Impact of thymoglobulin prior to pediatric unrelated umbilical cord blood transplantation on immune reconstitution and clinical outcome

• Published in: Blood 2014-01, Vol.123 (1), p.126-132
• Main Authors: Lindemans, Caroline A., Chiesa, Robert, Amrolia, Persis J., Rao, Kanchan, Nikolajeva, Olga, de Wildt, Arianne, Gerhardt, Corinne E., Gilmour, Kimberly C., B. Bierings, Marc, Veys, Paul, Boelens, Jaap J.
• Format: Article
• Language: English
• Subjects: Adolescent; Antilymphocyte Serum - metabolism; Antilymphocyte Serum - therapeutic use; Child; Child, Preschool; Cord Blood Stem Cell Transplantation - methods; Disease-Free Survival; Female; Fetal Blood - cytology; Graft vs Host Disease - immunology; Humans; Immunosuppressive Agents - therapeutic use; Infant; Male; Probability; Remission Induction; Retrospective Studies; Risk Factors; Transplantation Conditioning - methods; Treatment Outcome; Young Adult
• ISSN: 0006-4971; 1528-0020
• DOI: 10.1182/blood-2013-05-502385

In vivo T-cell depletion might contribute to the delayed immune reconstitution observed after unrelated umbilical cord blood transplantation (UCBT). We studied the impact of early, late, and no antithymocyte globulin (ATG) on immune reconstitution and outcome. One hundred twenty seven children receiving UCBT in London or Utrecht were divided into 3 groups: early ATG (days −9 to −5; n = 33), late ATG (days −5 to 0; n = 48), and no ATG (n = 46). The no-ATG group received mycophenolate mofetile + cyclosporin A as graft-versus-host disease (GVHD) prophylaxis, while the ATG groups received cyclosporin A + prednisone. End points studied were survival, immune recovery, infections, and GVHD. The probability of survival was similar in all groups: no ATG, 71% ± 8%; early ATG, 68% ± 9%; and late ATG, 61% ± 7%. CD3+, CD4+, and CD4+-naive T-cell counts were significantly higher (P < .001) in the no-ATG group at 1, 2, 3, 6, and 12 months post-UCBT. In the no-ATG group, significantly fewer viral reactivations (P = .021) were noted. A higher probability of severe acute GVHD (aGVHD; 31%) was found in the no-ATG group compared with 18% (P = .018) for early-ATG and 5% (P < .001) for late-ATG groups. This was not associated with more chronic GVHD (cGVHD). •For good immune reconstitution and fewer viral reactivations, thymoglobulin should be omitted in cord blood transplants.•Because omission of thymoglobulin is associated with higher acute GVHD rates, further improvement of outcome may require individualized dosing.