sirolimus and Anemia--Sickle-Cell

Non-myeloablative haematopoietic progenitor cell transplantation (HPCT) from matched related donors (MRD) has been increasingly utilized in sickle cell disease (SCD). A total of 122 patients received 300 cGy of total body irradiation (TBI), alemtuzumab, unmanipulated filgrastim-mobilized peripheral blood HPC and sirolimus. The median follow-up was four years; median age at HPCT was 29 years. Median neutrophil and platelet engraftment occurred on day 22 and 19 respectively; 41 patients required no platelet transfusions. Overall and sickle-free survival at one and five years were 93% and 85% respectively. Age, sex, pre-HPCT sickle complications, ferritin and infused HPC numbers were similar between graft failure and engrafted patients. Mean donor myeloid chimaerism at one and five years post HPCT were 84% and 88%, and CD3 was 48% and 53% respectively. Two patients developed grade 1 and 2 skin graft-versus-host disease (GVHD) with no chronic GVHD. Median days of recipients taking immunosuppression were 489; 83% of engrafted patients have discontinued immunosuppression. Haemoglobin, haemolytic parameters and hepatic iron levels improved post HPCT. Pulmonary function testing, hepatic histology and neurovascular imaging remained stable, suggesting cessation of further sickle-related injury. Fourteen patients had children. In this largest group of adult SCD patients, this regimen was highly efficacious, well-tolerated despite compromised organ functions pre HPCT, and without clinically significant GVHD.

Topics: Adolescent; Adult; Alemtuzumab; Anemia, Sickle Cell; Antineoplastic Agents, Immunological; Child; Female; Graft Rejection; Graft Survival; Graft vs Host Disease; Hematopoietic Stem Cell Transplantation; HLA Antigens; Humans; Immunosuppressive Agents; Male; Middle Aged; Sirolimus; Tissue Donors; Transplantation, Homologous; Treatment Outcome; Young Adult

Myeloablative allogeneic hematopoietic stem cell transplantation (HSCT) is curative for children with severe sickle cell disease, but toxicity may be prohibitive for adults. Nonmyeloablative transplantation has been attempted with degrees of preparative regimen intensity, but graft rejection and graft-vs-host disease remain significant.. To determine the efficacy, safety, and outcome on end-organ function with this low-intensity regimen for sickle cell phenotype with or without thalassemia.. From July 16, 2004, to October 25, 2013, 30 patients aged 16-65 years with severe disease enrolled in this nonmyeloablative transplant study, consisting of alemtuzumab (1 mg/kg in divided doses), total-body irradiation (300 cGy), sirolimus, and infusion of unmanipulated filgrastim mobilized peripheral blood stem cells (5.5-31.7 × 10(6) cells/kg) from human leukocyte antigen-matched siblings.. The primary end point was treatment success at 1 year after the transplant, defined as a full donor-type hemoglobin for patients with sickle cell disease and transfusion independence for patients with thalassemia. The secondary end points were the level of donor leukocyte chimerism; incidence of acute and chronic graft-vs-host disease; and sickle cell-thalassemia disease-free survival, immunologic recovery, and changes in organ function, assessed by annual brain imaging, pulmonary function, echocardiographic image, and laboratory testing.. Twenty-nine patients survived a median 3.4 years (range, 1-8.6), with no nonrelapse mortality. One patient died from intracranial bleeding after relapse. As of October 25, 2013, 26 patients (87%) had long-term stable donor engraftment without acute or chronic graft-vs-host disease. The mean donor T-cell level was 48% (95% CI, 34%-62%); the myeloid chimerism levels, 86% (95% CI, 70%-100%). Fifteen engrafted patients discontinued immunosuppression medication with continued stable donor chimerism and no graft-vs-host disease. The normalized hemoglobin and resolution of hemolysis among engrafted patients were accompanied by stabilization in brain imaging, a reduction of echocardiographic estimates of pulmonary pressure, and allowed for phlebotomy to reduce hepatic iron. The mean annual hospitalization rate was 3.23 (95% CI, 1.83-4.63) the year before, 0.63 (95% CI, 0.26-1.01) the first year after, 0.19 (95% CI, 0-0.45) the second year after, and 0.11 (95% CI, 0.04-0.19) the third year after transplant. For patients taking long-term narcotics, the mean use per week was 639 mg (95% CI, 220-1058) of intravenous morphine-equivalent dose the week of their transplants and 140 mg (95% CI, 56-225) 6 months after transplant. There were 38 serious adverse events: pain and related management, infections, abdominal events, and sirolimus related toxic effects.. Among 30 patients with sickle cell phenotype with or without thalassemia who underwent nonmyeloablative allogeneic HSCT, the rate of stable mixed-donor chimerism was high and allowed for complete replacement with circulating donor red blood cells among engrafted participants. Further accrual and follow-up are required to assess longer-term clinical outcomes, adverse events, and transplant tolerance.. clinicaltrials.gov Identifier: NCT00061568.

