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ZusammenfassungDie medizinische Rehabilitation nach allogener hämatopoetischer Stammzelltransplantation muss die Komplexität der Behandlung und mögliche Nebenwirkungen berücksichtigen. Diese interdisziplinär erarbeiteten Empfehlungen stellen einen Rahmen für die Qualitätssicherung der stationären Rehabilitation dar. more...

Vancomycin-resistant Enterococcus faecium and Enterococcus faecalis (VRE) are a common cause of healthcare-associated infections. Whole genome sequencing-based typing methods yield the highest discriminatory power for outbreak surveillance in the hospital. We analysed the clonal composition of enteric VRE populations of at-risk patients over several weeks to characterise VRE population diversity and dynamics.Five bone marrow transplant recipients (three colonised with vanA-positive isolates, two colonised with vanB-positive isolates) contributed three rectal swabs over a course of several weeks. Fourteen VRE colonies per swab were analysed by core genome multi locus sequence typing (cgMLST) and typing of the van-element.VRE populations were clonally diverse in three of five patients, and population composition changed dynamically over the time of observation. Besides new acquisition of VRE isolates, shared van-elements localised on nearly identical plasmids between clonally different isolates indicate horizontal gene transfer as a mechanism behind VRE population diversity within single patients.Outbreak detection relies on typing of isolates, usually by analysing one isolate per patient. We here show that this approach is insufficient for outbreak surveillance of VRE in highly vulnerable patients, as it does not take into account VRE population heterogeneity and horizontal gene transfer of the resistance element. more...

Unbiased nontargeted metagenomic RNA sequencing (UMERS) has the advantage to detect known as well as unknown pathogens and, thus, can significantly improve the detection of viral, bacterial, parasitic, and fungal sequences in public health settings. In particular, conventional diagnostic methods successfully identify the putative pathogenic agent in only 30% to 40% of respiratory specimens from patients with acute respiratory illness. Here, we applied UMERS to 24 diagnostic respiratory specimens (bronchoalveolar lavage [BAL] fluid, sputum samples, and a swab) from patients with seasonal influenza infection and 5 BAL fluid samples from patients with pneumonia that tested negative for influenza to validate RNA sequencing as an unbiased diagnostic tool in comparison to conventional diagnostic methods. In addition to our comparison to PCR, we evaluated the potential to retrieve comprehensive influenza virus genomic information and the capability to detect known superinfecting pathogens. Compared to quantitative real-time PCR for influenza viral sequences, UMERS detected influenza viral sequences in 18 of 24 samples. Complete influenza virus genomes could be assembled from 8 samples. Furthermore, in 3 of 24 influenza-positive samples, additional viral pathogens could be detected, and 2 of 24 samples showed a significantly increased abundance of individual bacterial species known to cause superinfections during an influenza virus infection. Thus, analysis of respiratory samples from known or suspected influenza patients by UMERS provides valuable information that is relevant for clinical investigation. more...

Arteriogenesis is an inflammatory process associated with rapid cellular changes involving vascular resident endothelial progenitor cells (VR-EPCs). Extracellular cell surface bound 20S proteasome has been implicated to play an important role in inflammatory processes. In our search for antigens initially regulated during collateral growth mAb CTA 157-2 was generated against membrane fractions of growing collateral vessels. CTA 157-2 stained endothelium of growing collateral vessels and the cell surface of VR-EPCs. CTA 157-2 bound a protein complex (760 kDa) that was identified as 26 kDaα7 and 21 kDaβ3 subunit of 20S proteasome in mass spectrometry. Furthermore we demonstrated specific staining of 20S proteasome after immunoprecipitation of VR-EPC membrane extract with CTA 157-2 sepharose beads. Functionally, CTA 157-2 enhanced concentration dependently AMC (7-amino-4-methylcoumarin) cleavage from LLVY (N-Succinyl-Leu-Leu-Val-Tyr) by recombinant 20S proteasome as well as proteasomal activity in VR-EPC extracts. Proliferation of VR-EPCs (BrdU incorporation) was reduced by CTA 157-2. Infusion of the antibody into the collateral circulation reduced number of collateral arteries, collateral proliferation, and collateral conductancein vivo.In conclusion our results indicate that extracellular cell surface bound 20S proteasome influences VR-EPC functionin vitroand collateral growthin vivo. more...

In a retrospective single-centre study, we analysed the prognostic impact of factors identifiable at initial diagnosis of acute GVHD (aGVHD). We retrospectively analysed 495 adult patients of whom 308 (62 %) developed acute GVHD (I-IV) and were included in further analysis. Gut aGVHD was diagnosed in 163/308 cases (53 %). Conditioning was myeloablative conditioning (MAC) in 123 (39.9 %) and reduced intensity (RIC) in 185 (60.1 %) patients. Median serum albumin level at diagnosis of aGVHD was 34 g/l, which was used as cut-off for low vs. normal albumin levels. In patients with gut aGVHD, low albumin level at the time of diagnosis of aGVHD was associated with poorer overall survival (OS) which was 52 vs. 67 % at 1 year and 40 vs. 61 % at 3 years, p = 0.015. In patients with only skin aGVHD, 1- and 3-year OS of patients with low vs. normal albumin levels were 72 vs. 72 % and 59 vs. 57 %, respectively, p = 0.69. In multivariate analysis of patients with gut aGVHD, low serum albumin level ≤34 g/l (relative risk (RR) 2.13, p = 0.003), gut aGVHD grades 3-4 (RR 2.70, p = 0.001), RIC (RR 1.84, p = 0.024), matched unrelated donor (RR 1.86, p = 0.18) and mismatched unrelated donor (RR 2.76, p = 0.03) retained negative impact on OS. Subgroup analysis revealed that impact of albumin was restricted to patients with gut aGVHD after RIC. Low serum albumin levels are associated with poorer OS in patients with gut but not skin aGVHD after RIC but not MAC allogeneic stem cell transplantation. more...

