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. Author manuscript; available in PMC: 2014 Feb 1.
Published in final edited form as: Bone Marrow Transplant. 2013 Feb 11;48(8):1050–1055. doi: 10.1038/bmt.2013.6

Long term Outcome of Non-Ablative Booster Bone Marrow Transplantation in Patients with Severe Combined Immunodeficiency

Claire L Teigland 1, Roberta E Parrott 1, Rebecca H Buckley 1
PMCID: PMC3737279  NIHMSID: NIHMS434950  PMID: 23396406

Abstract

Severe combined immunodeficiency (SCID) is a fatal syndrome caused by mutations in at least 13 different genes. It is characterized by the absence of T-cells. Immune reconstitution can be achieved through non-ablative related donor bone marrow transplantation. However, the first transplant may not provide sufficient immunity. In these cases, booster transplants may be helpful. A prospective/retrospective study was conducted of 49 SCID patients (28.7 percent of 171 SCIDs transplanted over 30 years) who had received booster transplants to define the long term outcome, factors contributing to a need for a booster and factors that predicted success. Of the 49 patients, 31 (63 percent) are alive for up to 28 years. Age at initial transplantation was found to have a significant effect on outcome (mean of 194 days old for patients currently alive, versus a mean of 273 days old for those now deceased, p=0.0401). Persistent viral infection was present in most deceased booster patients. In several patients, the use of two parents as sequential donors resulted in striking T and B cell immune reconstitution. A majority of the patients alive today have normal or adequate T-cell function and are healthy. Non-ablative booster bone marrow transplantation can be life-saving for SCID.

Keywords: Booster, bone marrow transplantation, severe combined immunodeficiency, 2-parent bone marrow transplants

Introduction

Severe combined immunodeficiency (SCID) is a fatal syndrome characterized by the absence of T cells and, in some molecular types, also of B or NK cells.1,2 Without immune reconstitution by hematopoietic stem cell transplantation or gene therapy, infants with SCID will die in the first two years of life. The use of HLA identical or haploidentical allogeneic bone marrow stem cell transplantation without pre-transplant chemotherapy or post-transplantation graft-versus-host disease (GVHD) prophylaxis has resulted in a survival rate at this institution of 94% if SCID patients are transplanted prior to 3.5 months of age.2–4 However, the survival rate is significantly lower in those presenting later and, in some cases, patients fail to achieve immune reconstitution after one transplant. For such patients, “booster” transplants from the same or different donors have been given in efforts to achieve immune reconstitution.5

Most of what has been reported about booster bone marrow transplantation has been in cancer patients.6–8 Booster transplantations have been reported to improve T-cell immunity in SCID patients5 and in those with other primary immunodeficiencies9,10 who had received a chemoablated first transplant. We report here the longterm outcomes in 49 SCID infants all of whom had initially received non-ablative T-cell-depleted haploidentical transplants and who subsequently received one or more non-ablative booster bone marrow transplants at this institution from 1982–2012 in efforts to improve their immune reconstitution.

Subjects and Methods

Patients

Forty-nine of 171 (28.7%) severe combined immunodeficiency (SCID) patients who received non-ablative T cell-depleted haploidentical parental bone marrow transplants at this institution from 1982–2012 received 1 to 3 subsequent transplants from either the same (N=29) or a different (N=20) donor for a total of 81 additional transplants. All 49 patients met criteria of the World Health Organization for the diagnosis of SCID, and none had “leaky” SCID or Omenn syndrome.11 The age at diagnosis ranged from 0 days to 1.7 years. Comparisons of age at first transplant and survival in boosted and non-boosted patients are shown in Table 1 according to the molecular type of SCID. The different donors included the other parent (N=17), an HLA-identical sibling (N=2), a grandmother (N=1) or matched unrelated cord blood donors (N=5). Two patients received booster transplants only in an attempt to reconstitute B-cell function. Conditioning was used only in patients who received matched unrelated donor cord blood transplants (N=5). Additionally, one patient received a thymus transplant between her second and third stem-cell transplants. Three patients received gene therapy elsewhere following three, four, and two transplants at this institution, respectively; this was unsuccessful in all cases.12 Only one of the 3 surviving boosted ADA-deficient patients is receiving PEG-ADA therapy, and all 3 of the deceased ones received it. Finally, four patients received additional matched unrelated donor transplants at other institutions following transplants at this institution and two subsequently died. Altogether, 18 boosted patients died. The control subjects for all immunological studies were healthy adult volunteers. The studies were approved by the Duke University Institutional Review Board, and written informed consent was obtained from the parents of all patients.

Table 1.

