Bone Marrow Transplantation (2018) 53:392–399

https://doi.org/10.1038/s41409-017-0015-2

ARTICLE

Haploidentical bone marrow transplantation with post transplant

cyclophosphamide for patients with X-linked adrenoleukodystrophy:
a suitable choice in an urgent situation
Juliana Folloni Fernandes1,2 Carmem Bonfim3,4 Fábio Rodrigues Kerbauy1 Morgani Rodrigues1
● ● ● ●

Iracema Esteves1 Nathalia Halley Silva1,2 Alessandra Prandini Azambuja1,2 Luiz Fernando Mantovani1,2
● ● ● ●

José Mauro Kutner1 Gisele Loth3,4 Cilmara Cristina Kuwahara3,4 Clarissa Bueno5 Andrea Tiemi Kondo1
● ● ● ● ●

Andreza Alice Feitosa Ribeiro1 Fernando Kok5,6 Nelson Hamerschlak1

● ●

Received: 28 June 2016 / Revised: 23 January 2017 / Accepted: 15 April 2017 / Published online: 12 January 2018
© Macmillan Publishers Limited, part of Springer Nature 2018

Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is the only treatment that enhances survival and stabilizes
neurologic symptoms in X-linked adrenoleukodystrophy (X-ALD) with cerebral involvement, a severe demyelinating
1234567890

disease of childhood. Patients with X-ALD who lack a well-matched HLA donor need a rapid alternative. Haploidentical
HSCT using post transplant cyclophosphamide (PT/Cy) has been performed in patients with malignant and nonmalignant
diseases showing similar outcomes compared to other alternative sources. We describe the outcomes of transplants
performed for nine X-ALD patients using haploidentical donors and PT/Cy. Patients received conditioning regimen with
fludarabine 150 mg/m2, cyclophosphamide 29 mg/kg and 2 Gy total body irradiation (TBI) with or without antithymocyte
globulin. Graft-vs.-host disease prophylaxis consisted of cyclophosphamide 50 mg/kg/day on days +3 and +4, tacrolimus or
cyclosporine A and mycophenolate mofetil. One patient had a primary graft failure and was not eligible for a second
transplant. Three patients had secondary graft failure and were successfully rescued with second haploidentical transplants.
Trying to improve engraftment, conditioning regimen was changed, substituting 2 Gy TBI for 4 Gy total lymphoid
irradiation. Eight patients are alive and engrafted (17–37 months after transplant). Haploidentical HSCT with PT/Cy is a
feasible alternative for X-ALD patients lacking a suitable matched donor. Graft failure has to be addressed in further studies.

