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Lancet Haematol. Author manuscript; available in PMC 2023 September 01.
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Published in final edited form as:

Lancet Haematol. 2022 September ; 9(9): e660–e669. doi:10.1016/S2352-3026(22)00206-X.

Haploidentical bone marrow transplantation in patients with

relapsed or refractory severe aplastic anaemia in the USA (BMT
CTN 1502): a multicentre, single-arm, phase 2 trial
Amy E DeZern,
The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA

Mary Eapen,
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Division of Hematologic Malignancies, Medical College of Wisconsin, Milwaukee, WI, USA

Juan Wu,
The EMMES Company, Rockville, MD, USA

Julie-An Talano,
Division of Hematologic Malignancies, Medical College of Wisconsin, Milwaukee, WI, USA

Melhem Solh,
The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA

Blachy J Dávila Saldaña,

Children’s National Health System, Washington, DC, USA
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Chatchada Karanes,
City of Hope National Medical Center, Duarte, CA, USA

Mitchell E Horwitz,
Duke University School of Medicine, Durham, NC, USA

Kanwaldeep Mallhi,
Fred Hutchinson Cancer Research Center, Seattle, WA, USA

Sally Arai,

Correspondence to: Dr Amy E DeZern, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD 21287,
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USA [email protected] .
Contributors
AED, MAP, and ME designed the study, treated the patients, accessed and verified the data, analysed the results, and wrote the
manuscript. JW and BRL performed the statistical analysis and wrote the manuscript. J-AT, MS, BJDS, CK, MEH, KM, SA, NF, EH,
PW, JHA, HJD, EL, RAB, BRL, MMH, and RJJ advised on the protocol, treated the patients (at centres where patients were enrolled),
analysed the results, and reviewed the manuscript. All authors had full access to all the data in the study and had final responsibility
for the decision to submit for publication.
Declaration of interests
We declare no competing interests.
Data sharing
Deidentified participant data for BMT CTN 1502 will be deposited in the National Heart, Lung, and Blood Institute Biologic
Specimen and Data Repository Information Coordinating Center (BioLINCC), a publicly available database. Study documents,
including the study protocol, informed consent form, data dictionary, and case report forms for data collection are also available via
the repository. Data will become accessible 3 years after the end of clinical activity and 2 years after the primary publication, as
anticipated in 2024. Instructions on specimen or data requests and contact information for BioLINCC are also available.
 DeZern et al. Page 2

Blood and Marrow Transplantation and Cellular Therapy Division, Stanford University, Stanford,
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CA, USA

Nosha Farhadfar,
UF Health Bone Marrow Transplant, University of Florida, Gainesville, FL, USA

Elizabeth Hexner,
University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Peter Westervelt,
Washington University School of Medicine, St Louis, MO, USA

Joseph H Antin,
Dana-Farber Cancer Institute, Boston, MA, USA

H Joachim Deeg,
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Fred Hutchinson Cancer Research Center, Seattle, WA, USA

Eric Leifer,
Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, MD, USA

Robert A Brodsky,
The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA

Brent R Logan,
Division of Hematologic Malignancies, Medical College of Wisconsin, Milwaukee, WI, USA

Mary M Horowitz,
Division of Hematologic Malignancies, Medical College of Wisconsin, Milwaukee, WI, USA

Richard J Jones,
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The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA

Michael A Pulsipher
Huntsman Cancer Institute, Salt Lake City, UT, USA

Summary
Background—Relapsed severe aplastic anaemia is a marrow failure disorder with high
morbidity and mortality. It is often treated with bone marrow transplantation at relapse post-
immunosuppressive therapy, but under-represented minorities often cannot find a suitably matched
donor. This study aimed to understand the 1-year overall survival in patients with relapsed or
refractory severe aplastic anaemia after haploidentical bone marrow transplantation.

Methods—We report the outcomes of BMT CTN 1502, a single-arm, phase 2 clinical trial done
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at academic bone marrow transplantation centres in the USA. Included patients were children
and adults (75 years or younger) with severe aplastic anaemia that was refractory (fulfilment of
severe aplastic anaemia disease criteria at least 3 months after initial immunosuppressive therapy)
or relapsed (initial improvement of cytopenias after first-line immunosuppressive therapy but then
a later return to fulfilment of severe aplastic anaemia disease criteria), adequate performance
status (Eastern Cooperative Oncology Group score 0 or 1, Karnofsky or Lansky score ≥60%),
and the presence of an eligible related haploidentical donor. The regimen used reduced-intensity

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conditioning (rabbit anti-thymocyte globulin 4·5 mg/kg in total, cyclophosphamide 14·5 mg/kg
daily for 2 days, fludarabine 30 mg/m2 daily for 5 days, total body irradiation 200 cGy in a
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single fraction), related HLA-haploidentical donors, and post-transplantation cyclophosphamide-

based graft-versus-host disease (GVHD) prophylaxis. Additionally, for GVHD prophylaxis,
mycophenolate mofetil was given orally at a dose of 15 mg/kg three times a day up to 1 g
three times a day (maximum dose 3000 mg per day) from day 5 to day 35, and tacrolimus was
given orally or intravenously from day 5 to day 180 as per institutional standards to maintain a
serum concentration of 10–15 ng/mL. The primary endpoint was overall survival 1 year after bone
marrow transplantation. All patients treated per protocol were analysed. This study is complete
and is registered with ClinicalTrials.gov, NCT02918292.

Findings—Between May 1, 2017, and Aug 30, 2020, 32 patients with relapsed or refractory
severe aplastic anaemia were enrolled from 14 centres, and 31 underwent bone marrow
transplantation. The median age was 24·9 years (IQR 10·4–51·3), and median follow-up was
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24·3 months (IQR 12·1–29·2). Of the 31 patients who received a transplant, 19 (61%) were
male and 12 (39%) female. 13 (42%) patients were site-reported as non-White, and 19 (61%)
were from under-represented racial and ethnic groups; there were four (13%) patients who were
Asian, seven (23%) Black, one (3%) Hawaiian/Pacific Islander, and one (3%) more than one race,
with seven (23%) patients reporting Hispanic ethnicity. 24 (77%) of 31 patients were alive with
engraftment at 1 year, and one (3%) patient alive with autologous recovery. The 1-year overall
survival was 81% (95% CI 62–91). The most common grade 3–5 adverse events (seen in seven
or more patients) included seven (23%) patients with abnormal liver tests, 15 (48%) patients
with cardiovascular changes (including sinus tachycardia, heart failure, pericarditis), ten (32%)
patients with gastrointestinal issues, seven (23%) patients with nutritional disorders, and eight
(26%) patients with respiratory disorders. Six (19%) deaths, due to disease and unsuccessful bone
marrow transplantation, were reported after transplantation.
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Interpretation—Haploidentical bone marrow transplantation using this approach results in

excellent overall survival with minimal GVHD in patients who have not responded to
immunosuppressive therapy, and can expand access to bone marrow transplantation across all
populations. In clinical practice, this could now be considered a standard approach for salvage
treatment of severe aplastic anaemia. Attention to obtaining high cell doses (>2·5 × 108 nucleated
marrow cells per kg of recipient ideal bodyweight) from bone marrow harvests is crucial to the
success of this approach.