To investigate the impact of anti-lymphocyte globulin (ATG-Fresenius) as part of the HLA-sibling transplantation, we evaluated 238 patients (median age 48 years) with different diagnoses (AML, ALL, CML and lymphoproliferative disorders). A total of 79 patients received ATG and 159 patients did not. In the ATG group, there were more HLA-mismatched donors (6% vs 1%, p=0.02), bad risk patients (70% vs 55%, P=0.04), reduced intensity conditioning (RIC) regimens (65% vs 34%, P= more...

In a retrospective study of 168 patients with AML in CR who underwent allo-SCT, we compare the impact of young unrelated donors (UD) vs older matched related donors (MRD) on 5-year OS (5-yr OS). Median follow-up was 59 months and median donor age was 39 years, which was used as cutoff for young vs older donors. Kaplan-Meier-estimated 5-yr OS was better with UD ≤39 years vs MRD >39 years (66% vs 34%, P=0.001). In multivariate analysis, only donor age and cytogenetic risk impacted 5-yr OS. Compared with UD ≤39 years, both MRD >39 years (relative risk (RR): 4.31, P=0.001) and UD >39 years (RR: 2.14, P=0.03) were associated with poorer 5-yr OS. Standard-risk cytogenetics was associated with better 5-yr OS compared with bad-risk cytogenetics, (RR: 0.53, P=0.02). Subgroup analyses of patients ≥50 years (n=76) revealed similar results, with 5-yr OS of 62% for UD ≤39 yrs and 26% for MRD >39 yrs (P=0.022). In patients undergoing allo-HSCT for AML, young UD may improve outcome as compared with older MRD. more...

The introduction of tyrosine kinase inhibitors (TKIs) for chronic myeloid leukemia (CML) led to a dramatic change in the role of allogeneic stem cell transplantation (SCT) with a rapid decline in the number of patients receiving SCT in first chronic phase (CP1). We evaluated 68 consecutive patients in all phases of CML (male/female = 39:29, 27 in CP1), who received SCT from related/unrelated donors (related/unrelated = 23:45) under myeloablative or reduced intensity conditioning (MAC/RIC = 45:23). Forty-eight patients (71 %) received TKIs pre-SCT, 20 patients post-SCT (29 %). Overall survival (OS) of CP1 patients achieved a plateau of 85 % at 10 months. Relapse-free survival (RFS) of CP1 patients was 85 % at 1 and 2 years, and 81 % at 5 years. Multivariate analysis showed adverse OS and RFS for patients transplanted >CP1 (hazard ratio (HR) = 6.61 and 4.62) and those who had grade III–IV aGvHD (HR = 2.45 and 1.82). Patients with advanced CML had estimated OS of 65 and 47 %; and RFS of 41 and 32 % at 1 and 2 years respectively. Therefore, for patients with advanced CML phases, allogeneic SCT provides an acceptable chance of cure. Transplant research should focus on improving conditioning regimens and post-SCT management for this subgroup of CML patients. more...

Invasive aspergillosis (IA) is a major cause of mortality in immunocompromised patients. Substantial improvements of treatment have been achieved by the introduction of new antifungal agents including azoles (e.g. posaconazole) and echinocandins (e.g. caspofungin). However, mortality associated with treatment-refractory aspergillosis remains high. Preliminary data suggest that the combination of azoles and echinocandins may increase activity against refractory IA. The objective of the present study was to evaluate efficiency and safety of caspofungin plus posaconazole for salvage therapy in immunocompromised patients. In this monocentric, retrospective study, 31 hospitalised haematopoietic stem cell transplant recipients with IA refractory to primary treatment were treated with a combination therapy of caspofungin 50 mg a day and posaconazole 200 mg four times per day. Efficacy was assessed by signs, symptoms and the degree of pulmonary infiltrate regression. A favourable response was seen in the majority of patients (77%). In two patients (6%), clinical improvement, but no decline in pulmonary infiltrates, was observed. Five patients (16%) did not respond to combination therapy with a fatal outcome in four of them. Combination therapy was well tolerated. No patient discontinued treatment due to toxicity. This study indicates that the combination of caspofungin and posaconazole may provide an effective and tolerable therapy of IA in immunocompromised patients refractory to primary treatment. more...

