TABLE OF CONTENTS: BONE MARROW TRANSPLANT AND ITS TYPES AND AS A CURATIVE TREATMENT FOR THALASEMIA.........................................................................2 INTRODUCTION:......................................................................................................

2 BONE MARROW:.......................................................................................................3 STEM CELLS:.............................................................................................................4 BONE MARROW TRANSPLANT (BMT)...............................................................5 DEFINITION:..............................................................................................................5 TYPES OF BONE MARROW TRANSPLANT:.......................................................5 STEM CELL TRANSPLANT INDICATIONS:........................................................7 PATIENT ASSESSMENT BEFORE TRANSPLANT..............................................9 DONOR SELECTION FOR TRANSPLANT.........................................................11 THE TRANSPLANT PROCESS..............................................................................15 NEUTROPENIC PHASE:.........................................................................................18 ENGRAFTMENT PHASE:.......................................................................................18 PROCEDURE OF AUTOLOGOUS SCT................................................................19 Table 1.4 ALLOGENEIC SCT advantages and disadvantages:............................20 PROCEDURE OF ALLOGENEIC STEM CELL TRANSPLANT......................20 BONE MARROW TRANSPLANT AS A CURATIVE TREATMENT FOR THALASEMIA..........................................................................................................21 TRANSPLANT PROCEDURE:...............................................................................22 MIXED CHIMERISM:.............................................................................................23 CONCLUSION...........................................................................................................24 Hamilton HC, Foxcroft DR. Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term
1

intravenous therapy. Cochrane Database Syst Rev. 2007 Jul 18 ;( 3):CD004084 25

BONE MARROW TRANSPLANT AND ITS TYPES AND AS A CURATIVE TREATMENT FOR THALASEMIA

INTRODUCTION:
Over past four decades, hematopoietic stem cell transplantation (HSCT) and bone marrow transplantation (BMT) have increasingly been used to treat various nonmalignant and malignant disorders. After Second World War the nuclear radiation effects on human body developed interest in study of this field. Primitive studies on animals showed bone marrow as the most sensitive organ to the lethal radiation effects. In irradiated animals marrow cells were re-infused to save those animals. In 1950, for leukaemia treatment fatal irradiation doses were given to patients. Even though many had recovery after the treatment, all patients sooner or later entered into relapse phase of malignancy or developed infections. Between 1950-1960 nearly 200 allogeneic bone marrow transplants were carried out in humans but there were no long lasting success. Though, in this time, transplantation using donors like identical twin showed reasonable success and laid a foundation for further clinical research. In 1959, french oncologist George Math carried out first bone marrow transplant on five nuclear workers but all were rejected. He later pioneered application of BM transplants in leukaemia treatment. E. Donnall Thomas received Nobel Prize in 1990
2

for the first successful hematopoietic stem cell transplantation in acute leukaemias treatment1. The first successful bone marrow transplant on non-malignant disease was performed by Robert A. Good in 1968.

BONE MARROW:
It is fundamental part of human body. It is soft and spongy tissue, present in the central part of bone. Bone marrow most commonly in the breast bone, ribs, spine, skull and hips contain cells which produce bodys blood forming cells. The three common types of hematopoietic cells formed in bone marrow are:
1. White blood cells (WBC): also called leukocytes, fight against infection and

help in immune system.

2. Red blood cells (RBC): also called erythrocytes, functions in oxygen transport

in the body.
3. Platelets: helps in primary hemostasis.

FIG 1.1 Hematopoietic and stromal cell differentiation

STEM CELLS:
These are immature primitive cells, also known as hematopoietic stem cells or blood forming cells, which are capable: 1. Of self renewal. 2. To divide indefinitely. 3. Produce progeny of highly specified functional cells. Most blood forming cells are present in bone marrow but some are present in blood stream. These are known as peripheral blood stem cells (PBSC). Hematopoietic stem cells are also found in umbilical cord blood. SOURCES OF STEM CELLS: Main sources for stem cells are; 1. Bone marrow
4

2. Peripheral blood 3. Umbilical cord blood 4. Fetus liver

Table 1.1 characteristics of HSCs CHARATERISTICS OF HEMATOPOEITIC STEM CELLS POSITIVE CD34 AC133 Aldehyde dehydrogenase LOW POSITIVE Thy 1 c-KIT CD38 CD33 T- and B-cell markers CD71 HLA-DR NEGATIVE

BONE MARROW TRANSPLANT (BMT)

DEFINITION:
It is defined as a procedure in which damaged or diseased hematopoietic stem cells are substituted with non-malignant stem cells in order to repopulate or replace hematopoietic system as a whole or in parts, so that it can develop healthy new cells. BMT is generally used when malignancy treatments have damaged the normal bone marrow stem cells. BMT can also be performed when healing chances are low after treatment with chemotherapy alone.

