMI (20) was significantly correlated with an increased transplant-related mortality, a decreased survival and relapse-free survival after ASCT. BMI should be considered when analyzing outcome after ASCT.

Acute graft-versus-host disease (GVHD) may affect several organs. Syndecan-1 is a heparan sulfate proteoglycan that can be shed from the surface of most epithelial cells (skin, liver, and gut among others), which are target organs for GVHD. Syndecan-1 was measured in serum samples from 60 patients after allogeneic stem-cell transplantation and was related to the degree of GVHD. Syndecan-1 levels increased in patients who developed acute GVHD but not in patients without GVHD. The difference between groups was significant 3 to 10 weeks after transplantation. The peak level of syndecan-1 in serum correlated with the degree of acute GVHD (r=0.46, P

Some patients become full donor chimeras (DC) early after stem-cell transplantation (SCT), while others remain mixed chimeras for a longer time. Little is known about the mechanism behind these phenomena.Serum cytokine levels during conditioning and during the first month after SCT were analysed in 30 patients. Of the 21 patients who became full T-cell DC from the first analysed sample, 12 developed grade II-IV acute graft-vs.-host disease (GVHD) and the other nine, mild or no acute GVHD. Another nine patients were T-cell mixed chimeras (MC). All MC patients had no or mild acute GVHD.During the pretransplant conditioning, DC patients had higher levels of tumour necrosis factor (TNF)-alpha and lower levels of transforming growth factor (TGF)-beta and interleukin (IL)-10, compared with MC patients. During the first week after SCT, lower levels of TGF-beta and IL-10 and higher levels of soluble Fas (sFas) were found in DC patients compared with MC patients. During the second and third weeks after SCT, increased levels of TNF-alpha, interferon (IFN)-gamma and sFas were found among DC patients compared with MC patients. Patients who developed moderate-to-severe acute GVHD had higher levels of TNF-alpha, IFN-gamma, IL-10 and sFas at 2 weeks post-SCT than in those with less GVHD. Patients homozygous for the TNFd microsatellite alleles 3 or 4 had significantly higher TNF-alpha levels during conditioning and more often developed acute GVHD grades II-IV.These results indicate that an imbalance between pro-inflammatory and immune- modulating cytokines are involved in the development of chimerism and acute GVHD after allo-SCT. The Fas/FasL pathway is probably involved in the elimination of recipient cells leading to full donor chimerism.

Severe acute graft-vs.-host disease (aGVHD) remains a major cause of transplantation-related mortality. However, because of a graft-vs.-leukaemia effect, a mild (grade I) aGVHD is desirable. As risk factors predisposing for aGVHD are not necessarily the same in children and adults, we have performed a retrospective analysis of risk factors (RFs) for grade II-IV aGVHD in 258 paediatric patients undergoing allogeneic stem cell transplantation at our centre. Thirty-two potential RFs were assessed with univariate analysis in logistic regression. Eleven factors were selected for further evaluation in stepwise elimination multivariate analysis. Three independent RFs were found: (1) donor other than human lekocyte antigen (HLA)-identical sibling [odds ratio (OR) 6.1, p0.001); (2) single drug [cyclosporine A (CsA) or methotrexate (Mtx)] graft-vs.-host disease (GVHD) prophylaxis (OR 7.0, p0.001); and (3) ABO disparity of any kind (OR 2.4, p = 0.02). The RFs were additive: moderate-to-severe aGVHD was seen in none of the patients without any RFs; in 16% with one RF; in 32% with two RFs and in 67% with all three RFs present. Single drug GVHD prophylaxis (CsA or Mtx), any kind of ABO mismatch, and non-sibling donors are RFs for grade II-IV acute GVHD in paediatric SCT. We encourage the use of combination GVHD prophylaxis in children. ABO mismatch should be considered when choosing between otherwise equally suitable donors.