Between August 1996 and December 2004, 369 patients with a median age of 41 years (range: 1-68 years) received stem cell transplantation (SCT) from unrelated donors after an antithymocyte-globulin (ATG)-containing conditioning regimen. In 268 patients, complete molecular typing (4-digit) of HLA-A, -B, -C, -DRB1, and -DQB1 was available: 110 patients were completely matched for 10 alleles, 91 patients had 1 allele-mismatch (9/10), and 67 patients were mismatched for 2-4 alleles (6-8/10). The incidence of grade II-IV acute graft-versus-host disease (aGVHD) was 33% in the 10/10, 41% in the 9/10, and 40% in the 6-8/10 group, respectively (P = .1). The cumulative incidence of treatment-related mortality (TRM) and relapse among the groups were similar (27%, 31%, and 32%, P = .2; and 28%, 27%, and 26%, P = .9. After a median follow-up of 35 months (range: 3-120 months), the estimated 5-year disease-free survival (DFS) was 42% and did not differ among the 10/10, the 9/10, and the 6-8/10-mismatched groups (45% versus 42% versus 39%) (P = .5). In multivariate analysis, only age (hazard ratio [HR] 1.013) (P = .004) and bad-risk disease (HR 1.975) (P < .001) were independent risk factors for DFS. In conclusion, pretransplant ATG allows allogeneic SCT from unrelated donors with HLA disparities. more...

Infections due to vancomycin-resistant enterococci (VRE) are of significant importance in high-risk populations, and daptomycin is a bactericidal antibiotic to treat multidrug-resistant VRE in these patients. The emergence of daptomycin non-susceptibility invasive VRE during daptomycin therapy is a major clinical issue. Here the hypothesis was tested that systemic daptomycin therapy also induces the emergence of daptomycin non-susceptible (DNS-) isolates in colonizing VRE populations. 11 vancomycin-resistant Enterococcus faecium strain pairs recovered from rectal swabs were available for analysis. All initial isolates exhibited daptomycin MICs within the wild type MIC distribution of E. faecium (MIC≤4 mg/L). In follow-up isolates from five patients a 4-16-fold daptomycin MIC increase was detected. All patients carrying DNS-VRE received daptomycin (14-28 days) at 4 mg/kg body weight, while two patients in whom no DNS-VRE emerged were only treated with daptomycin for 1 and 4 days, respectively. Comparative whole genome sequencing identified DNS-VRE-specific single nucleotide polymorphisms (SNP), including mutations in cardiolipin synthase (Cls), and additional SNPs in independent genes potentially relevant for the DNS phenotype. Mutations within cls were also identified in three additional, colonizing DNS-VRE. Of these, at least one strain was transmitted within the hospital. In none of the VRE isolates tested, pre-existing or de novo mutations in the liaFSR operon were detected. This is the first report documenting the emergence of DNS-VRE in colonizing strains during daptomycin treatment, putting the patient at risk for subsequent DNS-VRE infections and priming the spread of DNS-VRE within the hospital environment. more...

Chronic graft versus host disease (cGvHD) is the most common cause of late morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). We retrospectively evaluated the impact of NIH classification on outcome of patients at our center. Primary endpoint was overall survival at 5 years. Two hundred one patients with cGVHD according to NIH were included. Platelets more...

We describe a fusion transcript of Gal4 linked to its specific inhibitor protein Gal80 by 276 nucleotides of apolipoprotein (apo) B sequence as a selectable marker for mRNA editing. Editing of apoB mRNA is catalyzed by an editing enzyme complex that introduces a stop codon by deamination of C to U. The catalytic subunit APOBEC-1 is a cytidine deaminase and requires a second essential component recently cloned and termed APOBEC-1 complementing factor (ACF) or APOBEC-1-stimulating protein (ASP). The aim of this study was to demonstrate that APOBEC-1 plus ACF/ASP comprise all that is required for editing of apoB mRNA in vivo. Expression of APOBEC-1 and Gal4 fused to its inhibitor Gal80 by an intervening unedited apoB sequence (Gal4-apoB(C)-Gal80) did not result in the Gal4-dependent expression of HIS3 and beta-galactosidase in the yeast strain CG1945. Co-expression of APOBEC-1 and ACF/ASP induced editing of the apoB site in up to 13% of the Gal4-apoB(C)-Gal80 transcripts and enabled selection of yeast cells for robust expression of HIS3 and beta-galactosidase. Additional expression of the alternative splicing regulatory protein KSRP increased the editing of the apoB site by APOBEC-1 and ACF/ASP to 21%. Thus, APOBEC-1 and ACF/ASP represent the core apoB mRNA editing enzyme in vivo. This study demonstrates for the first time the successful use of a selectable marker for mRNA editing. The Gal4-Gal80 system is analogous to the two-hybrid assay and may have broader applications for the study of other mRNA processing reactions. more...

Micafungin has been approved for the prophylaxis of Candida infections in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT). Here, we report a single-center experience of three different dose levels regarding efficacy, toxicity, and colonization with Candida ssp. in clinical practice. In total, 150 consecutive adult patients who underwent allo-HSCT received micafungin at a dosage of 50, 100, or 150 mg once daily for primary antifungal prophylaxis. Of those patients receiving more than six d of micafungin prophylaxis, 12/46 (26%), 6/44 (14%), and 9/46 (20%) were switched to empiric antifungal treatment. The frequency of invasive fungal infections (IFIs) according to EORTC criteria did not differ significantly (7/46; 15% vs. 5/44; 11% vs. 5/46; 11%) across the different dosage groups. In the 50-mg group, there was one case of candidemia with C. parapsilosis after 12 d of micafungin prophylaxis. In all three groups, micafungin prophylaxis was well tolerated without any case of toxicity-related treatment discontinuation. Renal function was not significantly altered, while increase of bilirubin was mainly due to concomitant ATG application. The incidence of IFIs is similar irrespective of the micafungin dosage while there was a trend toward more frequent change to empiric antifungal treatment as well as oropharyngeal colonization with candida in the lowest dosage group. more...