Topics: Adolescent; Adult; Aged; Alemtuzumab; Anemia, Sickle Cell; Antibodies, Monoclonal, Humanized; beta-Thalassemia; Chimerism; Erythrocytes; Female; Filgrastim; Graft vs Host Disease; Granulocyte Colony-Stimulating Factor; Hematopoietic Stem Cell Mobilization; Hematopoietic Stem Cell Transplantation; HLA Antigens; Humans; Immunosuppressive Agents; Infections; Male; Middle Aged; Pain; Prospective Studies; Recombinant Proteins; Sirolimus; Transplantation Conditioning; Transplantation, Homologous; Treatment Outcome; Whole-Body Irradiation; Young Adult

Myeloablative allogeneic hematopoietic stem-cell transplantation is curative in children with sickle cell disease, but in adults the procedure is unduly toxic. Graft rejection and graft-versus-host disease (GVHD) are additional barriers to its success. We performed nonmyeloablative stem-cell transplantation in adults with sickle cell disease.. Ten adults (age range, 16 to 45 years) with severe sickle cell disease underwent nonmyeloablative transplantation with CD34+ peripheral-blood stem cells, mobilized by granulocyte colony-stimulating factor (G-CSF), which were obtained from HLA-matched siblings. The patients received 300 cGy of total-body irradiation plus alemtuzumab before transplantation, and sirolimus was administered afterward.. All 10 patients were alive at a median follow-up of 30 months after transplantation (range, 15 to 54). Nine patients had long-term, stable donor lymphohematopoietic engraftment at levels that sufficed to reverse the sickle cell disease phenotype. Mean (+/-SE) donor-recipient chimerism for T cells (CD3+) and myeloid cells (CD14+15+) was 53.3+/-8.6% and 83.3+/-10.3%, respectively, in the nine patients whose grafts were successful. Hemoglobin values before transplantation and at the last follow-up assessment were 9.0+/-0.3 and 12.6+/-0.5 g per deciliter, respectively. Serious adverse events included the narcotic-withdrawal syndrome and sirolimus-associated pneumonitis and arthralgia. Neither acute nor chronic GVHD developed in any patient.. A protocol for nonmyeloablative allogeneic hematopoietic stem-cell transplantation that includes total-body irradiation and treatment with alemtuzumab and sirolimus can achieve stable, mixed donor-recipient chimerism and reverse the sickle cell phenotype. (ClinicalTrials.gov number, NCT00061568.)

Topics: Adolescent; Adult; Alemtuzumab; Anemia, Sickle Cell; Antibodies, Monoclonal; Antibodies, Monoclonal, Humanized; Antibodies, Neoplasm; Antigens, CD34; Antineoplastic Agents; Clinical Protocols; Female; Follow-Up Studies; Hematopoietic Stem Cell Transplantation; Hemoglobins; Histocompatibility Testing; Humans; Leukocyte Count; Male; Middle Aged; Narcotics; Neutrophils; Sirolimus; Substance Withdrawal Syndrome; Transplantation Chimera; Transplantation Conditioning; Transplantation, Homologous; Whole-Body Irradiation; Young Adult

We studied the effects of rapamycin on cultures of erythroid progenitors derived from the peripheral blood of 10 beta-thalassaemia patients differing widely with respect to their potential to produce foetal haemoglobin (HbF). For this, we employed the two-phase liquid culture procedure for growing erythroid progenitors, high performance liquid chromatography for analysis of HbF production and reverse transcription polymerase chain reaction for quantification of the accumulation of globin mRNAs. The results demonstrated that rapamycin induced an increase of HbF in cultures from all the beta-thalassaemia patients studied and an increase of their overall Hb content/cell. The inducing effect of rapamycin was restricted to gamma-globin mRNA accumulation, being only minor for beta-globin and none for alpha-globin mRNAs. The ability of rapamycin to preferentially increase gamma-globin mRNA content and production of HbF in erythroid precursor cells from beta-thalassaemia patients is of great importance as this agent (also known as sirolimus or rapamune) is already in clinical use as an anti-rejection agent following kidney transplantation. These data suggest that rapamycin warrants further evaluation as a potential therapeutic drug in beta-thalassaemia and sickle cell anaemia.