After allogeneic stem cell transplantation (SCT), donor T-cells are primarily responsible for the antihost activity, resulting in graft-versus-host disease (GVHD). Three effector pathways have been described for T-cell cytotoxicity: perforin/granzyme B; Fas/Fas ligand (FasL) and secreted molecules such as TNF-alpha. The goal of this pilot study was to utilize competitive reverse transcription (RT)-PCR to evaluate the pattern of granzyme B, perforin, FasL and TNF-alpha gene expression in peripheral blood in patients after SCT. Protein levels of granzyme B, soluble FasL (sFasL) and TNF-alpha in plasma were also analyzed. Eight patients who underwent allogeneic SCT were included; five were diagnosed with acute GVHD. In the patients diagnosed with acute GVHD, we found increased levels of granzyme B, perforin and FasL mRNA, although this did not correlate with the clinical severity. However, patients with increasing levels of gene expression during acute GVHD treatment may have an increased risk of developing severe acute GVHD, as two out of three patients with increasing immune transcript levels during GVHD therapy developed life-threatening acute GVHD. In conclusion, the quantitative RT-PCR of granzyme B, perforin and FasL may serve as a guide to the clinician in diagnosing acute GVHD and monitoring treatment.

Among 810 consecutive hematopoietic stem cell transplantation (HSCT) patients, 679 survived more than 3 months and were evaluated for chronic GVHD. The aim of this study was to find predisposing factors increasing the risk of development of moderate-to-severe chronic GVHD. Many of the donors were HLA-identical siblings or related (n = 435), 185 were HLA-matched unrelated, and 59 were mismatched related or unrelated donors. Most of the patients had a hematological malignancy (n = 568), but 111 patients with a nonmalignant disease were included. Two hundred twenty-three patients (33%) developed mild, 41 (6%) moderate, and 15 (2.2%) severe chronic GVHD. The 5-year probability of development of moderate-to-severe chronic GVHD was 10%. We analyzed 30 potential risk factors for chronic GVHD. In the multivariate analysis, acute GVHD grades II to IV (relative hazard [RH], 2.30; 95% CI, 1.29- 4.10; P = .005), CML diagnosis (RH, 2.37; CI, 1.38-4.08; P = .002) and transplantation from an immunized female donor to a male recipient (RH, 2.16; CI, 1.14-4.11; P = .02) were independent risk factors for moderate-to-severe chronic GVHD. Recipient age also was significant (RH, 2.42; CI, 1.23-4.77; P = .01) if CML was not included in the analysis. In patients with no risk factors, the 5-year probability of development of moderate-to-severe chronic GVHD was 5%. In patients with 1 risk factor, the probability was 13%; 2 risk factors, 23%; and 3 risk factors, 45%. Among patients who developed chronic GVHD (n = 279), acute GVHD grades II to IV (RH, 2.18; CI, 1.23-3.86; P < .01) was the only predictive factor for moderate-to-severe chronic GVHD versus mild disease. Patients with previous acute GVHD grades II to IV may benefit from more aggressive initial treatment. This possibility would have to be examined in clinical trials.Biol Blood Marrow Transplant 2002;8(12):674-82.

After myeloablative treatment and allogeneic stem cell transplantation (SCT), patients are kept in isolation rooms in the hospital to prevent neutropenic infections. During a 3-year period, patients were given the option of treatment at home after SCT. Daily visits by an experienced nurse and daily phone calls from a physician from the unit were included in the protocol. We compared 36 patients who wished to be treated at home with 18 patients who chose hospital care (control group 1). A matched control group of 36 patients treated in the hospital served as control group 2. All home care patients had hematologic malignancies and 19 were in first remission or first chronic phase. Of the donors, 25 were unrelated. The patients spent a median of 16 days at home (range, 0-26 days). Before discharge to the outpatient clinic after SCT, patients spent a median of 4 days (range, 0-39 days) in the hospital. In the multivariate analysis, the home care patients were discharged earlier (relative risk [RR] 0.33, P = .03), had fewer days on total parenteral nutrition (RR 0.24, P

