Bone Marrow Transplantation

https://doi.org/10.1038/s41409-020-01179-5

PERSPECTIVE

Consensus opinion on immune-mediated cytopenias after

hematopoietic cell transplant for inherited metabolic disorders
Ashish O. Gupta 1 Jaap Jan Boelens 2 Christen L. Ebens1 Joanne Kurtzberg3 Troy C. Lund1
● ● ● ● ●

Angela R. Smith1 John E. Wagner1 Robert Wynn4 Bruce R. Blazar1 Paul J. Orchard 1
● ● ● ●

Received: 16 July 2020 / Revised: 4 November 2020 / Accepted: 25 November 2020

© The Author(s), under exclusive licence to Springer Nature Limited 2021

Abstract
Hematopoietic stem cell transplantation (HCT) has been increasingly used for patients with inherited metabolic disorders
(IMD). Immune mediated cytopenias (IMCs) after HCT, manifesting as hemolytic anemia, thrombocytopenia, and/or
neutropenia, are recognized as a significant complication in this patient population, yet our understanding of the incidence,
risk factors, and pathophysiology is currently limited. Review of the published literature demonstrates a higher incidence in
younger patients who undergo HCT for a nonmalignant disease indication. However, a few reports suggest that the incidence
1234567890();,:
1234567890();,:

is even higher among those with IMD (incidence ranging from 10 to 56%). This review summarizes the literature, provides
an approach to better understanding of the possible etiology of IMCs, and proposes a diagnostic and management plan for
patients with IMD who develop single or multi-lineage cytopenias after HCT.

Introduction alone or in combination [1–3]. The very task of naming this

cluster as autoimmune or alloimmune cytopenias is difficult
Over the past 30 years, use of hematopoietic stem cell as the underlying etiology is still largely unclear. We have
transplantation (HCT) has expanded beyond the treatment referred to these as broadly IMCs owing to the lack of
of malignant disorders, with increasing numbers of trans- clarity in the pathophysiology of the condition in some
plants being performed for a wide spectrum of non- cases. IMC includes both autoimmune and alloimmune
malignant conditions that include primary etiology for the development of these immune cytopenias.
immunodeficiency diseases, marrow failure syndromes, and For the purpose of this review, we have used the term IMC
inherited metabolic disorders (IMD). Immune mediated and the individual cytopenias labeled as immune-mediated
cytopenias (IMC), often described as either allo- or auto- hemolytic anemia (IMHA), immune-mediated thrombocy-
immune cytopenias, after HCT have been increasingly topenia (IMT), and immune-mediated neutropenia (IMN).
recognized as a significant complication in patients with Reports from single centers and international registries
both malignant and nonmalignant diseases, manifesting as have provided some guidance on the general incidence, risk
hemolytic anemia, thrombocytopenia, and/or neutropenia factors, time of onset, treatment strategies, and outcomes of
patients who develop IMC [4–9]. However, only limited
information is available on the incidence of IMC in those
with IMD, potentially a higher risk population. Further-
* Ashish O. Gupta more, there are no clear guidelines on the diagnosis and
gupta461@umn.edu
management of IMC after transplantation. Since IMD itself
1
Department of Pediatrics, Division of Blood and Marrow appears to be an independent risk factor for IMC or has a
Transplantation, University of Minnesota, Minneapolis, MN, USA relatively higher incidence of IMC [10–14], a multinational
2
Stem Cell Transplantation and Cellular Therapy, MSK Kids, panel of physician experts in the treatment of IMD was
Memorial Sloan Kettering Cancer Center, New York, NY, USA convened, with the primary aim to identify the strategies for
3
Marcus Center For Cellular Cures, Duke University School of effective and timely diagnosis and develop a management
Medicine, Durham, NC, USA strategy for IMC in this patient population. The panel
4
Department of Blood and Marrow Transplantation, Royal included experts in HCT for IMDs from centers with
Manchester Children’s Hospital, Manchester, UK experience in treating these disorders as well experts in
 A. O. Gupta et al.