Topics: Adult; Anemia, Sickle Cell; beta-Thalassemia; Cells, Cultured; Drug Evaluation, Preclinical; Erythroid Precursor Cells; Female; Fetal Hemoglobin; Gene Expression Regulation; Globins; Humans; Immunosuppressive Agents; Kidney Transplantation; Male; Middle Aged; Sirolimus

Topics: Adult; Anemia, Sickle Cell; Feasibility Studies; Graft vs Host Disease; Hematopoietic Stem Cell Transplantation; Humans; Sirolimus; Transplantation Conditioning

Topics: Adolescent; Anemia, Sickle Cell; Child; Child, Preschool; Female; Graft vs Host Disease; Hematopoietic Stem Cell Transplantation; Humans; Hyperlipidemias; Immunosuppressive Agents; Male; Retrospective Studies; Sirolimus

Sirolimus is an immunosuppressive agent used in organ rejection prophylaxis in solid-organ transplantation, graft-vs-host disease prophylaxis in hematopoietic stem cell transplantation, and as an immune modulator for patients with lymphangioleiomyomatosis and vascular malformations. Sirolimus has a narrow therapeutic index with potential severe side effects, including hypertension, hepatotoxicity, nephrotoxicity, and neurotoxicity.. We report a case of a 19-year-old woman with severe sickle cell disease who underwent a matched unrelated hematopoietic stem cell transplantation, whose course was complicated by sirolimus toxicity. This case was challenging because sirolimus has no specific antidote, is largely bound to red blood cells (RBCs), has a high distribution volume, and cannot be removed by dialysis or plasmapheresis.. Due to the concern for toxicity, we looked into possibilities for rapid sirolimus clearance using automated RBC exchange. The treatment was effective in decreasing blood sirolimus levels within the therapeutic ranges.. The use of RBC exchange is potentially safe and effective in the management of a case of sirolimus toxicity.

Topics: Adult; Allografts; Anemia, Sickle Cell; Erythrocytes; Female; Hematopoietic Stem Cell Transplantation; Humans; Immunosuppressive Agents; Sirolimus

Topics: Adult; Anemia, Sickle Cell; Female; Fetal Hemoglobin; Humans; Hydroxyurea; Kidney Transplantation; Male; Middle Aged; Sirolimus

Allogeneic bone marrow transplantation or peripheral blood stem cell transplantation (PBSCT) are the only curative therapies for patients with sickle cell disease (SCD). Once the patients have successfully undergone transplantation and engrafted, the hallmark of hemolytic anemia resolves, and normal hemoglobin levels are achieved. Some transplant protocols exclude patients with open wounds, including leg ulcers, because of infection risks associated with transplantation and long-term immunosuppression required to prevent graft-versus-host disease. Recalcitrant and recurrent leg ulcers are a serious complication of SCD and a determinant of morbidity. Here, we report the case of a 37-year-old man with sickle cell anemia and a chronic leg ulcer, who underwent PBSCT, engrafted successfully, and then had complete healing of his ulcer 16 months posttransplant.

Topics: Adult; Anemia, Sickle Cell; Antibiotic Prophylaxis; Humans; Immunosuppressive Agents; Leg Ulcer; Male; Peripheral Blood Stem Cell Transplantation; Risk Adjustment; Sirolimus; Treatment Outcome; Wound Healing; Wound Infection