Clinical tolerance, defined as discontinuation of immunosuppression without immunological events, is often achieved after allogeneic hematopoietic stem cell transplantation, unlike after organ transplantation. However, this phenomenon has rarely been studied.Between September 1977 and December 1997, we evaluated 354 allogeneic hematopoietic stem cell recipients who had had more than 1 year of relapse-free survival, regarding time to discontinuation of immunosuppression. Factors such as patient age, donor age, donor sex, immunosuppressive protocols, cell dose, and graft-versus-host-disease (GVHD) were studied.Patients who did not develop GVHD had discontinued immunosuppression according to the protocols, within 1 year for malignant diseases and within 2 years for nonmalignant diseases. Patients given methotrexate as a single drug were off immunosuppression faster than those given cyclosporine alone (P=0.05). Children (18 years) discontinued immunosuppression faster than adults (P=0.05). Low donor age was of greater importance than low recipient age for early discontinuation (P=0.003). Male recipients of stem cells from immunized female donors needed a longer time to discontinuation (P0.001). Patients without acute GVHD had a shorter time to discontinuation than patients with any grade of GVHD (P=0.02). Thirteen months after hematopoietic stem cell transplantation, 54% of HLA-identical sibling marrow recipients and 36% of unrelated marrow recipients with malignant disease had discontinued immunosuppression (P=0.002). Twenty-five months after hematopoietic stem cell transplantation, the corresponding figures were 69% and 75% in the two groups, respectively.In multivariate analysis, high donor age, immunized female donor to male recipient, and grades II-IV acute GVHD were significantly associated with a longer time to clinical tolerance.

Between 1991 and 1999, 44 leukemic patients received donor lymphocyte infusions (DLIs) at our center (22 patients with chronic myelogenous leukemia [CML]; 10 with acute myelogenous leukemia; 11 with acute lymphatic leukemia; and 1 with myelodysplastic syndrome). Seventeen patients received graft-versus-host disease (GVHD) prophylaxis with methotrexate (MTX) at the time of DLI. In CML patients, 15 of 22 (68%) re-entered complete remission after DLI. At 3 years post-DLI, patients with cytogenetic (n = 10) or molecular (n = 3) relapse had a current leukemia-free survival (cLFS) rate of 85% compared with 0% for patients with hematologic relapse (P < .001). Among 15 CML patients who initially responded to DLI, 4 patients relapsed within the first 2 years. Four of 16 patients (25%) with acute leukemia had an initial response with complete remission after DLI. Two of them subsequently relapsed within 1 year. Patients with acute leukemia who relapsed within 1 year of hematopoietic stem cell transplantation (n = 9) had 0% cLFS at 18 months; patients with later relapse had 29% cLFS (P = .015). The overall probability of cLFS at 3 years for CML patients was 46%. For other diseases, cLFS was 13% at 18 months after DLI. Patients who developed chronic GVHD secondary to DLI showed a 3-year cLFS of 51% compared with 18% for patients without chronic GVHD (P = .022). This study emphasizes the importance of early disease stage and presence of chronic GVHD for effective DLI.Biol Blood Marrow Transplant 2001;7(1):31-8.

In order to compare the outcomes of unrelated umbilical cord blood transplants (UCBTs) or bone marrow transplants, 541 children with acute leukemia (AL) transplanted with umbilical cord blood (n = 99), T-cell-depleted unrelated bone marrow transplants (T-UBMT) (n = 180), or nonmanipulated (UBMT) (n = 262), were analyzed in a retrospective multicenter study. Comparisons were performed after adjustment for patient, disease, and transplant variables. The major difference between the 3 groups was the higher number in the UCBT group of HLA mismatches (defined by serology for class I and molecular typing for DRB1). The donor was HLA mismatched in 92% of UCBTs, in 18% of UBMTs, and in 43% of T-UBMTs (P

The clinical course of 59 children, who underwent BMT during 1988-1998 with a matched unrelated donor (MUD), was compared with 59 case controls receiving a sibling donor marrow. Thirty-eight patients had haematological malignancies while 21 had a nonmalignant disorder. The cumulative incidence of acute GVHD grade II-IV was 28% for MUD recipients vs 11% (P = 0.014) for sibling recipients. Extensive chronic GVHD was rare in both groups. The 5-year probability of survival was 52% for MUD vs 77% for sibling recipients (P= 0.014). For children with malignancies the 4-year probability of survival was 52% for MUD vs 67% for sibling recipients with a RFS of 49% vs 62%. In the ALL patients the survival of the MUD recipients was 77% and equalled that of the sibling group. For SAA survival was 43% vs 86% (P = 0.09) and for metabolic disorders 63% vs 89% (P = 0.025). The transplant-related mortality was higher in the MUD group, while death due to relapse was equally distributed. These results of MUD BMT in children compare favourably with most previous reports, and support the use of alternative donors in cases who lack an HLA-identical siblings. Bone Marrow Transplantation (2000).

