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Non-Infectious Fever during Engraftment Following Autologous Hematopoietic Stem Cell Transplantation: Does Plerixafor Play a Role?
Abstracts / Biol Blood Marrow Transplant 23 (2017) S18–S391
Table 1 Apheresis results
D1 CD34+ cell yield, median Total CD34+ cell yield, median PM, N (%) GM, N (%) RM, N (%) Completed in 1 apheresis, N (%)
CM/G (n = 29)
CM/G/P (n = 15)
P/G (n = 46)
P
4.76 4.76
3.97 4.13
4.60 5.15
.062 .535
4 (14) 12 (41) 22 (76) 23 (79)
0 6 (40) 7 (47) 9 (60)
0 24 (52) 26 (57) 31 (67)
.012 .562 .112 .357
Table 2 Engraftment
Median time to ANC recovery (days) Median time to plt recovery (days)
CM/G
CM/G/P
P/G
10 12
11 14
10 15
Table 3 Toxicities
Delay in apheresis, N (%) Severe neutropenia, N (%) Neutropenic fever, N (%) pRBC transfusions, N (%) Platelet transfusions, N (%)
CM/G
CM/G/P
P/G
P
6 (21) 23 (79) 2 (7) 7 (24) 6 (21)
11 (73) 12 (80) 0 7 (47) 6 (40)
0 0 0 1 (2) 0
<.0001 <.0001 .116 .0001 .0001
Conclusion: Our data indicate that CM/G, CM/G/P and P/G result in robust SCM in most lymphoma pts. All 3 strategies were comparable in efficacy and efficiency. However, P/G was better tolerated and had a more predictable course without delay in apheresis, which may positively impact resource utilization. Therefore, P/G may be considered the preferred SCM method in lymphoma patients eligible for autologous stem cell transplant Tables 2 and 3.
165 Acute Renal Injury and Vancomycin Levels in Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation Juan J. Toro 1, Adolfo E. Diaz-Duque 2, Michael J. Gass 1, David J. Haile 1, Francisca Gushiken 1. 1 South Texas Veterans Health Care System, San Antonio, TX; 2 Department of Hematology and Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX Background: Infections are potential life-threatening complications during profound neutropenia in patients receiving high dose chemotherapy undergoing autologous hematopoietic stem cell transplantation (AHSCT). Adequate empirical antibacterial therapy in this setting may reduce infection related morbidity and mortality. Vancomycin is commonly used to cover for gram-positive infections due to its effectiveness and cost. In our institution, patients are initially treated with a broad spectrum antibiotic and vancomycin is added if fever persists after 48 hours. We observed that a significant number of patients develop acute kidney injury (AKI) after the addition of vancomycin. Monitoring vancomycin and other drugs with nephrotoxic profile can be difficult during transplantation as many factors
S139
need to be accounted for. Indeed, renal hypo-perfusion due to fluid redistribution around engraftment time and loss of lean body mass inherent to high dose chemotherapy need to be considered. The main objective of this study is to determine if the development of AKI is related to serum vancomycin levels in patients undergoing AHSCT. Methods: We retrospectively analyzed 169 consecutive patients who underwent AHSCT from January 2011 to December 2013 at the Audie L. Murphy Memorial Veterans Hospital in San Antonio, TX. All patients who developed neutropenic fever (ANC <.5 × 109/L and temperature >38.0°C) and received vancomycin were included. Serum creatinine (Cr) and vancomycin levels were recorded after the initiation of vancomycin. AKI was defined as an increase in serum Cr of ≥.3 mg/dL within 48 hours, according to the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines. Vancomycin levels were classified as low (≤10 mg/L), intermediate (>10 and <15 mg/L) and high (≥15 mg/L). Results: One hundred-nineteen (70%) patients developed fever from which 48 (28%) received vancomycin. Out of these 48, 18 (38%) patients had an increase in serum Cr of ≥.3 mg/dL within 48 hours and two required dialysis. The serum levels of vancomycin were similar and within the intermediate range in the AKI and non-AKI groups. Interestingly there was a trend of higher vancomycin levels in patients with no increase in Cr. The number of doses of vancomycin and number of days of treatment were also similar among both groups. Conclusions: 1. Patients undergoing AHSCT are very susceptible to develop AKI. In our population 38% of patients developed AKI after receiving vancomycin for neutropenic fever. 2. The development of AKI was independent of serum levels of vancomycin, number of doses or days of treatment. 3. Close monitoring of renal function in patients undergoing AHSCT is warranted as they are frequently exposed to nephrotoxic drugs.