Comparisons of Age at Initial Transplant and Survival in Boosted and Non-Boosted SCIDs According to Molecular Type

Defect: ADA Def Auto Rec CHH CD45 Def CD3ε Def Cd3ζ Def Cd3δ Def Artemis Def RAG 2 Def RAG 1Def IL7Rα Def Jak3 Def X-linked Unknown Totals Mn ± SD
# Boosted 6 6 1 0 1 1 0 0 5 1 7 4 15 2 49
Mean Age (Da) 1st BMT 179 241 207 NA 171 395 NA NA 164 25 259 296 226 205 223§ ± 130
# Booster Transplants 7 10 1 0 2 3 0 0 10 2 11 7 24 4 81
# Dead Boosted 3 3 0 NA 0 1 NA NA 1 0 3 1 4 2 18*
# Non-Boosted 20 9 0 1 0 0 2 3 0 1 17 5 62 2 122
Mean Age (Da) 1st BMT 133 171 NA 341 NA NA 124 473 NA 128 210 175 146 148 165§ ± 152
# Dead Non-Boosted 3 1 0 0 0 0 2 0 0 4 0 13 1 24**
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*

18/49= 63% Boosted survival rate.

**

24/122=80.3% Non-boosted survival rate.

§

p=0207

Immunologic Studies

Humoral and cellular immune studies were performed approximately every 3 weeks until T-cell function was established, then every three months for the next nine months, every six months for the following two years, then annually.

Serum Immunoglobulin and Antibody Measurements

Serum IgG, IgA, IgM and IgE were quantified by single radial diffusion or nephelometry.13 Anti-diphtheria and anti-tetanus antibodies were determined by tanned cell hemagglutination14 or by an ELISA after standard vaccines had been administered, and isohemagglutinins were measured by a microtiter plate assay.

Flow Cytometry and T-Cell Function

Lymphocyte phenotypes were determined by immunofluorescent staining of PBMC or whole blood with labeled antibodies to CD3, CD4, CD8, CD14, CD16, CD20, CD45RA, CD45RO, CD132, CD56, TCRαβ, and TCRγδ from BD Biosciences, San Jose, CA and multi-color flow cytometry. Lymphocyte proliferation was assessed by measuring [3H] thymidine incorporation into PBMCs following culture with the stimuli.15

T-Cell Depletion

Donor bone marrow was rigorously depleted of T-cells by soybean lectin agglutination followed by two cycles of rosetting with sheep erythrocytes treated with aminoethylisothiuronium bromide, reducing the number of T-cells by a factor of 10,000.3,16,17

Chimerism

This was detected using karyotyping, fluorescence in situ hybridization or short tandem repeats.

Statistical Methods

Statistical comparisons were made using the Mann-Whitney U test for non-parametric analyses and Student’s t-test or Chi-square for parametric data. All analyses were performed using Stata 12 (College Park, Tx).

Results

Of the 49 patients receiving booster transplants, 31 (63 %) are alive today, a survival rate lower than the 80.3% survival rate in the 122 non-boosted SCIDs (Table 1) and the 75% survival rate for the entire group. The length of survival ranges from 0.33 to 27.6 years from their first transplant (Supplementary Figure 1).

Factors associated with need for booster transplantation

Infections and poor or no immune reconstitution

The average time for donor T cells to appear in SCID infants after a successful rigorously T cell depleted stem cell transplant is from 90 to 120 days post-transplantation.15 If a SCID patient had no or poor T cell function at between 120 and 180 days post-transplantation, particularly if there was a chronic viral infection, he or she was considered for booster transplantation. If there was no T cell function or chimerism, the other parent was used as the donor for the booster transplant. If there was some but inadequate T cell function despite donor T cell chimerism, the donor used for the first transplant was used for the booster.

Age at initial transplantation

This was significantly correlated with need for a booster transplant. Patients who required booster transplantation were an average of 223 days old at initial transplantation (SD 131), whereas patients who did not require booster transplantation were an average of 165 days at initial transplantation (SD 152). This difference was significant (t=−2.3358, N=171, P=0.0207).

Factors influencing survival of the boosted patients

Age at Initial Transplantation

The effect of age at the time of the first transplantation on survival of the boosted patients is displayed in Supplementary Figure 2. The average age at initial transplantation for those who are currently alive was 194 days (S.D. 111) and for those who are deceased, the average age at initial transplantation was 273 days (S.D. 148). This difference was found to be significant (t=−2.1117, N=49, P=0.0401).

Sex, Race and Ethnicity

No significant differences in survival were found. Seventy-one percent of non-Hispanic white patients survive, whereas only 50 percent of the 8 Hispanic and 4 black patients survive (X2=5.3566, N=49 P=0.253).

Type of Molecular Defect

The sample sizes were too small to evaluate statistically whether the molecular defect had an effect on mortality (Table 1).

Donor Source of Transplanted Cells

Of the 42 patients who received only haploidentical booster transplants, 27 (64%) are still alive. Of the 27 who received a booster only from the same parent, 17 (63%) survive, and of the 14 who received a booster from the other parent, 10 (71%) survive. Only 2 of 5 (40%) patients who received a matched unrelated cord blood transplant are alive, and the patient who received a booster transplant from his grandmother died. The 2 patients who received HLA-identical donor subsequent transplants both survive.

Number of Nucleated Marrow Cells Given

The number of nucleated bone marrow cells per kilogram given in the original transplant to the 49 booster transplantation patients was not significantly different from the number of cells given to all other SCID patients transplanted at this institution (z=1.647, N=171, P=0.0996) (Supplementary Table 1). However, the average number of cells per kilogram for the “booster” transplants was significantly lower (z=7.517, N=200, P<0.0001), as the patients were older and weighed more (z=−10408, N=200, P<0.0001).