Introduction
Severe aplastic anaemia is an immune-mediated, acquired haematopoietic stem-cell disorder
that presents with hypocellular marrow and pancytopenia.1 Severe aplastic anaemia is
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associated with early and late morbidity and mortality. Infection, often fungal, in the
setting of severe neutropenia is the most common cause of early death; however,
haemorrhage, myelodysplastic syndrome, acute myeloid leukaemia, paroxysmal nocturnal
haemoglobinuria, avascular necrosis, and transfusional iron overload are other causes
of severe morbidity and mortality.2 Improved supportive care has led to substantial
progress in controlling the acute aspects of the disease. Nevertheless, late complications
of severe aplastic anaemia after immunosuppressive therapy, especially the risk of

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relapse and secondary clonal neoplasms, remain a substantial concern. The anticipated
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haematopoietic response rate to first-line immunosuppressive therapy is about 70–80%, and

the probability of overall survival at 5 years ranges from 60% to 85%.3 However, failure-
free survival (survival without relapse or secondary clonal disease beyond 10 years) after
immunosuppressive therapy is less than 50%.4 Confirming the safety of a haploidentical
platform in this setting is crucial to broaden therapeutic options at relapse. Data emphasise
limitations to long-term clinical success and the shortcomings of immunosuppressive
therapy,5–7 and additional therapeutic options are warranted for these patients.

Allogeneic bone marrow transplantation in severe aplastic anaemia can rapidly reconstitute
haematopoiesis and decrease the risk of relapse and secondary clonal disease. Allogeneic
bone marrow transplantation produces long-term survival approaching 90% at 5 years
in patients younger than 20 years, and more than 75% for patients older than 20
years. Older patients, especially those older than 40 years, historically have less
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favourable transplantation outcomes, attributable to issues including higher rates of graft

failure and graft-versus-host disease (GVHD). Additionally, identifying fully matched
donors is particularly difficult for some ethnic groups, such as patients of African
descent and Hispanic patients, reflecting high HLA diversity and under-representation
in donor registries.8 Allogeneic bone marrow transplantation using alternative donors,
including related HLA-haploidentical donors, has been relegated to late in the therapeutic
algorithm,9,10 owing to concerns of transplantation-related morbidity and mortality.11,12

Post-transplantation cyclophosphamide has greatly improved the safety and efficacy of

alternative donor bone marrow transplantation by facilitating engraftment and decreasing the
risk of GVHD, even with high degrees of HLA mismatch.13–15 Overall outcomes following
haploidentical bone marrow transplantation with post-transplantation cyclophosphamide in
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haematological malignancies are similar to outcomes with matched unrelated donors.16

Furthermore, with the use of rabbit anti-thymocyte globulin during conditioning and
tacrolimus for 6 months to a full year to further reduce the risk of GVHD, this platform
is effective in non-malignant diseases,9,10,17–19 in which a graft-versus-tumour effect
is not necessary. The approach in relapsed or refractory severe aplastic anaemia using
haploidentical donors led to good overall survival in a singleinstitution study,20 but required
validation in a multicentre prospective trial. Thus, we present the results of the Blood and
Marrow Transplant Clinical Trials Network (BMT CTN) 1502, a prospective clinical trial
of haploidentical donor allogeneic bone marrow transplantation with post-transplantation
cyclophosphamide for relapsed or refractory severe aplastic anaemia.

Methods
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Study design and participants

BMT CTN 1502 was a single-arm, phase 2 clinical trial done at academic bone marrow
transplantation centres in the USA. Included patients were 75 years or younger with a
diagnosis of acquired severe aplastic anaemia who had not responded to at least one course
of immunosuppressive therapy without a fully matched related sibling donor available, but
with a haploidentical marrow donor available. Absence of response to immunosuppressive
therapy was defined in the protocol as refractory (persistence of severe cytopenias and

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fulfilment of severe aplastic anaemia disease criteria at least 3 months after initial
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immunosuppressive therapy) or having relapsed (initial improvement of cytopenias after

first-line immunosuppressive therapy but then a later return to fulfilment of severe aplastic
anaemia disease criteria when immunosuppressive therapy was decreased or ceased). The
choice of immunosuppressive therapy and number of courses of immunosuppressive therapy
before bone marrow transplantation were at the discretion of the treating physician. Data
on previous therapies were not collected in detail on this protocol. Patients needed adequate
organ function as previously reported.15 Additional eligibility criteria included adequate
performance status (Eastern Cooperative Oncology Group score 0 or 1, Karnofsky or Lansky
score ≥60%), ability to provide written informed consent (and assent as appropriate for
minors), and the presence of an eligible related haploidentical donor. Monosomy 7 was
specifically excluded as it is considered to be consistent with myelodysplastic syndrome
or leukaemia. Exclusion criteria included inherited bone marrow failure syndrome,
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previous haematopoietic stem-cell or solid organ transplantation, uncontrolled infection, and

inadequate organ function.

The study protocol was approved by institutional review boards at all participating sites. The
study was initially designed to enroll patients to an unrelated cord blood group in addition
to the haploidentical group. Due to lack of accrual to the unrelated cord blood group,
this group was closed 8 months after the study opened at the recommendation of the data
safety monitoring board. The unrelated cord blood group was removed from the protocol for
version 2.0, which was released on June 19, 2018. An independent medical monitor and the
data safety monitoring board oversaw trial safety and integrity with patients monitored for
graft failure and death.

Procedures
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A suitable donor was defined as an available haploidentical relative of the patient, including
biological parents, siblings or half siblings, children, uncles or aunts, first cousins, and
extended relatives. Eligible haploidentical donors had two to four mismatches if HLA-A,
HLA-B, HLA-C, and HLA-DRB1 typing was used; two to five mismatches if HLA-A,
HLA-B, HLA-C, HLA-DRB1, and HLA-DQB1 typing was used; and two to six mismatches
if HLA-A, HLA-B, HLA-C, HLA-DRB1, HLA-DQB1, and HLA-DPB1 typing was used.
A unidirectional mismatch in either the graft-versus-host or host-versus-graft direction was
considered a mismatch. The donor was defined as a full haplotype match by being identical
at a minimum of one allele (at high-resolution DNA-based typing) at the following genetic
loci: HLA-A, HLA-B, HLA-C, and HLA-DRB1 if eight-allele typing was used; HLA-A,
HLA-B, HLA-C, HLA-DRB1, and HLA-DQB1 if ten-allele typing was used; and HLA-A,
HLA-B, HLA-C, HLA-DRB1, HLA-DQB1, and HLA-DPB1 if 12-allele typing was used by
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the local centre. Donor-specific antibodies (at mean fluorescence intensity >1000 by solid
phase immunoassay) were an exclusion criterion.