Invasive aspergillosis is an important cause of morbidity and mortality in haematological patients. Current guidelines recommend voriconazole as first-line therapy. A change in class of antifungal agent is generally recommended for salvage therapy. The focus of this analysis was to assess if posaconazole is suitable for salvage therapy following voriconazole treatment. This was a retrospective investigation on patients with sequential antifungal therapy of posaconazole after voriconazole identified at four German hospitals. Response rates at 30 and 60 days following start of posaconazole application and toxicity of azoles by comparing liver enzymes and cholestasis parameters were evaluated. Data were analysed by descriptive statistics. Overall, the success rate was 72.2% [15 of 36 patients showed complete response (41.7%), 11 patients partial response (30.6%) at any time point], eight patients failed treatment and two were not evaluable. Mean laboratory values increased during voriconazole and decreased during posaconazole treatment: aspartate aminotransferase (increase: 31.9 U l(-1) vs. decrease: 19.6 U l(-1) ), alanine aminotransferase (32.4 U l(-1) vs. 19.8 U l(-1) ), gamma-glutamyl transferase (124.2 U l(-1) vs. 152.3 U l(-1) ) and alkaline phosphatase (71.5 U l(-1) vs. 40.3 U l(-1) ) respectively. No patient discontinued posaconazole therapy due to an adverse event. In this analysis posaconazole was a safe and effective antifungal salvage therapy in patients with prior administration of another triazole. more...

We analyzed a collection of carbapenem-resistant Gram-negative bacterial isolates and detected VIM-1, VIM-2, and KPC-2 in diverse enterobacterial species and Pseudomonas aeruginosa isolates. Our findings suggest a more widespread dissemination of carbapenemases in Germany than currently appreciated. more...

Invasive aspergillosis (IA) is a major cause of mortality in immunocompromised patients. Substantial improvements of treatment have been achieved by the introduction of new antifungal agents including azoles (e.g. posaconazole) and echinocandins (e.g. caspofungin). However, mortality associated with treatment-refractory aspergillosis remains high. Preliminary data suggest that the combination of azoles and echinocandins may increase activity against refractory IA. The objective of the present study was to evaluate efficiency and safety of caspofungin plus posaconazole for salvage therapy in immunocompromised patients. In this monocentric, retrospective study, 31 hospitalised haematopoietic stem cell transplant recipients with IA refractory to primary treatment were treated with a combination therapy of caspofungin 50 mg a day and posaconazole 200 mg four times per day. Efficacy was assessed by signs, symptoms and the degree of pulmonary infiltrate regression. A favourable response was seen in the majority of patients (77%). In two patients (6%), clinical improvement, but no decline in pulmonary infiltrates, was observed. Five patients (16%) did not respond to combination therapy with a fatal outcome in four of them. Combination therapy was well tolerated. No patient discontinued treatment due to toxicity. This study indicates that the combination of caspofungin and posaconazole may provide an effective and tolerable therapy of IA in immunocompromised patients refractory to primary treatment. more...

Fatal problems encountered in allogeneic stem cell transplantation include EBV reactivation and post transplant lymphoproliferative disorders (PTLDs) with high mortality rates. We performed a retrospective analysis in all consecutive adult and pediatric EBV reactivations and PTLD during a period of 8.5 years. There were 26 patients with EBV reactivation/PTLD out of a total of 854 transplantations giving an overall incidence of 3.0%. Specifically, the incidence of EBV-PTLD was 1.3%, whereas that of EBV reactivation was 1.8%. Median age was 46.0 and 11.0 years in the adult and pediatric patients, respectively. There were high rates (54%) of concomitant bacterial, viral, fungal and parasitic infections at the time of EBV manifestation. Variable treatment regimens were applied including in most cases an anti-CD20 regimen often in combination with virustatic compounds, polychemotherapy or donor lymphocytes. The mortality rates were 9 of 11 (82%) in patients with EBV-PTLD and 10 of 15 (67%) in patients with reactivation. Only 7 of 26 patients (27%) are alive after a median follow-up of 758 days (range 24-2751). The high mortality rates of EBV reactivation and of EBV-PTLD irrespective of multimodal treatment approaches emphasize standardization and optimization of post transplant surveillance and treatment strategies to improve control of these often fatal complications. more...

Editing of apolipoprotein B (apoB) mRNA requires the catalytic component APOBEC-1 together with "auxiliary" proteins that have not been conclusively characterized so far. Here we report the purification of these additional components of the apoB mRNA editing enzyme-complex from rat liver and the cDNA cloning of the novel APOBEC-1-stimulating protein (ASP). Two proteins copurified into the final active fraction and were characterized by peptide sequencing and mass spectrometry: KSRP, a 75-kDa protein originally described as a splicing regulating factor, and ASP, a hitherto unknown 65-kDa protein. Separation of these two proteins resulted in a reduction of APOBEC-1-stimulating activity. ASP represents a novel type of RNA-binding protein and contains three single-stranded RNA-binding domains in the amino-terminal half and a putative double-stranded RNA-binding domain at the carboxyl terminus. Purified recombinant glutathione S-transferase (GST)-ASP, but not recombinant GST-KSRP, stimulated recombinant GST-APOBEC-1 to edit apoB RNA in vitro. These data demonstrate that ASP is the second essential component of the apoB mRNA editing enzyme-complex. In rat liver, ASP is apparently associated with KSRP, which may confer stability to the editing enzyme-complex with its substrate apoB RNA serving as an additional auxiliary component. more...