166 Non-Infectious Fever during Engraftment Following Autologous Hematopoietic Stem Cell Transplantation: Does Plerixafor Play a Role? Tamna Wangjam 1, Matthew James Butler 1, Juan J. Toro 2, Shuko Lee 2, Francisca Gushiken 2. 1 Department of Medicine/ Division of Hematology and Medical Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX; 2 South Texas Veterans Health Care System, San Antonio, TX Introduction: Patients undergoing hematopoietic stem cell transplant (HSCT) commonly develop a variable constellation of signs and symptoms around the time of bone marrow recovery, which has been termed engraftment syndrome (ES). This is thought to reflect a systemic inflammatory state corresponding with reconstitution of immune cells, associated with cytokine release and capillary leakage. The presentation is highly variable, with a range of manifestations including fever, erythematous maculo-papular skin rash, noncardiogenic pulmonary edema, weight gain, diarrhea, liver and renal dysfunction, and encephalopathy. Fever, with or without other features of ES, is a significant event in the pre-engraftment phase of ASCT in that it can lead to additional diagnostic testing, empiric antibiotic therapy, and other changes in management. Several predisposing factors for ES have been proposed. One possible factor is exposure to plerixafor, a CXCR4 agonist that is being increasingly used for mobilization of hematopoietic stem cells.
S140
Abstracts / Biol Blood Marrow Transplant 23 (2017) S18–S391
Objective: To determine if the use of plerixafor during mobilization of stem cells play a role in the devepment of engraftment fever. Methods: We retrospectively reviewed Medical records from of all patients who underwent an autologous HSCT at the Audie L. Murphy Memorial VA Hospital between 2011 to 2015. Data were gathered on the use of plerixafor for mobilization of cells, transplant diagnosis, conditioning regimen, number of CD34 + and nucleated cells infused, timing of fever, timing of engraftment (defined as recovery of peripheral neutrophil count above 500 cells per microliter), and length of hospital stay. Peri-engraftment fever was defined as temperature >100.4 F with onset between four days prior to and two days after engraftment, with negative infectious workup. Results: 255 patients underwent an autologous HSCT between 2011 to 2015. Of those, 162 (64%) patients developed fever, and 90 (35%) met our criteria for peri-engraftment fever. All patients received filgrastim, and 128 (50%) also received plerixafor for stem cell mobilisation. No association was found between use of plerixafor and peri-engraftment fever (OR .804, 95% CI .480-1.345, P = .405). The doses of nucleated cells (OR .967, CI .926-1.011, P = .136) and CD34 + stem cells (OR .996, CI .908-1.093, P = .935) infused did not correlate with periengraftment fever. Patients 60 years of age or older were more likely to develop peri-engraftment fever than younger patients (OR 1.833, CI 1.045-3.214, P = .034). Peri-engraftment fever was also more common in patients with multiple myeloma than those with other diagnoses (OR 2.189, CI 1.1644.116, P = .015). Conclusion: The use of plerixafor does not appear to increase the risk of fever during engraftment following autologous HSCT in the population studied.