nonmalignant disorders and transplant immunology. This conditioning regimen, use of an anti T-cell serotherapy,
report summarizes a review of the current literature and recipient cytomegalovirus serostatus, use of umbilical
proposes a diagnostic algorithm, monitoring plan, and cord blood stem cells, use of an unrelated donor source, and
treatment strategy, that might inform future trials focused the development of graft versus host disease (GVHD)
on IMD. [6, 7, 10–12, 14, 16]. The use of serotherapy such as
alemtuzumab based conditioning [9, 19] and minor ABO
Incidence mismatch between recipient and the donor have also been
reported [18]. Since the majority of patients in these reports
The literature review was performed using the key words were treated with myeloablative conditioning, a calcineurin
“posttransplant cytopenias”, “HCT and autoimmune inhibitor and unprocessed hematopoietic stem cells, the risk
hemolytic anemia”, “HCT and autoimmune thrombocyto- related to the conditioning intensity, the use of ex vivo
penia”, and “HCT and autoimmune neutropenia” investi- lymphocyte depletion or GVHD prophylaxis without a
gating the databases such as Pubmed, Google Scholar, and calcineurin inhibitor remains unclear.
Medline. Despite the recognized importance of IMC after
transplantation, review of the literature demonstrated a lack Pathophysiology
of consistent rules for the diagnosis of IMC following HCT.
Inconsistency in the criteria for diagnosis and management The pathophysiology of IMC continues to evolve. The
of IMC by individual investigators highlight the challenge interaction of reconstituting donor immune system and
with developing a uniform approach for this complex issue. depleted but persistent recipient immune system further
Based on the review of available literature, seven publica- questions allo- or autoreactivity in the setting of an immune
tions were identified that examined the incidence of cyto- cytopenia. Multiple factors can influence the immune
penias in recipients of HCT for IMDs (Table 1). In these reconstitution after HCT such as the underlying disease,
analyses, the diagnosis of IMC either required the presence conditioning regimen, age at transplant, cellular composi-
of documented antibody directed against one or more tion, and the type of donor graft used, immunoprophylaxis,
hematopoietic lineages or used other laboratory markers in complications such as microbial infections and GVHD.
the setting of cytopenias consistent with such a diagnosis in Immune status and the degree of immune reconstitution
the absence of documented antibody. While the presence of prior to development of IMC can help with better under-
antibody is highly likely documented for the red blood cell standing of the immunobiology. A developing thymus in
lineage, it is less commonly detected in those with throm- young children, where T cells undergo selection and dif-
bocytopenia and neutropenia [10, 12]. For this reason, the ferentiation, might also play an important role in the
physician’s working diagnosis of IMC was sufficient in development of immune tolerance and autoreactivity
some reports, despite the absence of a documented antibody [20, 21].
[7, 15]. The overall incidence of IMC after allogeneic Kruizinga et al. examined the immune status of patients
HCT for various indications ranged from 2.1 to 52.6% with and without IMC [9]. The absolute number of natural
[7, 9–12, 16–18]. However, the studies focusing specifically killer (NK), total T-cell numbers and B cells was noted to be
on the IMD cohort, the incidence of IMCs were reported similar in the two groups at the time of clinical diagnosis of
between 10 and 52.6% [6, 7, 10–14, 16], which seems to be IMC. However, the absolute number of CD8 + T-cell count
substantially higher relative to other disease groups. The was lower and the Th2-specific cytokines (IL-4, IL-5, and
cumulative incidence in this patient population from various IL-13 but not IL-6) were elevated in patients with IMC.
studies is noted to be 22%, which is higher than those with This suggests the difference in immune reconstitution and
other nonmalignant disorders (9%) and malignant disorders possible B-cell dysregulation [22]. Skewing toward a Th2
(2%) (Table 1). Time to onset was typically within the first response and possible T-effector- regulatory T-cell (Treg)
year after transplant with a median onset of about imbalance can result in poor Treg mediated autoimmune
4–6 months, though a later onset (median, 1 year) was dysregulation [23]. However, the results from this limited
observed in one study [10–12, 17, 18]. dataset (n = 25 for IMC patients; n = 6 cases and controls
each for cytokine analysis) needs further understanding to
Risk factors discern the underlying pathophysiology. In a recent study
by Szanto et al. lower trend for NK and CD3 + CD8 +
Review of the literature for the studies including IMD T cells was identified in patients prior to the diagnosis of
patients potential risk factors for IMC were identified IMC, but were not reported to be statistically significant
(Table 1). For example, transplantation for a nonmalignant [14]. The study also reported increase in IgM prior to
disease and younger recipient age are consistent between development of IMC compared to patients who did not
the reports. Other risk factors suggested include the type of develop IMC, at similar time points after HCT, but the
Table 1 Reported incidence of immune-mediated cytopenias in patients with inherited metabolic disorders.
Study IMD Other nonmalignant disorders Malignant disorders Risk factors

O’Brien et al. [10] 11/100 (IMHA-11) 5/68 (IMHA-5) 3/135 (IMHA-3) • Age <10 years (incidence of IMC 8% in younger
patients vs. 1%; p = 0.04)
• Diagnosis of IMD (11% vs. 7% in other NMD, vs.
2% malignant)
Daikler et al. [6]a 12/30 14/155 26/570 • Nonmalignant disease using CBT vs. bone marrow
graft (HR 3.36; p < 0.001)
• Interval from diagnosis to CBT 11.4 months
(median interval; HR 1.85; p = 0.034)
Page et al. [11] 10/18 (IMHA-4, IMT-1, ES-3, NR NR Age <1 year (28% vs. 5% in those >1 year; p < 0.01)
Pancytopenia- 2)
Faraci 2013b NE; six IMD patients with IMC 22/355 (6/22 with IMD) 11/1219 (IMHA-6, IMT-1, • Nonmalignant disease vs. malignant disease (OR
(IMHA-2, IMT-1, ES-3) (IMHA-7, IMT-6, ES-1) IMN-1 ES-1) 6.87; p = 0.00017)
• Use of an alternate donor (MUD vs. MFD); (OR
3.73, p = 0.019)
Ahmed et al. [16] 1/10 (IMHA-1) 4/152 (IMHA-4) 7/326 (IMHA-7) Unrelated donor status (0% MRD vs. 3.7% other
donors; p = 0.04)
Deambrosis et al. [12] 8/32 NR NR Pretransplant ALC (adjusted OR = 2.186;
p = 0.037)
Szanto et al. [14]b NE; ten IMD patients with IMC 21/184 (10 with IMD) (ES-1, 9/196 IMT-1, ES-2, • aGvHD grade II-IV (HR 2.45; p = 0.0167)
(IMT-2, ES-3, pancytopenia-5) pancytopenia-10) pancytopenia-6) • Chemo-naive prior to HCT (HR 2.36; p = 0.0499)
• Serotherapy (HR 8.00; p = 0.045)
Incidence of IMC 42/190 (22%, range 10–56%) 45/730 (6%, range 2–10%) 60/2723 (2%; range 1–4%)
Bold entries represent the column labels. The cumulative findings in the last row are marked in bold.
IMD indicates inherited metabolic disorders, IMC immune-mediated cytopenia, IMHA immune-mediated thrombocytopenia, IMN immune-mediated neutropenia, ES Evans syndrome, HR hazards
ratio, OR odds ratio, MUD matched unrelated donor, MFD matched family donor, CBT cord blood transplant, HCT hematopoietic cell transplant, CMV cytomegalovirus, ALC absolute
lymphocyte count, aGVHD acute graft versus host disease, NE not evaluated, NR not reported.
a
The study does not report type of cytopenia based on the subgroups.
Consensus opinion on immune-mediated cytopenias after hematopoietic cell transplant for inherited. . .