TYPES OF BONE MARROW TRANSPLANT:

The two main types of bone marrow transplant are;

1. AUTOLOGOUS TRANSPLANT: it is also known as self transplant. It

involves gathering of patients own bone marrow cells. These are calculated, evaluated and then stored and frozen for later on use. It is most frequently carried out for multiple myeloma, lymphoma and associated diseases. Less frequently it is performed for leukaemias treatment as well.
TANDEM TRANSPLANT: it is a form of autologous transplant. In a

number of clinical trials, it has been studied for the management of different forms of cancers. During tandem transplant, a patient gets two chronological courses of the high-dose chemotherapy by means of stem cell transplant. The duration of two courses is weeks to months apart. Researchers anticipate that by this method cancer recurrence can be prevented later on.
2. ALLOGENEIC TRANSPLANT: for this type of transplant, stem cells are

obtained from a donor who could be a relative (sibling) or any other donor (volunteer unrelated donor) or umbilical cord blood. But the tissue type of donor should closely match with the patient. The probability of sister or brother to be a suitable match is 1 in 4. The odds of other members of family as a suitable match are less. Such transplants are commonly recommended for leukaemias. Other than that allogeneic transplant also indicated for bone marrow and immuno-deficiency disorders.
SYNGENEIC TRANSPLANT: it is also called as identical twin transplant.

Identical twin is the perfect donor since the genetic individuality between donor and recipient. The cells are identical to own cells apart from the fact that they are healthy cells and not damaged by earlier chemotherapy.

 MINI TRANSPLANT: it is one of the forms of allogeneic transplant and

also called as low intensity or non-myeloablative transplant. In minitransplant less lethal quantity of chemotherapy and/or radiation therapy is used for preparation of patient. Low dose therapy removes some of the patient bone marrow, leaving rest intact. It also lowers cancer cells and restrains the immune system of the patient to prevent transplant rejection. After mini transplant both the patient and donor cells co exist in patients body for some time. So once engraftment occur, this result in graft versus tumor effect and destroy the remaining cancerous cells left after therapy. To enhance this graft versus tumor effect, patient is given donors WBC injection. This method is called donor lymphocyte infusion.

STEM CELL TRANSPLANT INDICATIONS:

Table 1.2 indications for SCT

AUTO STEM CELL TRANSPLANT

ALLO STEM CELL TRANSPLANT

RELATED (SIBLING) AML with 1st CR

Good cytogenetics

UNRELATED (VUD) NR NR R R

NR R R R

NR R R R

Standard cytogenetic Poor cytogenetics AML with 2nd CR

ALL with 1st CR ALL t(9;22) 1st CR ALL with 2nd CR CML with 1st CP MYELOMA MDS HD with 1st CR HD relapsed NHL with DLBCL 1st CR NHL with DLBCL relapsed Follicular NHL AA(Aplastic anemia)

D R R NR R NR NR R D

R R R R(after imatinib trial) R R NR R D

NR R R R(after imatinib trial) D R NR D D

D NR

R R

D D

Haemoglobinopathie NR R D s AML: acute myeloid leukaemia ALL: acute lymphoblastic leukaemia CR: complete remission CML: chronic myeloid leukaemia MDS: myelodysplastic syndrome DLBCL: diffuse large B-cell lymphoma NHL: non-Hodgkin lymphoma VUD: volunteer unrelated donor R: recommended NR: not recommended D: developmental

STEM CELL TRANSPLANT is indicated for both the malignant/premalignant disorders as well as the non-malignant disorders. The malignant diseases mainly include all leukaemias that is, AML, ALL, CML and the immature myelomonocytic leukaemia. Other malignant conditions include disorders of plasma cell, the myelodysplastic syndrome and non-Hodgkin and Hodgkin lymphomas. The nonmalignant conditions include a variety of disorders like:
8

 Inherited metabolic diseases: hurler syndrome, osteoporosis, Acquired immuno-deficiency disorders: like HIV (a HIV patient having AML

was treated by allogeneic BMT used from a donor lacking CCR5 surface proteins. These are important for HIV access to human cells. In the final report, patient was responding well and stayed off of antiretroviral treatment for 2 years after BMT2,3 Inherited immune diseases: Wiskott-Aldrich syndrome etc
Inherited RBC disorders: -thalasemia, SCD, pure red cell aplasia. Auto-immune disorders: rheumatoid arthritis, crohns disease, systemic

sclerosis, multiple sclerosis and SLE etc4,5

Marrow failure conditions: Fanconi anemia, aplastic anemia and other

disorders.