Sickle cell disease (SCD), an inherited blood disorder caused by a point mutation that renders hemoglobin susceptible to polymerization when deoxygenated, affects millions of people worldwide. Manifestations of SCD include chronic hemolytic anemia, inflammation, painful vaso-occlusive crises, multisystem organ damage, and reduced life expectancy. Part of SCD pathophysiology is the excessive formation of intracellular reactive oxygen species (ROS) in SCD red blood cells (RBCs), which accelerates their hemolysis. Normal RBC precursors eliminate their mitochondria during the terminal differentiation process. Strikingly, we observed an increased percentage of RBCs retaining mitochondria in SCD patient blood samples compared with healthy individuals. In addition, using an experimental SCD mouse model, we demonstrate that excessive levels of ROS in SCD are associated with this abnormal mitochondrial retention. Interestingly, the LSD1 inhibitor, RN-1, and the mitophagy-inducing agent mammalian target of rapamycin (mTOR) inhibitor, sirolimus, increased RBC lifespan and reduced ROS accumulation in parallel with reducing mitochondria-retaining RBCs in the SCD mouse model. Furthermore, gene expression analysis of SCD mice treated with RN-1 showed increased expression of mitophagy genes. Our findings suggest that reduction of mitochondria-retaining RBCs may provide a new therapeutic approach to preventing excessive ROS in SCD.

Topics: Anemia, Sickle Cell; Animals; Disease Models, Animal; Erythrocytes; Histone Demethylases; Humans; Mice; Mitochondria; Models, Biological; Reactive Oxygen Species; Rhodamines; Sirolimus; Spiro Compounds; Thiophenes; TOR Serine-Threonine Kinases

Mechanistic target of rapamycin (mTOR) has been shown to play an important role in red blood cell physiology, with inhibition of mTOR signalling leading to alterations in erythropoiesis. To determine if mTOR inhibition would improve anaemia in sickle cell disease (SCD), mice with SCD were treated with the dual mTORC1/2 inhibitor, INK128. One week after daily oral drug treatment, erythrocyte count, haemoglobin, and haematocrit were all significantly increased while reticulocyte counts were reduced. These parameters remained stable during 3 weeks of treatment. Similar effects were observed following oral treatment with the mTORC1 inhibitor, sirolimus. Sirolimus treatment prolonged the lifespan of sickle cell erythrocytes in circulation, reduced spleen size, and reduced renal and hepatic iron accumulation in SCD mice. Following middle cerebral artery occlusion, stroke size was reduced in SCD mice treated with sirolimus. In conclusion, mTOR inhibition is protective against anaemia and organ damage in a murine model of SCD.

Topics: Anemia; Anemia, Sickle Cell; Animals; Benzoxazoles; Disease Models, Animal; Erythrocytes; Hematocrit; Hemoglobins; Mice; Pyrimidines; Sirolimus; Splenomegaly; TOR Serine-Threonine Kinases

Phenotypic improvement of hemoglobinopathies such as sickle cell disease and β-thalassemia (β-thal) has been shown in patients with high levels of Hb F. Among the drugs proposed to increase Hb F production, hydroxyurea (HU) is currently the only one proven to improve the clinical course of these diseases. However, Hb F increase and patient's response are highly variable, indicating that new pharmacological agents could be useful for patients not responding to HU or showing a reduction of response during long-term therapy. In this study we evaluated the efficacy of rapamycin, a lypophilic macrolide used for the prevention of acute rejection in renal transplant recipients, as an inducer of Hb F production. The analyses were performed in cultured erythroid progenitors from 25 sickle cell disease and 25 β-thal intermedia (β-TI) patients. The use of a quantitative Real-Time-polymerase chain reaction ReTi-PCR technique and high performance liquid chromatography (HPLC) allowed us to determine the increase in γ-globin mRNA expression and Hb F production in human erythroid cells treated with rapamycin. The results of our study demonstrated an increase in vitro of γ-globin mRNA expression in 15 sickle cell disease and 14 β-TI patients and a corresponding Hb F increase. The induction by rapamycin, even if lower or similar in most of samples analyzed, in some cases was higher than HU. These data suggest that rapamycin could be a good candidate to be used in vivo for the treatment of hemoglobinopathies.

Topics: Adolescent; Adult; Aged; alpha-Globins; Anemia, Sickle Cell; beta-Globins; beta-Thalassemia; Cells, Cultured; Erythroid Precursor Cells; Female; Fetal Hemoglobin; gamma-Globins; Gene Expression Regulation; Genotype; Humans; Hydroxyurea; Male; Middle Aged; Mutation; Sirolimus; Young Adult