Transplantation Interval

The mean interval between the first and second transplants in living patients was 1262 days (S.D. 1737, N=31) vs. 326 days for deceased patients (S.D. 323, N=18). The difference between means was significant (t=−2.2534, N=49, P=0.0289).

Graft-versus-Host Disease

Of all 171 SCID patients transplanted at this institution since 1982, 54 (32%) developed GVHD. Among the entire group, those who had GVHD were not more likely to require a booster transplant. Only 14 (28.6%) of the 49 boosted patients experienced GVHD following their first transplant and only one developed it after a booster transplant The latter patient developed fatal grade IV GVHD after a chemoablated matched unrelated cord blood transplant elsewhere. The boosted patients who had GVHD following their original transplant were no more likely to require more than one booster transplant than those who did not (X2=4.8782, N=49 P=0.181).

Infections

Eleven of the 18 deceased patients died of one or more clinically apparent viral infections: three of cytomegalovirus, one of EBV lymphoproliferative disease, two of rotavirus, two of adenovirus, two of varicella, two of parainfluenza 3, and one of a herpes simplex infection. One patient died of a fungal infection, one of gram negative sepsis, one of an undefined neurologic disease, two of pulmonary complications, one of hemorrhage following surgery and one of graft-vs-host disease.

Other than viral infections, Pneumocystis jiroveci pneumonia and oral moniliasis were found to be most common at presentation and resolved with appropriate therapy. All but 4 deceased patients had a clinically documented chronic viral infection, whereas 93.33% of living patients have never had a clinically documented chronic viral infection. This difference was highly significant (X2=24.85, N=47 P<0.0000).

Current Clinical Statuses

The 31 living patients’ current clinical statuses were evaluated in 6 categories and a score was calculated with 6 being the most unhealthy. Patients were included in this evaluation if they had been seen within the last 2 years or had responded to a recent questionnaire (N=28).18 The categories were regular antibiotic use, ADHD, neurological issues, gastrointestinal issues, receiving Cs or lower in school, and being in the 5th percentile or below in height or weight. The average clinical total score was 1.8 (S.D. 1.6).

Immune Reconstitution

Lymphocyte Enumeration and T-Cell Function

All infants lacked T-cells prior to initial transplantation. As expected, transplants that resulted in improved immune function were more often found in patients who are now alive. Shown in Table 2 are the latest results of immune evaluations in all patients. The absolute numbers of CD3 (z=3.609, p=0.0003) and CD4 (z=4.096, P<0.0001) positive T cells were significantly higher in the surviving patients, but the percentage of CD45RA positive T cells was not significantly different when compared to that of the deceased (z=1.535, p=0.1247). Improved T-cell function, measured by lymphocyte proliferation assays, was used to assess immune reconstitution. If a patient had one response greater than 50,000 CPM to any of the mitogens tested, the transplant was considered to have “improved T-cell function.” Seventy-five of 130 transplants given to these patients resulted in improved T-cell function; 62 (78%) of these transplants were in patients who are currently living, while only 13 were in patients who are deceased. This difference was found to be highly significant (p<0.0000 X2=32.4369, N=129). Mean responses to PHA (cpm) at the latest evaluations were also significantly higher in the living patients (z= 4.210, p<0.0001) (Table 2).

Table 2.

