【作者】 肖毅；

【导师】 孙汉英；

【作者基本信息】 华中科技大学 ， 血液病学， 2011， 博士

【摘要】 目的为了提高预处理方案的抗肿瘤效应,我们探讨含每日一次白消安注射液(ⅣBu)预处理方案进行异基因造血干细胞移植(allo-HSCT)的疗效和毒副作用。方法对27例患者(其中25例为恶性血液病,2例为肾上腺脑白质营养不良)分别采用了含每日一次ⅣBu的改良白消安/环磷酰胺(Bu/Cy)、改良Bu/Cy+猪抗人胸腺淋巴细胞球蛋白(ATG)和氟达拉滨(Flu)/白消安+猪ATG预处理方案进行了allo-HSCT,患者的中位年龄是31岁(3岁～61岁),其中亲缘人类白细胞抗原(HLA)全合移植19例,亲缘HLA不合移植4例,非亲缘成人供者移植3例,非亲缘脐带血移植1例。在预处理过程中使用ⅣBu每日剂量为3.2mg.kg-1.d-1,每日剂量稀释至原溶液体积的10倍,使用输液泵一次注射完毕,输注时间维持4小时,在使用ⅣBu过程中采集开始使用后2h、3.9h、6h、8h、12h、16h、22h七个时间点的血样,采用液相色谱的方法检测了白消安注射液在各个时间点的血药浓度,并记录预处理相关毒性、移植后并发症发生的情况及生存和原发病状况。结果中位随访了8个月(0.3月～18月)。中位白消安清除浓度是0.241L/h/kg,平均每日曲线下面积是13877.5ug/L·h。除1例在移植后第10天死于脑出血,干细胞未植入外,余患者在移植后30天行短串联重复序列(STR-PCR)检测,除1例肾上腺脑白质营养不良患者行非亲缘脐带血移植未植入外,其余患者均显示为完全供者的基因型。移植过程中3例患者出现轻度口腔粘膜炎,11例患者出现轻度胃肠道反应,7例患者出现肝功能异常(其中6例为可逆的轻度异常,1例为重度黄疸),6例发生出血性膀胱炎,但均为迟发性,无1例发生癫痫和肝静脉闭塞病(VOD)。在可评价的患者中,急性移植物抗宿主病(aGVHD)的发生率为64.0%(16/25),其中Ⅲ～Ⅳ度的aGVHD仅为28.0%(7/25),慢性移植物抗宿主病(cGVHD)的发生率为77.0%(17/22),其中广泛型为41.0%(9/22)。结论每日一次ⅣBu预处理方案进行allo-HSCT血药浓度稳定,使用方便,安全有效,临床耐受性好,毒性并未增加,克服了口服白消安生物利用度低和难以确保准确剂量的不足。目的探讨异基因造血干细胞移植(allo-HSCT)治疗重型再生障碍性贫血(SAA)的方法和疗效。方法对30例SAA的患者进行了allo-HSCT。男18例,女12例,中位年龄25岁(3岁～48岁)。其中非血缘脐带血移植2例,非血缘成人供者移植4例,人类白细胞抗原(HLA)相合的亲缘移植19例,HLA一个位点不合的亲缘移植5例,其中3例患者采用环磷酰胺(200mg/kg)+猪抗人胸腺淋巴细胞球蛋白(100mg/kg)的非清髓性预处理,余患者均采用环磷酰胺(100-120mg/kg)+氟达拉宾(150mg/m2)+猪抗人胸腺淋巴细胞球蛋白(100mg/kg)。其中15例采用的是粒细胞集落刺激因子动员的骨髓联合外周血干细胞移植,10例采用粒细胞集落刺激因子动员的外周血干细胞移植,3例采用的是粒细胞集落刺激因子动员的骨髓,2例采用的是双份非血缘脐带血输注。预防移植物抗宿主病(GVHD)在HLA全合的亲缘移植采用环胞菌素A(CsA)联合短疗程甲氨蝶呤(MTX)的方案,对于HLA不合的亲缘移植和非血缘成人供者移植移植在CsA联合短疗程MTX的方案基础上加用霉酚酸酯(MMF)的方案,对于非血缘脐带血移植采用CsA联合霉酚酸酯(MMF)的方案。结果除3例患者在移植期间死亡外(1例脐带血移植患者在移植后18天死于感染,1例在移植后9天死于死于感染性休克,1例在移植后8天死于重度肝静脉闭塞病引起的多器官功能衰竭),1例患者血小板未植活,后再次输注供者外周血干细胞后获得植活外,余患者移植后造血恢复顺利,于中位+12天(+6～+21天)WBC植入,+15天(+9～+30天)PLT植入,除1例脐带血移植患者移植物未植入,自身恢复外,余患者+30天行患者骨髓STR-PCR检测显示为完全供者的基因型,中位随访了25.6月(0.3月～84月),所有患者的总生存率(OS)是83.3%。在可评价的患者中,急性移植物抗宿主病(aGVHD)的发生率为11.1%(3/27),其中Ⅲ的aGVHD仅为1例,慢性移植物抗宿主病(cGVHD)的发生率为21.7%(5/23),其中广泛型为8.7%(2/23)。结论异基因造血干细胞移植是治疗重型再生障碍性贫血的有效方法,但非脐带血干细胞植入不理想,需谨慎,亲缘HLA全合的移植与HLA一个位点不合的移植在干细胞植入和总生存率方面无差异,亲缘移植患者在使用骨髓联合外周血干细胞移植还是单用外周血干细胞移植两者在干细胞植入方面亦无差异。非血缘成人供者移植的晚期排斥率增加,尚需优化预处理方案以防止晚期植入失败。目的探讨自体外周血干细胞移植(APBSCT)联合免疫抑制剂治疗自身免疫性疾病(AID)的初步疗效。方法对17例AID患者进行APBSCT同时联合或不联合使用猪抗胸腺淋巴细胞球蛋白(ATG)或利妥昔单抗体内净化。其中16例患者为系统性红斑狼疮,1例为重叠综合征(系统性红斑狼疮合并系统性硬化症),1例为自身免疫性溶血性贫血。17例均采用环磷酰胺(CTX) 4g/m2化疗联合粒细胞集落刺激因子(G-CSF) 5μg/kg/d动员患者的外周血干细胞,14例患者予CTX 50mg/kg/d×4d预处理后回输保存的外周血干细胞,1例患者予BEAM方案预处理后回输保存的外周血干细胞,回输前予ATG(猪)20mg/kg/d×2d,回输后予ATG(猪)20mg/kg/d×2d行体内净化。1例在预处理中出现真菌性败血症而仅使用CTX 50mg/kg/d×4d预处理,未使用ATG行体内净化,1例自身免疫性溶血性贫血患者未使用ATG,而是分别于移植后+1d及+8d予抗利妥昔单抗600mg/d (375mg/m2)行体内净化。回输中位单个核细胞(MNC)大于5.0×108/kg,中位CD34+细胞大于2.0×106/kg,移植后口服泼尼松5～10 mg/d或霉酚酸酯(MMF) 0.5g/d维持治疗。结果17例患者移植后造血均恢复顺利,中性粒细胞绝对计数(ANC)于中位时间+9d(+8d～+11d)植活,血小板于于中位时间+12d(+9d～+15d)。干细胞动员过程中有5例患者出现疾病活动,加用泼尼松后控制。1例自身免疫性溶血性贫血患者在移植后网织红细胞降至正常,胆红素恢复正常,未再发生溶血表现。移植后5月Coomb’s试验转阴,所有结缔组织病患者均于移植后1个月左右皮疹及关节疼痛逐渐消失,SIEDAI降至5分以下,尿蛋白减少或消失。移植后3月复查自身抗体滴度下降。所有患者中位随访至移植后42.6个月,5例患者死亡,均为系统性红斑狼疮的患者,3例复发,亦为系统性红斑狼疮,余患者造血功能恢复良好,病情处于持续缓解状态。结论APBSCT是治疗自身免疫性疾病的有效方法之一,要严格掌握适应症,要注意在移植过程中有感染和疾病活动的可能,移植后要注意致命性间质性肺炎的发生。目的探讨异基因造血干细胞移植治疗X连锁的肾上腺脑白质营养不良(X-ALD)的方法和可行性。