The transgene expression of the catalytic subunit APOBEC-1 of the apo B mRNA editing enzyme-complex can cause hepatocellular carcinoma in mice and rabbits. It has been proposed that aberrant editing of mRNA may represent a novel oncogenic principle. This investigation aimed to define whether such aberrant hyperediting mediated by APOBEC-1 occurs in human carcinomas. Editing and hyperediting of apo B, NAT1 or NF1 mRNA was not identified in any of 28 resected tumor specimens, including hepatocellular, bile duct, gastric, colorectal, pancreatic adeno- and neuroendocrine, lung adeno-, medullary thyroid and breast carcinoma, soft tissue sarcoma and neuroblastoma. In most types of carcinoma, significant levels for full-length APOBEC-1 mRNA could not be detected. Low level expression of APOBEC-1 was found in colorectal and gastric carcinoma where most of the APOBEC-1 mRNA is inactivated by alternate splicing. The `auxiliary' components of the apo B mRNA editing enzyme-complex are missing in many tumors including colorectal and gastric carcinoma, but are highly expressed in hepatocellular, lung adeno- and breast carcinoma all of which lack APOBEC-1. Taken together, either APOBEC-1 or the `auxiliary' components of the apo B mRNA editing enzyme-complex or both are missing in human carcinomas resulting in the absence of mRNA editing. Currently, there is no evidence that aberrant editing mediated by APOBEC-1 contributes to the tumorigenesis of natural human carcinomas. more...

The apolipoprotein (apo) B mRNA can be modified by a posttranscriptional base change from cytidine to uridine at nucleotide position 6666. This editing of apo B mRNA is mediated by a specific enzyme-complex of which only the catalytic subunit APOBEC-1 (apo B mRNA editing enzyme component 1) has been cloned and extensively characterized. In this study, two-hybrid selection in yeast identified hnRNP C1 protein to interact with APOBEC-1. Recombinant hnRNP C1 protein inhibited partially purified apo B mRNA editing activity from rat small intestine and bound specifically to apo B sense RNA around the editing site. The inhibition of apo B mRNA editing by hnRNP C1 protein was not due to masking of the RNA substrate as the mutant protein M104 spanning the RNA-binding domain of hnRNP C1 protein bound strongly to the apo B RNA, but did not inhibit the editing reaction. The apo B mRNA editing enzyme-complex of rat liver nuclear extracts sedimented in sucrose density gradients around 22-27S, but did not contain hnRNP C1 protein that was found exclusively within 40S hnRNP complexes. The removal of 40S hnRNP complexes increased the activity of the 22-27S editing enzyme-complex. Adding back 40S hnRNP complexes with hnRNP C1 protein resulted in an inhibition of the 22-27S apo B mRNA editing enzyme-complex, while addition of 18S fractions had no effect. In conclusion, hnRNP C1 protein identified by two-hybrid selection in yeast is a potent inhibitor of the apo B mRNA editing enzyme-complex. The abundant hnRNP C1 protein, which is contiguously deposited on nascent pre-mRNA during transcription and is involved in spliceosome assembly and mRNA splicing, is a likely regulator of the editing of apo B mRNA which restricts the activity of APOBEC-1 to limited and specific editing events. more...

Abstract 4147 Introduction: AML is one of the most common indications for allogeneic hematopoietic stem cell transplantation (allo-HSCT). A matched sibling donor (matched related donor, MRD) is generally considered preferable to an unrelated donor (UD). It has been reported before that donor age may influence outcome of allo-HSCT. Sibling donors of older patients will generally be old as well. How a young unrelated donor compares with an old sibling donor is unclear. In this retrospective study we evaluate the influence of donor age on outcome of MRD and UD allo-HSCT and compare the impact of young unrelated donors vs. old related donors on overall survival (OS). Patients and Methods: We performed a retrospective analysis of 298 consecutive patients transplanted for AML at our center between January 2000 and December 2009. Median follow-up was 56 months. The median age of donors and patients were 39 and 50 yrs. respectively. These two ages were used as cut-off points for young and old donors and patients respectively. Accordingly, four donor aged groups were assigned: UD ' 39 years, UD > 39 yrs, MRD ≤ 39 yrs and MRD > 39 yrs. Analyses were performed in the more homogeneous population of patients in CR at time of transplant (n = 170) as well for patients older than 50 years and in CR at time of transplant (n = 77). Patient characteristics for the 170 Patients in CR are summarized in table 1. Results: In the cox-regression multivariate analysis of all 298 patients including factors significant in the univariate analysis (conditioning intensity, cytogenetic risk group, remission status at time of transplant and donor age) remission status (RR: 1.88, p < 0.001) and cytogenetic risk (RR: 5.50, p = 0.004) significantly impacted overall survival (OS). Donor age (p = 0.08) and patient age (p = 0.063) tended to influence OS in this group. In the more homogenous group of 170 patients who were in CR at time of transplantation the Kaplan Meier estimated 5 yr OS was 66% (95% CI: 54%-78%) for patients transplanted from UD ≤ 39 yrs, 41% (95% CI: 25–57%) for UD >39 yrs, 61% (41–81%) for MRD ≤ 39 yrs and 33% (19–47%) for MRD > 39 yrs (p =0.002 comparing all 4 groups), fig. 1. OS of patients with UD ≤ 39yrs was significantly better than for those with MRD > 39 yrs (66% vs. 33%, p = 0.001). In the multivariate cox-regression analysis (including donor age, patient age and cytogenetic risk) only donor age (p = 0.001) and cytogenetic risk (p = 0.011) significantly impacted OS whereby MRD > 39 yrs. was associated with poorer OS compared to UD ≤ 39 yrs (RR: 3.07, p< 0.001). Further subgroup analyses of patients > 50 years old and in CR at time of transplant (n = 77) revealed similar findings with 5 yr OS of 62% for UD ≤ 39 yrs and 25% for MRD >39 yrs (p = 0.016). Conclusions: In patients undergoing allo-HSCT for AML our findings suggest that young unrelated donors may improve survival outcome as compared to old related donors. Further studies are necessary to confirm these findings and better define possible age limits for choosing young unrelated donors vs. older sibling donors. Disclosures: No relevant conflicts of interest to declare. more...