Latest Immune Function in Boosted Patients

Pat. No. SCID Type Age (da) 1st Trans* # Boosts D→R Sex** Days to 1st Boost Days to Last Boost Donor B cells mg/dl IgA mg/dl IgM IG RX*** Donor T Cells #/cmm CD3 #/cmm CD4 #/cmm CD8 % CD3+ CD45RA+ % CD3+ CD45RO+ TREC μg/ml Medium CPM PHA CPM Yrs Post Trans*
Alive
1 ADADef 112 1 F-F→M 2908 NA Yes 78 44 0 Yes 514 297 152 ND ND N.D. 4,460 40,447 23.68
2 ADADef 182 2 F-F-M→M 145 702 No 67 63 1 No 107 61 36 7.0 67.0 112 191 24,257 15.22
3 ADADef 135 1 F-F→M 4074 NA No 5 224 1 Yes 457 266 142 11.8 69.4 N.D. 1,738 24,846 12.59
4 AutoRec 147 2 F-M-F→M 168 154 No 0 0 1 ND 509 478 31 ND ND N.D. 149 24,056 14.40
5 AutoRec 170 2 F-F-M→F 1251 1374 No 0 0 1 ND 58 26 32 8.0 56.0 <100 108 7,296 12.52
6 AutoRec 303 1 F-M→F 215 NA No 7 10 1 Yes 506 352 142 41.2 37.0 N.D. 190 137,615 3.29
7 CartHair 207 1 F-F→M 4515 NA No 0 0 1 Yes 1925 834 1170 32.8 45.6 N.D. 194 2,443 22.45
8 CD3εDef 171 2 M-F-M→F 183 1027 No 108 121 0 Yes 551 440 94 13.8 57.9 1,130 691 255,038 23.56
9 RAG2Def 119 2 F-F-F→M 1381 2198 No 0 0 1 Yes 241 97 127 2.3 76.2 <100 166 23,457 24.10
10 RAG2Def 395 3 F-F-F-F→M 586 699 No 0 0 1 Yes 559 301 247 6.8 64.2 <100 86 16,058 11.65
11 RAG2Def 33 2 F-F-F→M 329 1430 No 12 0 1 Yes 27 26 1 1.6 91.6 N.D. 1,620 18,089 6.58
12 RAG2Def 162 1 F-F→M 616 NA No 0 4 1 Yes 314 154 154 2.0 71.8 <100 203 62,602 6.10
13 RAG1Def 25 2 F-F-M→M 189 483 No 0 0 1 Yes 1197 378 582 9.8 77.9 <100 226 226,290 8.22
14 IL7RαDef 164 1 F-M→M 174 NA No 259 113 0 Yes 903 509 426 53.1 23.6 906 327 242,178 22.7
15 IL7RαDef 394 1 M-M→F 614 NA No 103 197 0 Yes 530 221 255 13.0 54.4 119 151 184,906 11.96
16 IL7RαDef 322 1 F-F→F 210 NA No 0 178 0 Yes 1095 736 336 52.4 20.6 6,010 293 177,138 7.55
17 IL7RαDef 12 2 F-F-M→M 254 154 No 29 76 1 Yes 646 283 320 60.5 22.3 <100 128 142,342 3.68
18 Jak3Def 238 1 F-F→M 3129 NA No 0 83 1 Yes 926 339 490 22.9 40.7 126 785 260,860 27.2
19 Jak3Def 334 2 M-M-C→F 317 195 Yes 139 277 0 Yes 7466 5097 2063 77.6 9.8 2,740 847 203,595 16.9
20 Jak3Def 165 2 M-M-F→F 203 196 Yes 97 64 0 Yes 1446 765 575 61.1 14.1 14,000 247 160,328 8.2
21 X-linked 45 2 F-F-F→M 4869 532 No 0 16 1 Yes 4136 937 3372 3.8 86.0 874 84 29,118 27.1
22 X-linked 217 1 F-F→M 6941 NA No 38 46 1 Yes 1588 620 920 14.7 56.2 <100 98 60,076 24.8
23 X-linked 175 2 M-M-M→M 131 4823 No 0 13 1 Yes 1851 433 1368 10.6 65.0 <100 97 87,139 19.4
24 X-linked 289 3 F-M-F-M→M 146 796 Yes 12 176 0 Yes 824 532 231 35.5 28.6 <100 292 157,805 19.0
25 X-linked 367 2 F-F-F→M 1304 1827 No 0 8 1 Yes 290 187 101 3.8 82.3 <100 175 28,448 17.2
26 X-linked 351 1 F-F→M 1641 NA No 12 49 1 Yes 839 573 259 30.3 50 <100 876 212,320 16.8
27 X-linked 10 1 M-M→M 238 NA No 0 25 1 Yes 1827 387 1289 19.4 40.5 <100 318 85,519 16.7
28 X-linked 163 1 F-C→M 141 NA Yes 76 162 0 Yes 1749 691 862 54.2 23.9 N.D. 179 181,497 16.0
29 X-linked 224 1 F-F→M 182 NA No 0 105 1 Yes 2047 1146 798 55.0 11.3 7410 2,658 112,410 9.82
30 X-linked 110 1 F-F→M 1750 NA No 0 19 1 Yes 1140 447 604 35.5 36.4 352 128 212,632 8.88
31 X-linked 260 3 F-F-M-M→M 322 700 No 17 66 1 Yes 59 47 11 5.3 79.3 <100 282 55,454 7.09
Medians 171 2 322 701 5 46 824 387 259 15 54 906 203 87,139 15
Means 194 2 1,262 1,081 5/31 34 69 22/31 28/31 1,172 570 555 26 50 3,071 580 111,492 15
Deceased
32 ADADef 255 1 F-F→M 276 NA No 388 42 1 Yes 1150 129 254 ND ND ND 258 321 3.56
33 ADADef 250 1 M-M→F 340 NA No 149 94 1 0 375 97 277 22.5 67.9 151 467 45,445 18.27
34 ADADef 140 1 F-F→M 196 NA No 0 0 1 0 127 63 ND 1.7 72.9 ND 2,621 10,833 0.58
35 AutoRec 198 3 M-F-F-C→F 138 252 No 0 0 1 Yes 8 10 2 50.0 10.0 ND 1084 1,179 1.72
36 AutoRec 181 1 F-F→F 1271 NA No 0 0 1 Yes 290 235 52 5.1 80.4 36 99 56,795 12.36
37 AutoRec 447 1 F-M→F 159 NA No 2 18 1 0 75 46 23 0.0 74.7 ND 235 8,123 0.88
38 Cd3ζDef 395 3 F-F-M-M→F 105 651 No 62 70 1 0 9 102 192 25.5 14.8 ND 87 2,264 6.95
39 RAG2Def 109 2 F-F-F→M 161 751 No 0 0 1 0 186 58 169 10.6 92.3 ND 4,565 11,511 3.16
40 IL7RaDef 199 1 F-F→M 117 NA No 0 18 1 0 11 10 48 ND ND ND 1,231 1,282 0.3
41 IL7RaDef 559 3 F-F-M-F→M 91 266 No 54 318 1 0 55 5 102 1.0 88.5 0 766 2,873 2.0
42 IL7RaDef 162 2 F-F-M→M 154 91 No 8 32 1 0 5 3 18 25.8 9.7 ND 223 1,853 0.8
43 Jak3Def 448 2 F-F-G-→M 161 119 No 0 48 1 0 4 2 2 40.8 30.8 0 250 494 1.9
44 X-linked 597 2 F-F-F→M 208 558 No 0 2 1 0 15 117 11 ND ND ND 1061 1557 2.4
45 X-linked 194 2 F-F-C→M 543 51 No 67 186 1 Yes 34 18 18 37.1 50.4 ND 7710 138,608 2.0
46 X-linked 222 1 F-F→M 987 NA No 0 415 1 Yes 1341 212 973 5.8 50.6 0 391 27,005 4.6
47 X-linked 147 1 F-F→M 357 NA Yes 156 1570 1 Yes 8406 1562 4250 0.1 88.4 ND 466 26,564 1.2
48 Unknown 220 1 F-F→M 483 NA No 11 0 1 0 35 24 28 7.5 84.6 ND 594 35184 4.2
49 Unknown 190 4 F-M-F-M-C→M 124 323 No 17 25 1 0 182 ND ND 11.7 44.7 ND 986 8,714 2.2
Medians 210 2 179 266 5 29 65 58 50 11 68 531 8,419 2
Means 273 2 326 340 1/18 51 158 18 6/18 684 158 401 16 57 1,283 21,145 4
p=0.04 p=0.02 p= 0.03 p=0.0003 p<0.0001 p=0.02 p=0.13 p<0.0001 p<0.0001
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*