PATIENT ASSESSMENT BEFORE TRANSPLANT

The most crucial step in assessment is the tissue typing as HLA mismatching poses serious problems during transplant. A complete medical history showed be taken and general physical examination along with specific systemic examination should be carried out to assess the conditions of patient. Transplant may sound a terrifying procedure for the patients and therefore emotional and psychological support should be provided through out the procedure. Before the procedure, different laboratory tests and other tests are carried out for patient assessment. These include: Biopsy of bone marrow Computed tomography scan Magnetic resonance imaging Cardiac function analysis
9

Electrocardiogram Echocardiogram

Respiratory system analysis Pulmonary function tests(PFTs) CXR(chest x-ray)

Hematological tests Complete blood count(CBC) Viral screening HIV HBV CMV

CENTRAL VENOUS ACCESS (CVA) IN BMT:

For CVA a large bore catheter is inserted into the vein in neck, femoral area or upper chest area. It is mainly used for drugs administration which otherwise cannot be given conveniently by mouth or by a cannula in arm. Two authors carried relevant studies to evaluate which route presents as lower frequencies of venous stenosis, venous thrombosis and central venous catheter related infections.6 The studies showed that subclavian access is preferred over femoral access because of less association with complications in long term therapy6. In auto transplant CVC is also used for stem cell harvesting for apheresis.

ELIGIBILITY CRITERIA FOR TRANSPLANT:

10

Younger individuals, in early phase of disease or those people who donot have already gone through a number of treatments, show better results with transplant. Some centers for transplant set an age limit. For example, some donot allow allogeneic transplant for patients over 50 years of age while for autologous transplant, transplant is not allowed in those people who are over 60-65 years old. Some people are excluded from transplant, if there are other major medical problems are present, such as lung, heart and kidney or liver diseases. In such cases mini-transplant can be an alternative option.

DONOR SELECTION FOR TRANSPLANT

Matched donor selection is the most crucial part in stem cell transplant. The lymphocytes and hematopoietic progenitor cells of the donor when infused into patient result in the activation of immunological responses in otherwise immunosuppressed recipient. The different forms of resulting reaction include host versus graft (HVG) reaction which is rare and the major graft versus host (GVH) reaction. The HVG can lead to graft rejection, which ultimately can result in graft failure. While GVH can be evident as graft versus host disease or graft versus leukaemic response. These complications are mainly associated with allogeneic transplantation. While in autologous transplantation these responses are missing. The antigens aligned with GVH and HVG reactions include: Major HLA antigen complex which is present on chromosome 6
Minor H antigens (i-e histocompatibility antigens). These are programmed by

number of unrelated genes which are present exterior to HLA system.

11

The HLA complex consist of six major antigens and a match is consider 6/6 match if all the major elements are present and thus regarded as best match. These antigens are: HLA-A HLA-B HLA-C HLA-DR HLA-DQ HLA-DP Thus the different probable sources for these are: A sibling, related or the unrelated donor. Thus the donor is either HLA identical, haploidentical or can be mismatched. This is for Allo transplant Identical twin results in syngeneic transplant and is always HLA identical Patient can also be a donor as in Auto transplant and therefore HLA identical Blood from umbilical cord can also be used in Allo transplant and therefore it may be identical or mismatched or even haploidentical.

12

FIG 1.2 selections of donors for immediate allogeneic transplant in case of absent sibling donor

DIFFERENT CONSIDERATIONS CONCERNING THE OPTIONS FOR UNRELATED DONORS (UD):

HLA-A, -B, -C, -DRB1, -DQB1 matching i-e 10/10 matching7, 8, 9 Mismatch of single allele can be tolerated and thus overall survival (OS) in long term is obvious
13

 Individual loci mismatches show different results mismatch for HLA-A is usually well tolerated mismatch for HLA-B shows considerably worse OS and thus be avoided mismatch for HLA-C shows tolerance in term of overall survival but shows increase frequency regarding acute and chronic GVHD

mismatch for KIR ligand shows increased transplant-related mortality (TRM), also poor OS. Therefore if possible better to avoid