Introduction

X-linked adrenoleukodystrophy (X-ALD) is the most

common peroxisomal disease, with an estimated incidence
1:20,000 males [1]. It is caused by a defect in the ABCD1
* Nelson Hamerschlak (ATP binding cassette transporter 1) gene, which is located
hamer@einstein.br at Xq28 and encodes for a peroxisomal membrane protein
1 involved in the metabolism of very long chain fatty acids
Hematology and Bone Marrow Transplantation Program, Hospital
Israelita Albert Einstein, São Paulo, Brazil (VLCFAs). These VLCFAs accumulate in the brain and
2 adrenal tissues [2]. There are six distinct clinical pheno-
Instituto da Criança, Hospital das clínicas da Faculdade de
Medicina da Universidade de São Paulo, São Paulo, Brazil types, including: adrenal insufficiency alone, adrenomye-
3 loneuropathy with or without cerebral disease (CALD), and
Bone Marrow Transplantation Department, Hospital de Clinicas
da Universidade Federal do Paraná, Curitiba, Brazil CALD, of childhood, adolescent, or adult onset [3]. The
4 plasma VLCFA assay is the recommended diagnostic pro-
Bone Marrow Transplantation Department, Hospital Nossa
Senhora das Graças, Curitiba, Brazil cedure. Characteristic magnetic resonance imaging (MRI)
5 findings are found in patients with the cerebral form of the
Department of Neurology, Hospital das Clinicas da Faculdade de
Medicina da Universidade de São Paulo, São Paulo, Brazil disease. The childhood-onset cerebral ALD is the most
6 devastating form of the disease; it typically affects young
Centro de Estudos do Genoma Humano da Universidade de São
Paulo, São Paulo, Brazil boys from 4 to 8 years of age, presenting initially with
Haploidentical HSCT with PT/Cy for X-ALD
behavioral changes and adrenal insufficiency (in most
cases), followed by a rapid progressive neurologic dete-
rioration (visual impairment, auditory processing problems,
seizures, loss of cognitive, and motor function) leading to
death approximately 2–5 years after symptom onset.
Approximately 35% of boys with X-ALD will develop
CALD [4–6].
Allogeneic hematopoietic stem cell transplantation
(HSCT) may cease the progression of cerebral X-ALD in
patients with early stages of disease [7, 8]. The exact
mechanism of the HSCT benefit is still not well defined [4,
5]. Early-stage CALD is defined as that in which the patient
performs well, has intelligence quotient (IQ) of 80 or higher
and less white matter involvement on brain MRI, e.g., Loes
score (a 34-point MRI rating scale reported by Loes et al.
[9]) of 9 or less [7]. Prognosis of HSCT in this group is
excellent, with mortality rates of <8% reported [10]. Sta-
bilization of the disease usually occurs 6 months after the
transplantation [11]. In a study comparing HSCT to the
natural history of cerebral X-ALD without treatment, a
group of patients with early-stage disease had a 5-year
overall survival (OS) estimate of 95% after HSCT, while in
the group not receiving transplant, the 5-year OS probability
was 54%. Also, the disability status was different between
groups: 53% of patients who received transplants and were
alive 5 years after the onset of symptoms had a neurologi-
cally stable disease, compared with 6% of the non-
transplanted group [6].
Due to the rapid progression of the disease, it is not
possible to identify, in a suitable time, an appropriately
matched marrow donor, sibling or unrelated, for many
patients. In these urgent situations, the use of alternative
sources, such as the umbilical cord blood units from unre-
lated donors and partially mismatched related donors
(haploidentical), might be considered [12–14].
Historically, the use of alternative sources has been
associated with increased incidences of graft-vs.-host dis-
ease (GVHD) and graft rejection. Recently, it has been
shown by several groups that cyclophosphamide at high
doses after HSCT (post transplant cyclophosphamide (PT/
Cy)) can regulate the alloreactivity associated with partially
matched donors in pre-clinical [15] and clinical studies [16].
The administration of PT/Cy may selectively deplete the
T cells from the alloreactive donor that are responsible for
the GVHD, preserving the non-alloreactive, resting memory
T cells that can facilitate engraftment and accelerate
immune reconstitution [14–17]. Studies using the non-
myeloablative (NMA) regimen with PT/Cy have shown
good outcomes mostly in adults with hematological
malignancies, while the experience with children and non-
malignant disorders are scarce [18–21].
Here, we hypothesized that NMA transplant with PT/CY
using partially matched grafts from related donors
393
(haploidentical) could offer acceptable results for X-ALD
patients with indication of an immediate allogeneic HSCT.
The objective of this study was to describe a series of cases in
which patients with ALD were treated with haploidentical
HSCT following NMA conditioning and PT/CY, combining
the experience of two institutions, and the effects of this
intervention on engraftment, OS, and neurological outcomes.
Materials and methods
Study design, setting and ethics
This is the description of a series of patients with CALD
treated in two institutions in Brazil (Hospital of the Federal
University of Paraná and Albert Einstein Hospital, through
a philanthropic collaboration with the federal Ministry of
Health). The study was approved by the institutional review
board of both participating institutions. Patients and/or
parents signed an institutional review board-approved
informed consent forms before HSCT.
Participants: patients and donors
Eligibility criteria for this study included X-ALD diagnosed
by VLCFA assay with cerebral involvement showed by
characteristic lesions on MRI, good performance status
(Karnofsky or Lansky 70–100), ability of parents to sign
consent forms, and the presence of a partially (at least
haploidentical) HLA-matched relative willing to donate.
The patients included had no sibling donor available, and
the initial search for matched unrelated donor (MUD) in the
national and international donor registries had shown no
possibility of a rapidly available well-matched marrow
donor.
Donors were screened among first- and second-degree
relatives who shared at least one HLA haplotype with the
patient and were in good health. HLA typing was done with
high-resolution typing (loci A, B, C, DRB1, and DQB1 at
allele level) for all patients and donors. Donors were
excluded if the patient had donor-specific HLA antibodies
detected or if there were other medical reasons. Donor and
recipient degree of HLA disparities are described in Table 1
(considering 10 HLA loci—A, B, C, DRB1, and DQB1).
Preparation of donors
Donors received granulocyte colony-stimulating factor
(GCSF, 300 μg/day) starting 3 days before marrow harvest.
The bone marrow was harvested with a target of >5 × 108
nucleated cells/kg of the recipient body weight. There was
no graft manipulation except for plasma reduction, and
major incompatible ABO grafts had red blood cells depleted
Table 1 Patient, donor, and transplant characteristics
394