CLINICAL CELLULAR THERAPY
167 Development of a GMP Production Protocol for a Cord Blood-Derived Dendritic Cell-Based Vaccine to Prevent Relapses after Hematopoietic Cell Transplantation in Children with AML Colin de Haar 1, Jaap-Jan Boelens 2, Stefan Nierkens 3, Ester Dunnebach 1, Maud Plantinga 1. 1 Applied Tumor Immunology Section, Lab Translational Immunology, UMC Utrecht, Utrecht, Netherlands; 2 Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, Netherlands; 3 Laboratory of Translational Immunology, Applied Tumor Immunology Section, University Medical Center Utrecht, Utrecht, Netherlands Intro: Pediatric patients with refractory/relapsed acute myeloid leukemia (AML) have only one treatment option: hematopoietic cell transplantation (HCT). Using cord blood (CB)derived stem cells, instead of cells from bone marrow cells or peripheral blood, results in less relapses (increased antitumor reactivity) and less graft-versus-host disease (increased safety). Although this treatment is potentially curative, still more than half of the children die from relapses. As such, we want prevent relapses by inducing anti-AML immunity using a CB-derived dendritic cell (CBDC) vaccine. We have therefore optimized and validated the GMP production of the CBDC vaccine needed for our upcoming clinical trial. Methods: We have successfully translated and further optimized our pre-clinical protocol for generations of the CBDC vaccine from CD34+ CB stem cells into a GMP production process. This GMP protocol enables us to generate sufficient CBDC vaccine cells when using only the 20% of the CB
unit as a source of C34+ cells. After CliniMACS CD34-isolation the cells undergo expansion for two weeks in culture bags using medium containing FLT3L, SCF, IL-3 and IL-6. Next, the cells are differentiated into DCs using medium containing FLT3L, SCF, GM-CSF and IL-4. The CBDCs are then matured using proinflammatory cytokines and loaded with Wilms’ Tumor 1 (WT1) antigen by electroporation with WT1 encoding mRNA and pulsing with a WT1 15-mer-peptide pool. After 4 hours recovery, cells are cryopreserved until time of validation or intradermal vaccination. CBDC vaccine containing ampules are thawed and washed before being analyzed phenotypically and functionally. Results: Starting with approximately .3 × 10^6 CD34+ cells we were able to generate sufficient vaccine per patient for the three round of vaccination planned in our clinical trial. The CBDCs in our vaccine show upregulated co-stimulatory molecules after maturation and showed enhanced CCR7dependent migration towards CCL19 in a trans-well migrations assay. CD83 expression was used to assess the amount of mature CBDC in our vaccine. In addition, CBDCs expressed WT1 protein after electroporation with WT1mRNA. The WT1-loaded CBDCs were not only able to stimulate T cells in a mixed lymphocyte reaction but in an antigen-specific setting as well. Conclusions: We are able to set-up the GMP production process of a WT1-loaded CBDC vaccine with the goal to stimulate the anti-tumor reactivity of the newly developing immune system in AML patients after CB-HCT in a phase I/II clinical trial starting early 2017.
168 Optimizing Autologous Mononuclear Cell Collections for Cellular Therapy Using the Novel Optia Apheresis Device in Pediatric Patients with High Risk Leukemia Ehud Even-Or 1, Maria Di Mola 2, Muhammad Ali 1, Sarah Courtney 1, Elizabeth McDougall 3, Sarah Alexander 1, Tal Schechter 1, James Whitlock 1, Christoph Licht 2, Joerg Krueger 1. 1 Division of Hematology / Oncology / BMT, The Hospital for Sick Children, Toronto, ON, Canada; 2 Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; 3 Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada Background: Manufacturing of cellular products for immunotherapy such as CAR T-cells requires successful collection of mononuclear cells (MNC). Collections from children with high risk leukemia present a challenge as the established COBE Spectra apheresis device (COBE) is being replaced by the novel Spectra Optia device (Optia) and published experience with the Optia device in children is lacking. Our aim was to compare the two collection devices, and describe settings to optimize MNC collections on the new Optia device. Study Design and Methods: As a quality initiative we retrospectively collected and compared data from MNC collections on both devices. Collected data included patient’s demographic and clinical characteristics, collection parameters including pre collection lymphocyte and CD3+ counts, total blood volumes (TBVs) processed, procedure runtimes, side effects including CBC and electrolyte changes, and product characteristics including product volumes and cell counts. Collection efficiencies and collection ratios were calculated. Results: Twenty six MNC collections were performed on 20 pediatric patients; 11 with the COBE device and 15 with the Optia device. Adequate MNC products were successfully collected with a single procedure from all patients on both machines except the first collection on the Optia. The mean calculated MNC collection efficiency was significantly higher