Donor bone marrow was harvested with a target yield of 4 × 108 nucleated marrow cells per
kg of recipient ideal bodyweight21 and infused on day 0. Dose of nucleated marrow cells
per kg was calculated as previously described.21 The marrow was unmanipulated except
that major ABO-incompatible grafts were red blood cell depleted by buffy coat preparation

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and minor ABO-incompatible grafts were plasma depleted as per institutional standards.
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Correlatives included telomere length before bone marrow transplantation in all consenting
patients and consenting donors.

Rabbit anti-thymocyte globulin (Thymoglobulin [Sanofi]) was dosed at 0·5 mg/kg on day
−9 and at 2 mg/kg on days −8 and −7, intravenously. Fludarabine was administered at
30 mg/m2 intravenously daily for 5 days, from day −6 to day −2 (total dose received
150 mg/m2). Cyclophosphamide was given at 14·5 mg/kg intravenously daily for 2 days
from day −6 to day −5 and administered as a 1–2 h infusion (total dose received 29
mg/kg) and total body irradiation was delivered in a single fraction of 200 cGy on day
−1. The marrow graft was infused on day 0. Filgrastim was given on day 5 at 5 μg/kg
per day and continued until absolute neutrophil count was greater than 1·5 × 109 cells per
L for 3 days. In addition to rabbit anti-thymocyte globulin, GVHD prophylaxis included
post-transplantation cyclophosphamide administered at 50 mg/kg per day intravenously on
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days 3 and 4; mycophenolate mofetil given at a dose of 15 mg/kg orally three times a day
up to 1 g three times a day (maximum dose 3000 mg per day) from day 5 to day 35; and
tacrolimus given orally or intravenously from day 5 to day 180 as per institutional standards
to maintain a serum concentration of 10–15 ng/mL.

Blood product replacement and other supportive care measures were per institutional
practices, as were prophylactic and empirical antibiotics, antifungal prophylaxis,
Pneumocystis jirovecii pneumonia prophylaxis, and intravenous immunoglobulin. Patients
were monitored for viral reactivation by weekly measurement of cytomegalovirus and
Epstein-Barr virus copy number by PCR of serum until day 100. If a patient had evidence of
viral reactivation, it was managed at the discretion of the treating site. Human herpesvirus 6
copy number was monitored weekly until day 60. In the event of development of either acute
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or chronic GVHD, therapy was at the discretion of treating centres. The same was true for
the management of graft failure.

Adverse event reporting was consistent with the BMT CTN manual of procedures.22
Adverse events were assessed at multiple timepoints (day 28, day 56, day 100, day 180,
and day 365) after transplantation using the National Cancer Institute Common Terminology
Criteria for Adverse Events version 4.0. Of note, the study did not collect data on grade
1–2 toxicities as per the BMT CTN manual of procedures (although grade 2 infection data
were collected). Donor chimerism studies were done on peripheral blood or bone marrow on
days 28, 56, 180, and 360. Lineage-specific, myeloid, and T-cell chimerism were required.
The management beyond any documented graft failure was not specified by this protocol.
Acute GVHD was graded by consensus grading as per the BMT CTN manual of procedures.
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Assessment for acute GVHD was done weekly up to day 100 and then monthly to 1-year
post-transplantation. The time of onset of grades 2–4 and grades 3–4 acute GVHD were
recorded, as well as the maximum grade incurred. Chronic GVHD was assessed on the basis
of 2014 US National Institutes of Health Consensus Criteria.23 Quantitative assessments
of peripheral blood CD3, CD4, CD8, and CD56-positive lymphocytes were measured by
flow cytometric analysis at baseline, day 100, day 180, and day 365 post-transplantation to
monitor for immune reconstitution. Health-related quality of life was measured at baseline
and then change from baseline at day 100, day 180, and day 365 post-transplantation using

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two instruments: the Medical Outcomes Study 36-Item Short Form Healthy Survey (SF-36)
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for adult participants (older than 18 years), and the PedsQLTM Stem Cell Transplant
Module for paediatric participants (8–18 years).

Outcomes
The primary endpoint was overall survival 1 year after bone marrow transplantation. For
overall survival, death from any cause was considered an event and surviving patients were
censored at last follow-up. The secondary endpoints were assessment of the proportion of
patients alive and engrafted, neutrophil and platelet recovery, graft failure (primary and
secondary), grade 2–4 acute GVHD and chronic GVHD, immune reconstitution, infectious
complications (cytomegalovirus viraemia and disease, Epstein-Barr virus viraemia with or
without post-transplantation lymphoproliferative disorder), and health-related quality of life,
all within the first year after transplantation.
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Alive with engraftment was described using graft-failure-free survival, with events including
death, primary graft failure, and secondary graft failure; patients alive without graft failure
were censored at last follow-up. Neutrophil recovery was defined as an absolute neutrophil
count of more than 0·5 × 109 cells per L on three consecutive measurements on different
days. Platelet recovery was defined as a platelet count greater than 20 × 109 platelets per L
for 7 days without transfusion. Primary graft failure was defined by the lack of neutrophil
engraftment by day 56 following bone marrow transplantation or not having at least 5%
donor chimerism (whole blood or marrow) on any measurement up to and including day 56.
Patients could have met this definition before day 56. Secondary graft failure was defined
as any one of the following: initial neutrophil engraftment followed by sustained subsequent
decline in absolute neutrophil count to less than 0·5 × 109 cells per L for three consecutive
measurements on different days; or initial whole blood or marrow donor chimerism greater
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than or equal to 5%, but then declining to less than 5% on subsequent measurements; or
second infusion or transplantation given for graft failure.

In an additional prespecified exploratory analysis, recipient and donor telomere length

was assessed by flow cytometry fluorescent in-situ hybridisation (FISH) in lymphocytes
and granulocytes in the standard clinical fashion.24 These results were then analysed with
clinical outcomes. Patients and donors could choose to consent to this testing separately.