Trans=first transplant

**

F=female, M=male, C=unrelated cord, G=gene therapy

***

IG RX=immunoglobulin treatment, 1=Yes

B-cell Function

B-cell function has proven difficult to reconstitute in SCID patients.3,19–21 Two patients reported here (#’s 9 and 18, Table 2) were given boosters solely to gain B-cell function, and both failed. Currently, only 9 (29%) of the boosted patients have normal B cell function and do not require IG (Table 2). By contrast, 57 of the 98 (58%) non-boosted SCID patients who survive have B cell function and no longer require IG replacement.21

Patients with Two Parental Donors

In 7 of the 10 surviving patients who were given a booster transplant only with marrow from the other parent, T-cell function improved remarkably and became normal in 6 of these cases. One CD3 epsilon-deficient SCID patient received her first transplant from her father, but because she showed no immune function at 183 days post-transplantation, she was given a rigorously T-cell-depleted maternal marrow transplant (Figure 1). One month following the administration of the second transplant (maternal marrow), the patient’s T-cell proliferation improved to 53,237 CPM to Con A. However, T-cell chimerism studies at the time demonstrated that the proliferating T-cells were 100% of paternal origin. She subsequently demonstrated T-cell chimerism from both parents, but the paternal T-cells dominated. Because her T-cell function was still not normal, a third transplant was given, this time again from her father, and she subsequently developed and maintained normal T-cell function and remains healthy at age 24. She also has normal B-cell function and does not require IVIG.

Figure 1.

Figure 1

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The development of T cell function following sequential bone marrow transplants in a girl with CD3 epsilon deficient SCID. Her father was the first donor, but due to the lack of T cell function at 183 days post-transplantation, she received a rigorously T cell-depleted booster transplant from her mother. Following that, she developed some T cell function but chimerism studies revealed that most of the dividing cells were from her father. A third rigorously T cell-depleted transplant was then given from her father and she has subsequently gone on to have excellent long term T cell reconstitution. Subsequent T cell chimerism studies have revealed some chimerism from both parents, with the dominant chimerism being from the father. She does not require IVIG therapy although her B cells are all host.

Figure 2 shows the post-transplantation course of a boy with IL7Rα-Def SCID who received his first haploidentical transplant from his mother. No immune reconstitution was evident at 174 days post-transplantation. A T-cell-depleted haploidentical transplant was then given from his father. His T-cell function subsequently developed normally and has been sustained. Chimerism studies have shown all of his T-cells to be of paternal origin. He has normal B-cell function and does not require IG. He is now healthy at age 23 years.

Figure 2.

Figure 2

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Development of T cell function in an IL7Rα-Def SCID boy following two rigorously T cell-depleted haploidentical bone marrow transplants. The second one was given after T cell function had failed to develop at 174 days post-transplantation of marrow from his mother. The second transplant was marrow from his father, following which he developed and sustained excellent T cell function. Chimerism studies reveal the T cells to be all paternal. He does not require IVIG therapy although his B cells are all host.

One boy with IL7Rα-Def SCID who received his first two transplants from his mother had no immune reconstitution at 408 days post-transplantation (Figure 3). A rigorously T-cell-depleted haploidentical transplant was then given from his father. He subsequently developed normal T-cell function and normal immunoglobulin levels. His T-cell chimerism is paternal. He is now 3.5 years old and healthy.