Table 1 Apheresis results
D1 CD34+ cell yield, median Total CD34+ cell yield, median PM, N (%) GM, N (%) RM, N (%) Completed in 1 apheresis, N (%)
CM/G (n = 29)
CM/G/P (n = 15)
P/G (n = 46)
P
4.76 4.76
3.97 4.13
4.60 5.15
.062 .535
4 (14) 12 (41) 22 (76) 23 (79)
0 6 (40) 7 (47) 9 (60)
0 24 (52) 26 (57) 31 (67)
.012 .562 .112 .357
Table 2 Engraftment
Median time to ANC recovery (days) Median time to plt recovery (days)
CM/G
CM/G/P
P/G
10 12
11 14
10 15
Table 3 Toxicities
Delay in apheresis, N (%) Severe neutropenia, N (%) Neutropenic fever, N (%) pRBC transfusions, N (%) Platelet transfusions, N (%)
CM/G
CM/G/P
P/G
P
6 (21) 23 (79) 2 (7) 7 (24) 6 (21)
11 (73) 12 (80) 0 7 (47) 6 (40)
0 0 0 1 (2) 0
<.0001 <.0001 .116 .0001 .0001
Conclusion: Our data indicate that CM/G, CM/G/P and P/G result in robust SCM in most lymphoma pts. All 3 strategies were comparable in efficacy and efficiency. However, P/G was better tolerated and had a more predictable course without delay in apheresis, which may positively impact resource utilization. Therefore, P/G may be considered the preferred SCM method in lymphoma patients eligible for autologous stem cell transplant Tables 2 and 3.
165 Acute Renal Injury and Vancomycin Levels in Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation Juan J. Toro 1, Adolfo E. Diaz-Duque 2, Michael J. Gass 1, David J. Haile 1, Francisca Gushiken 1. 1 South Texas Veterans Health Care System, San Antonio, TX; 2 Department of Hematology and Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX Background: Infections are potential life-threatening complications during profound neutropenia in patients receiving high dose chemotherapy undergoing autologous hematopoietic stem cell transplantation (AHSCT). Adequate empirical antibacterial therapy in this setting may reduce infection related morbidity and mortality. Vancomycin is commonly used to cover for gram-positive infections due to its effectiveness and cost. In our institution, patients are initially treated with a broad spectrum antibiotic and vancomycin is added if fever persists after 48 hours. We observed that a significant number of patients develop acute kidney injury (AKI) after the addition of vancomycin. Monitoring vancomycin and other drugs with nephrotoxic profile can be difficult during transplantation as many factors
S139
need to be accounted for. Indeed, renal hypo-perfusion due to fluid redistribution around engraftment time and loss of lean body mass inherent to high dose chemotherapy need to be considered. The main objective of this study is to determine if the development of AKI is related to serum vancomycin levels in patients undergoing AHSCT. Methods: We retrospectively analyzed 169 consecutive patients who underwent AHSCT from January 2011 to December 2013 at the Audie L. Murphy Memorial Veterans Hospital in San Antonio, TX. All patients who developed neutropenic fever (ANC <.5 × 109/L and temperature >38.0°C) and received vancomycin were included. Serum creatinine (Cr) and vancomycin levels were recorded after the initiation of vancomycin. AKI was defined as an increase in serum Cr of ≥.3 mg/dL within 48 hours, according to the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines. Vancomycin levels were classified as low (≤10 mg/L), intermediate (>10 and <15 mg/L) and high (≥15 mg/L). Results: One hundred-nineteen (70%) patients developed fever from which 48 (28%) received vancomycin. Out of these 48, 18 (38%) patients had an increase in serum Cr of ≥.3 mg/dL within 48 hours and two required dialysis. The serum levels of vancomycin were similar and within the intermediate range in the AKI and non-AKI groups. Interestingly there was a trend of higher vancomycin levels in patients with no increase in Cr. The number of doses of vancomycin and number of days of treatment were also similar among both groups. Conclusions: 1. Patients undergoing AHSCT are very susceptible to develop AKI. In our population 38% of patients developed AKI after receiving vancomycin for neutropenic fever. 2. The development of AKI was independent of serum levels of vancomycin, number of doses or days of treatment. 3. Close monitoring of renal function in patients undergoing AHSCT is warranted as they are frequently exposed to nephrotoxic drugs.