Statistical analysis
The primary hypothesis was that haploidentical bone marrow transplantation for severe
aplastic anaemia using the protocol regimen would result in overall survival at 1 year
after bone marrow transplantation of 75% or greater. The sample size of 30 patients
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was calculated so that an observed overall survival of 75% would have a 95% Wald
confidence interval with a margin of error of plus or minus 15·5% on the basis of a
binomial proportion assuming complete 1-year followup of study participants. The lower
bound of this confidence interval would exclude a true overall survival rate of 59%, which
is close to historical overall survival rates with haploidentical transplantations reported to
the Center for International Blood and Marrow Transplant Research. Overall survival and
graft-failure-free survival were described using the Kaplan-Meier estimator. Cumulative

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incidences of GVHD, neutrophil recovery, platelet recovery, toxicity, and infection events
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were summarised using the Aalen-Johansen estimator along with 95% confidence intervals;
death was considered as a competing risk. Confidence interval estimates for the cumulative
incidence function at a fixed timepoint were constructed using a point estimate and its
variance estimate obtained from the Aalen-Johansen estimator of cumulative incidence. The
SF-36 physical and mental component scores for adult patients and the PedsQL Stem Cell
Transplant Module for paediatric patients are summarised for each timepoint, as well as
change from baseline to each timepoint after transplantation, compared by the paired t-test.
Other endpoints were summarised using descriptive statistics. Analyses were performed
using SAS version 9.4 and R version 3.6. This study is registered with ClinicalTrials.gov,
NCT02918292.

Role of the funding source

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The funder of the study had no role in study design, data collection, data analysis, data
interpretation, or writing of the report.

Results
Between May 19, 2017, and Aug 31, 2020, 32 patients were enrolled from 14 centres
(figure 1). 31 of 32 patients enrolled received a transplant. One 65-year-old White Hispanic
male patient died of bacterial infection after enrolment but before receiving any protocol
treatment. The majority of patients underwent transplantation well after initial diagnosis;
however, five patients underwent transplantation within 6 months of diagnosis, allowable
on protocol, because their cytopenia was deemed too severe to wait additional months to
respond to previous immunosuppressive therapy. All other data describe the 31 patients who
received a transplant. Of the 31 transplant recipients, 19 (61%) were male, with 13 (42%)
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of the cohort site-reported as non-White (table 1). There were four (13%) patients who
were Asian, seven (23%) Black, one (3%) Hawaiian/Pacific Islander, and one (3%) more
than one race, with seven (23%) patients reporting Hispanic ethnicity. The median age at
enrolment was 24·9 years (IQR 10·4–51·3). No patients had donor-specific HLA antibodies
requiring desensitisation against their donors as specified in the protocol. The median age of
haploidentical donors was 38·6 years (26·9–46·5).

1-year overall survival was 81% (95% CI 62–91; appendix p 7). The median follow-up for
all patients was 24–3 months (IQR 12–1-29–2). 24 (77%) of 31 patients were alive with
sustained engraftment at 1 year. Seven (23%) patients did not meet this endpoint, including
four (13%) patients with primary graft failure, one (3%) patient with secondary graft failure,
and two (6%) deaths without graft failure. There were no withdrawals reported on the study.
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Six (19%) deaths were reported after transplantation. The site-reported primary causes of
death include graft failure (n=1), fungal infection (n=1), organ failure (n=2), interstitial
pneumonia (n=1), and encephalopathy (n=1). Two of these deaths occurred due to
complications after the first transplantation procedure. Overall, five patients (16%)
developed graft failure and all went on to receive a second transplant. Four of these five
patients died due to complications of their second transplantation procedure (three had

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developed primary graft failure and one secondary graft failure). Additional adverse events
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are noted, by grade, in table 2.

Donor bone marrow was harvested with a target yield of 4 × 108 nucleated marrow cells
per kg of recipient ideal bodyweight,21 and a recommended minimum yield of 2·5 × 108
nucleated marrow cells per kg of recipient ideal bodyweight. The marrow grafts had a
median total nucleated marrow cell count of 4·4 × 108 cells per kg of recipient ideal
bodyweight (IQR 3·0–5·5 × 108), a median CD34+ cell count of 3·9 × 106 cells per kg of
recipient ideal bodyweight (2·5–6·5 × 106) and a median CD3+ cell count of 14·6 × 107 cells
per kg of recipient ideal bodyweight (6·7–31·8 × 107). Among the 31 patients who received
a transplant, four (13%) did not attain the minimum marrow cell counts according to the
guidelines for minimum donor harvest included in the protocol, attaining cell counts of 1·7
× 108, 1·9 × 108, 2·0 × 108, and 2·0 × 108 nucleated marrow cells per kg of recipient ideal
body-weight. Three of these four patients developed either primary graft failure or secondary
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graft failure. The fourth patient attained long-term engraftment. This finding illustrates
the decreased graft-failure-free survival in patients with low-cell-dose allografts, as these
patients had only 50% (95% CI 6–85) 1-year overall survival, mostly due to a 25% (1–67)
1-year graft-failure-free survival rate. In contrast, patients receiving more than 2·5 × 108
nucleated marrow cells per kg of recipient ideal bodyweight had a 1-year graft-failure-free
survival rate of 85% (65–94).

The proportion of patients alive and engrafted at 1 year (graft-failure-free survival) was 77%
(95% CI 58–89; 24 of 31 patients). 22 patients had sustained 100% donor chimerism in
both myeloid and T-cell compartments at 1 year, and two patients had mixed chimerism
with more than 95% donor chimerism in both myeloid and T-cell compartments at 1 year.
One patient was alive at 1 year but with only 4% donor chimerism in the myeloid lineage,
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indicative of autologous recovery with improved blood counts.

29 (94%) of 31 patients had neutrophil recovery by day 28. The median time to neutrophil
recovery was 17 days (IQR 15–19). The day-28 cumulative incidence of neutrophil recovery
was 94% (95% CI 72–99). The median time to engraftment as defined by ANC recovery (for
the 27 patients who did not develop primary graft failure) was 17 days (IQR 15–19). Among
the 24 patients who had platelet recovery by day 100, the median time of platelet recovery
to 20 000 platelets per μL or greater was 23 days (IQR 17–33; appendix p 6). The day-100
incidence of platelet recovery was 77% (95% CI 57–89).

19 (61%) of 31 patients developed infections after transplantation (appendix p 3). Of these

19 patients, 12 developed a maximum of grade 2 infection and seven a maximum of grade
3 infection. Grade 2 or higher infection occurred in five (100%) of five patients with graft
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failure and 14 (54%) of 26 patients without graft failure. Four of the documented grade 3
infections (three fungal and one bacterial) occurred in the five patients with graft failure. The
majority of all documented infections were bacterial, followed by viral. Three patients had
documented fungal infections and all were in patients with graft failure.

Seven (23%) of 31 patients developed cytomegalovirus reactivation, three (10%) had

Epstein-Barr viraemia detected in routine testing, and two (6%) were diagnosed with post-

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transplantation lymphoproliferative disorder with positive viraemia. All of these infections

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were successfully treated (ie, the patients had undetectable viral loads). The 1-year
cumulative incidence, treating death as a competing risk, was 23% (95% CI 10–39) for
cytomegalovirus infection, 10% (2–23) for Epstein-Barr virus infection, and 7% (1–19) for
post-transplantation lymphoproliferative disorder.