Figure 3.

Figure 3

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Development of T cell function in another IL7Rα-Def SCID boy following three rigorously T cell depleted haploidentical parental bone marrow transplants. The mother was the donor for the first two, but T cell function failed to develop after either transplant, so a third transplant was given from the father and was subsequently followed by the development of sustained normal T cell function and paternal T cell chimerism.

A Jak3-Def SCID also had a remarkable improvement in her T-cell function following a transplant from the other parent, as previously reported.22 She had received two paternal transplants without achieving adequate T-cell function or engraftment. Finally, following a third transplant of maternal origin, normal T-cell function was achieved. Chimerism studies have shown that she has 2% paternal cells and 98% maternal T-cells. She also has normal B-cell function and does not require IVIG. She is now 8.5 years old and healthy.

Discussion

Our studies demonstrate that non-ablative booster transplantation is an effective means of enhancing immune system reconstitution following an unsatisfactory initial non-ablative T-cell-depleted HLA-haploidentical bone marrow transplant. The explanation for the higher rate of failure of haploidentical transplants (as opposed to HLA identical transplants) is unknown but appears to be related to the necessity to rigorously T cell deplete. In most cases, booster transplants were effective in improving immune function. No pre-transplant conditioning was used for any of the first or booster haploidentical transplants. Conditioning was used only prior to matched unrelated donor umbilical cord blood transplants. Omitting toxic chemoablative agents prior to bone marrow transplantation in SCID allows the patients to avoid later infertility, veno-occlusive disease and damage to the lungs, endocrine organs, or brain.23–25

No increased incidence of GVHD following the first transplant was found when boosted patients were compared to non-boosted patients. In both groups, most of the donors were mismatched haploidentical parents whose marrow was rigorously T-cell depleted. Therefore, there was no need in either group for immunosuppressive drugs to be given for GVHD prophylaxis post-transplantation.

As with non-booster transplanted SCID patients, opportunistic viral infections and malnutrition were the main factors associated with mortality in booster-transplanted SCID patients.3 Chronic viral infections were the most lethal complication among booster SCID patients, and in most patients these viral infections were present prior to their original transplant. All but four of 18 deceased patients in this study had clinically documented chronic viral infections and these were the direct cause of death in eleven. Early diagnosis and isolation are key to preventing infection in all SCIDS.4,26

The underlying molecular defect had little effect on the need for a booster transplant, with the exception of RAG1 and RAG2-deficiency, where 6 of 7 transplanted SCIDs required booster transplants. In the case of ADA-deficient SCID, often considered problematic for achieving engraftment,27 this Center has transplanted 26 such patients over the past 30 years. Twenty (77%) survive and only 6 required booster transplants. Three of the six deceased had been given booster transplants. Two received successful gene therapy,28 one received an ablated transplant elsewhere, and two are receiving PEG-ADA. The other fifteen are alive and well and are chimeric with related donor T cells after rigorously T cell-depleted non-ablative haploidentical parental (n=10, 2 boosted) or HLA identical (n=5) bone marrow transplants.

The use of bone marrow from both parental donors sequentially can improve immune reconstitution in some patients. In some cases, we found that the recipients became double parental chimeras, although usually chimerism with one parent’s cells dominated. This is somewhat similar to the situation seen when multiple cord blood units are given to one recipient, in which case chimerism from one particular unit becomes dominant.29 Although the factors that determine dominance of one donor over another have not been clarified, immune-mediated mechanisms are suspected. This was clearly the case in one such patient in our group who failed two paternal T-cell-depleted haploidentical bone marrow transplants but rapidly became immune reconstituted after her mother’s T-cell-depleted haploidentical bone marrow transplant.22 In that case, we suspected the later-identified transplacentally-transferred maternal T-cells rejected the paternal marrow transplants. Closer HLA matching of one haploidentical parent to the patient as opposed to the other parent’s matching was examined, but review of the HLA typing data (not shown) found that in only one of the examples given was there such a possibility.

Booster transplantation has proven to be an effective means of prolonging life in SCID patients. Though the survival rate among booster patients (63%) is lower than the overall SCID survival rate at this institution (75%),2 this is most likely due to the fact that the patients who received boosters were older at the time of initial transplantation and were sicker, primarily with chronic viral infections. Without receiving a booster transplant, these patients would not have survived. Clinically, most surviving booster transplanted patients are doing well. The majority have adequate T-cell function. As in our previous studies of the entire group, age at transplantation was a key factor in survival,4 most likely because the older patients were already infected with viral agents. Recognition of the beneficial effect of very young age on treatment outcome was an important factor in securing approval for newborn screening for SCID.26 (3000 words)

Supplementary Material

1. Supplementary Figure 1.

Kaplan Meier Survival Curve showing the long-term survival of the patients who received booster transplants. Currently, 31 of the 49 patients (63%) are surviving up to 28 years post-transplantation.

2. Supplementary Figure 2.

Kaplan Meier Survival Curve of patients according to their age at time of initial transplantation. The mean age at transplantation of the survivors was 194 days (S.D. 111) and the mean age for those who are deceased was 273 days (S.D. 148). This difference was found to be significant (t =−2.117, N=49, P=0.0401).