方法对2例已经有神经系统症状的X-ALD的患者进行了异基因造血干细胞移植。均采用氟达拉宾(150mg/m2)+白消安注射液(9.6mg/kg)+猪抗人胸腺淋巴细胞球蛋白(100mg/kg)的非清髓性预处理后,1例患者回输了非血缘双份脐带血,另1例患者回输父亲HLA 5/6相合的经粒细胞集落刺激因子(G-CSF)动员的外周血干细胞。非血缘脐带血移植预防移植物抗宿主病(GVHD)采用环胞菌素A(CsA)联合霉酚酸酯(MMF)的方案,亲缘父亲HLA 5/6相合的移植GVHD采用CsA联合短疗程甲氨蝶呤(MTX)的基础上加用霉酚酸酯(MMF)的方案。结果两例患者移植后造血恢复顺利,但行非血缘脐带血移植患者短串联重复序列(STR-PCR)检测显示为脐带血未植入,亲缘父亲HLA 5/6相合的移植获得供者的完全嵌合体,行脐带血移植患者白细胞自行恢复,血小板在回输备用的自体外周血干细胞后恢复。脐带血移植患者无移植物抗宿主病(GVHD)表现,在移植过程中神经系统病变有加重。另一例接受父亲HLA 5/6相合移植的患者发生Ⅱ度的急性GVHD,Ⅲ级的病毒性出血性膀胱炎,巨细胞病毒血症,均经治疗后好转,但卧床时间较长,活动能力下降,早期测长链脂肪酸较移植前有所下降。结论本中心经验结合文献复习认为异基因造血干细胞移植是一种可行的治疗X-ALD的有效方法,但对早期神经系统症状不明显的患者疗效较好,在移植过程中患者的神经系统损伤可能会加重,且移植的疗效尚需长期观察。更多还原

【Abstract】 Objective To improve the conditioning regimen of anti-tumor effect, we explore the of efficacy and toxicity with once-daily intravenous busulfan (IV Bu)-based conditioning regimen for allogeneic hematopoietic stem cell transplantation (allo-HSCT). Methods Of 27 patients (25 cases with hematologic malignancies and 2 cases with adrenoleukodystrophy) were used once-dailyⅣBu with the improvement of busulfan/ cyclophosphamide (Bu/Cy), improvement of Bu/Cy + Pig anti-human thymocyte globulin (ATG) and fludarabine (Flu)/busulfan+ pig ATG conditioning regimens for allo-HSCT.The median age of patients was 31 years (3 years to 61 years). In which genetic human leukocyte antigen (HLA) full matched transplantation in 19 cases, relatives of HLA mismatched-transplantation in 4 cases, unrelated adult donor transplantation in 3 cases, unrelated cord blood transplantation in 1 case. Used in the pretreatment dose of IV Bu daily 3.2mg.kg-1.d-1, the daily dose was diluted to 10 times the original solution volume, the use of infusion pump completed the first injection, infusion time for 4 hours. Collected blood samples from using the IV Bu process started after the 2h,3.9h,6h,8h,12h,16h,22h in seven time points, the use of liquid chromatography to detect the intravenous busulfan at various time points blood concentration, and record related toxicity, the case of complications after transplantation,and survival and the primary disease condition.Results Median follow-up of 8 months (0.3 months to 18 months). The median concentration of busulfan clearance 0.067ml/min/kg, the average daily area under the curve is 13877.5ug/L*h. After transplantation 1 patient died of cerebral hemorrhage in 10 days, stem cells are not implanted, the more than 30 days after transplantation in patients with short tandem repeat lines (STR-PCR) test, only 1 case with adrenoleukodystrophy patients received cord blood transplantation is not implanted, the remaining patients showed complete donor for the genotypes.3 patients had mild mucositis,11 patients had mild gastrointestinal reactions,7 patients had abnormal liver function (including 6 cases of mild reversible abnormalities in 1 case severe jaundice),6 cases of hemorrhagic cystitis, but were delayed and no one case occured epilepsy and hepatic veno-occlusive disease (VOD). In the evaluable patients, incidence of acute graft-versus-host disease (aGVHD) was 64.0% (16/25), in which the degree