Three different types of anti-T cell antibody were used in patients undergoing haematopoietic stem cell transplantation (HSCT) with an HLA-A, -B and -DR compatible unrelated donor: ATG-Fresenius (ATG-F) (n = 26), Thymoglobuline (TMG) (n = 61) and OKT-3 (n = 45). The groups were comparable regarding diagnosis, stage, age, conditioning and GVHD prophylaxis, Adverse events were less frequent after ATG-F treatment. Levels of IL-2, IL-6, IFN-gamma, TNF-alpha and GM-CSF were increased after OKT-3 infusion. In multivariate analysis OKT-3 treatment (P = 0.01), G-CSF treatment (P = 0.02) and a cell dose >/=2.7 x 108/kg (P = 0.03) gave a faster engraftment. Acute GVHD grades II-IV occurred in 25% of the ATG-F patients, 12% of the TMG-patients and 43% (P < 0.001 vs TMG) of the OKT-3 patients. OKT-3 was associated with acute GVHD in multivariate analysis. TRM was 26% using TMG as compared to 43% in the OKT-3 group (P = 0.03). Patient survival at 4 years was 63%, 50% and 45% in the ATG-F, TMG and OKT-3-treated patients, respectively (NS). Relapses were 8%, 49% and 34%, respectively (ATG-F vs TMG, P = 0.03). Relapse-free survivals were 61%, 40% and 37% (NS). Among CML patients the probability of relapse was 61% in TMG-treated patients, while no patients relapsed in the other two groups. To conclude, the type of anti-T cell antibody affects GVHD and relapse after HSCT using unrelated donors.

Episodes of bacteraemia during the aplastic phase were studied in 500 allogeneic bone marrow (BMT) recipients, regarding incidence, microbial aetiology, risk factors, mortality and causes of death. One hundred and sixty-four patients (33%) had at least one positive blood culture. Gram-positive cocci (alpha-streptococci and coagulase-negative staphylococci) were found in 146/164 cases (89%). Gram-negative bacteria were present in only seven cases. Receiving marrow from an unrelated donor was the only significant risk factor for bacteraemia in univariate regression analysis. Within 60 days after BMT, 69/500 patients died. The mortality rate was significantly higher among those with positive blood cultures during the aplastic phase, 44/164 (27%) than in those without bacteraemia, 25/336 (7%). Death directly caused by sepsis was unusual in patients with alpha-streptococci or CNS-bacteraemia (8/146, 5%). In contrast, three of seven patients with gram-negative bacteraemia died of the infection. However, in patients with bacteraemia, 21 of 44 deaths were attributable to invasive fungal infections (18 candida, three aspergillus; autopsy findings). Among patients with negative blood cultures during the aplastic phase, 6/25 died of invasive fungal infection (three candida, one saccharomyces and two aspergillus). This indicates that early bacteraemia is associated with death from invasive fungal infection. Therefore, efforts to shorten the neutropenic period after BMT, prevention, early detection of invasive fungal infections and adjustments of immunosuppressive regimens when marrow from an unrelated donor is used, may improve the outcome after BMT.