3

Acknowledgments

Funding for this research was provided by NIH Grants AI047605 and AI042951 and by a Dean’s Research Fellowship to CLT from Duke University.

Footnotes

Conflict of Interest

No author has either financial or intellectual conflicts of interests to disclose.

Reference List

  • 1.Buckley RH. Molecular defects in human severe combined immunodeficiency and approaches to immune reconstitution. Annu Rev Immunol. 2004;22:625–655. doi: 10.1146/annurev.immunol.22.012703.104614. [DOI] [PubMed] [Google Scholar]
  • 2.Buckley RH. Transplantation of hematopoietic stem cells in human severe combined immunodeficiency: longterm outcomes. Immunol Res. 2011;49:25–43. doi: 10.1007/s12026-010-8191-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Buckley RH, Schiff SE, Schiff RI, Markert L, Williams LW, Roberts JL, et al. Hematopoietic stem cell transplantation for the treatment of severe combined immunodeficiency. N Engl J Med. 1999;340:508–516. doi: 10.1056/NEJM199902183400703. [DOI] [PubMed] [Google Scholar]
  • 4.Myers LA, Patel DD, Puck JM, Buckley RH. Hematopoietic stem cell transplantation for severe combined immunodeficiency in the neonatal period leads to superior thymic output and improved survival. Blood. 2002;99:872–878. doi: 10.1182/blood.v99.3.872. [DOI] [PubMed] [Google Scholar]
  • 5.Kline RM, Stiehm ER, Cowan MJ. Bone marrow “boosts” following T cell depleted haploidentical bone marrow transplantation. Bone Marrow Transplantation. 1996;17:543–548. [PubMed] [Google Scholar]
  • 6.Remberger M, Ringden O, Ljungman P, Hagglund H, Winiarski J, Lonnqvist B, et al. Booster marrow or blood cells for graft failure after allogeneic bone marrow transplantation. Bone Marrow Transplant. 1998;22:73–78. doi: 10.1038/sj.bmt.1701290. [DOI] [PubMed] [Google Scholar]
  • 7.Min CK, Kim DW, Lee JW, Min WS, Kim CC. Additional stem cell therapy for graft failure after allogeneic bone marrow transplantation. Acta Haematol. 2000;104:185–192. doi: 10.1159/000046513. [DOI] [PubMed] [Google Scholar]
  • 8.Wolff SN. Second hematopoietic stem cell transplantation for the treatment of graft failure, graft rejection or relapse after allogeneic transplantation. Bone Marrow Transplant. 2002;29:545–552. doi: 10.1038/sj.bmt.1703389. [DOI] [PubMed] [Google Scholar]
  • 9.Slatter MA, Bhattacharya A, Abinun M, Flood TJ, Cant AJ, Gennery AR. Outcome of boost haemopoietic stem cell transplant for decreased donor chimerism or graft dysfunction in primary immunodeficiency. Bone Marrow Transplant. 2005;35:683–689. doi: 10.1038/sj.bmt.1704872. [DOI] [PubMed] [Google Scholar]
  • 10.Booth C, Ribeil JA, Audat F, Dal Cortivo L, Veys PA, Thrasher AJ, et al. CD34 stem cell top-ups without conditioning after initial haematopoietic stem cell transplantation for correction of incomplete haematopoietic and immunological recovery in severe congenital immunodeficiencies. Br J Haematol. 2006;135:533–537. doi: 10.1111/j.1365-2141.2006.06333.x. [DOI] [PubMed] [Google Scholar]
  • 11.Al-Herz W, Bousfiha A, Casanova J-L, Chapel H, Conley ME, Cunningham-Rundles C, et al. Primary immunodeficiency diseases: an update on the classification from the International Union of Immunological Societies Expert Committee for Primary Immunodeficiency. Frontiers in Immunology. 2011;2:54. doi: 10.3389/fimmu.2011.00054. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Chinen J, Davis J, De Ravin SS, Hay BN, Hsu AP, Linton GF, et al. Gene therapy improves immune function in preadolescents with X-linked severe combined immunodeficiency. Blood. 2007;110:67–73. doi: 10.1182/blood-2006-11-058933. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Buckley RH, Dees SC, O’Fallon WM. Serum immunoglobulins I. levels in normal children and in uncomplicated childhood allergy. Pediatr. 1968;41:600–611. [PubMed] [Google Scholar]
  • 14.Buckley RH, Dees SC. Serum immunoglobulins. III. Abnormalities associated with chronic urticaria in children. J Allergy. 1967;40:294–303. doi: 10.1016/0021-8707(67)90077-9. [DOI] [PubMed] [Google Scholar]
  • 15.Buckley RH, Schiff SE, Sampson HA, Schiff RI, Markert ML, Knutsen AP, et al. Development of immunity in human severe primary T cell deficiency following haploidentical bone marrow stem cell transplantation. J Immunol. 1986;136:2398–2407. [PubMed] [Google Scholar]
  • 16.Reisner Y, Kapoor N, Kirkpatrick D, Pollack MS, Cunningham-Rundles S, Dupont B, et al. Transplantation for severe combined immunodeficiency with HLA-A, B, D, DR incompatible parental marrow cells fractionated by soybean agglutinin and sheep red blood cells. Blood. 1983;61:341–348. [PubMed] [Google Scholar]