Patient

1 2 3 4 5 6 7 8 9

HSCT

2nd (after 1st 2nd 1st 2nd 1st 2nd

CBT failure)

Age at ALD diagnosis 13 7 5 6 2 5 6 6 6

(years)
Age at HSCT (years) 13 7 5 6 18 19 6 6 7 7 10 6
Absolute lymphocyte 2030 1560 3877 2177 2408 – 2515 – – 1420 3589
count (before transplant)
Loes score (before 6 12 12 8 19 21 12 12 7 10 2.5 11
transplant)
PIQ (before transplant) 99 95 105 103 97 96 103 98 97
NFS score (before 0 4 4 0 0 – 1 – 1 – 0 1
transplant)
Donor Father Father Father Father Uncle Uncle Father Brother Father Uncle Father Aunt
Donor’s age 51 51 42 51 47 49 37 18 48 46 52 29
HLA matching 06/10 06/10 05/10 06/10 06/10 06/10 05/10 05/10 05/10 06/out 05/10 05/10
Conditioning regimen Cy/Flu/TBI Cy/Flu/TBI Cy/Flu/TBI 2 Gy/ Cy/Flu/TBI 2 Cy/Flu/TBI 2 Cy/Flu/TLI Cy/Flu/TBI 2 Cy/Flu/TBI Cy/Flu/TBI 2 Cy/Flu/TBI Cy/Flu/ Cy/Flu/
2 Gy 2 Gy/ATG ATG Gy/ATG Gy/ATG 4 Gy Gy/ATG 2 Gy Gy 2 Gy TBI 2 Gy TLI 4 Gy
GVHD prophylaxis MMF/FK/ MMF/FK/ MMF/FK/PT Cy MMF/FK/PT Cy MMF/FK/PT MMF/FK/ MMF/FK/PT MMF/FK/ MMF/CsA/PT MMF/FK/ MMF/ MMF/FK/
PT Cy PT Cy Cy PT Cy Cy PT Cy Cy PT Cy CsA/PT PT Cy
Cy
Number of nucleated 5.68 6.18 9.59 7.81 4.31 4.28 4.8 8,4 7.5 8.83 6.83 9.6
cells infused (x108/kg)
Number of CD34+ cells 1.91 4.54 7.06 4.9 1.93 3.39 2.07 7,11 7.3 5,18 1.23 9,04
infused (x106/kg)
Neutrophil recovery 17 14 – 13 16 16 13 17 16 13 15 17
(days)
Donor chimerism (% > 98% 100% 0% 100% 27% 100% < 5% 100% 45% 100% 29% 100%
donor cells in whole
blood)
Graft failure No No Primary No Secondary No Secondary No Secondary No No No
Acute GVHD 0 III – III – II I 0 0 II II II
Chronic GVHD – – – – – Limited – – – Limited – –
Infections RSV CMV Parainfluenza Adenovirus – – CMV CMV CMV – CMV
NFS (most recent FCU) 0 17 18 9 – 0 – 10 – 7 0 13
Loes score (most recent 17 – 14 – 21 – 18 – 20 3 17
FCU)
J. F. Fernandes et al.
Haploidentical HSCT with PT/Cy for X-ALD 395

by buffy coat preparation. Total nucleated cell doses and

TLI total lymphoid irradiation, CBT cord blood transplantation, GVHD graft-vs.-host disease, MMF mycophenolate mofetil, CsA cyclosporine A, FK tacrolimus; CMV cytomegalovirus, RSV
ALD adrenoleukodystrophy, HSCT hematopoietic stem cell transplantation, Cy cyclophosphamide, PT post transplant, TBI total body irradiation, Flu fludarabine, ATG antithymocyte globulin,
CD34+ cell doses are described in Table 1.