Thirty-eight patients (> or = 18 years) receiving marrow transplants from HLA-identical or one antigen-mismatched related donors were randomized to intraosseous (i.o.) + intravenous (i.v.) (n = 10), i.o. (n = 8) or i.v. (n = 20) infusions of bone marrow. There were no significant differences in patient characteristics. PMN/l more than 0.5 x 10(9) occurred on days 19 (median), 20 and 18.5 in the i.o. + i.v., i.o. and i.v. groups, respectively. We found a significant reduction in the number of days on total parenteral nutrition (P = 0.03) and a tendency to a reduction in the number of days on antibiotics (P = 0.06) in the i.o. compared to the i.v. group. Bacteraemia did not occur in the i.o. group, but was seen in 30% of the i.v. group (NS). The incidences of acute and chronic graft-versus-host disease, transplantation-related mortality, relapse and patient survival rates were similar in the three groups. Five patients examined with bone marrow scintigraphy showed the same distribution of granulocytes in the bone marrow directly after transplantation and 3 weeks after transplantation, whether the bone marrow was given by the i.o. or by the i.v. route. We conclude that allogeneic bone marrow transplantation can safely be performed by i.o. infusion, but haematopoietic recovery is not improved.

Cadaveric bone marrow was harvested from 20 brain-dead donors to determine optimal conditions for procurement for transplantation. The number of nucleated cells obtained from 1 ml of bone marrow was significantly higher in vertebrae (87+/-20 x 10(6), mean +/- s.e.m.) than in the sternum (10.2+/-3.8 x 10[6]) or ribs (4.9+/-2.0 x 10[6]). Viability of cells was not significantly affected by storage temperature (4 degrees C or 20 degrees C) or duration of storage (6-72 h). In addition to bone marrow, spleen cells were harvested from three cadaveric donors. The mean yield from 1 g of spleen tissue was 4.4 x 10(6) nucleated cells. Using magnetic beads, we removed 96% of T lymphocytes without affecting the total yield of stem cells from cadaveric bone marrow. Using CD34-positive cell selection, we obtained a 99.6% T cell depletion efficiency, but with a loss of 60% of CD34-positive cells. Using optimized techniques, we obtained an estimated mean yield of 5.5 x 10(10) mononuclear cells from the whole thoracic and lumbar vertebral column. With a mean fraction of CD34-positive cells of 2.1+/-0.3%, recovery and purity were not affected by site of sample, temperature or donor age. In contrast, the CD34-positive fraction in spleen preparations was 0.41+/-0.06%. When analyzing the number of colony-forming units (CFU-GM, BFU-E and CFU-GEMM), we found no significant differences between cadaveric bone marrow and bone marrow aspirates from living donors. However, cells harvested from the spleen gave significantly fewer CFUs than did bone marrow from living donors. We conclude that bone marrow from cadaveric donors can be harvested and procured with a high degree of viability and good function. With an appropriate technique of harvesting and procurement, it seems feasible to recover enough stem cells for transplantation.

Bone marrow transplantation (BMT) in childhood has improved the survival for children with leukaemia, severe aplastic anaemia and some metabolic disorders. However, transplant procedures are associated with a high incidence of deleterious long-term complications. This study included 49 children, conditioned according to the Seattle protocols. Follow-up oral examinations were performed 1 year after BMT. Forty risk factors that may have influenced a low stimulated salivary secretion rate (SSSR) were studied. An SSSRor = 0.5 ml/min, 1 year after BMT was regarded as the event. One year after BMT, the mean SSSR was 0.5 +/- 0.4 ml/min in children conditioned with total body irradiation (TBI) compared to 1.0 +/- 0.5 ml/min in non-irradiated children (P = 0.0013). Significant predictors for low SSSR in multivariate analysis were: conditioning with TBI (P = 0.0023), recipient female sex (P = 0.0121) and recipient seropositivity for between three and four herpes viruses (P = 0.0157).

Myeloablative conditioning for hematopoietic stem-cell transplantation in patients with non-malignant diseases

We investigated the cytokine profile and peak levels of interleukin (IL) -6, IL-8, IL-10 and tumour necrosis factor (TNF) -alpha levels in 42 patients after allogeneic bone marrow transplantation (BMT). Eleven of them developed veno-occlusive disease (VOD) of the liver. Fourteen patients had moderate-to-severe acute graft-versus-host disease (aGvHD), 10 isolated bacteraemia and 7 had no major complication. Those who developed severe VOD (n=6) showed a short, very high IL-8 peak (median: 6632 pg/ml, range: 5546-10,000 vs. 280 pg/ml, 0-2042 in controls, p

