Original research article/Praca oryginalna
Mobilization of hematopoietic stem cells in patients undergoing HSCT as a treatment of early diabetes type 1
Mobilizacja macierzystych komórek krwiotwórczych u chorych z niedawnorozpoznan ą cukrzyc ą typu 1 przed przeszczepieniem autologicznych komórek krwiotwórczych
Emilian Snarski
1,*, Kazimierz Ha łaburda
1, Ma łgorzata Król
1, Maria Król
1, El żbieta Urbanowska
1, Tigran Torosian
1, Alicja Milczarczyk
2,
Krystyna Jedynasty
2, Edward Franek
2,3, Wies ław Wiktor-Jedrzejczak
11DepartmentofHematology,OncologyandInternalDiseases,MedicalUniversityofWarsaw,Warszawa,Poland
2DepartmentofInternalDiseases,DiabetologyandEndocrinology,CentralHospital,MinistryofInteriorAffairsand Administration,Warszawa,Poland
3Departmentof Endocrinology, Mossakowski Medical ResearchCentre, Polish Academy of Sciences, Warszawa, Poland
actahaematologicapolonica 45(2014) 269–271
article info
Articlehistory:
Received:16.11.2013 Accepted:28.01.2014 Availableonline:6.02.2014
Keywords:
Mobilization
Autoimmunediseases
Diabetestype1
Hematopoieticstemcelldonors
abstract
Background:Theimmunoablationwithautologoushematopoieticstemcelltransplanta- tionisanewexperimentaltreatmentofearlydiabetestype1.Thetreatmentisbasedon destructionofimmunesystemwithcytotoxicdrugswhichleadstohaltofimmunereac- tiondirectedagainstbeta cellsofpancreas.Duringthattreatmentyoungpatientswith diabetestype1whoareotherwisehealthyundergomobilizationwithcyclophosphamide (CY)andG-CSF.Theyarenaïvetocytotoxicdrugsandmobilizationistheirfirstcontact withchemotherapy.Weanalyzedtheefficiencyofmobilizationwithcyclophosphamide andG-CSFinthispopulation.Methods: Weanalyzedthemedicalrecordsof25patients withdiabeteswhounderwentmobilization withcyclophosphamideandG-CSF.Results:
Themedianwhitebloodcellcountonthefirstdayofapheresiswas14.6103/mL(range 1.5–33.3)inCY+G-CSFmobilizedpatients.MedianabsoluteCD34+cellcountinperiphe- ral blood on the first apheresis day was 0.095 127103/mL (range 0.026–0.477). The mediantotalnumber ofcollectedCD34+ cellsduringone ortwo(if needed)aphereses was466106(range 204–816) or 7.24106 CD34+ cellsper kgof patient body weight (range 3.03–13.1). Therewere nopoor mobilizers whowereunable to collectsufficient
*Correspondingauthorat:MedicalUniversityofWarsawHematology,OncologyandInternalMedicine,ul.Banacha1a,02-097Warszawa, Poland.Tel.:+48662700772.
E-mailaddress:emiliansnarski@gmail.com(E.Snarski).
ContentslistsavailableatScienceDirect
Acta Haematologica Polonica
journalhomepage:www.elsevier.com/locate/achaem
http://dx.doi.org/10.1016/j.achaem.2014.01.007
0001-5814/©2014PolskieTowarzystwoHematologówiTransfuzjologów,InstytutHematologiiiTransfuzjologii.PublishedbyElsevier Urban&PartnerSp.zo.o.Allrightsreserved.
Introduction
Since2008theexperimentalautologoushematopoieticstem celltransplantation(AHSCT)programinearlytype1diabetes mellitus (T1DM) was conducted at our institution [1].
The transplantation can only be performed if there are asufficientnumber ofautologous hematopoieticstemcells mobilized prior to transplantation. The standard protocol for mobilization in patients with autoimmune diseases is cyclophosphamide (CY) (2–4g/m2) with granulocyte colony stimulatingfactor (G-CSF)[1–3].Thispopulationof patients withT1DM isnaïve tocytotoxicdrugs, and mobilizationis their first contact with chemotherapeutics (such as CY).
T1DM has been diagnosed only a few weeks prior to the procedure,thus reducingthe likelihoodof influenceofthis diseaseonthestemcellcompartmentinthebonemarrow.