b
The total number of IMD patients transplanted in the study duration not mentioned, excluded from final incidence calculation for IMD and other nonmalignant disorders.
 A. O. Gupta et al.

underlying mechanism for this is unclear. Effectiveness of mAb (rituximab) [7]. Complete and sustainable response to
agents such as rituximab, that target CD20+ B cells, have anti-CD20 mAb as a second line agent was more likely in
shown efficacy in IMCs [4, 6–9], suggesting an important their autoimmune hemolytic anemia group (78%) compared
role of B cells. T cells on the other hand are important for to those with IMT (33%). For patients with Evans syndrome
B-cell activation and antibody production. Previous reports use of multiple agents resulted in CR in four out of five
have demonstrated the expansion of autoreactive T- and B- patients. Additionally, in patients treated with rituximab,
lymphocytes in development of autoimmune disease CR was obtained after a median of 60 days (range,
[15, 24] and the crucial role of the Treg in immune 30–180 days) from the start of rituximab treatment. In the
restoration after HCT [25, 26]. With limited information on study by Daikler et al. only partial response was noted in
these variables, further studies are needed for in-depth four patients to IVIG alone in single line cytopenias (IMHA
exploration of the role and interaction of several T- and B- and IMT), while additional agents were used in two other
cell mediated factors. patients [6]. Bortezomib, a proteasome inhibitor, has also
In patients with IMD, several of these factors might been used more recently as it targets T cells and plasma
predispose to development of IMCs. Unlike other indica- cells, which produce antibodies that can be directed against
tions for HCT, the underlying immune system in these one or more hematopoietic lineages [33–35].
patients is presumably intact with no prior exposure to Other agents that have been used for refractory IMC with
chemotherapy or an inherent immune dysregulation. How- variable responses including sirolimus [36], mycophenolate
ever, lysosomes play an important role in immune processes mofetil [37], vincristine [38, 39], cyclophosphamide [38],
including antigen processing and presentation on MHCs, azathioprine [11], as well as physical removal of antibodies
though the impact of lysosomal glycosaminoglycan accu- by plasma exchange [9]. More recently daratumumab, an
mulation on innate and adaptive immune system is little anti-CD38 mAb that can eliminate CD38 high plasma cells
understood [27–29]. Impact of a developing thymus in IMD has been used for hemolytic anemia or Evan’s syndrome
patients, who are relatively younger, along with a higher that developed after allogeneic HCT [40–42]. Though
incidence of mixed T-cell chimerism in patients receiving multiple agents are available, and used either alone or in
reduced intensity or reduced toxicity conditioning in the combination depending on the severity of cytopenias, there
setting of HLA disparity with mismatched UCBs, could has been no consistent treatment approach that identifies
potentially further increase the risk of IMC after HCT. best practices.
However, no clear consensus could be derived from the Despite use of multiple agents, sometimes IMCs are
limited available literature regarding the impact of mixed refractory and difficult to treat. In a recent report in patients
chimerism and HLA disparity [9, 14, 30]. Nevertheless, with Hurler syndrome, Deambrosis et al. [12] reported
IMC could be mediated by recipient T- and B cells targeting secondary graft failure in two patients who developed
donor-derived hematopoietic populations or by B-cell dys- pancytopenia related to IMC, requiring second transplant
regulation secondary to T-cell B-cell imbalance due to after failing multiple immunosuppressive agents. Gupta
delayed T-cell reconstitution leading to auto-antibody et al. also reported two patients developing pancytopenia
(donor anti-donor) production. secondary to IMC in the IMD cohort using busulfan and
fludarabine based conditioning following lack of response
Management and treatment response to multiple immunosuppressive agents [13]. The cumulative
mortality in the reported data for those with IMHA (33/90),
Management of IMC after transplant is often challenging, as IMT (1/28), Evans syndrome (2/10), and pancytopenia (1/4)
it can be refractory to multiple lines of treatment or recur as after HCT was summarized by Holbro et al. [8]. Despite the
the immune suppression is tapered [10]. Administration of efficacy of initial therapies, IMC can result in graft failure
corticosteroids and/or intravenous immunoglobulin (IVIG) and death from the associated profound immunosuppression
along with supportive therapy (e.g., use of granulocyte [9, 10, 18]. A complete understanding of these risk factors
colony stimulating factor [G-CSF] and transfusion of for progression to graft failure and mortality is still largely
packed red cells and/or platelets) appears to be the current unclear.
mainstay of first-line therapy based on the literature
[6, 7, 12, 31, 32]. Over the past few years rituximab has Consensus recommendations
increasingly been used as an earlier line of therapy, but with
variable response as shown in multiple studies [7, 9]. IMDs are a major group of nonmalignant diseases for which
Kruizinga et al. reported an ~13% complete remission rate allogeneic HCT has been shown to stabilize disease pro-
and durable response with steroids alone [9] while Faraci gression. As the number of patients with IMD treated with
et al. reported a complete response (CR) in ~36% with HCT increases, IMC is increasingly recognized as a major
steroids alone while 87% sustained CR with anti-CD20 cause of morbidity that limits the successful use of this
Consensus opinion on immune-mediated cytopenias after hematopoietic cell transplant for inherited. . .