Gathering evidence suggest that sufficient vitamin D levels are beneficial for patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Vitamin D deficiency seems common in the pediatric population, especially in children undergoing treatment for hematologic malignancies. In the present study we followed 123 pediatric patients for up to eight years post-HSCT with the main objective to evaluate the clinical importance of vitamin D status in children following HSCT. The patients underwent HSCT at our center mostly due to hematologic malignancies, but patients with non-malignant conditions and primary immunodeficiency disorders were also included. Procedures and conditioning regimens followed international guidelines. Data on each patient were obtained from medical records and included basic parameters, transplant characteristics, outcome parameters, data on vitamin D and immunoglobulin substitution and data on nutritional support. Patients were divided into two cohorts based on calcidiol (25-OH-vitamin D) level pre-SCT; low level ( Acute GvHD (aGvHD) occurred in almost every other patient with higher frequency in the sufficient level group (47 vs. 29 %). Chronic GvHD (cGvHD) occurred in 17 % of patients with higher frequency of moderate to severe cGvHD in the low level group. Neutrophil granulocyte numbers rose faster during the first 3 months in the sufficient group whereas no such difference was observed during the later follow-up. The number of infections did not significantly differ between the groups. Overall survival in patients with malignant diseases was significantly better in the sufficient level group (87 % vs. 50 %). Graft rejection did not occur in patients with sufficient levels of vitamin D. Relapse was more common among patients in the low level group. We conclude that vitamin D seems to have a role in the outcome for children undergoing HSCT as hypovitaminosis D was associated with increased risk of death, relapse and cGvHD. At the same time effects on immune reconstitution and risk of infections were not obvious and aGvHD occurred more frequently among patients with sufficient vitamin D levels at baseline. It might be postulated that vitamin D has both inhibiting and stimulatory effects on the immune system. This study is an important step towards understanding the role of micronutrients such as vitamin D in pediatric HSCT. Disclosures: No relevant conflicts of interest to declare.

Treatment-requiring hypogammaglobulinemia is common early after allogeneic hematopoietic stem cell transplantation (SCT) in children. Usually, it resolves but in several children it persists, demanding long-term immunoglobulin (Ig) G replacement therapy. By IgG replacement, the morbidity risk may not be reduced, but infectious complications are decreased. Here we studied clinical events, Ig and immune cell recovery, IgG2m allotypes and dynamics of cytokines important for B-lymphocytes and Ig production in 84 children undergoing SCT. The aim was to identify risk factors for ≥3 months IgG replacement need as well as studying the biology behind the hypogammaglobulinemia seen post-SCT. Clinical data were collected from charts. Interleukin (IL)-4, -5, -6, -7 and -10, BAFF and APRIL were analyzed in patient sera pre- and post-SCT. Donors and patients were IGHG2 genotyped. Uni- and multivariate statistic analyzes were applied. As many as 48% of the children needed ≥3 months IgG replacement. These were commonly younger (50 pg/mL (OR 8.03, 95% CI 1.26-51.0, P=0.024) were identified as significant risk factors for ≥3 months IgG replacement need. To conclude, requiring ≥3 months IgG replacement does not need to be unfavorable and could be an effect of deteriorated cytokine signaling resulting in impaired Ig production. Further prospective studies investigating post-SCT hypogammaglobulinemia with and without IgG replacement are warranted. Disclosures: No relevant conflicts of interest to declare.