The day-100 cumulative incidence of grade 2–4 acute GVHD was 16% (95% CI 6–31); all
five of the cases were grade 2. Eight (26%) of 31 patients developed chronic GVHD. One
case was moderate and the others were mild chronic GVHD; three of these eight patients
were not on immunosuppressive therapy at 1 year (appendix p 2). The 1-year incidence of
chronic GVHD was 26% (12–42; figure 2). All patients with chronic GVHD and at least 2
years of follow-up were reported to be off therapy. The GVHD-free survival (an exploratory
composite endpoint of survival without grade 3–4 acute GVHD or any chronic GVHD) was
55% (36–70).
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Quantitative assessments of peripheral blood CD3, CD4, CD8, and CD56-positive

lymphocytes showed that, notably, T-cell counts (CD3, CD4, and CD8) decreased
substantially after bone marrow transplantation and slowly returned to baseline counts by
1 year. As expected, natural killer cells and B cells were very low before transplantation,
with natural killer cells rising quickly after transplantation and reaching a plateau by 6
months, while B cells recovered slowly over the first year (appendix p 8).

21 (68%) of 31 patients were alive and evaluable for health-related quality of life surveys at
1 year; 15 (nine adults and six children; 71% completeness among survivors) had completed
both baseline and 1-year surveys (appendix p 4). For the six evaluable children, there was
significant improvement in their physical, emotional, social, and school functions from
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before transplantation to 1 year after transplantation. Similarly, for the nine evaluable adults,
there was significant improvement in their physical component scores (general health,
pain, physical, emotional, and social functions) from before transplantation to 1 year after
transplantation. Participants did not report significant changes in mental component scores
between baseline and other timepoints studied.

For this cohort of patients with known acquired severe aplastic anaemia, normalised delta
telomere lengths were in the normal range (>1st–99th percentile) for all donors and nearly
all patients. Two patients had borderline low values in the granulocytes (with neutropenia)
but not in the lymphocytes. No significant associations were observed between the age-
adjusted telomere length and clinical outcomes of survival or engraftment (data not shown).

Discussion
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Here we show, in a multicentre study, overall survival of 81% and graft-failure-free

survival of 77% with haploidentical bone marrow transplantation in heavily pretreated
paediatric and adult patients with relapsed or refractory severe aplastic anaemia without an
HLA-matched sibling or HLA-matched unrelated donor. These findings have great clinical
relevance, given that the prognosis for patients with severe aplastic anaemia treated with
immunosuppressive therapy remains suboptimal, with response rates of less than 80%,

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 DeZern et al. Page 11

relapse rates up to 40%, and evolution to myelodysplastic syndrome in more than 15% of
patients in their lifetime.5,25 For the more than 40% of patients with disease that is refractory
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to immunosuppressive therapy, the risk of death from bleeding or infection within 5 years
has historically been more than 50% in patients ineligible for bone marrow transplantation.26
Six patients older than 60 years were enrolled on this study and all engrafted, with only
one death in this age group. Additionally, this trial was able to enroll 61% of patients who
self-identified their race and ethnicity as non-Hispanic White.

Long-term failure-free survival for patients treated with immunosuppressive therapy is poor.
The median follow-up for nearly 200 patients treated on a prospective trial of equine
anti-thymocyte globulin with ciclosporin (with or without trial growth factor support) was
11·7 years and showed an overall survival at 15 years of 60%. Event-free survival was only
23%, with events including relapse, transplantation, secondary myelodysplastic syndrome
or acute myeloid leukaemia, and death.7 At the time of relapse for a patient with severe
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aplastic anaemia, eltrombopag is currently the only therapy for salvage approved by the
US Food and Drug Administration. There is a published response rate of 44% for a single
lineage response, but less than 25% of patients achieved a trilineage response.27 Concern
has been raised about insufficient durability and longterm complications. Data suggest
that the addition of eltrombopag upfront improved rapidity and rates of response over
anti-thymocyte globulin and ciclosporin among previously untreated patients.6 With follow-
up, relapse occurred at shorter median times with the three-drug combination,5,6 further
demonstrating a need for alternative approaches for these patients after immunosuppressive
therapy. Although salvage with repeat immunosuppressive therapy has been attempted in
some patients, intensification of the regimen with more potent drugs, such as rabbit anti-
thymocyte globulin, sirolimus, alemtuzumab, or mycophenolate, has not improved response
rates, which are generally 40% or less. This is a patient group in need of effective therapies
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at relapse or non-responsiveness after immunosuppressive therapy, as highlighted as an area

of medical need for patients with severe aplastic anaemia by the 2014 BMT CTN Scientific
Symposium. The approach presented here originated in a single-centre trial,15,20 the results
of which were validated in this multicentre trial. The survival shown in the single-centre trial
(overall survival 94% [90% CI 88–100]) and the multicentre results reported here (overall
survival 81% [95% CI 62–91]) have overlapping CIs, which is reassuring for the broader
applicability of this platform in severe aplastic anaemia.15 Limitations of the current study
include a paucity of available information on the previous immunosuppressive therapies
(number of cycles, response, and duration of response) before enrolment, relatively low
numbers of patients despite the study’s multicentre nature, and limited characterisation
of the bone marrow graft. Additionally, we followed up patients for cytomegalovirus and
Epstein-Barr virus reactivation but not for human herpesvirus 6 reactivation in the long term.
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Availability of HLA-matched donors has been a limitation to bone marrow transplantation

at relapse in severe aplastic anaemia. Although results of bone marrow transplantation
from alternative donors for malignant diseases are improving,15 particularly with the use
of post-transplantation cyclophosphamide, there has been reluctance to adopt this approach
for severe aplastic anaemia. The results of this study support the idea that this curative
path for severe aplastic anaemia can be offered to all patients, including under-represented

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 DeZern et al. Page 12

minorities, who historically have a low likelihood of finding a matched donor. More than
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60% of patients on this trial were from groups other than non-Hispanic White.