therapeutic approach. The first challenge is defining the Szanto et al. tested for the presence of antibodies against all
diagnostic criteria for IMC. Testing for antibody to hema- lineages even though there was evidence of cytopenias in
topoietic lineage cells, HLA, antigens, antibody bound to only a single lineage and demonstrated the presence of
red cells (DAT, direct antiglobulin test) or autoantigens in lineage-reactive antibody even when that lineage was not
the setting of a new onset cytopenias is often used to yet affected.
establish the diagnosis. The relatively low sensitivity of Based on the evidence from literature and the recom-
antiplatelet and anti-neutrophil antibody testing compared mendation of the expert panel, the approach to treatment
to that for IMHA, adds another hurdle to diagnose multiple should be based on risk stratification and response to first-
lineage or non-IMHA single lineage restricted cytopenias. line therapy (Fig. 1). The proposed treatment approach is
Earlier techniques, such as ELISA-based monoclonal anti- based on the diagnosis and is irrespective of the detection of
body immobilization of platelet antigen assay and lineage specific antibody. Patients with an isolated lineage
immunobead-based radioimmune assay for platelet anti- defect with a limited need for transfusion support or G-CSF
body testing are less sensitive and specific (70%). The more and usually resolve without the need for further therapy.
recent assays (e.g., flow cytometric immunobead assays) are Moderate risk patients, however, are those with IMHA and/
only marginally better with a sensitivity and specificity of or IMT requiring transfusions not more than once a week to
about 80% [43, 44]. Similarly, neutrophil antibody testing maintain a hemoglobin >7 g/dL and/or platelet count
based on indirect and direct immunofluorescence assays >10,000/μL, or frequent G-CSF support (more than twice a
have low sensitivity and specificity (60–70%) [45]. Since week) to maintain an absolute neutrophil count (ANC)
these tests identify the presence of circulating IgG against ≥200/μL. Overall, these patients usually respond well to a
neutrophils, prior treatment with recently administered combination of steroids and IVIg as the first-line of therapy.
IVIG can confound results. For these reasons, the panel felt Rituximab can be added to the therapy for those who fail to
that the diagnostic criteria could not be based on the pre- respond to first-line agents. Severe/high-risk patients are
sence of antibody alone. The initial workup should exclude those with severe IMN (ANC <200/μL), IMHA requiring at
other causes of cytopenias, such as use of myelosuppressive least twice weekly transfusions (red cells and platelets) to
drugs, active infections, or other known etiologies of maintain a hemoglobin >7 g/dL, and/or to maintain a pla-
cytopenia, including acute and chronic GVHD, transplant telet count >10,000/μL. These patients are at higher risk for
associated thrombotic microangiopathy, viral associated needing prolonged courses of immune suppression and are
graft suppression or failure, or splenic sequestration sec- more likely to require multiple agents to control the disease.
ondary to other etiologies. The consensus panel proposed a In addition, these patients are at a higher risk of infection
set of diagnostic criteria for IMC (Table 2), recognizing and graft failure. For these reasons, a more aggressive
specific limitations as noted. This also presents a diagnostic approach is recommended. The rationale for this systematic
framework for evaluation of patients suspected to have IMCs approach and the agents used to target different components
and exclude other possible causes of cytopenias post HCT. of the immune system, such as plasma cells, activated T-
Diagnosis of IMC involving multiple cell lines can be and B cells, dendritic cells, macrophages, NK cells, and the
especially difficult to differentiate from other etiologies of complement system are shown in Fig. 2. As majority of
graft suppression or failure. IMC, however, typically occurs patients develop IMCs while on post-HCT immunosup-
after primary hematopoietic recovery with substantial, if not pression, another important consideration is switching the
complete, chimerism in the myeloid compartment. It is calcineurin inhibitors to sirolimus, which has shown
commonly associated with an unexplained, rapid decline in improvement in recurrent and refractory IMCs [36]. Use of
hemoglobin with evidence of hemolysis (increased reticu- daratumumab has also now been favored for upfront ther-
locyte count, increased lactate dehydrogenase, low hap- apy in moderate to severe IMCs [40–42]. These recom-
toglobin, indirect hyperbilirubinemia, and the presence of mendations from the consensus panel are for consideration
spherocytes on peripheral smear) and a positive DAT. but the treating physicians should choose the best approach
However, in the setting of a negative DAT the diagnosis for their patients based on the individual patient scenario
should still be considered if other evidence of hemolysis is and the availability as well as experience with various
present. IMT can present as a decrease in platelets without agents.
proven antiplatelet antibodies but with a poor response to
platelet transfusions. While the marrow can demonstrate Future directions
normal to decreased megakaryopoiesis, chimerism is often
complete. Similarly, IMN can present as decrease in neu- Additional research is necessary to better understand the
trophils without proven anti-neutrophil antibodies. Bone etiopathophysiology of IMC. Since patients with IMD who
marrow evaluation often shows islands of neutrophil pre- undergo HCT are typically young and naive to chemotherapy
cursors and occasionally clear evidence of maturation arrest. with an intact immune system, often receive reduced toxicity
Table 2 Proposed diagnostic approach and criteria.
Lineage Diagnostic approach Diagnostic criteria for IMC Limitations