Introduction Chronic Graft-versus-Host disease (cGVHD) remains a major cause of morbidity and mortality in long-term survivors after allogeneic hematopoietic stem cell transplantation (ASCT). Among the major risk factors previously noted is sex-mismatch, acute GVHD and peripheral hematopoietic blood stem cell grafts (PBSC). Our aim in this study was to determine risk factors for cGVHD and evaluate the impact of ATG on cGVHD in a multi-centre setting. Methods Patients from three centers (Stockholm, Sant Pau, Barcelona and Salamanca) were included. Retrospective data analysis was conducted for all patients (n=820) transplanted between 2000 and 2006. In our cohort 91% had malignant disease, 57% received HLA-identical sibling donor grafts, 13% received grafts with one HLA-A, -B or –DR antigen mismatch and 30% received grafts from HLA-A, -B and –DR matched unrelated donors. Reduced intensity conditioning was given to 65% of the patients. Chronic GVHD was classified according the National Institute of Health consensus criteria. Results Overall incidence of cGVHD was 46% for patients surviving more than three months after ASCT (n=747). Older patient age HR 1.15 (95% CI 1.07-1.24), p Conclusion RIC increases the risk for both overall and moderate to severe cGVHD. Acute GVHD and older recipient age are significant risk-factors for overall cGVHD and female donor to male recipient and PBSC for moderate to severe cGVHD. ATG significantly reduces the risk of all grades of cGVHD without having a negative outcome on RFS. Therefore, in order to prevent overall and moderate-extensive cGVHD it should be added to the RIC regimen in older patients and in male patients with female donors after PBSC grafts. Disclosures: Ringden: Gilead : Invited to Gilead on July 28, 2011, to participate in an Advisory Board Meeting on Treatment of invasive fungal infection. Other. San Miguel:Jansen, Celgene, Onyx, Novartis, Millenium: Consultancy, Membership on an entity’s Board of Directors or advisory committees.

A decade ago reduced intensity conditioning (RIC) allogeneic hematopoietic stem cell transplantation (allo-HSCT) was successfully introduced to facilitate transplantation in patients with co-morbidities. In contrast to myeloablative conditioning regimens RIC transplants are associated with less toxicity and thus preferred in the elderly population. However, there are also disadvantages with RIC such as the increased risk of graft failure caused by rejection by remnant recipient T-cells at transplant, which often results in mixed chimerism during the first months post-transplant. Here, we present risk factors for graft failure in all first RIC allo-HSCTs performed at our center from 1995 to mid-2010 (n=357). Graft failure was defined as >95% recipient T-cells any time after engraftment or reinfusion of donor cells due to >50% recipient cells with no clinical or laboratory signs of relapse. Thirty-six patients (10%) experienced graft failure. The median age of the patients was 51 and 57% were males. In univariate analysis, graft failure was 3-fold increased in male compared to female patients (15% versus 4%; P10 x 108/kg, whereas CD34+ cell dose had no impact on graft failure (P=0.15). Moreover, in univariate analyses year of transplant, donor sex, cell source, CMV mismatch, ABO mismatch, or pre-planned G-CSF did not influence graft failure rates (P>0.05). In multivariate analysis (Table 1), solid tumors were associated with markedly increased risk of graft failure (RR=10.95; P=0.03), whereas there was a tendency towards increased graft failure risk in non-malignant disorders (RR=8.01; P=0.05). Graft failures were also increased in male recipients (RR=3.27; P14870.240.08-0.750.01GVHD profylaxisCSA+MTX2401CSA+Pred142.160.63-7.400.22CSA+MMF403.611.38-9.44 Disclosures: No relevant conflicts of interest to declare.

Median age; years (range) 59 (26-72) Male (%) 13 (65%) Diagnosis, no. (%) Acute Myeloid Leukemia 4 (20%) Non-Hodgkin Lymphoma 11 (55%) Chronic Leukemia (CLL or CML) 4 (20%) Hemophagocytic syndrome 1 (5%) Disease risk, no. (%) High risk 5 Intermediate risk 10 Low risk 4 Prior autografting, no. (%) Yes 1 (5%) No 19 (95%) Donors, no. (%) Related 5 (25%) Unrelated 15 (75%) Sex mismatch, no (%) M to M 9 (45%) M to F 3 (15%) F to M 4 (20%) F to F 4 (20%) Degree of HLA match, no. (%) 10/10 19 (95%) 9/10 1 (5%) Median KPS; (range) 80 (70-100) Median HCT-CI; (range) 1 (0-5) Median CD34 cell dosey (10 cells/kg recipient body weight), (range) 5.7 (1.5-11.3) Abstracts / Biol Blood Marrow Transplant 19 (2013) S313eS341 S339