Abstract 3496 Introduction: Allogeneic hematopoietic stem cell transplantation (allogeneic HSCT) has found entrance into treatment of patients (patients) with poor-risk T-cell malignancies, but post-transplant relapse rates of ~30% were reported (Marks et al. Blood 2009). Improvement of the pre-transplant remission status in relapsed/refractory disease might lead to better outcomes. Nelarabine - a novel purine antimetabolite - has been approved by the FDA in 2005 as salvage approach for patients with T-cell malignancies, but data on pre-transplant use are limited (Goekbuget et al. ASH Annual Meeting 2005). Patients/Methods: Aiming to estimate its clinical applicability and efficacy in the pre-transplant period, we evaluated its use in 8 patients (5 males, 3 females; 22–56 years) with precursor/mature T-cell neoplasms who had failed to ≥2 previous conventional/intensified chemotherapy regimens (including a history of autologous/allogeneic HSCT in 2 patients) and were consequently proceeded to allogeneic HSCT (in 6 cases the 1st, in 2 cases the 2nd allogeneic HSCT). Five had T-ALL (1 pre-T-, 3 cortical, 1 mature), 3 had mature T-cell lymphomas (angioimmunoblastic lymphoma, n=1; peripheral T-cell lymphoma not otherwise specified, n=2), all with bone marrow involvement. Patients entered conventional chemotherapy in 6 cases at the 1st manifestation of disease, in 2 cases at the 1st relapse. Following conventional chemotherapy, 5 patients developed an early relapse, while 2 patients were refractory to treatment; one patient was minimal residual disease (MRD) positive as assessed by multiparameter flow cytometry. Therefore, all 8 patients were offered an allogeneic HSCT (1st allogeneic HSCT: n=6; 2nd allogeneic HSCT: n=2) with pre-treatment with nelarabine. The median interval from the last chemotherapy to 1st nelarabine administration was 8 weeks (range, 1– 252 weeks). Nelarabine (1,500 mg/m2 i.v.) was administrated on days 1, 3, and 5 at a median of 11 weeks (range, 2–53 weeks) before allogeneic HSCT. Three patients received a 2nd cycle of nelarabine after a median of 4 weeks (range, 2–9 weeks) from the 1st. Six patients had unrelated (HLA-match, n=4; mismatch, n=2) and 2 patients matched related donors. Most patients received myeloablative conditioning (TBI, 12 Gy; cyclophosphamide 120 mg/kg; n=3; treosulfan 36 g/m2; etoposide 30 mg/kg; cyclophosphamide 120 mg/kg; n=4). In the 8th patient who had already received 2 courses of nelarabine, a 3rd nelarabine application was incorporated as pre-phase into reduced-intensity conditioning (nelarabine 2 × 1,500 mg/m2; fludarabine 90 mg/m2; TBI 8 Gy). Results: i) Pre-transplant application of nelarabine: Immediate neurotoxicity was observed in 1 patient (grand mal seizure day +3 after the last nelarabine administration). Grade II hematotoxicity was observed in 3/8 patients. There were no treatment-related deaths. Seven of 8 patients showed response to nelarabine (86%; CR, n=5; PR, n=2) after a median of 4 weeks (1 – 35 days) from the 1st cycle. One patient had stable disease (SD). ii) Peri-/post-transplant period: there were no uncommon adverse events. After HSCT, prolonged leukocytopenia (WBC 20 days) and thrombocytopenia (thrombocytes 30 days) were observed in 3 and 5 patients, respectively. At the 1st post-transplant bone marrow control, 3 patients with residual disease (PR or SD) prior to allogeneic HSCT achieved CR, and all other patients maintained CR. Acute (grade II) and chronic GvHD developed in 2/8 (25%) and in 2/6 (33%) patients, respectively; there was no case of grade III-IV acute GvHD. At a median follow up of 9 months (range, 1–24), 3 patients had died (38%; relapse, n=1, t-AML, n=1; transplant-related toxicity, n=1). All 5 patients being alive were in CR; 4 patients required no further treatment, and one patient received donor lymphocyte infusions (DLIs) due to mixed chimerism. Conclusions: Nelarabine improves pre-transplant remission in patients with relapsed/refractory T-cell neoplasms and seems to be well tolerated immediately before allogeneic HSCT even in heavily pre-treated patients. The compound might be used as pre-phase or be incorporated into conditioning for allogeneic HSCT which should be further evaluated. Disclosures: No relevant conflicts of interest to declare. more...