of aGVHDⅢ～Ⅳonly in 28.0%(7/25), the incidence of chronic graft-versus-host Disease (cGVHD) 77.0%(17/22), the extensive type was 41.0% (9/22). Conclusions Once-daily IV Bu allo-HSCT conditioning regimen has good plasma stability, easy to use, safe and effective, and good clinical tolerance, toxicity did not increase to overcome the oral busulfan bioavailability is low and difficult to ensure accurate dosage. Objective To explore the method and effect of allogeneic hematopoietic stem cell transplantation (allo-HSCT) for patients with severe aplastic anemia (SAA). Methods 30 cases with SAA patients received allo-HSCT.18 males and 12 females, median age 25 years (3 years to 48 years). Including 2 cases reveived unrelated cord blood transplantation, unrelated adult donor transplantation in 4 cases, human leukocyte antigen (HLA) matched transplantation in 19 cases, HLA one locus incompatible transplants in 5 cases,3 patients were treated with cyclophosphamide (200mg/kg)+ pig anti-human thymocyte globulin (100mg/kg) of non-myeloablative conditioning, the other patients were treated with cyclophosphamide (100～120mg/kg)+Fludarabine (150mg/m2)+pig anti-human thymocyte globulin (100mg/kg). Among them,15 cases were reveived the granulocyte colony stimulating factor to mobilize bone marrow combined peripheral blood stem cell transplantation,10 patients reveived granulocyte colony stimulating factor mobilized peripheral blood stem cell transplantation,3 cases reveived bone marrow of granulocyte colony stimulating factor mobilization,2 cases received double unrelated umbilical cord blood infusion. Prevention of graft versus host disease (GVHD) in the matched relatives of HLA transplantation with cyclosporine A (CsA) combined short course methotrexate (MTX) program, the affinity for the HLA one locus mismatched transplants and unrelated donor transplantation received CsA combined transplantation program short course MTX based on the use of mycophenolate mofetil (MMF) program, for unrelated cord blood transplantation mycophenolate mofetil combined with CsA (MMF) program. Results In addition 3 patients died during the transplant outside (n=1 cord blood transplant patients died of infection 18 days after transplantation,1 patient died 9 days after transplantation died of septic shock,1 patient died 8 days after transplantation and severe hepatic veno-occlusive disease caused and multiple organ failure),1 patient without platelet engraftment, again obtained engraftment after the infusion of donor peripheral blood stem cells, the hematopoietic recovery after transplantation in patients over the smooth, the median day+12 (+6 To+21 days) WBC implantation,+15 days (+9 to+30 days) PLT implantation in patients with cord blood transplantation in 1 patient without graft implantation, self-recovery, the other patients were+30 days STR-PCR analysis showed that bone marrow is completely donor genotype, with a median follow-up of 25.6 months (0.3 months to 84 months), overall survival for all patients (OS) was 83.3%. In the evaluable patients, the