Therefore,patientswithT1DMastheycannotbedescribed as healthy, they are, so far, the healthiest population of patientsthathavebeenexposedtoupfrontmobilizationwith CY+G-CSF.Thereisapublishedreportofactualpatientdata treated with HSCT on mobilization in early T1DM which shows very good efficacy in mobilization [3]. On the other hand,diabeticpatientswereshowntohaveimpairedmobili- zationofCD34+hematopoieticstemcells[4].Asthediabetes is chronic disease some of the changes observed might be connected with prolonged influence of impaired glucose metabolismonbonemarrowniche.Mobilizationefficiencyin otherautoimmunediseasesvarieswithdisease–thepatients withmultiplesclerosishavingthehighestCD34+cellcounts and patients with systemic sclerosis the lowest [2]. The reasons fordifferences are not clear – it canbespeculated thattheobserveddifferencescouldbecausedbythedisease itself or theother drugs usedpriorto theuse of cyclopho- sphamideinsystemicsclerosisorinmultiplesclerosis[5].
Theaim of this retrospective studywas toanalyze the results of mobilization with CY+G-CSF in patients with earlydiabetestype1andnootherhematologicdisease.
Methods
The medical records of 25 patients with early T1DM who were mobilized at our institution were reviewed. T1DM patients were enrolled into the study 4–8 weeks after diagnosis.
Patients with early T1DM were mobilized as previously described [1]. They received CY (2g/m2) and subsequently G-CSF10mg/kgperdayfromday+1afterCYuntilthedayof collection(usuallybetweenday +7and+9) ofover3.0106 CD34+ cells/kg of body weight. The CD34+ cells were
collectedthroughthedoublelumencentralvenouscatheter whentheCD34+count reachedover15cells/mL.Thecollec- tion of HSC was performed on Cobe Spectracell separator (CaridianBCT,Lakewood,CO,USA)accordingtothecenters' standard operating procedures. Evaluation of CD34+ cells was performed according to ISHAGE guidelines. The study wasapprovedbythelocalbioethicscommittee.
Results
Thegroupof T1DM consistedof 25 patientsofmedianage of 23 (18–35). There were 16 males and 9 females. The patients were generally healthy except for the new onset diabetes.Patients5and9hadmildanemiaduetotheiron deficiency, patients 8and 14 autoimmune thyroiddisorder in euthyreosis. No other serious conditions that could influencestem cellmobilizationwerereported. Oneapher- esiswassufficientforcollectionofhematopoieticstemcells for transplantation in 13 out of 25 diabetic patients(52%).
Twoapheresesweresufficientforcollectionofhematopoie- ticstemcellsintherestofpatients(12patients–48%).The collectiondataareshowninTableI.Whitebloodcellcount cellnumbers.Conclusion: ThemobilizationofhematopoieticstemcellswithCY+G-CSF inpatientswithearlydiabetestype1is efficientandtheunderlyingdiabetesdoes not impairtheefficiencyofhematopoieticstemcellcollection.
©2014PolskieTowarzystwoHematologówiTransfuzjologów,InstytutHematologiii Transfuzjologii.PublishedbyElsevierUrban&PartnerSp.zo.o.Allrightsreserved.