In short, if mismatch for class 1 antigens is unavoidable then A mismatch is preferred, then C mismatch is chosen next and finally B mismatch or a C with KIR GVH mismatch Mismatching for multiple allele showed considerably impaired OS. In spite of the fewer single mismatches for class II or mixed mismatches for class I and II, the best approach is to avoid these due to major rise in severe GVHD, TRM and following poorer OS. HLA-DPB1 matching10
If a donor is DP-B1 matched then irrespective of the HLA matching status,

there is increased chance of relapse. Particularly in disorders like CML and ALL. Therefore DP-B1 typing should be done before every transplant and incompatible DP-B1 donor is preferred over compatible one. Observation of individual loci mismatching shows: mismatch of HLA-DPB1 at region D which is hyper variable and mismatch at amino acid location 65 or 57 results in increased TRM and poorer OS
14

Other permissive mismatches for DPB1 may also exist.

THE TRANSPLANT PROCESS

The transplant procedure in general can be divided into following phases: harvesting or cell mobilization phase, conditioning, stem cell infusion, cytopenic phase, engraftment and post-engraftment phase.

HARVESTING PHASE:
This is also called as cell mobilization phase. In this phase different growth factors and chemotherapeutic agents are used foe stem cell proliferation and for mobilization of stem cells from bone marrow to blood stream. Through apheresis process, these cells are harvested and later used for the replacement of stem cells that are destroyed through conditioning therapy. G-CSF is most commonly used for cell mobilization and is given alone or following myelosuppressive chemotherapy. The hematopoietic stem cells and the progenitor cells are localized inside marrow cavity by binding through certain adhesion molecules, these include VLA4 and CXCR4. G-CSF mainly acts by disrupting this binding. Harvesting is done on 5th and 6th day. G-CSF alone is given as 4 daily injections given subcutaneously. The minimum target cells harvested in more than 90% cases with G-CSF therapy is 2 x 106 CD34+ cells per Kg. Common adverse effects include bone pain, myalgia and headache.

CONDITIONING PHASE:
During this phase the bone marrow and immune system are prepared for the previously harvested cells, by conditioning with high-dose therapy, which include
15

either total body irradiation (TBI) or a mixture of chemotherapy and radiotherapy. The conditioning phase lasts for 7-10 days. The main purpose is to eliminate malignancy, avoid elimination of new stem cells and generate space for new cells.

A. MYELOABLATIVE CONDITIONING: IN AUTOLOGOUS STEM CELL TRANSPLANT: In autologous transplant, the conditioning regimens are planned with dose amplification but the main limitation to it is the extramedullary toxicity including mucositis and gastrointestinal toxicities. Common conditioning regimes include:
Myeloma Autografts: Melphalan 200mg/m2 is used

Lymphoma : BEAM (carmustine, Etoposide, cytarabine, Melphalan) AML and ALL: auto transplants rarely indicated but both cyclophosphamide/TBI or busulfan preparation can b used Solid tumors: different combinations including busulfan, thiotepa and Melphalan are used. IN ALLOGENEIC STEM CELL TRANSPLANT: The most frequently used conditioning regimens consist of TBI/Cyclophosphamide combination or Cyclophosphamide/Busulfan combination.
Cyclophosphamide: It is an alkylating agent. Dose is 120-200mg/kg. It has

both immunosuppressive and anti-leukaemic characteristics. The main dose related complications are hemorrhagic cystitis and cardiac toxicity.
TBI (total body irradiation): the therapeutic dose is 12-14.4Gy but for

decreased toxicity the general dose is decreased or administered in small proportions like 14.4Gy in divided doses of 8 parts over 4 days. The early complications with TBI are nausea, vomiting, diarrhea and parotitis and these
16

can be symptomatically treated. Amplified doses of TBI can result in pneumonitis or veno-occlusive disease of the liver (VOD) and both are life threatening complications. The long term complication manifest as hypothyroidism, cataract formation, growth retardation in children and infertility.
Busulfan: it is an alkylating agent. It is the central element of both Allo and

auto transplant. Dose is 14-16mg/kg orally administered 6 hourly for 4 days. Major complications include VOD, CNS toxicity and pulmonary toxicity.
Other combinations include various drugs in addition to the above mentioned

regimens. These are fludarabine, Melphalan, cytarabine, Etoposide and thiotepa. Also ATG (antithymocyte globulin) can be used in addition to above regimens to reduce graft rejection.