incidence of acute graft-versus-host disease (aGVHD) was 11.1%(3 /27), in which only 1 occurredⅢgrade aGVHD, incidence of chronic graft versus host disease (cGVHD) was 21.7%(5/23), which extensive type was 8.7%(2/23).Conclusions Allogeneic hematopoietic stem cell transplantation is the effective treatment for severe aplastic anemia, but cord blood stem cells will need to be cautious, HLA matched patients and one locus mismatched patients of implantation of stem cell transplantation and overall survival was no difference, in the use of bone marrow transplant patients peripheral blood stem cell transplantation in the joint or single peripheral blood stem cell transplantation with stem cells both in terms of implantation has no difference. Unrelated donor transplantation in adults with advanced rejection rate increases, still need to optimize the conditioning regimen to prevent late implant failure. Objective To explore the efficacy of autologous peripheral blood stem cell transplantation (APBSCT) combined immunosuppressive for autoimmune diseases (AID).Methods AID patients in 17 cases received APBSCT also use the pig with or without antithymocyte globulin (ATG) or rituximab in vivo purging. Of these,16 patients were systemic lupus erythematosus,1 case with overlap syndrome (systemic sclerosis systemic and lupus erythematosus),1 case of autoimmune hemolytic anemia.17 patients were using cyclophosphamide (CTX) 4g/m2 chemotherapy and granulocyte colony stimulating factor (G-CSF) 5μg/kg/d mobilized peripheral blood stem cells in patients,14 patients received tCTX 50mg/kg/d×4d before reinfusion of peripheral blood stem cell preservation, and 1 patient received the BEAM conditioning. Before pretreatment transfusion of peripheral blood stem cells, we reinfuse the ATG (pig) 20mg/kg/d×2d, after transplantation we reinfused the ATG (pig) 20mg/kg/d×2d for in vivo purging.1 case occurred in the pretreatment of fungal sepsis, use only CTX 50mg/kg/d×4d, ATG is not used in vivo purging, and 1 case with autoimmune hemolytic anemia was not using ATG, but after transplantation +8d and+1 d we use the rituximab 600mg/d (375mg/m2) for in vivo purging. The median transfusion mononuclear cells (MNC) is greater than 5.0×108/kg, the median CD34 + cells greater than 2.0×106/kg, oral prednisone after transplantation 5～10 mg/d or mycophenolate mofetil (MMF) 0.5g/d for maintenance therapy. Results 17 patients of hematopoietic function recovered smoothly after transplantation, absolute neutrophil count (ANC) at a median time of +9 d (+8 d～+11 d) engraftment, the median time to platelets in the +12 d (+9 d～+15 d). Stem cell mobilization in the process of disease activity occurred in 5 patients, after prednisone was added they were controlled, 1 case with autoimmune hemolytic anemia after transplantation, reticulocytes returned to normal, bilirubin returned to normal, no recurrence of hemolytic performance. After transplantation in 5 months, Coomb’s test was negative, all with connective tissue diseases caught in about 1 month after