24
9
Preparative regimen and GVHD prophylaxis

All patients received fludarabine 30 mg/m2 on days −6 to

30a
8

−2, and cyclophosphamide 14.5 mg/kg on days −6 and −5.

Most patients received total body irradiation (TBI) 2 Gy on
day −1, associated or not with rabbit antithymocyte glo-
2nd

29

bulin (ATG) 0.5 mg/kg on day −9 and 2 mg/kg on days −8

and −7. Bone marrow was collected and infused on day 0.
GVHD prophylaxis was made with cyclophosphamide 50
mg/kg on days +3 and +4 and a calcineurin inhibitor:
1st
7

tacrolimus (to maintain a level of 5–15 ng/dl) or cyclos-

porine A (to maintain a level of 200–400 ng/dl), together
with mycophenolate mofetil (MMF) 15 mg/kg every 8 h,
2nd

both started on day +5.

28

Treatment protocol evolution over time

The first patient (Table 1—patient #1) was transplanted

1st
6

after a primary graft failure following a double cord blood

transplant. He was rescued with the protocol described
above. After this first successful attempt, the same approach
2nd

17

was proposed as first-line therapy for other X-ALD patients

who needed urgent transplants and had no possibility of
respiratory syncytial virus, NFS Neurologic Function Score, PIQ Performance Intelligence Quotient

suitable related or unrelated donors (voluntary marrow

donors or cord blood). For subsequent patients, ATG was
added to the classical NMA regimen published by Luznik
1st
5

et al. [16], aiming to improve engraftment, following the

same idea proposed by Bolaños-Meade et al. [19] for sickle
Died at day

cell disease patients published in Blood Journal in 2012.

After treating five patients with this approach we still had
+257

disappointing results with mixed chimerism and late graft

4

failures. Therefore, in order to try to improve engraftment,

the protocol was revised and patient #9 (Table 1) received a
different regimen, without ATG and substituting 2 Gy TBI
for 4 Gy TLI (total lymphoid irradiation), sparing the brain
from radiation.
33
3

Supportive care
29
2

Patient with waning donor chimerism

All patients were hospitalized in reverse isolation with high-

CBT failure)

efficiency particulate air filtration. Patients received bac-

2nd (after
Patient

terial antibiotic prophylaxis with a quinolone, antifungal

HSCT

prophylaxis with micafungin or fluconazol, anti-HSV/VZ

37
1

prophylaxis with acyclovir and pneumocystis pneumonia

prophylaxis with sulfamethoxazole and trimethoprim.
Table 1 (continued)

Follow-up (months)