B. REDUCED-INTENSITY CONDITIONING: LOW-DOSE TBI BASED REGIMEN: This include TBI dose of 200-450cGy in combination with ciclosporin and mycophenolate mofetil.

NON-TBI BASED REGIMENS: It includes combination of fludarabine and alkylating agents like, Melphalan, cyclophosphamide and busulfan.

C. GVHD PROPHYLAXIS: After myeloablative conditioning the common form of GVHD prophylaxis is post transplant immunosuppression by ciclosporin, methotrexate, prednisolone and
17

mycophenolate mofetil. T-cell depletion (TCD) is also very effective way of decreasing the possibility of both acute and chronic GVHD.

NEUTROPENIC PHASE:
Duration of neutropenia is 2-4 weeks. During this time the patient is devoid of any effectual immune system and present with poor healing and prone to infection. The main management during this phase is by supportive care and also empirical antibiotic therapy. The potential pathogens are herpes simplex virus (HSV) and the endogenous flora. Nosocomial infections pose greatest risk and are more frequently resistant to typical antibiotic therapy.

ENGRAFTMENT PHASE:
This process may take several weeks. In this process the stem cells are engrafted back in the patient body to re develop the immune process. Occasionally purging techniques can be used to remove any residual tumor cells earlier to engraftment to shortly after that. Different clinical factors influence stem cell engraftment, these are:

IN AUTOLOGOUS AND SYNGENEIC TRANSPLANT: The main determining factor is stem cell dose. Graft failures are rare if stem cell dose transplanted is 2 x 106 CD34+ cells per kg. IN ALLOGENEIC TRANSPLANT: The main determining factors are: Intensity of conditioning regimen induced immunosuppression T-cell depletion
18

Level of genetic inequality between donor and recipient

PROCEDURE OF AUTOLOGOUS SCT

FIG 1.3 autologous transplant process

Table 1.3 AUTOLOGOUS SCT advantages and disadvantages: ADVANTAGES Increased dose therapy earlier to harvesting and following engraftment may : Reduces recurrence risk Curing destructive component of disease DISADVANTAGES Chances of contamination of engrafted cells with disease. Higher risk for secondary AML or for MDS. Increased incidence of TRM and this may be because of:
19

Produce long lasting remission

Regimen associated toxicity Infections during the different stages of transplant process

Avoid GVHD.

Table 1.4 ALLOGENEIC SCT advantages and disadvantages: ADAVNTAGES Tumor excluded graft. Unharmed stem cells. Secondary AML/MDS are avoided. (GVL) Graft versus leukaemic effect is produced.
DISADVANTAGES

Lack of availability of matched donor. Increased incidence of TRM related with: Regimen associated toxicity Infections GVHD

PROCEDURE OF ALLOGENEIC STEM CELL TRANSPLANT

20

FIG 1.4 allogeneic transplant process

BONE MARROW TRANSPLANT AS A CURATIVE TREATMENT FOR THALASEMIA

Thalasemia is the most common inherited single gene disorder, characterized by increased RBC disorder and therefore require regular blood transfusion to cure the anemia. However regular transfusion results in increased iron load as well, which ultimately causes multiple organ damage. Therefore the only major treatment for thalasemia in present times is correction of the genetic fault and that is carried out with HSCT.

21

Table 1.5 Risk factors for BMT in thalasemia: RISK FACTORS FOR BMT IN THALASEMIA Chelation Hepatomegaly Liver fibrosis Regular vs irregular Absent vs present Absent vs present

Table 1.6 Pesaro classifications11 RISK CLASSES FOR BMT IN THALASEMIA CHELATION Regular Regular / irregular Irregular HEPATOMEGALY Absent Absent / present Present FIBROSIS Absent Absent / present Present

CLASS 1 CLASS 2 CLASS 3

TRANSPLANT PROCEDURE:
The first step is search for the donor that is HLA identical. Then according to the Pesaro classification, patient is assigned to one of the three risk classes. The transplant procedure for 1st two classes, i-e class 1 and class 2 is same, while class 3 shows more progressive disease and therefore needs time and skill. The protocol for treatment is: Busulfan 14mg/kg total dose is given and then followed by cyclophosphamide 200mg/kg total dose. When Allo graft starts to reproduce inside patient, immunological GVH response develops. Thus prophylactic treatment is given for GVHD with Cyclosporin Methotrexate 3-4 doses together with cyclosporin in start 15 days following transplant. Then bone marrow is injected in peripheral vein in 4-6 hours
22

 Patient isolation as important as he is having aplastic marrow and therefore should receive