The necessity of adequate cell dose to facilitate engraftment and survival is very evident in
this small dataset. Additionally, severe infections and toxicities occurred more frequently in
patients who had early or late graft rejection than in those who had no graft rejection; thus,
high cell dose to maximise engraftment is a key to optimal outcomes, as seen in a similar
Brazilian series.28 Bone marrow harvesting is now performed less commonly than in past
decades, with more widespread use of peripheral blood grafts, and experience is lacking. 1
year after trial initiation, a series of rejections were reported in patients receiving very small
numbers of cells, and three of the first nine patients received grafts with small numbers of
cells. Training was provided to all sites on optimal harvest procedures. This training resulted
in larger harvested cell doses, and only one of 22 subsequent patients received a small cell
dose.
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Patients, their families, and sometimes their providers often have concerns about the long-
term toxicities of bone marrow transplantation in severe aplastic anaemia. Data here should
be reassuring. Chronic GVHD was low in both incidence and severity. Health-related quality
of life increased to normal levels in patients who engrafted, especially in adults, indicating
the tolerance of this platform and the benefit of improved haematopoiesis with engraftment.
It is acknowledged that long-term follow-up of patients receiving the post-transplantation
cyclophosphamide regimen must continue and assessment of late effects is ongoing, in
patients transplanted for both malignant and non-malignant diseases. We believe these data
support the use of a minimum of 200 cGy in a single fraction of total body irradiation for
patients with relapsed severe aplastic anaemia. However, other series have shown a benefit
of augmentation to the dose of total body irradiation to further facilitate engraftment in
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highly sensitised patients and treatment-naive patients.15,28

Conflicting reports29 on the effect of telomere length on survival outcomes for patients
with severe aplastic anaemia has confounded our understanding of how to use this
testing clinically. Most studies have used PCR-based methods as opposed to the Clinical
Laboratory Improvement Amendments-certified flow cytometry-FISH that was applied here.
The analysis in this trial does not support any difference in outcomes, by telomere length,
with this platform. However, the number of patients studied was small and the power to
detect an effect might be limited.

This study provides evidence for the role of haplo-identical bone marrow transplantation
using a post-transplantation cyclophosphamide-based regimen and a bone marrow graft
for patients with severe aplastic anaemia after failure of immunosuppressive therapy or
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relapse after immunosuppressive therapy. Furthermore, it shows the importance of adequate

graft cell dose with minimum requirement of 2·5 × 108 marrow mononuclear cells to
optimise engraftment. We suggest that haematopoietic stem-cell transplantation should be
pursued at 3–6 months after immunosuppressive therapy if the patient still meets criteria for
severe disease or as the immediate option at the time of relapse, forgoing further toxicity
such as readdition of ciclosporin, eltrombopag, or other toxic immunosuppressive therapy
platforms.30 Although 200 cGy was sufficient for engraftment here in the majority of

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 DeZern et al. Page 13

patients, 400 cGy appeared to result in better engraftment, without increased toxicity, in
other series and in the treatment-naive setting.15 The success of this approach in the salvage
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setting should encourage further study to evaluate its efficacy earlier in the disease course
for patients with severe aplastic anaemia, as was recommended by the most recent BMT
CTN State of the Science Symposium.31 Validation of upfront transplantation for patients
with severe aplastic anaemia in multicentre studies through the BMT CTN is anticipated.
Those results, along with the ongoing randomised trial of immunosuppressive therapy versus
transplantation in paediatric patients with severe aplastic anaemia32 will determine whether
this approach is appropriate for patients at the time of initial diagnosis.

Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
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Acknowledgments
Support for this clinical trial was provided to the BMT CTN by a grant (U01HL069294) from the National Heart,
Lung, and Blood Institute and the National Cancer Institute, both part of the US National Institutes of Health.
The lead centres for accrual included the Sidney Kimmel Cancer Center at the Johns Hopkins University School
of Medicine (Baltimore, MD, USA), Medical College of Wisconsin (Milwaukee, WI, USA), Miami Children’s
Hospital (Miami, FL, USA), Blood & Marrow Transplant Program at Northside Hospital (Atlanta, GA, USA), and
City of Hope National Medical Center (Duarte, CA, USA). The protocol team wishes to thank Andrew Dietz for his
contributions to planning and preparing this protocol before his move to industry. We also appreciate the role of the
Telomere Lab at Johns Hopkins Molecular Diagnostics for performance of the flow cytometry-FISH measurements.
Additionally, we are grateful to the patients, their families, and the research staff for the ability to complete this
study.

Funding
US National Heart, Lung, and Blood Institute and US National Cancer Institute.
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References
1. Bacigalupo A How I treat acquired aplastic anemia. Blood 2017; 129: 1428–36. [PubMed:
28096088]
2. Kim SY, Le Rademacher J, Antin JH, et al. Myelodysplastic syndrome evolving from
aplastic anemia treated with immunosuppressive therapy: efficacy of hematopoietic stem cell
transplantation. Haematologica 2014; 99: 1868–75. [PubMed: 25107891]
3. Townsley DM, Scheinberg P, Winkler T, et al. Eltrombopag added to standard immunosuppression
for aplastic anemia. N Engl J Med 2017; 376: 1540–50. [PubMed: 28423296]
4. Tichelli A, Schrezenmeier H, Socié G, et al. A randomized controlled study in patients with newly
diagnosed severe aplastic anemia receiving antithymocyte globulin (ATG), cyclosporine, with or
without G-CSF: a study of the SAA Working Party of the European Group for Blood and Marrow
Transplantation. Blood 2011; 117: 4434–41. [PubMed: 21233311]
5. Patel BA, Groarke EM, Lotter J, et al. Long-term outcomes in severe aplastic anemia patients treated
Author Manuscript

with immunosuppression and eltrombopag: a phase 2 study. Blood 2022; 139: 34–43. [PubMed:
34525188]
6. Peffault de Latour R, Kulasekararaj A, Iacobelli S, et al. Eltrombopag added to immunosuppression
in severe aplastic anemia. N Engl J Med 2022; 386: 11–23. [PubMed: 34986284]
7. Tichelli A, de Latour RP, Passweg J, et al. Long-term outcome of a randomized controlled study
in patients with newly diagnosed severe aplastic anemia treated with antithymocyte globulin
and cyclosporine, with or without granulocyte colony-stimulating factor: a Severe Aplastic
Anemia Working Party Trial from the European Group of Blood and Marrow Transplantation.
Haematologica 2020; 105: 1223–31. [PubMed: 31582549]

Lancet Haematol. Author manuscript; available in PMC 2023 September 01.

 DeZern et al. Page 14

8. Dehn J, Buck K, Maiers M, et al. 8/8 and 10/10 high-resolution match rate for the Be The Match
unrelated donor registry. Biol Blood Marrow Transplant 2015; 21: 137–41. [PubMed: 25307419]
Author Manuscript