Red cells • Rule out other attributable causes of severe anemia post • Hemoglobin ≤7 g/dL (or 70 g/L) or a drop in previously stable • DAT may not detect IgA and other low affinity
HCT: bone marrow suppression due to infections (CMV, hemoglobin of more than 2 g/dL within 5 days (or 20 g/L) antibodies
EBV, Adenovirus, HSV, and other related infections) or without any other attributable cause AND • Haptoglobin not always interpretable
medications, graft insufficiency or graft failure based on • Presence of red cell directed antibody, DAT positive; if • LDH is a non-specific marker
clinical evaluation and diagnostic testing negative the diagnosis should still be considered if there is • Reticulocytopenia can be seen in early IMC
• Rule out other identifiable cause of hemolytic anemia after evidence of hemolysis as suggested by: (recommend bone marrow evaluation to rule out
transplant: TA-TMA, GVHD, drug induced hemolysis, • Presence of spherocytosis and/or other evidence of red cell aplasia)
transfusion reaction and ABO or minor blood group hemolysis on the peripheral smear such as RBC clumping
incompatibility based on clinical evaluation and the or agglutination
diagnostic criteria for each • Suggestive findings: elevated LDH, elevated reticulocyte
count, indirect hyperbilirubinemia, low serum haptoglobin
Platelets • Rule out other attributable causes of severe • Platelet count <20,000 cells/mm3 (20 × 109 cells/L) after • Poor sensitivity and specificity of antibody testing
thrombocytopenia post HCT: etiologies causing increased initial platelet engraftmenta or a significant drop (>50% drop
platelet destruction (TA-TMA, GVHD, and TTP), splenic from previous stable platelet count) in platelet count from
sequestration; bone marrow suppression due to infections previously stable levels without any other attributable cause,
and/or medications, graft insufficiency or graft failure based AND either
on clinical evaluation and diagnostic testing • Presence of platelet directed antibody
• Anti-GPIIb/IIIa
• Donor specific anti-HLA, OR
• If antibody negative,
• Pattern of a transient response/refractory to platelet
transfusions
• Other suggestive finding: bone marrow shows normal
megakarypoiesis
Neutrophils • Rule out other attributable causes of severe neutropenia post • Absolute neutrophil count <500 cells/mm3 (0.5 × 109 cells/L) • Poor sensitivity and specificity of antibody testing
HCT: bone marrow suppression due to infections and/or after initial neutrophil engraftmentb, or a significant drop • False positive neutrophil antibody testing in the
medications, graft insufficiency or graft failure based on (>50% drop from previous stable neutrophil count) AND setting of IVIG use
clinical criteria and diagnostic testing either
• Presence of neutrophil directed antibody
• Anti-HNA
• Donor specific anti-HLA, OR
• If antibody negative, despite >95% donor myeloid chimerism
• Marrow myeloid arrest or absence with recovery of red
cells and platelets
• Poor or no response to G-CSF
C3 complement 3, DAT direct antibody test, GCSF granulocyte colony stimulating factor, GPIIb/IIIa glycoprotein IIb/IIIa, GVHD graft versus host disease, HLA human leukocyte antigen, HNA
human neutrophil antigen, IgG immunoglobulin G, IMC immune-mediated cytopenia, IVIG intravenous immunoglobulin, LDH lactate dehydrogenase, MMF mycophenolate mofetil, RBC red
blood cell, TA-TMA transplant associated thrombotic microangiopathy, TTP thrombotic thrombocytopenic purpura.
a
Platelet engraftment defined as platelet count of >50,000/mm3 for at least 7 consecutive days after transplant not supported by transfusion.
b
Neutrophil engraftment defined as absolute neutrophil count >500 cells/mm3 for 3 consecutive days after HCT.
A. O. Gupta et al.
Consensus opinion on immune-mediated cytopenias after hematopoietic cell transplant for inherited. . .

Risk Categories Treatment Approach

Fig. 1 Proposed risk categories
and treatment algorithm for
immune cytopenias. Standard Risk
• Isolated IMHA or IMT 1st line: transfusion
responsive to transfusions support*/intermittent G-CSF support
• Isolated IMN with ANC≥200
Lack of appropriate Alternate Agents (usually used in
response to G-CSF/ combination)
increased transfusion • Mycophenolate mofetil (used
support by some centers as initial
Moderate Risk
therapy for high-risk
IMHA and IMT/IMN temporarily • Methylprednisone 2 mg/kg/da cytopenias)
responsive to G-CSF/transfusions • IVIG 1 gram/kg IV daily x 3, then • Sirolimus (standard dosing;
(not requiring more than once consider weekly to maintain goal, taper consider discontinuing or
weekly transfusions to maintain based on responseAdd rituximab if switching calcineurin inhibitor
hemoglobin >7 g/dL and platelet inadequate response to sirolimus)
count >10,OOO/uL)
• Azathioprine 1 mg/kg/d x 14
Lack of appropriate days, then once daily at same
response in 3-4 dose (used by some centers as
weeks*** initial therapy)
• Vincristine (1.5 mg/m2 IV over
High Risk Initial Therapy 4 hours every week for 1-4
Any of following: • Methylprednisone 2 mg/kg/db doses)
• Severe IMN with ANC <200 • IVIG 1 gram/kg IV daily x 3c • Cyclophosphamide (750 mg/m2
despite G-CSF • Rituximab** weekly x 4 1-3 doses)
• IMHA requiring at least 2 • Bortezomib (1.3 mg/m2/dose SO/IV • Eltrombopag (start at lower
transfusions/week to maintain (SQ preferred) given twice a week for dose and titrate up for
hemoglobin >7 g/dL 4 doses) optimum response)
• IMT requiring at least 2 • Plasmapheresis • Daratumumab (16 mg/kg/week
transfusions/week to maintain Consider alternate agents if refractory 4-6 doses)
platelet count >10,OOO/uL or poor response
• Eculizumab weekly (standard
dosing as used for TA-TMA)

*Transfusion Goal: Maintain Hemoglobin ≥7 g/dL, Platelets ≥10 000/uL

a- Once counts stabilize, taper when transfusion needed <q7 days. Start tapering at 10% every 5-7 days over 8-10
weeks. Consider slower taper with longer treatment at 0.5mg/kg/day for recurrent or refactory cytopenias
b- Taper when ANC ≥200, transfusions needed <q7 days (IMHA) and <q3 days (IMT). Start tapering at 10% every 5-7 days
over 8-10 weeks.
c- Consider replacing IgG for levels below 400, especially when used with rituximab. When using along with plasmapheresis
recommended to do it after completion of plasmapheresis cycles.
**Rituximab- 375 mg/m2 dose weekly, up to 4 doses, use of rituximab can be [MOU1] associated with neutropenia
and thrombocytopenia ~8-10 weeks post treatment.
***includes reduced transfusion requirement and/or G-CSF support along with stable counts. Add bortezomib and
plasmapheresis, if refractory consider alternate agents.