166 Non-Infectious Fever during Engraftment Following Autologous Hematopoietic Stem Cell Transplantation: Does Plerixafor Play a Role? Tamna Wangjam 1, Matthew James Butler 1, Juan J. Toro 2, Shuko Lee 2, Francisca Gushiken 2. 1 Department of Medicine/ Division of Hematology and Medical Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX; 2 South Texas Veterans Health Care System, San Antonio, TX Introduction: Patients undergoing hematopoietic stem cell transplant (HSCT) commonly develop a variable constellation of signs and symptoms around the time of bone marrow recovery, which has been termed engraftment syndrome (ES). This is thought to reflect a systemic inflammatory state corresponding with reconstitution of immune cells, associated with cytokine release and capillary leakage. The presentation is highly variable, with a range of manifestations including fever, erythematous maculo-papular skin rash, noncardiogenic pulmonary edema, weight gain, diarrhea, liver and renal dysfunction, and encephalopathy. Fever, with or without other features of ES, is a significant event in the pre-engraftment phase of ASCT in that it can lead to additional diagnostic testing, empiric antibiotic therapy, and other changes in management. Several predisposing factors for ES have been proposed. One possible factor is exposure to plerixafor, a CXCR4 agonist that is being increasingly used for mobilization of hematopoietic stem cells.
S140
Abstracts / Biol Blood Marrow Transplant 23 (2017) S18–S391
Objective: To determine if the use of plerixafor during mobilization of stem cells play a role in the devepment of engraftment fever. Methods: We retrospectively reviewed Medical records from of all patients who underwent an autologous HSCT at the Audie L. Murphy Memorial VA Hospital between 2011 to 2015. Data were gathered on the use of plerixafor for mobilization of cells, transplant diagnosis, conditioning regimen, number of CD34 + and nucleated cells infused, timing of fever, timing of engraftment (defined as recovery of peripheral neutrophil count above 500 cells per microliter), and length of hospital stay. Peri-engraftment fever was defined as temperature >100.4 F with onset between four days prior to and two days after engraftment, with negative infectious workup. Results: 255 patients underwent an autologous HSCT between 2011 to 2015. Of those, 162 (64%) patients developed fever, and 90 (35%) met our criteria for peri-engraftment fever. All patients received filgrastim, and 128 (50%) also received plerixafor for stem cell mobilisation. No association was found between use of plerixafor and peri-engraftment fever (OR .804, 95% CI .480-1.345, P = .405). The doses of nucleated cells (OR .967, CI .926-1.011, P = .136) and CD34 + stem cells (OR .996, CI .908-1.093, P = .935) infused did not correlate with periengraftment fever. Patients 60 years of age or older were more likely to develop peri-engraftment fever than younger patients (OR 1.833, CI 1.045-3.214, P = .034). Peri-engraftment fever was also more common in patients with multiple myeloma than those with other diagnoses (OR 2.189, CI 1.1644.116, P = .015). Conclusion: The use of plerixafor does not appear to increase the risk of fever during engraftment following autologous HSCT in the population studied.