Patients were monitored for cytomegalovirus (CMV),

Epstein–Barr virus and adenovirus by weekly measurement
of viral copy numbers by real-time polymerase chain reac-
tion and preemptive therapy was initiated if threshold
number of virus copies was detected. Patients received
a
396
GCSF (10–15 μg/kg/day) from day +5 on, until neutrophil
recovery.
Time to neutrophil and platelet recovery and GVHD
analysis
“Time to neutrophil recovery” was defined as the period
required to reach at least 500 × 103/mm3 neutrophils in
peripheral blood for three consecutive days. “Time to pla-
telet recovery” was defined as the time to last platelet
transfusion to keep platelets counts over 20 × 103/mm3.
GVHD diagnosis and staging was based on published cri-
teria [22, 23].
Chimerism analysis
Patients had chimerism measured by short tandem repeat
analysis done on total peripheral blood on the day after
neutrophil recovery and days +60, +180, and +360.
Patients with mixed chimerism (between 5 and 95% donor
DNA detected) had studies done monthly to monitor chi-
merism evolution more closely. Patients with <5% donor
chimerism were considered as graft failure.
Neurologic assessment
Patients were administered the Wechsler Intelligence Scale
for Children Third Edition or the Wechsler Intelligence
Scale for Adults. A Performance Intelligence Quotient
below 80 was used as exclusion criteria [24, 25]. The 34-
point MRI rating scale devised by Loes et al. [9] was used
to grade MRI abnormalities [9]. The Neurologic Function
Score (NFS) scale reported by Moser et al. [26] was
assessed pre-transplantation and at the most recent follow-
up.
Results
Patient characteristics
From November 2012 to July 2014, nine patients with a
confirmed diagnosis of X-ALD were referred to the two
participating institutions to be considered for inclusion in
this study protocol. All patients had cerebral progressive
form of X-ALD with HSCT indication and had at least one
HLA-haploidentical related donor. These 9 patients were
submitted to 12 HSCT procedures with 11 different HLA-
haploidentical related donors (Table 1). The median age at
transplant was 7 (range, 6–18 years). They all had adrenal
insufficiency at the time of presentation and received low-
dose steroids. All patients had neuropsychological evalua-
tion with performance IQ results above 80. The NFS scale
J. F. Fernandes et al.
reported by Moser et al. [26] was also used to determine
neurologic dysfunction severity before and after transplant
(the most recent follow-up) and this is reported in Table 1.
Four patients presented with brain MRI with Loes score
below 9 (range, 2.5–8), four patients had Loes score
between 11 and 12, and one patient had a Loes score of 19.
These four cases with more advanced disease classified by
MRI (Loes score above 9) were individually and carefully
discussed by the HSCT team and families regarding the
benefit of the procedure. The entire cohort had very good
clinical conditions at the time of transplant. Data are pre-
sented as of December 15, 2015.
Donor and graft characteristics
All donors were first- or second-degree relatives (father, n
= 7; uncle, n = 2; aunt, n = 1; brother, n = 1) and shared an
HLA haplotype with the recipient. The median donor age
was 48 years, ranging from 18 to 52 years. All except two
grafts (n = 10) consisted of GCSF-primed bone marrow.
Grafts had a median nucleated cell count of 8.4 × 108/kg
recipient body weight (range, 4.3–9.6 × 108), and a median
CD34+ cell count of 7.1 × 106/kg recipient body weight
(range, 1.2–9 × 106).
Outcomes
Engraftment and chimerism
The median time to neutrophil recovery over 500 × 103/
mm3 was 16 days (range, 13–18 days). The median time to
last platelet transfusion, to keep platelets counts over 20 ×
103/mm3, was 19 days (range, 11–32 days). In four trans-
plants, platelets did not fall below 20 × 103/mm3, and there
was no need for platelet transfusions.
From the nine patients receiving first haploidentical
transplants, eight patients engrafted. Primary graft failure
with autologous reconstitution was seen in one patient
(patient #3) that recovered blood counts 14 days after
transplant with complete recipient chimerism in total blood
analysis. This patient with primary graft failure had rapid
progression of neurological symptoms and was considered
ineligible for a second transplant. Three patients (patient #5,
#6, and #7) had secondary graft failure (graft rejection with
autologous reconstitution), from 30 days to 12 months after
transplant. Patient #6 and #7 were submitted to second
transplants with different HLA-haploidentical donors fol-
lowing a preparative regimen with fludarabine 30 mg/m2 on
days −6 to −2, cyclophosphamide 14.5 mg/kg on days −6
and −5, TBI 2 Gy on day −1, and post transplant cyclo-
phosphamide 50 mg/kg on days +3 and +4. Patient #5 had
late graft failure and was submitted to a second transplant
with the same donor followed by preparative regimen with
Haploidentical HSCT with PT/Cy for X-ALD
fludarabine 30 mg/m2 on days −6 to −2, cyclophosphamide
14.5 mg/kg on days −6 and −5, TLI 4 Gy on day −1, and