9. Clay J, Kulasekararaj AG, Potter V, et al. Nonmyeloablative peripheral blood haploidentical stem
cell transplantation for refractory severe aplastic anemia. Biol Blood Marrow Transplant 2014; 20:
1711–16. [PubMed: 25016195]
10. Esteves I, Bonfim C, Pasquini R, et al. Haploidentical BMT and post-transplant Cy for severe
aplastic anemia: a multicenter retrospective study. Bone Marrow Transplant 2015; 50: 685–89.
[PubMed: 25730184]
11. DeZern AE, Brodsky RA. Haploidentical donor bone marrow transplantation for severe aplastic
anemia. Hematol Oncol Clin North Am 2018; 32: 629–42. [PubMed: 30047416]
12. Bacigalupo A, Giammarco S. Haploidentical donor transplants for severe aplastic anemia. Semin
Hematol 2019; 56: 190–93. [PubMed: 31202429]
13. Dezern A, Dorr D, Luznik L, et al. Using haploidentical (haplo) donors and high-dose post-
transplant cyclophosphamide (PTCy) for refractory severe aplastic anemia (SAA). Blood 2015;
126 (suppl): 2031 (abstr). [PubMed: 26276665]
14. Dezern AE, Luznik L, Fuchs EJ, Jones RJ, Brodsky RA. Post-transplantation cyclophosphamide
Author Manuscript

for GVHD prophylaxis in severe aplastic anemia. Bone Marrow Transplant 2011; 46: 1012–13.
[PubMed: 20838390]
15. DeZern AE, Zahurak ML, Symons HJ, et al. Haploidentical BMT for severe aplastic anemia with
intensive GVHD prophylaxis including posttransplant cyclophosphamide. Blood Adv 2020; 4:
1770–79. [PubMed: 32343796]
16. Luznik L, O’Donnell PV, Symons HJ, et al. HLA-haploidentical bone marrow transplantation for
hematologic malignancies using nonmyeloablative conditioning and high-dose, posttransplantation
cyclophosphamide. Biol Blood Marrow Transplant 2008; 14: 641–50. [PubMed: 18489989]
17. Bolaños-Meade J, Fuchs EJ, Luznik L, et al. HLA-haploidentical bone marrow transplantation
with posttransplant cyclophosphamide expands the donor pool for patients with sickle cell disease.
Blood 2012; 120: 4285–91. [PubMed: 22955919]
18. Marsh JC, Kulasekararaj AG. Management of the refractory aplastic anemia patient: what are the
options? Blood 2013; 122: 3561–67. [PubMed: 24052548]
19. Sarmiento M, Ramírez PA. Unmanipulated haploidentical hematopoietic cell transplantation with
Author Manuscript

post-transplant cyclophosphamide in a patient with paroxysmal nocturnal hemoglobinuria and

secondary aplastic anemia. Bone Marrow Transplant 2016; 51: 316–18. [PubMed: 26501768]
20. DeZern AE, Zahurak M, Symons H, Cooke K, Jones RJ,Brodsky RA. Alternative donor
transplantation with high-dose post-transplantation cyclophosphamide for refractory severe
aplastic anemia. Biol Blood Marrow Transplant 2017; 23: 498–504. [PubMed: 28013015]
21. Niederwieser D, Pepe M, Storb R, Loughran TP Jr, Longton G. Improvement in rejection,
engraftment rate and survival without increase in graft-versus-host disease by high marrow cell
dose in patients transplanted for aplastic anaemia. Br J Haematol 1988; 69: 23–28. [PubMed:
3289603]
22. BMT CTN. Administrative manual of procedures (MOP)/policy guidelines. Chapter
6: adverse event reporting. https://bmtctn.net/administrative-manual-procedures-moppolicy-
guidelines (accessed Nov 18, 2021).
23. Jagasia MH, Greinix HT, Arora M, et al. National Institutes of Health consensus development
project on criteria for clinical trials in chronic graft-versus-host disease: I. The 2014 Diagnosis
and Staging Working Group report. Biol Blood Marrow Transplant 2015; 21: 389–401. [PubMed:
Author Manuscript

25529383]
24. Alder JK, Hanumanthu VS, Strong MA, et al. Diagnostic utility of telomere length testing in a
hospital-based setting. Proc Natl Acad Sci USA 2018; 115: E2358–65. [PubMed: 29463756]
25. Dufour C, Pillon M, Sociè G, et al. Outcome of aplastic anaemia in children. A study by the severe
aplastic anaemia and paediatric disease working parties of the European group blood and bone
marrow transplant. Br J Haematol 2015; 169: 565–73. [PubMed: 25683884]
26. Viollier R, Passweg J, Gregor M, et al. Quality-adjusted survival analysis shows differences
in outcome after immunosuppression or bone marrow transplantation in aplastic anemia. Ann
Hematol 2005; 84: 47–55.

Lancet Haematol. Author manuscript; available in PMC 2023 September 01.

 DeZern et al. Page 15

27. Desmond R, Townsley DM, Dumitriu B, et al. Eltrombopag restores trilineage hematopoiesis in
refractory severe aplastic anemia that can be sustained on discontinuation of drug. Blood 2014;
Author Manuscript

123: 1818–25. [PubMed: 24345753]

28. Arcuri LJ, Nabhan SK, Cunha R, et al. Impact of CD34 cell dose and conditioning regimen
on outcomes after haploidentical donor hematopoietic stem cell transplantation with post-
transplantation cyclophosphamide for relapsed/refractory severe aplastic anemia. Biol Blood
Marrow Transplant 2020; 26: 2311–17. [PubMed: 32949751]
29. Wang Y, McReynolds LJ, Dagnall C, et al. Pre-transplant short telomeres are associated with high
mortality risk after unrelated donor haematopoietic cell transplant for severe aplastic anaemia. Br J
Haematol 2020; 188: 309–16. [PubMed: 31426123]
30. Pierri F, Dufour C. Management of aplastic anemia after failure of frontline immunosuppression.
Expert Rev Hematol 2019; 12: 809–19. [PubMed: 31311355]
31. Heslop HE, Stadtmauer EA, Levine JE, et al. Blood and Marrow Transplant Clinical Trials
Network State of the Science Symposium 2021: looking forward as the Network celebrates its
20th year. Transplant Cell Ther 2021; 27: 885–907. [PubMed: 34461278]
32. Pulsipher MA, Lehmann LE, Bertuch AA, et al. A study assessing the feasibility of
Author Manuscript

randomization of pediatric and young adult patients between matched unrelated donor bone
marrow transplantation and immune-suppressive therapy for newly diagnosed severe aplastic
anemia: a joint pilot trial of the North American Pediatric Aplastic Anemia Consortium and
the Pediatric Transplantation and Cellular Therapy Consortium. Pediatr Blood Cancer 2020; 67:
e28444. [PubMed: 32776425]
Author Manuscript
Author Manuscript

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Research in context
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Evidence before this study

Haploidentical bone marrow transplantation in severe aplastic anaemia historically
carried unacceptably high rates of graft-versus-host disease (GVHD) to use this approach
in a non-malignant disease. We considered all the evidence in the field of transplantation
for non-malignant diseases before undertaking this study. We searched PubMed (in all
languages) from Jan 1, 1999, to Dec 30, 2015, for case reports and trials in severe aplastic
anaemia and transplantation, using the search terms “aplastic anemia”, “haploidentical”,
“conditioning regimen”, “myeloablative”, “cyclophosphamide”, “non-myeloablative”,
“reduced-intensity”, “hematopoiesis”. Given the relative disease rarity, there were no
formal meta-analyses on the topic. The quality of the evidence was modest, including
multiple case series and retrospective series with no randomised prospective controlled
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trials. Previous noted rates of GVHD were as high as 70%, with overall survival varying
from 55% to 67%. For a non-malignant disease such as severe aplastic anaemia, it
was considered an undue risk in the bone marrow transplantation community to use
alternative donors to treat this condition. There were literature and research advocates in
the field calling for prospective trials that used conditioning to facilitate engraftment and
robust GVHD prophylaxis regimens to improve bone marrow transplantation outcomes in
severe aplastic anaemia with alternative donors.