conditioning leading to mixed chimerism, and frequently Newer agents and treatment strategies should be con-
transplanted with HLA mismatched unrelated donor HSCs, sidered for multi-lineage immune cytopenias and those
they may be particularly high risk for this complication. One refractory to first or second line agents. Daratumumab has
of the major challenges is the lack of a consistent definition been used in refractory immune cytopenias and more
for IMC after HCT. Various studies have defined it differently reports are encouraging earlier use in immune cytopenias
and there is a need for consensus on the definition in order to [40–42, 46]. Carfilzomib is a newer proteasome inhibitor
identify the true incidence and assess the risk factors. Larger that irreversibly binds and permanently inhibits activity.
registry based (such as CIBMTR, Eurocord) and multicenter More effective B-cell depletion can be achieved with newer
studies are required to further delineate populations at high agents such as obinutuzumab, a humanized, type II,
risk and develop strategies for diagnosis and management in immunoglobulin- G1 anti-CD20 mAb, which acts through
high-risk populations. antibody-dependent cellular cytotoxicity and leads to direct
Another challenge is to identify the underlying pathophy- apoptosis of mature B cells [47]. B-cell development and
siology of this process. Several biomarkers can be used to proliferation can also be targeted by agents such as ibrutinib
demarcate the immune biology with T-cell markers for Tregs that inhibit bruton tyrosine kinase, which is an important
(CD4/25br/127lo/FoxP3+), T-follicular helper cells, lym- signaling protein for B-cell receptor. Costimulatory block-
phocyte subsets including NK cells, B cells, T cells with ing of IgG Fc fusion protein containing cytotoxic T
activated CD4 and CD8 subsets, cytokine such as plasma B- lymphocyte-associated protein-4 (CTLA4-Ig) has shown to
cell activating factor, chemokines like CXCL13, CXCR4, modulate humoral immunity and B-cell function at the level
immunoglobulins IgG, A, M, D, and their subclasses, B-cell of B cell–T follicular helper cell interaction in renal trans-
activation markers and memory B-cell markers, plasmablasts plant patients [48] and could be another agent of potential
(CD19LO CD27−), interleukins (soluble IL-6), and com- interest. Antibodies targeting complement system (eculizu-
plement activation markers (C5a, sC5b9). mab) and IL-6/IL-6R (clazakizumab, tocilizumab) are other
 A. O. Gupta et al.

Fig. 2 Current and future targets

for intervention in immune
mediated cytopenias.

Dendritic
cell
* Plasmapheresis
Macrophage

* IVIG
NK cell

* Steroids * Azathioprine

Plasma cell * Cyclophosphamide

* Vincristine
Proteasome * MMF
CD40L CD4+
T-cell
CD4

TCR
Clonal * IVIG
proliferation CD40
CD20
MHC II
* Bortezomib
* Daratumumab Activated
B-cell

IgR
* Rituximab IL-6R
Clonal
proliferation

* Tociluzumab
Complement * Eculizumab
cascade

Intervention
Limited reports for use in pediatric patients post HSCT
IVIG = Intravenous immunoglobulin
MMF = Mycophenolate mofetil

agents that could play important role in blocking the Based on a 1-day, focused panel discussion of experts in
immune interaction. the treatment of patients with IMD by HCT, a consensus
IMC is a known complication in patients undergoing opinion was developed on the diagnostic criteria and man-
allogeneic HCT. It is a major complication with substantial agement of this increasingly important complication. This
morbidity in young children who receive HCT for IMDs. work represents a starting point for optimizing the treatment
Greater consistency in defining the immune cytopenias, the of IMC and possibly better understanding its etiology and
diagnostic workup and treatment may help identify best pathophysiology. Further analysis of multicenter data is
practices for reducing the morbidity and mortality associate ongoing to better understand the risk factors and outcomes
with this complication. Serial investigation of immune of IMC after HCT in children with IMDs.
reconstitution including enumeration of lymphocyte and
immunoglobulin subsets and cytokine profiles may yield Acknowledgements This expert consensus was based on information
developed for and during a meeting supported by Magenta
new surveillance strategies for identifying those at Therapeutics. The content of this paper is solely that of the authors.
highest risk.
Consensus opinion on immune-mediated cytopenias after hematopoietic cell transplant for inherited. . .