post transplant cyclophosphamide 50 mg/kg on days +3
and +4.
Graft-vs.-host disease
From eight evaluable patients receiving first haploidentical
transplants, two had grade II acute GVHD with good
response to treatment with steroids, and two patients had
grade III–IV GVHD refractory to steroids that needed fur-
ther immunosuppression (extracorporeal photopheresis,
mesenchymal stem cells, sirolimus). One patient (#2) had
good response to second-line treatment and resolved
GVHD; the other (patient #4) had associated gastro-
intestinal adenovirus infection and died 8 months post
transplantation with bacterial sepsis and progressive neu-
rological disease.
Transplant-related complications and infections
All patients developed mild or moderate signs of mucositis,
no patient had sinusoidal obstruction syndrome, and 1
patient developed hemorrhagic cystitis associated with BK
virus infection. From the nine patients receiving first hap-
loidentical transplants, five had fever and inflammatory
symptoms in the days following graft infusion, which
ceased with PT/Cy administration. Two of three patients
receiving two haploidentical transplantations also devel-
oped inflammatory symptoms after the second transplant
procedure.
Four patients developed CMV reactivation treated suc-
cessfully with ganciclovir or foscarnet. One of them had
severe CMV-related pneumonitis. Two patients had
respiratory infections (syncytial respiratory virus and para-
influenza) with mild symptoms. One patient (patient #4) had
severe adenovirus infection with gastrointestinal involve-
ment and one patient had poliomavirus- (BK virus) asso-
ciated cystitis.
Survival and neurological outcomes
All patients except a few were alive at a median of
29 months (range, 17–37 months). Patient #4 died from
severe GVHD and adenovirus infection and had a rapid and
severe neurological progressive disease. Patient #3 had
autologous reconstitution associated with rapid neurologic
disease progression and is currently alive but in poor neu-
rological condition. Patient #8 is alive and is currently being
evaluated for a late graft rejection (29% donor chimerism)
and a second transplant with a different donor is in con-
sideration. Until the latest follow-up, he presented with no
signs of neurological disease progression, and his brain
397
MRI remains stable. The remaining six patients are alive
and engrafted. At the time of last visit, patient #1 had stable
neurological disease (only mild symptoms with hyper-
activity and attention deficit) and he goes to school with
good performance. Patient #2, #5, #6, and #9 are alive and
have complete donor engraftment, but had initial neurologic
disease progression with stabilization of symptoms around
12 months after transplant. They receive supportive and
rehabilitation care (motor skills, visual adaptation) at home.
Patient #7 is alive and engrafted but has progressive neu-
rological disease. Patients’ NFS at the most recent follow-up
are described in Table 1.
Discussion
Allogeneic HSCT is still the only treatment that was shown
to halt the severe and progressive symptoms of cerebral X-
ALD. Excellent results are achieved when HSCT is per-
formed in the early phase of the disease and these patients
should be referred to a transplant center as soon as possible
[3, 10, 11, 27].
Finding a suitable matched donor in a timely manner is a
challenge. Particularly in populations with a major degree
of miscegenation, like our country’s population, this search
may take as long as 6 to 12 months. In a study performed by
the National Registry of Donors, the median time to find an
MUD was 85 days (personal communication). For this
reason, the use of alternative donors may be considered
early in the treatment of X-ALD patients.
Historically the use of mismatched related donors
(haploidentical) is associated with severe GVHD.
Removing mature cytotoxic T-cell lymphocytes from the
graft (e.g. CD34+ cell selection) has resolved this pro-
hibitive GVHD, but increased the incidence of graft fail-
ure and infections due to delayed immune reconstitution.
In addition, current techniques of T-cell depletion are
expensive and not easily available in low-income coun-
tries. By using post transplant cyclophosphamide, several
groups have reduced GVHD incidence significantly after
haploidentical HSCT for malignant diseases, reaching
levels similar to HSCT from a related sibling donor [16–
18]. Because of these results and the immediate avail-
ability of haploidentical donors, we proposed a protocol
using this technique for X-ALD patients with urgent
indication of HSCT. All nine patients included in our
study had CALD with HSCT indication, no sibling donor
available, and the initial search for MUD in the
national and international donor registries had shown no
possibility of a rapidly available well-matched marrow
donor.
Unlike patients with malignant diseases, patients with
X-ALD have never received chemotherapy or other
398
immunosuppressants before HSCT with the exception of
low-dose steroids for adrenal insufficiency. Thus, they
may have higher probability of failure of engraftment