Added value of this study

This trial adds value to the existing literature through demonstration, in a multicentre
setting, of a highly useful andbroadly applicable conditioning regimen and GVHD
prophylaxis for haploidentical bone marrow transplantation in severe aplastic anaemia,
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which resulted in improved overall survival and low rates of GVHD compared with
approaches described in previous reports. Additionally, novelty of the regimen combined
with adequate bone marrow cell dose allow for sustained engraftment, which has not
previously been shown in this setting. This study provides strong evidence for use
of post-transplantation cyclophosphamide-based GVHD prophylaxis for patients with
severe aplastic anaemia when a haploidentical donor is used.

Implications of all the available evidence

These results, in combination with smaller, single-centre trials previously published
in the literature, extend the knowledge of the use of haploidentical bone marrow
transplantation with post-transplantation cyclophosphamide in severe aplastic anaemia.
Furthermore, an important question for the field is how this approach could be
incorporated proactively into the therapeutic algorithm at the time of relapse or refractory
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disease after immunosuppressive therapy for severe aplastic anaemia. Future research
might support incorporation of haploidentical approaches into upfront therapy for severe
aplastic anaemia, using the same platform and emphasising graft cell dose.

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Figure 1: Trial profile

Data regarding number of patients assessed for eligibility and number excluded are not
available. The original study design included two cohorts: a haplo-identical bone marrow
transplantation group, and an unrelated cord blood group. No patients were enrolled in the
unrelated cord blood group so the protocol was revised to remove this group. The unrelated
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cord blood group was removed from the protocol for version 2.0, which was released on
June 19, 2018. The protocol revision was done before any patients were enrolled on the
study.
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Figure 2: Incidence of acute (grade 2–4) and chronic GVHD

(A) Grade 2–4 acute GVHD. (B) Chronic GVHD. GVHD=graft-versus-host disease. All five
cases of grade 2–4 acute GVHD were grade 2.
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Table 1:

Baseline characteristics of transplant recipients and haploidentical donors

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Study cohort (n=31)

Sex
Female 12 (39%)
Male 19 (61%)

Race and ethnicity

Non-Hispanic White 12 (39%)
Hispanic White 4 (13%)
Non-Hispanic Black 7 (23%)
Hispanic Black 0
Asian or Pacific Islander 5 (16%)
Native American 0
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More than one race 1 (3%)

Unknown 2 (6%)

Age, years 24·9 (10·4–51·3)

<10 years 7 (23%)
10–19 years 6 (19%)
20–29 years 5 (16%)
30–39 years 1 (3%)
40–49 years 4 (13%)
50–59 years 2 (6%)
60–69 years 5 (16%)
≥70 years 1 (3%)
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Interval from diagnosis to transplantation, months 10·8 (8·1–32·0)

≤6 months 5 (16%)
>6 and ≤12 months 11 (35%)
>12 and ≤18 months 4 (13%)
>18 and ≤24 months 1 (3%)
>24 and ≤30 months 1 (3%)
>30 and ≤36 months 3 (10%)
>36 and ≤42 months 1 (3%)
>42 and ≤48 months 0
>48 and ≤54 months 2 (6%)
>54 and ≤60 months 1 (3%)
>60 and ≤66 months 0
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>66 and ≤72 months 0

>72 months 2 (6%)

Donor age, years 38·6 (26·9–46·5)

Donor relationship

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Study cohort (n=31)

Related haploidentical 31 (100%)
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Donor sex
Female 18 (58%)
Male 13 (42%)

Donor/recipient cytomegalovirus serostatus at baseline

+/+ 17 (55%)
+/− 2 (6%)
−/+ 4 (13%)
−/− 7 (23%)
Missing 1 (3%)

Data are n (%) or median (IQR).

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Table 2:

Adverse events toxicity and infection summary by system organ class

Grade 3 Grade 4 Grade 5 Grades 3–5

DeZern et al.

Events Participants Events Participants Events Participants Events Participants

Abnormal liver symptoms 16 7 (23%) 0 0 0 0 16 7 (23%)

Blood and lymphatic disorders 0 0 1 1 (3%) 0 0 1 1 (3%)

Cardiovascular disorders* 35 15 (48%) 2 2 (6%) 1 1 (3%) 38 15 (48%)

Chemistry/investigations 3 2 (6%) 0 0 0 0 3 2 (6%)

Gastrointestinal disorders 15 9 (29%) 0 0 1 1 (3%) 16 10 (32%)

General disorders 6 4 (13%) 2 1 (3%) 0 0 8 5 (16%)

Haemorrhagic disorders 3 3 (10%) 2 1 (3%) 0 0 5 3 (10%)

Hepatic disorders 8 5 (16%) 2 2 (6%) 0 0 10 6 (19%)

Immune system disorders 0 0 1 1 (3%) 0 0 1 1 (3%)

† 12 7 (23%) 0 0 0 0 12 7 (23%)
Infections

Metabolism and nutrition disorders 11 7 (23%) 1 1 (3%) 0 0 12 7 (23%)

Musculoskeletal and connective tissue disorders 1 1 (3%) 0 0 0 0 1 1 (3%)

Nervous system disorders 4 3 (10%) 1 1 (3%) 0 0 5 4 (13%)

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Renal disorders 6 4 (13%) 2 1 (3%) 2 2 (6%) 10 5 (16%)

Respiratory, thoracic, and mediastinal disorders 13 8 (26%) 3 3 (10%) 2 2 (6%) 18 8 (26%)

Vascular disorders 0 0 0 0 0 0 0 0

Total (any above events) 133 23 (74%) 17 7 (23%) 6 4 (13%) 156 23 (74%)

Data are n or n (%). The denominator for all percentages is 31 (the total number of participants). Toxicity was as expected per the BMT CTN manual of procedures. The study did not collect data on grade
1–2 toxicities as per the BMT CTN manual of procedures (although grade 2 infection data were collected).
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*
Cardiovascular disorders included sinus tachycardia, heart failure, and pericarditis.
†
There were a total of 64 infection events in 19 patients, including 52 grade 2 infections in 17 patients. Additional data on infections are shown in the appendix (p 3). Infections were reported whenever an
infection event occurred, and infection onset date was also collected.
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