TableI–Theclinicaldataofthepatientswithearly diabetestype1mobilizedwithCy+G-CSF
Median(range)
Age(years) 23(18–35)
Sexdistribution 9females,16males
Weight(kg) 70(48–91)
Prefirstleukapheresis Whitebloodcellcounton
1stapheresisday(103/mL)
14.6(1.5–33.3)
CD34+cellsinperipheralblood(percent) 0.70%(0.21–4.20%) CD34+absolutecellcountin
peripheralblood(103/mL)
0.095(0.026–0.477)
Firstleukapheresis(n=25) Totalnucleatedcellcountin
leukapheresis(108)
103(56–202)
CD34+cellinleukapheresis(percent) 1.425(0.76–3.45%) TotalCD34+cellleukapheresis(106) 300(150–814) Secondleukapheresis(n=12)
Totalnucleatedcellcountin leukapheresis(108)
114(61–174)
CD34+cellinleukapheresis(percent) 1.15%(0.83–2.19%) TotalCD34+cellleukapheresis(106) 300(159–601) Totaloffirstandsecondleukaphereses
TotalCD34+cellleukaphereses(106) 466(204–816) TotalCD34+cell106/kgofpatientweight 7.24(3.03–13.1) acta haematologicapolonica 45 (2014) 269–271
270
(WBC)onthecollectiondayranged from1.5G/Lto33.3G/L (median 14.6103/mL) in T1DM patients. CD34+ cells accountedfor 0.21–4.2%WBC inT1DM (median0.70%).The absolutenumbersofcirculatingCD34+ cellsvariedbetween 26 and 477 per microliter in T1DM patients (median 127cells/mL).Intermsofcollectionefficacy,themedianyield of CD34+ cells during the first leukapheresis was 300106 (range150–814106).Whenthetotalcollectionwasanalyzed (day 1 plus day 2) the median yield of CD34+ cells was 466106 (range 204–816106). The median mobilized number of CD34+ cells per kilogram of body weight was 7.24106 (range 3.03–13). There were no poor mobilizers whowereunabletocollectsufficientcellnumbers
The mobilization was well tolerated with no serious adverseeffectsthathavebeenreported.Mostofthepatients reported mild nausea which was well controlled with ondansetron–asthesymptomsweremildthedetaileddata onnauseahavenotbeenrecorded.Noinfectionsduringthe mobilizationwerereported.
Discussion
In conclusion,the CY+ G-CSF mobilization isthe standard protocolusedinhematologicandnon-hematologicpatients undergoingautologoushematopoieticstemcelltransplanta- tion. Our results show that CY+ G-CSF used for HSC mobilizationinchemotherapynaïveindividualsworkswell.
TherationaletoCYinmobilizationisreduction intherisk offlare(incaseofautoimmunediseases)andantineoplastic activity in hematologic patients. Elimination of CY from suchprotocolshasdisadvantageoflosingtheantineoplastic oranti-autoimmunityeffectof mobilization–however, the data supporting this view come from limited number of cases [2]. Here we show that the addition of CY does not influencenegativelythecellyieldofmobilizationindiabetic patientsas all of the diabeticpatients reachedthe desired levelofover3106CD34+cellsperkgofweight.
The obvious limitation of the study is relatively small groupofpatients–however,itisthebiggestdescribedgroup of patientsundergoing thistreatmentand comparablewith groupdescribedbyDeSantisetal.[3].Wealsocannotbesure to what extent diabetes itself influences mobilization. Our institutionhastheexperiencewithcollectionofhematopoie- tic stem cells from healthy unrelated donors (over 500 collections). When the results of mobilization among the patients with diabetes mobilized with Cy+G-CSF are com- paredwith resultsofmobilizationwith G-CSFamonggroup unrelateddonorsadjustedforsex,ageandbodyweight the stemcellyieldishigheramongpatientswithdiabetes(data notshown).OurresultsshowthatCY+G-CSFcombinationin this population is very efficient and if diabetes has any negative influence on mobilization addition of CY clearly overcomesit.Wedid nothavethecontrolgroupofpatients withearlydiabeteswithsoleuseofG-CSFformobilizationto reducetheriskofflareofautoimmunedisorder[2].
Concluding,mobilizationprotocolwiththeCYandG-CSF in patients with early diabetes type 1 is safe and results
insufficientCD34+cellsyieldwithnoriskofpoormobiliza- tion.
Authors' contributions/Wkład autorów
ES – studydesign,data collection,statistical analysis,data interpretation, manuscript preparation, literature search.
AM, WWJ, EF – study design. KH, MłK, MK, EU, TT, AM, KJ–datacollection.
Conflict of interest/Konflikt interesu
Nonedeclared.
Financial support/Finansowanie
Nonedeclared.
Ethics/Etyka
The work described in this articlehas been carried out in accordance with The Code of Ethics of the World Medical Association (Declarationof Helsinki)for experiments invol- ving humans; EU Directive 2010/63/EU for animal experi- ments;UniformRequirementsformanuscriptssubmittedto Biomedicaljournals.
references/pi smiennictwo
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[2] StatkuteL,VerdaL,OyamaY,TraynorA,VillaM,ShookT, etal.Mobilization,harvestingandselectionofperipheral bloodstemcellsinpatientswithautoimmunediseases undergoingautologoushematopoieticstemcell transplantation.BoneMarrowTransplant2007;
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