when compared to patients with already damaged immune
responses. For this reason, we decided to increase immu-
nosuppression by adding ATG to the classic NMA regi-
men following the idea used already in patients with
hemoglobinopathies by Bolaños-Meade et al. [19]. In
addition, we tried to increase CD34+ cell concentration in
grafts using GCSF in donors prior to marrow collection.
Regardless of these modifications, among our seven first
treated patients, one had primary graft failure and four had
progressive graft failure after initial engraftment. Three of
them received a successful second haploidentical trans-
plant. At this moment, we decided to augment immuno-
suppression by increasing irradiation dose. Instead of
using 2 Gy TBI, we proposed to use 4 Gy TLI, trying to
spare brain from irradiation. With this new regimen we
treated two patients; both of them reached stable full donor
chimerism. Other alternatives could be proposed aiming to
optimize immunossupression and prevent autologous
reconstitution, including: changing ATG doses and sche-
dule, increasing dose of irradiation or including more
myeloablative drugs in the regimen.
The high incidence of graft failure may have been due to
the use of an NMA conditioning regimen. In our study this
was initially proposed because patients had already
advanced neurologic disease. Even after the decision to
improve immunossupression with higher radiation doses,
we tried to avoid brain irradiation in order to minimize
neurotoxicity to these patients already with advanced cer-
ebral disease. This decision may also have to be reviewed
since there are studies (mainly pre-clinical studies in other
similar diseases) that show that donor-derived microglial
engraftment is associated with better neurological out-
comes, and that better microglial engraftment is achieved
with myeloablative regimens with CNS penetrating drugs or
radiation [28, 29].
Although it is well known that transplants have to be
performed early after CALD diagnosis, patients in our
protocol were referred with already significant progression
of symptoms and MRI abnormalities. Among the nine
patients transplanted, four of them had stable engraftment
of donor cells. From these, only one patient (patient #1)
remained with stable neurologic disease after HSCT. The
other three patients, despite engraftment, had worsening of
symptoms and MRI abnormalities early after HSCT. One
patient died of transplant-related complications and the
other two patients are alive, having had neurologic
symptoms stabilized around 1 year after transplant. Three
patients had progressive graft failure (with autologous
reconstitution) and were submitted to a second transplant;
all of them had signs of disease progression between the
J. F. Fernandes et al.
two transplants. One of them stabilized symptoms after the
second HSCT; the remaining two patients are alive with
progressive disease. The demyelination process in patients
with CALD is associated with a strong inflammatory
reaction in the CNS white matter, with perivascular infil-
tration with CD8 cytotoxic T lymphocytes leading to
cytolysis of oligodendrocytes. It has been reported that
inflammatory reactions like acute GVHD can be associated
with rapid clinical deterioration in X-ALD patients [3, 6,
27].
In the scenario of haploidentical transplantation using
PT/Cy as GVHD prophylaxis, several groups reported the
occurrence of noninfectious fever between day 0 and day 5
after graft infusion. It was hypothesized that this finding
could be related to a cytokine release from proliferating
alloreactive T cells [30]. In 6 of the 12 transplant procedures
in our study, patients had fever episodes between day 0 and
day +5, and four of them presented fever later on, with the
occurrence of grades II–III acute GVHD. We could then
speculate that these inflammatory reactions could also have
influenced in the progression of the demyelination process.
This association, however, has to be studied more carefully
and in larger cohorts.
In conclusion, we have shown that haploidentical HSCT
with post transplant cyclophosphamide is a feasible alter-
native for patients with CALD lacking a well-matched HLA
donor, but graft rejection is still an issue when using NMA
conditioning regimen. Optimal conditioning regimen to
prevent graft rejection (increasing intensity) and support
therapy aiming to reduce inflammatory reaction after cell
infusion are still points that need to be better addressed in
larger patient cohorts.
Acknowledgements We thank all the nurses, physicians, and multi-
disciplinary staff of the services for excellent patient care delivered to
these patients and families.
Author contributions J.F.F. designed the study, enrolled, and cared for
patients, analyzed data, and wrote the paper. C.B. and N.H. designed
the study, enrolled, and cared for patients, analyzed data, and reviewed
the paper. All the other authors contributed to data collection, patient
care, and reviewed the paper.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
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