  • 17.Schiff SE, Kurtzberg J, Buckley RH. Studies of human bone marrow treated with soybean lectin and sheep erythrocytes: stepwise analysis of cell morphology, phenotype and function. Clin Exp Immunol. 1987;68:685–693. [PMC free article] [PubMed] [Google Scholar]
  • 18.Railey MD, LoKhnygina Y, Buckley RH. Long term clinical outcome of patients with severe combined immunodeficiency who received related donor bone marrow transplants without pre-transplant chemotherapy or post-transplant GVHD prophylaxis. J Pediatr. 2009;155:834–840. doi: 10.1016/j.jpeds.2009.07.049. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Haddad E, Deist FL, Aucouturier P, Cavazzana-Calvo M, Blanche S, Basile GD, et al. Long-term chimerism and B-cell function after bone marrow transplantation in patients with severe combined immunodeficiency with B cells: A single-center study of 22 patients. Blood. 1999;94:2923–2930. [PubMed] [Google Scholar]
  • 20.Buckley RH. B-cell function in severe combined immunodeficiency after stem cell or gene therapy: a review. J Allergy Clin Immunol. 2010;125:790–797. doi: 10.1016/j.jaci.2010.02.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Buckley RH, Win CM, Moser BK, Parrott RE, Sajaroff E, Sarzotti-Kelsoe M. Post-transplantation B cell function in different molecular types of SCID. J Clin Immunol. 2012 Sep 24; doi: 10.1007/s10875-012-9797-6. Published Online. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Palmer K, Green TD, Roberts JL, Sajaroff E, Cooney M, Parrott R, et al. Unusual clinical and immunologic manifestations of transplacentally acquired maternal T cells in severe combined immunodeficiency. J Allergy Clin Immunol. 2007;120:423–428. doi: 10.1016/j.jaci.2007.02.047. [DOI] [PubMed] [Google Scholar]
  • 23.Koppelmans V, Breteler MM, Boogerd W, Seynaeve C, Gundy C, Schagen SB. Neuropsychological performance in survivors of breast cancer more than 20 years after adjuvant chemotherapy. J Clin Oncol. 2012;30:1080–1086. doi: 10.1200/JCO.2011.37.0189. [DOI] [PubMed] [Google Scholar]
  • 24.Titman P, Pink E, Skucek E, O’Hanlon K, Cole TJ, Gaspar J, et al. Cognitive and behavioural abnormalities in children following haematopoietic stem cell transplantation for severe congenital immunodeficiencies. Blood. 2008;112:3907–3913. doi: 10.1182/blood-2008-04-151332. [DOI] [PubMed] [Google Scholar]
  • 25.Sanders JE the Seattle Marrow Transplant Group. Late Effects of Treatment for Childhood Cancer. Wiley-Liss Publishing Ltd; New York, NY: 1992. Effects of bone marrow transplantation on reproductive function; pp. 95–101. [Google Scholar]
  • 26.Buckley RH. The long quest for neonatal screening for severe combined immunodeficiency. J. Allergy Clin. Immunol. 2012;129:597–604. doi: 10.1016/j.jaci.2011.12.964. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Hassan A, Booth C, Brightwell A, Allwood Z, Veys P, Rao K, et al. Outcome of hematopoietic stem cell transplantation for adenosine deaminase-deficient severe combined immunodeficiency. Blood. 2012;120:3615–3624. doi: 10.1182/blood-2011-12-396879. [DOI] [PubMed] [Google Scholar]
  • 28.Aiuti A, Cattaneo F, Galimberti S, Benninghoff U, Cassani B, Callegaro L, et al. Gene therapy for immunodeficiency due to adenosine deaminase deficiency. N Engl J Med. 2009;360:447–458. doi: 10.1056/NEJMoa0805817. [DOI] [PubMed] [Google Scholar]
  • 29.Sideri A, Neokleous N, De La Grange PB, Guerton B, Le Bousse Kerdilles MC, Uzan G, et al. An overview of the progress on double umbilical cord blood transplantation. Haematologica. 2011;96:1213–1220. doi: 10.3324/haematol.2010.038836. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1. Supplementary Figure 1.

Kaplan Meier Survival Curve showing the long-term survival of the patients who received booster transplants. Currently, 31 of the 49 patients (63%) are surviving up to 28 years post-transplantation.

NIHMS434950-supplement-1.pdf (9MB, pdf)
2. Supplementary Figure 2.

Kaplan Meier Survival Curve of patients according to their age at time of initial transplantation. The mean age at transplantation of the survivors was 194 days (S.D. 111) and the mean age for those who are deceased was 273 days (S.D. 148). This difference was found to be significant (t =−2.117, N=49, P=0.0401).

NIHMS434950-supplement-2.pdf (8.8MB, pdf)
3
NIHMS434950-supplement-3.doc (29.5KB, doc)

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