transplantation, skin rashes and joint pain gradually disappeared, SIEDAI decreased to 5 points or less, urine protein decreased or disappeared. Review 3 months after transplantation, autoantibodies titer decreased. Median follow-up of all patients to 42.6 months after transplantation,5 patients died, both in patients with systemic lupus erythematosus,3 cases of recurrence, were patients with systemic lupus erythematosus. Hematopoietic function in other patients with good recovery, the condition is sustained remission. Conclusions APBSCT is a effective treatment for autoimmune diseases,but we have strictly indications for AID. We should note the possibility of infection and disease activity during the transplantation process. After transplantation we should pay attention to the occurrence of fatal interstitial pneumonia. Objective To explore the allogeneic hematopoietic stem cell transplantation for patients with X linked adrenoleukodystrophy (X-ALD). Methods 2 cases with X-ALD have eurological symptoms received allogeneic stem cell transplantation. We used Fludarabine (150mg/m2)+intravenous busulfan (9.6mg/kg)+pig anti-human thymocyte globulin (100mg/kg) for non-myeloablative pretreatment,1 patient received transfusion of double unrelated umbilical cord blood, and the other 1 patient received transfusion of father’s HLA 5/6 by the consistency of granulocyte colony stimulating factor (G-CSF) mobilized peripheral blood stem cells. Unrelated cord blood transplantation to prevent graft versus host disease (GVHD) with cyclosporine A (CsA) combined mycophenolate mofetil (MMF) program, HLA 5/6 matched transplant to prevent GVHD with CsA combined short course MTX, was added on the basis of mycophenolate mofetil (MMF) program. Results Two patients of hematopoietic function recovered smoothly after transplantation, but the unrelated cord blood transplantation in patients with short tandem repeat (STR-PCR) analysis showed that the cord blood is not implanted, father’s HLA 5/6 matched donor transplant get a complete chimera, cord blood transplant patients after resume their own autologous peripheral blood stem cell transfusion, white blood cells and platelet recovery. Cord blood transplantation in patients with no graft-versus-host disease (GVHD), performance of the migration process in the nervous system diseases have increased. The other patient received the father’s HLA 5/6 matched transplant patients with gradeⅡacute GVHD,Ⅲgrade viral hemorrhagic cystitis, cytomegalovirus viremia were improved after treatment, but stay in bed longer, decreased activity. Early testing long chain fatty acids decreased compared with before transplantation. Conclusions Experience with review of the literature shows that allogeneic hematopoietic stem cell transplantation is a feasible and effective treatment method for X-ALD, but not obvious early symptoms in the nervous system in patients with good effect, patients in the transplant process may damage the nervous system, and the efficacy of transplantation still need long-term observation.更多还原