Fetal hemoglobin-inducing therapies are disease-modifying and ameliorate the pain phenotype in sickle cell disease (SCD). Rapamycin, a mammalian target of rapamycin (mTOR) inhibitor, increases HbF in erythroid precursor cells in vitro. We hypothesized that rapamycin would increase HbF levels and improve nociception phenotype in SCD mice. We used sine-wave electrical stimulation to examine nocifensive phenotype and evaluate myelinated [2000Hz (Aβ-fiber) and 250Hz (Aδ-fiber)] and unmyelinated (5Hz C-fibers)] sensory fiber function. Rapamycin significantly increased γ-globin mRNA and HbF levels [+2.3% (0.7, 3.9), mean increase (95% confidence interval, CI), p=0.006]. In homozygous (sickling) mice, long- (16 weeks), but not short-term (6 weeks), rapamycin treatment increased 2000Hz and 250Hz current thresholds in a pattern that varied according to sex. In male, but not female mice, rapamycin (compared with vehicle) was associated with increases in 2000Hz [21Units (7, 35), mean difference (95% CI), p=0.009 for sex∗treatment interaction] and 250Hz [9Units (1, 16), p=0.01] current thresholds. In rapamycin-treated homozygotes, HbF levels directly correlated with myelinated [2000Hz(Aβ-fiber, r=0.58, p=0.01) and 250Hz(Aδ-fiber, r=0.6, p=0.01)] but not unmyelinated sensory fiber current thresholds. These findings suggest that in SCD mice, rapamycin increases HbF and modulates current thresholds of myelinated fibers. Therefore, mTOR signaling might be implicated in the pathobiology of SCD.

Topics: Anemia, Sickle Cell; Animals; Bone Marrow; Disease Models, Animal; Female; Fetal Hemoglobin; Gene Expression Regulation; Genotype; Male; Mice; Mice, Transgenic; Nociception; Phenotype; Sensory Thresholds; Sirolimus; Thermosensing

Topics: Alemtuzumab; Anemia, Sickle Cell; Antibodies, Monoclonal, Humanized; beta-Thalassemia; Female; Hematopoietic Stem Cell Transplantation; Humans; Immunosuppressive Agents; Male; Sirolimus

Topics: Adult; Allografts; Anemia, Sickle Cell; Angioedema; Angiotensin-Converting Enzyme Inhibitors; Female; Hematopoietic Stem Cell Transplantation; Humans; Male; Middle Aged; Sirolimus

The patient was a 45-year-old woman who was referred to a physical therapist and a physiatrist in a rehabilitation medicine department for evaluation and treatment of severe bilateral lower leg, ankle, and foot pain. The patient's past medical history was significant for sickle cell disease and she had undergone an allogeneic stem cell transplant 4 months prior with Sirolimus prescribed to prevent rejection. Magnetic resonance imaging of both lower legs revealed extensive bone marrow edema, as well as soft tissue swelling about the lower legs and ankles. These findings, along with the patient's presentation (constant bilateral pain and erythema of the lower legs within 6 months of transplantation) were found to be consistent with an atypical condition called posttransplant distal limb syndrome.

Topics: Anemia, Sickle Cell; Ankle; Complex Regional Pain Syndromes; Female; Foot; Humans; Immunosuppressive Agents; Leg; Magnetic Resonance Imaging; Middle Aged; Opiate Alkaloids; Sirolimus; Stem Cell Transplantation; Treatment Outcome

Topics: Anemia, Sickle Cell; Graft vs Host Disease; Hematopoietic Stem Cell Transplantation; Histocompatibility Testing; Humans; Immunosuppression Therapy; Sirolimus; Transplantation Chimera; Transplantation, Homologous

Topics: Adult; Alemtuzumab; Anemia, Sickle Cell; Antibodies, Monoclonal; Antibodies, Monoclonal, Humanized; Antibodies, Neoplasm; Antineoplastic Agents; Hematopoietic Stem Cell Transplantation; Humans; Sirolimus; Transplantation Conditioning; Transplantation, Homologous; Whole-Body Irradiation

Topics: Adult; Anemia, Sickle Cell; Antibiotics, Antineoplastic; Female; Humans; Peripheral Blood Stem Cell Transplantation; Pneumonia; Sirolimus

Topics: Anemia, Sickle Cell; Antibiotics, Antineoplastic; Antigens, CD20; Benzamides; Benzenesulfonates; CD40 Antigens; Diphenylamine; Hematologic Neoplasms; Hematology; Humans; Ki-1 Antigen; Leukemia, Myeloid; Lymphoma; MAP Kinase Kinase Kinases; Niacinamide; Phenylurea Compounds; Pyridines; Sirolimus; Sorafenib