Beth Kamp, PharmD, a medical writer supported by funding from haematopoietic cell transplantation in paediatric patients: high
Magenta Therapeutics provided initial editorial assistance to the incidence and significant mortality in unrelated donor transplants
authors during preparation of this paper. for non-malignant diseases. Br J Haematol. 2004;127:67–75.
11. Page KM, Mendizabal AM, Prasad VK, Martin PL, Parikh S,
Author contributions AG, JB, CE, TL, PO, AS, JW, and RW provided Wood S, et al. Posttransplant autoimmune hemolytic anemia and
review of the literature and contributed to the development of the other autoimmune cytopenias are increased in very young infants
content of the paper. BB provided critical input regarding pathophy- undergoing unrelated donor umbilical cord blood transplantation.
siology of IMC and critical review of paper. AG wrote the paper with Biol Blood Marrow Transplant. 2008;14:1108–17.
contributions from all authors. 12. Deambrosis D, Lum SH, Hum RM, Poulton K, Ogden W, Jones
S, et al. Immune cytopenia post-cord transplant in Hurler syn-
drome is a forme fruste of graft rejection. Blood Adv.
Compliance with ethical standards 2019;3:570–4.
13. Gupta A, Downey M, Shanley R, Jennissen C, Miller WP, Lund
Conflict of interest This expert consensus was based on information TC, et al. Reduced-toxicity (BuFlu) conditioning is better toler-
developed for and during a meeting supported by Magenta ated but has a higher second transplantation rate compared to
Therapeutics and subsequent data and literature review along with myeloablative conditioning (BuCy) in children with inherited
discussions. The content of this paper is solely that of the authors. metabolic disorders. Biol Blood Marrow Transplant.
2020;26:486–92.
Publisher’s note Springer Nature remains neutral with regard to 14. Szanto CL, Langenhorst J, de Koning C, Nierkens S, Bierings M,
jurisdictional claims in published maps and institutional affiliations. Huitema ADR, et al. Predictors for autoimmune cytopenias after
allogeneic hematopoietic cell transplantation in children. Biol
Blood Marrow Transplant. 2020;26:114–22.
15. Daikeler T, Tyndall A. Autoimmunity following haematopoietic
References stem-cell transplantation. Best Pract Res Clin Haematol.
2007;20:349–60.
1. Chen FE, Owen I, Savage D, Roberts I, Apperley J, Goldman JM, 16. Ahmed I, Teruya J, Murray-Krezan C, Krance R. The incidence of
et al. Late onset haemolysis and red cell autoimmunisation after autoimmune hemolytic anemia in pediatric hematopoietic stem
allogeneic bone marrow transplant. Bone Marrow Transplant. cell recipients post-first and post-second hematopoietic stem cell
1997;19:491–5. transplant. Pediatr Transplant. 2015;19:391–8.
2. Dovat S, Roberts RL, Wakim M, Stiehm ER, Feig SA. Immune 17. Hwang-Bo S, Kim SK, Lee JW, Jang PS, Chung NG, Jeong DC,
thrombocytopenia after umbilical cord progenitor cell transplant: et al. Treatment and response of autoimmune cytopenia occurring
response to vincristine. Bone Marrow Transplant. 1999;24:321–3. after allogeneic hematopoietic cell transplantation in children.
3. Horn B, Viele M, Mentzer W, Mogck N, DeSantes K, Cowan M. Blood Res. 2017;52:119–24.
Autoimmune hemolytic anemia in patients with SCID after T cell- 18. Scordo SM, Shah GL, Kosuri S, Adrianzen Herrera DA, Hsu M,
depleted BM and PBSC transplantation. Bone Marrow Transplant. Devlin SM, et al. Immune-mediated hemolytic anemia (IMHA)
1999;24:1009–13. and immune thrombocytopenia (ITP) after ex-vivo CD34+
4. Bhatt V, Shune L, Lauer E, Lubin M, Devlin SM, Scaradavou A, selected allogeneic hematopoietic stem cell transplantation. Biol
et al. Autoimmune hemolysis and immune thrombocytopenic Blood Marrow Transplant. 2017;23:S129–30.
purpura after cord blood transplantation may be life-threatening 19. Lum SH, Selvarajah S, Deya-Martinez AA, McNaughton P, Sobh
and warrants early therapy with rituximab. Bone Marrow Trans- A, Waugh S, et al. Outcome of autoimmune cytopenia after
plant. 2016;51:1579–83. hematopoietic cell transplantation in primary immunodeficiency. J
5. Chang TY, Jaing TH, Wen YC, Huang IA, Chen SH, Tsay PK. Allergy Clin Immunol. 2020;146:P406–16.
Risk factor analysis of autoimmune hemolytic anemia after allo- 20. Griesemer AD, Sorenson EC, Hardy MA. The role of the thymus
geneic hematopoietic stem cell transplantation in children. Medi- in tolerance. Transplantation. 2010;90:465–74.
cine. 2016;95:e5396. 21. Takahama Y, Nitta T, Mat Ripen A, Nitta S, Murata S, Tanaka K.
6. Daikeler T, Labopin M, Ruggeri A, Crotta A, Abinun M, Hussein Role of thymic cortex-specific self-peptides in positive selection
AA, et al. New autoimmune diseases after cord blood transplan- of T cells. Semin Immunol. 2010;22:287–93.
tation: a retrospective study of EUROCORD and the Autoimmune 22. Barr TA, Shen P, Brown S, Lampropoulou V, Roch T, Lawrie S,
Disease Working Party of the European Group for Blood and et al. B cell depletion therapy ameliorates autoimmune disease
Marrow Transplantation. Blood. 2013;121:1059–64. through ablation of IL-6-producing B cells. J Exp Med.
7. Faraci M, Zecca M, Pillon M, Rovelli A, Menconi MC, Ripaldi 2012;209:1001–10.
M, et al. Autoimmune hematological diseases after allogeneic 23. Chapoval S, Dasgupta P, Dorsey NJ, Keegan AD. Regulation of
hematopoietic stem cell transplantation in children: an Italian the T helper cell type 2 (Th2)/T regulatory cell (Treg) balance by
multicenter experience. Biol Blood Marrow Transplant. IL-4 and STAT6. J Leukoc Biol. 2010;87:1011–8.
2014;20:272–8. 24. King C, Ilic A, Koelsch K, Sarvetnick N. Homeostatic expansion
8. Holbro A, Abinun M, Daikeler T. Management of autoimmune of T cells during immune insufficiency generates autoimmunity.
diseases after haematopoietic stem cell transplantation. Br J Cell. 2004;117:265–77.
Haematol. 2012;157:281–90. 25. Roord ST, de Jager W, Boon L, Wulffraat N, Martens A, Prakken
9. Kruizinga MD, van Tol MJD, Bekker V, Netelenbos T, Smiers FJ, B, et al. Autologous bone marrow transplantation in autoimmune
Bresters D, et al. Risk factors, treatment, and immune dysregu- arthritis restores immune homeostasis through CD4+CD25
lation in autoimmune cytopenia after allogeneic hematopoietic +Foxp3+ regulatory T cells. Blood. 2008;111:5233–41.
stem cell transplantation in pediatric patients. Biol Blood Marrow 26. Seidel MG, Fritsch G, Lion T, Jurgens B, Heitger A, Bacchetta R,
Transplant. 2018;24:772–8. et al. Selective engraftment of donor CD4+25high FOXP3-positive
10. O’Brien TA, Eastlund T, Peters C, Neglia JP, Defor T, Ramsay T cells in IPEX syndrome after nonmyeloablative hematopoietic
NK, et al. Autoimmune haemolytic anaemia complicating stem cell transplantation. Blood. 2009;113:5689–91.
 A. O. Gupta et al.