CLINICAL CELLULAR THERAPY
167 Development of a GMP Production Protocol for a Cord Blood-Derived Dendritic Cell-Based Vaccine to Prevent Relapses after Hematopoietic Cell Transplantation in Children with AML Colin de Haar 1, Jaap-Jan Boelens 2, Stefan Nierkens 3, Ester Dunnebach 1, Maud Plantinga 1. 1 Applied Tumor Immunology Section, Lab Translational Immunology, UMC Utrecht, Utrecht, Netherlands; 2 Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, Netherlands; 3 Laboratory of Translational Immunology, Applied Tumor Immunology Section, University Medical Center Utrecht, Utrecht, Netherlands Intro: Pediatric patients with refractory/relapsed acute myeloid leukemia (AML) have only one treatment option: hematopoietic cell transplantation (HCT). Using cord blood (CB)derived stem cells, instead of cells from bone marrow cells or peripheral blood, results in less relapses (increased antitumor reactivity) and less graft-versus-host disease (increased safety). Although this treatment is potentially curative, still more than half of the children die from relapses. As such, we want prevent relapses by inducing anti-AML immunity using a CB-derived dendritic cell (CBDC) vaccine. We have therefore optimized and validated the GMP production of the CBDC vaccine needed for our upcoming clinical trial. Methods: We have successfully translated and further optimized our pre-clinical protocol for generations of the CBDC vaccine from CD34+ CB stem cells into a GMP production process. This GMP protocol enables us to generate sufficient CBDC vaccine cells when using only the 20% of the CB
unit as a source of C34+ cells. After CliniMACS CD34-isolation the cells undergo expansion for two weeks in culture bags using medium containing FLT3L, SCF, IL-3 and IL-6. Next, the cells are differentiated into DCs using medium containing FLT3L, SCF, GM-CSF and IL-4. The CBDCs are then matured using proinflammatory cytokines and loaded with Wilms’ Tumor 1 (WT1) antigen by electroporation with WT1 encoding mRNA and pulsing with a WT1 15-mer-peptide pool. After 4 hours recovery, cells are cryopreserved until time of validation or intradermal vaccination. CBDC vaccine containing ampules are thawed and washed before being analyzed phenotypically and functionally. Results: Starting with approximately .3 × 10^6 CD34+ cells we were able to generate sufficient vaccine per patient for the three round of vaccination planned in our clinical trial. The CBDCs in our vaccine show upregulated co-stimulatory molecules after maturation and showed enhanced CCR7dependent migration towards CCL19 in a trans-well migrations assay. CD83 expression was used to assess the amount of mature CBDC in our vaccine. In addition, CBDCs expressed WT1 protein after electroporation with WT1mRNA. The WT1-loaded CBDCs were not only able to stimulate T cells in a mixed lymphocyte reaction but in an antigen-specific setting as well. Conclusions: We are able to set-up the GMP production process of a WT1-loaded CBDC vaccine with the goal to stimulate the anti-tumor reactivity of the newly developing immune system in AML patients after CB-HCT in a phase I/II clinical trial starting early 2017.
168 Optimizing Autologous Mononuclear Cell Collections for Cellular Therapy Using the Novel Optia Apheresis Device in Pediatric Patients with High Risk Leukemia Ehud Even-Or 1, Maria Di Mola 2, Muhammad Ali 1, Sarah Courtney 1, Elizabeth McDougall 3, Sarah Alexander 1, Tal Schechter 1, James Whitlock 1, Christoph Licht 2, Joerg Krueger 1. 1 Division of Hematology / Oncology / BMT, The Hospital for Sick Children, Toronto, ON, Canada; 2 Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; 3 Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada Background: Manufacturing of cellular products for immunotherapy such as CAR T-cells requires successful collection of mononuclear cells (MNC). Collections from children with high risk leukemia present a challenge as the established COBE Spectra apheresis device (COBE) is being replaced by the novel Spectra Optia device (Optia) and published experience with the Optia device in children is lacking. Our aim was to compare the two collection devices, and describe settings to optimize MNC collections on the new Optia device. Study Design and Methods: As a quality initiative we retrospectively collected and compared data from MNC collections on both devices. Collected data included patient’s demographic and clinical characteristics, collection parameters including pre collection lymphocyte and CD3+ counts, total blood volumes (TBVs) processed, procedure runtimes, side effects including CBC and electrolyte changes, and product characteristics including product volumes and cell counts. Collection efficiencies and collection ratios were calculated. Results: Twenty six MNC collections were performed on 20 pediatric patients; 11 with the COBE device and 15 with the Optia device. Adequate MNC products were successfully collected with a single procedure from all patients on both machines except the first collection on the Optia. The mean calculated MNC collection efficiency was significantly higher