Abstract 3393 Poster Board III-281 Background: HLA-mismatched unrelated donors are increasingly becoming a graft source for both standard myeloablative (MAC) and reduced intensity conditioning (RIC) hematopoetic stem cell transplantation (HSCT). Patients and methods: We retrospectively analysed the effects of HLA-mismatching in 553 patients undergoing MAC (n = 342) or RIC (n = 211) unrelated donor HLA-matched (n = 289) or -mismatched (n = 264) HSCT with antithymocyte globulin as part of conditioning. Patient characteristics well matched between HLA-matched and –mismatched groups of MAC and RIC patients. Results: Median follow-up was 1946 days for MAC patients and 765 days for RIC patients. In MAC patients, there was no difference in the incidence of aGvHD, treatment related mortality (TRM) and overall survival (OS) between recipients of HLA-matched vs. –mismatched allografts. In RIC patients on the contrary, the incidence of aGvHD II-IV (46%, vs. 32.0% p = 0.05), III-IV (18%, % vs. 9.0 p = 0.07) and TRM (35% vs. 20%, p = 0.04) were higher and OS lower (31% vs. 50%, p = 0.001) for recipients of HLA-mismatched vs. –matched transplants. In the RIC patients, female donor gender (RR: 1.8; p = 0.02) and HLA-mismatch (RR: 1.8; p = 0.02) negatively influenced TRM while female donor gender (RR: 1.58, p = 0.03), HLA-mismatch (RR: 1.82, p = 0.003) and bad risk disease (RR: 2.14, p < 0.001) negatively impacted OS. Conclusion: Our analyses surprisingly reveal that the positive effect of ATG in HLA-mismatched transplants is only limited to patients undergoing standard myeloablative conditioning. HLA-mismatching and female donor gender negatively impact outcome of RIC allogeneic unrelated donor HSCT despite the use of ATG, highlighting the need for improved strategies. Acknowledgments We thank the staff of the BMT unit for providing outstanding care to our patients and the medical technicians for their excellent work in the BMT laboratory. Disclosures: Off Label Use: Antithymocyte globulin for prevention of severe GVHD. more...

Abstract 3387 Poster Board III-275 <>Introduction: Allogeneic stem cell transplantation after a dose-reduced conditioning has become a reasonable treatment option for elderly patients with MDS/sAML. For patients with high number of blasts prior transplantation, the risk of relapse is considerably. To reduce the risk of relapse after dose-reduced allograft we performed a study using an anthracycline based induction chemotherapy (amsacrine, cytosine-arabinoside, fludarabine) followed immediately by a reduced intensity conditioning therapy consisting of busulfan (8mg/kg). Patients and Methods: Between November 2005 and November 2008, 49 patients with MDS (n = 24), CMML (n = 8) and sAML (n = 17) and a median age of 61 years (r: 26 – 73) and a median number of 13% blasts were included. Stem cell source were unrelated (n = 43) or related donor (n = 6). Results: No graft failure was observed and the median time to leukocyte engraftment (> 1.0 × 109 /l) was only 10 days (r: 7 – 32). The incidence of acute graft-versus-host disease grade II to IV was 39 % and of grade III / IV was 14 %. Chronic GvHD was noted in 57 % of the patients, which was limited in 35 % and extensive in 32 % of the patients. After a median follow-up of 15 months (r: 3 – 35) the two-years estimated disease-free and overall survival was 49 % (95 % CI 33 – 65 %) and 54 % (95 % CI 39 – 69 %), respectively. The 1 year cumulative incidence of treatment-related mortality was 29 % (95 % CI 15 – 43 %). The 2 year cumulative incidence of relapse was 18 % (95 % CI 6 – 30 %). Patients with fully matched related or unrelated donor had a better survival than patients transplanted from mismatched donor (69 % vs. 37 %; p=0.06). Conclusions: A sequential approach using anthracycline based induction chemotherapy followed immediately by a busulfan based reduced conditioning regimen and allogeneic stem cell transplantation from related and unrelated donors resulted in a fast engraftment and a relative low risk of relapse in elderly patients with advanced MDS or sAML. To lower the therapy related mortality a careful donor selection is mandatory. Disclosures: No relevant conflicts of interest to declare. more...