Platelet transfusion RBC transfusion Prophylactic management with anti-fungal, anti-bacterial and anti-viral drugs

Prophylactic management for GVHD

Medical examination and blood tests are initially performed twice every week till patient is back home Class 1 and class 2 patients return home around day 70 or plus Class 3 patients can return home by day 90 or plus Cyclosporin is continued for a year following treatment with steadily tapering dose

MIXED CHIMERISM:
To create conditions for absolute marrow engraftment, patients stem cells should Be completely ablated. This condition is called as complete chimerism (CC). Using PCR, short tandem repeats were analyzed for marrow engraftment evaluation. A total of 93 thalassemic patients who had received BMT were evaluated12. All these patients were selected from Asian countries and from Middle East. Early mixed chimerism following BMT was observed in 46% patients. Further analysis revealed that, out of 27 patients with complete engraftment, 7 patients presented with graft rejection while 8 showed mixed chimerism. Out of those 7 patients, 5 patients showed presence 25% of residual host cells before the commencement of transplant12
23

CONCLUSION
Developments in supportive management, anti-biotic therapy and HLA typing have produce important role in improving overall survival and life quality after transplant. In broad spectrum, patients with steady disease or in remission state have improved outcome compared to those who are transplanted during advanced disease phase and those with disease relapse. Young age present with favourable outcome. CMVnegative class of donor and recipient increases the probability of overall survival. A large dose of hematopoietic cells speed up engraftment and results in better outcome but also enhances the chances of GVHD. Non-malignant disorders show more favourable results.

REFERENCES:
1.

Thomas ED, Lochte HL, Lu WC, Ferrebee JW. Intravenous infusion of bone marrow in patients receiving radiation and chemotherapy. N. Engl. J. Med. 1957; 257:491.

2.

Htter G, Nowak D, Mossner M, Ganepola S, Mssig A, Allers K. Long -term control of HIV by CCR5 Delta32/Delta32 stem-cell transplantation. N Engl J Med. Feb 12 2009; 360(7):692-8. [Medline]

3.

Schoofs M.A Doctor, a mutation and a potential Cure for AIDS. WallStreet Journal. November 7, 2008.

24

4.

Rabusin M, Andolina M, Maximova N, Haematopoietic SCT in autoimmune diseases in children: rationale and new perspectives in Bone Marrow Transplant. Jun 2008; 41 Suppl 2:S96-9. [Medline]

5.

Craig RM, Traynor A, Oyama Y, Burt RK. Hematopoietic stem cell transplantation for severe Crohn's disease. Bone Marrow Transplant. Aug 2003; 32 Suppl 1:S57-9. [Medline]

Hamilton HC, Foxcroft DR. Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy. Cochrane Database Syst Rev. 2007 Jul 18 ;( 3):CD004084
6.

Morishima Y, Sasazuki T, Inoko H, Juji T, Akaza T, Yamamoto K et al. The clinical significance of human leukocyte antigen (HLA) allele compatibility in patients receiving a marrow transplant from a serologically HLA-A, HLA-B and HLA-DR matched unrelated donors. Blood 2002; 99: 4200-4206.

7.

Petersdorf EW, Gooley TA, Anasetti C, Martin PJ, Smith AG, Mickelson EM et al. Optimizing outcome after unrelated marrow transplantation by comprehensive matching of HLA class I and II alleles in the donor and recipient. Blood1998; 92: 35153520.

8.

Flomenberg N, Baxter-Lowe LA, Confer DL, Fernndez-Vina M, Filipovich A, Horowitz M et al. Impact of HLA class I and class II high-resolution matching on outcomes of unrelated donor bone marrow transplantation: HLAC mismatching is associated with a strong adverse effect on transplantation outcome. Blood 2004; 104: 1923

25

9.

Shaw BE, Marsh SGE, Mayor NP, Russell NH, Madrigal JA. HLA-DP1 matching status has significant implications for recipients of unrelated donor stem cell transplants. Blood 2006; 107: 12201226.

10. Lucarelli G, Andreani M, Angelucci E. The cure of thalassemia by bone marrow transplantation. Blood Rev 2002; 16: 8185 11. Marco Andreani,1 Manuela Testi,1 Mariarosa Battarra,1 Paola Indigeno,1Annalisa Guagnano,1 Paola Polchi,1 Giorgio Federici,2 and Guido Lucarelli. Relationship between mixed chimerism and rejection after bone marrow transplantation in thalassemia. Blood Transfus.2008 July; 6(3): 143 149

26