如何提高臍血移植的植入

促進(jìn)臍血造血干細(xì)胞的植入的策略郝思國(guó)上海交大醫(yī)學(xué)院附屬新華醫(yī)院血液內(nèi)科UCBT存在的問(wèn)題1.Slowengraftment,2.Delayedimmunereconstitution,3.Increasedopportunisticinfections.FactorsaffectingoutcomeofUCBT1.TNCDose;2.DegreeofHLAMatching;3.Intensityoftheconditioningregimen;4.TypeofimmunosuppressionusedforGvHDprophylaxis.？NEngJMed,1998;339(22):1565-1577Non-relapseMortality0123100 80 60 40 20 0100806040200

7/8HLA-matched,TNC<3x107/kg(N=33;45%)

7/8HLA-matched,TNC>5x107/kg

(N=138;21%)7/8HLA-matched,TNC≥3–5x107/kg

(N=52;24%)EapenMetal,Blood2014Incidence(%)2.TotalNucleatedCellDoseHowtoovercomeinsufficientof

celldosageofUCB？Blood.2009;114:4293-4299Blood.2009;114:4293-4299Theincidenceofsustainedengraftmentwassimilarforrecipientsof1versus2UCBunits(90%vs86%;P=0.36).Timetoneutrophilrecoverywasnotdifferentbetweensingleanddoubleunitrecipients(22days[range,9-38days]vs25days[range,8-41days],respectively[P=0.11]).Likewise,theproportionofpatientsachievingplateletrecovery(50X109/L)at6monthswassimilarinrecipientsof1and2units(70%[95%CI,58%-82%]vs62%[95%CI,50%-74%],respectively[P=0.24]).EngraftmentMichaelR.Verneris,etal.BLOOD,2009;114,19Probabilityofleukemiarelapseforallpatientsbasedonthenumberofunitsinfused.20%30%48%At2years,NRMwas44%forgroup1,33%forgroup2and34%forgroup3(P=0.46).The2-yearLFSwas30%forgroup1(sUCBT-otherconditioning),48%forgroup2(sUCBT-TBF)and48%forgroup3(dUCBT-TCF)(P=0.03)113patients111patients雙份臍血移植后最終只有1份優(yōu)勢(shì)臍血植入成功，但是很難預(yù)測(cè)雙份臍血中哪一份會(huì)成為優(yōu)勢(shì)臍血而成功植入。目前只有1項(xiàng)研究提示CD3+細(xì)胞比例（p=0.04）及復(fù)蘇后CD34細(xì)胞活力（p=0.008）和臍血優(yōu)勢(shì)植入有關(guān).DoubleUCBtransplantsshowhighratesofengraftment(85–100%)withthemediantimetoneutrophilengraftmentrangingfrom9to33daysdependingontheconditioningregimenand/ortheuseofG-CSF).Interestinglythough,NOTasignificantdifferenceintherateofengraftmenthasbeendemonstratedbetweenpatientsreceivingoneortwoCBUs.Blood(2007)110(8):3064–70Blood(2010)116(22):4693–9.Blood(2009)114(19):4293–9.DOUBLECORDBLOODTRANSPLANTATIONEurocord`srecommendationsforselectionofCBUsfortransplantation.WhenasingleCBU(6/6or5/6HLA-matched)doesnotcontainsufficientnumberofcells(TNC>2.5X107/kguponfreezing;>2.0X107/kgonthawing),doubleCBTshouldbeconsidered,aimingforacombinedTNCdose>3.0X107/kg.EvenhigherdosesarerecommendedifthesingleCBUisonly4/6HLA-matched(TNC>3.5X107/kguponfreezing;>2.5X107/kgonthawingformalignantdisorders;TNC>4.0X107/kguponfreezing;>3.5X107/kgonthawingfornonmalignantdisorders).RochaV,etal.BrJHaematol(2009)147(2):262–74.CORDBLOODEXPANSIONAnalternativeapproachbeingusedtoincreasecelldoseinUCBTex-vivoexpansionofcordblood.AswellasincreasingthetotalnumberofHSCcellsforlong-termengraftment,thismayalsoincreasethenumberofcommittedprogenitorstoreducetheinitialperiodofneutropenia.Targetcell：CD34+,CD133+cellsExpansionmethods:CytokinesNotchligandexpansionStromalcultureBioreactors圖1.純化的UCBCD133+細(xì)胞的免疫表型及形態(tài)學(xué)ProjectsDay-6Day-10TNC41.07±9.59235.66±32.36CD133+cells7.98±1.5915.58±6.04CD34+cells18.32±7.9822.92±7.56CD34+CD38-cells51.10±15.2591.84±25.64CD34+CD133+cells3.10±1.0813.56±9.92Expansionfoldsofcordbloodatday6