For patients lacking an HLA-identical sibling, more than ten million unrelated donor (UD) are available for donation of hematopoietic stem cells. Despite this increasing number of UD, up to 30 % of the patients will not find a completely-HLA-matched donor. HLAmismatched unrelated stem cell transplantation (SCT) is associated with an increased risk of acute and chronic graft-versus-host disease and a higher transplant-related mortality resulting in a lower survival after allogeneic SCT. We analyzed on outcome of allele- and antigen-mismatch SCT from UD using pre-transplantation anti-thymocyte globulin (ATGFresenius ®) at a median dose of 60 mg/kg as part of the conditioning regimen. Between 08/1996 and 12/2004, 369 patients received SCT from UD in our institution. In 268, complete molecular typing (4-digit) of HLA-A, -B, -C, and DRB1, and DQB1 was available for donor as well as for recipient. According to high-resolution HLA-typing, 110 of the patients were completely matched for 10 alleles, whereas 91 patients had at least one allele-mismatch (9/10), 67 patients were mismatched for 2–4 alleles (6–8/10). The median age of patients was 41 years (range, 1–68). Diagnoses were acute leukemia or MDS in 135, chronic myeloproliferative disease (CML or PMF) (n=53), lymphoid malignancy (CLL, NHL, Hodgkin’s disease, MM) (n=60), or others (n=20). Stem cell source was either bone marrow (n=103) or peripheral blood stem cells (n=165). The matched and the mismatched group did not differ significantly between age, sex, risk category, graft source, CMV-status, conditioning, or CD34+ transplanted cells. Two patients (1 %) experienced primary graft-failure and were transplanted from 10/10-matched donors while in none of the mismatch-transplanted patients primary graftfailure occurred. The incidence of grade II–IV acute GvHD was 33 % in the 10/10-matched group, 41 % in the 9/10-mismatch-group, and 40 % in the 6–8/10-mismatch-group (p=0.1). The overall rate of chronic GvHD was 42 % in the 10/10-matched group, 46 % in the 9/10-mismatch group, and 46 % in the 6–8/10-mismatch group (p=0.8). Non-relapse mortality (NRM) in the 10/10-matched group was 27 %, in the 9/10-mismatch group 31 %, and in the 6–8/10-mismatch group 32 % (p=0.2). In a multivariate analysis, only age as continuous variable (HR 1.023) (p more...

Background: Patients with haematogical diseases and undergoing stem cell or bone marrow transplantation are at high risk for an invasive fungal infection. The appearance and course of this is a significant threat to the overall success of transplantation. The optimal antifungal prophylaxis for stem cell transplanted patients has not yet been clearly etablished. Whereas oral medication seems to be convenient it is often hampered in the course of administration by mucositis or/and unclear absorption. We analysed the impact of antimycotic prophylaxis in our unit. We started with Voriconazol (tbl.) or Itraconazol (solution) followed by an early switch to liposomal amphotericin B with a dose 1 mg/kgBW, if the patients didn’t tolerate oral medications. Patients and methods: 48 patients (18f/30m) with a history of possible (n=4), probable (n=1) or proven (n=3) invasive fungal infection according to EORTC-MSG criteria or no (n=40) fungal infection underwent allogeneic stem cell transplantation in our centre between 08/2005 and 05/2006. Mean age was 47 (6–67) and underlying disease was acute leukaemia (18 AML, 5 ALL, 3 NHL, 4 MM, 4 CML, 14 other). Transplants were unrelated in 38 and related in10 cases. Results: Prophylaxis started on average 6 days prior to transplant (mean 6, range 0–19) with ITZ (n=24), VOR (n=8) or LAMB (n=8). 8 pts. developed early signs of fungal infection precluding analysis within the prophylaxis population. 15/24 pts. on ITZ and 3/8 pts. on VOR needed a switch to i.v.-medication with LAMB. 3/24 pts. starting with ITZ developed a fungal infection (2 possible, 1 probable). Pts. starting with VOR or LAMB required empiric therapy in 1 and 4 cases, respectively. 12 pts. after switching to LAMB required no further antifungal-therapy. Conclusions: In our experience antifungal prophylaxis with oral medication being switched to LAMB in case of mucositis or side effects is an effective and tolerated option to prevent invasive fungal infection in patients during allogeneic stem cell or bone marrow transplantation. more...

Background: Aspergillosis is a lethal infection of immunocompromised patients that respond poorly to antifungal therapy. Caspofungin (CAS) or Posaconazole (POS) as salvage monotherapy for IA have response rates of 45% and 42% respectively. Preliminary results of in vitro studies, animal models and clinical studies suggest that combination therapy with azoles and echinocandins may have additive activity against Aspergillus species. Methods: Seven adult patients after unrelated haematopoietic stem cell transplantation, with proven, probable or possible IA (per EORTC/MSG criteria) and refractory to standard antifungal therapy received Caspofungin plus Posaconazole (standard monotherapy dosage). All patients had > 3 days of combination antifungal therapy. Underlying diseases were AML (n=5), Biphenotypic leukaemia (n=1), Mantle cell Lymphoma (n=1). Three patients were neutropenic (ANC Results: Success at end of combination therapy (EOCT) was seen in six patients (86%). One critically ill patient died (due to bacterial sepsis and severe acute GvHD) four days after first administration of combination therapy. One patient with complete radiographic response died 20 days after EOCT due to bacterial sepsis in relapse of AML. Combination therapy at 4 to 59 (mean 35.7) days was well tolerated. No patient discontinued combination therapy due to toxicity. Follow up from start of combination therapy was 4 to 204 (mean 79.8) days. Conclusion: Randomized trials are warranted to determine whether this combination should be used as primary therapy for aspergillosis. more...