27. Archer LD, Langford-Smith KJ, Bigger BW, Fildes JE. Muco- 38. Bowen DA, Call TG, Shanafelt TD, Kay NE, Schwager SM,
polysaccharide diseases: a complex interplay between neuroin- Reinalda MS, et al. Treatment of autoimmune cytopenia compli-
flammation, microglial activation and adaptive immunity. J Inherit cating progressive chronic lymphocytic leukemia/small lympho-
Metab Dis. 2014;37:1–12. cytic lymphoma with rituximab, cyclophosphamide, vincristine,
28. Dani A, Chaudhry A, Mukherjee P, Rajagopal D, Bhatia S, and prednisone. Leuk Lymphoma. 2010;51:620–7.
George A, et al. The pathway for MHCII-mediated presentation of 39. Waespe N, Zeilhofer U, Gungor T. Treatment-refractory multi-
endogenous proteins involves peptide transport to the endo- lineage autoimmune cytopenia after unrelated cord blood trans-
lysosomal compartment. J Cell Sci. 2004;117:4219–30. plantation: remission after combined bortezomib and vincristine
29. Rigante D, Cipolla C, Basile U, Gulli F, Savastano MC. Overview treatment. Pediatr Blood Cancer. 2014;61:2112–4.
of immune abnormalities in lysosomal storage disorders. Immunol 40. Blennerhassett R, Sudini L, Gottlieb D, Bhattacharyya A. Post-
Lett. 2017;188:79–85. allogeneic transplant Evans syndrome successfully treated with
30. Neely JA, Dvorak CC, Pantell MS, Melton A, Huang JN, Shi- daratumumab. Br J Haematol. 2019;187:e48–51.
mano KA. Autoimmune cytopenias in pediatric hematopoietic cell 41. Even-Or E, Naser Eddin A, Shadur B, Dinur Schejter Y, Najajreh
transplant patients. Front Pediatr. 2019;7:171. M, Zelig O, et al. Successful treatment with daratumumab for
31. Crowther M, Chan YL, Garbett IK, Lim W, Vickers MA, post-HSCT refractory hemolytic anemia. Pediatr Blood Cancer.
Crowther MA. Evidence-based focused review of the treatment of 2020;67:e28010.
idiopathic warm immune hemolytic anemia in adults. Blood. 42. Schuetz C, Hoenig M, Moshous D, Weinstock C, Castelle M,
2011;118:4036–40. Bendavid M, et al. Daratumumab in life-threatening autoimmune
32. Hartert A, Willenbacher W, Gunzelmann S, Roemer E, Basara N, hemolytic anemia following hematopoietic stem cell transplanta-
Fauser AA, et al. Successful treatment of thrombocytopenia and tion. Blood Adv 2018;2:2550–3.
hemolytic anemia with IvIG in a patient with lupus-like syndrome 43. Zhai J, Ding M, Yang T, Zuo B, Weng Z, Zhao Y, et al. Flow
after mismatched related PBSCT. Bone Marrow Transplant. cytometric immunobead assay for quantitative detection of platelet
2001;27:337–40. autoantibodies in immune thrombocytopenia patients. J Transl
33. Khandelwal P, Davies SM, Grimley MS, Jordan MB, Curtis BR, Med. 2017;15:214.
Jodele S, et al. Bortezomib for refractory autoimmunity in 44. Zhao Y, Zhu M, Jiang M, Zuo B, Wu Q, Ruan C, et al. An
pediatrics. Biol Blood Marrow Transplant. 2014;20:1654–9. improved flow cytometric immunobead array to detect auto-
34. Mehta B, Mahadeo K, Zaw R, Tang S, Kapoor N, Abdel-Azim H. antibodies in plasma from patients with immune thrombocyto-
Bortezomib for effective treatment of a child with refractory penic purpura. Clin Chim. 2015;438:396–400.
autoimmune hemolytic anemia post allogeneic hematopoietic stem 45. Porretti L, Farruggia P, Colombo FS, Cattaneo A, Ghilardi R,
cell transplant. Pediatr Blood Cancer. 2014;61:2324–5. Mirra N, et al. Diagnostic value of cell bound and circulating
35. Ratnasingam S, Walker PA, Tran H, Kaplan ZS, McFadyen JD, neutrophil antibody detection in pediatric neutropenia. Pediatr
Tran H, et al. Bortezomib-based antibody depletion for Blood Cancer. 2018;65:65:e26904.
refractory autoimmune hematological diseases. Blood Adv. 46. Salas MQ, Alahmari A, Lipton JH. Successful treatment of refrac-
2016;1:31–5. tory red cell aplasia after allogeneic hematopoietic cell transplanta-
36. Bride KL, Vincent T, Smith-Whitley K, Lambert MP, Bleesing JJ, tion with daratumumab. Eur J Haematol. 2020;104:145–7.
Seif AE, et al. Sirolimus is effective in relapsed/refractory auto- 47. Pavlasova G, Mraz M. The regulation and function of CD20: an
immune cytopenias: results of a prospective multi-institutional “enigma” of B-cell biology and targeted therapy. Haematologica.
trial. Blood. 2016;127:17–28. 2020;105:1494–506.
37. O’Connell N, Goodyer M, Gleeson M, Storey L, Williams M, 48. Leibler C, Thiolat A, Henique C, Samson C, Pilon C, Tamagne M,
Cotter M, et al. Successful treatment with rituximab and myco- et al. Control of humoral response in renal transplantation by
phenolate mofetil of refractory autoimmune hemolytic anemia belatacept depends on a direct effect on B cells and impaired T
post-hematopoietic stem cell transplant for dyskeratosis congenita follicular helper-B cell crosstalk. J Am Soc Nephrol.
due to TINF2 mutation. Pediatr Transplant. 2014;18:E22–4. 2018;29:1049–62.