andday10

Immunophenotypeofexpandedcellsday-0day-6Cytokinescocotailday-10day-1597.5%1.05%9.27%15.3%6.98%7.03%2.49%4.09%3.21%0..59%1.26%ExpansionwithCytokineCocktailStromalcellexpansionsystemCytokinecoktailStromalcell9.78%8.56%17.32%13.28%11.04%11.15%22.15%5.14%Immunophenotypeofexpandedcellsonday6SubsetsCumulativeexpansionfoldsDay-6Day-10StromalcellCytokinecoktailStromalcellCytokinecoktailNC77.94±23.32▲47.28±4.58296.32±41.36▲229.88±27.96CD34+Cell32.72±7.22▲▲15.86±3.1835.52±6.04▲▲17.72±2.32CD133+Cell21.10±9.92▲10.20±3.8636.08±5.64▲▲14.12±1.68CD34+CD38-Cell153.62±44.92▲61.48±18.02136.36±8.96▲▲89.24±3.80CD34+CD133+Cell16.90±8.70▲7.38±3.1027.32±9.84▲▲10.76±1.52Tab1.CumulativeexpansionfoldsofallsubsetsfromNC▲:P<0.05;▲▲P<0.01,comparedwithcontrolNEnglJMed367;24,DEC13,2012FromtheDepartmentsofStemCellTransplantationandCellularTherapy,UniversityofTexasM.D.AndersonCancerCenter,theCenterforCellandGeneTherapy,BaylorCollegeofMedicine;theCenterforInternationalBloodandMarrowTransplantResearch,DepartmentofMedicine,MedicalCollegeofWisconsin,theDivisionofHematologyandOncology,CaseWesternReserveUniversity,UniversityHospitalsCaseMedicalCenter31adultswithhematologiccancerswhoreceivedtransplantsof2cordbloodunits,1ofwhichcontainedcordbloodthatwasexpandedexvivoinco-cultureswithallogeneicmesenchymalstromalcells.1.Mesenchymalstromalcells:fromahaploidenticalfamilymember.2.14daysbeforetransplantation,thecord-bloodunitwasthawed,andequalfractionswereplacedintoeachof10flaskscontainingmesenchymalstromalcellswith50mlofGMP–gradeserum-freemediumcontaining100ng/mleachofSCF,Flt3ligand,thrombopoietin,G-CSF.NEnglJMed367;24,DEC13,2012METHODSNEnglJMed367;24,DEC13,2012Spearmancorrelationcoefficient,?0.51;P=0.004Spearmancorrelationcoefficient,?0.48;P=0.006ChallengesassociatedwithcordbloodexpansionDifferentiationoftheprogenitorcellGraftcontamination-strictadherencetoGMPprotocolsisnecessary.3.TimingoftransplantationIMPROVINGDELIVERYOFUCBHSCMETHODS:Inaretrospectiveregistry-basedanalysis,comparedoutcomesof87directintraboneinfusion(IB-UCBT)with149dUCBTrecipients,aftermyeloablativeconditioningregimenadjustingforthedifferencesbetweenthetwogroups.Median-infusedtotalnucleatedcellswere2.5×107/kgforIB-UCBTand3.9×107/kgfordUCBT(P<0.001).IB-UCBTdUCBTPDay+30,neutrophilrecovery76%62%0.014Mediantimetoengraftment(days)23280.001Atday+180,CIofplateletsrecovery74%64%0.003At2years,CIofnonrelapsemortality30%25%Relapseincidence34%29%Disease-freesurvival45%37%CONCLUSIONIB-UCBTisassociatedwithfastermyeloidandplateletrecoveryandloweracutegraftversushostdiseaseandmayreducethetotalcost.However,studiesoncosteffectivenessareneededtocomparebothstrategies.ENHANCEDHLA-MATCHINGNEngJMed,1998;339(22):1565-1577Incidence%Non-relapseMortality0123604020 0100 806040200100804/8HLA-matched(N=254;37%)5/8HLA-matched(N=464;34%)6/8HLA-matched(N=410;26%)

3/8HLA-matched(N=85;41%)

7/8HLA-matched(N=226;26%)

8/8HLA-matched(N=117;9%)

EapenMetal,Blood2014Incidence,%NeutrophilRecovery1000806040200100806040200301058/8(71%)1520255/8(58%)6/8(66%)

3/8(53%)4/8(56%)7/8(62%)P=0.005EapenMetal,Blood2014DaysConditioningregimensforUCBT

Condit