Influence of stored aqueous ceftriaxone solutions on colony formation by neutrophil and macrophage precursor cells

Aqueous solutions of ceftriaxone in concentrations similar to those achieved in man and stored at temperatures of 4 degrees C, 22 degrees C and 37 degrees C for up to four weeks were tested in methylcellulose cultures of normal bone marrow from ten donors. No significant differences were detected between the colony formation by neutrophil and macrophage precursors in control cultures and in cultures containing stored ceftriaxone. It is concluded that aqueous ceftriaxone solutions stored for up to four weeks at temperatures up to 37 degrees C are not altered to such an extent that they adversely affect colony formation by bone marrow progenitor cells from healthy donors.

[Serum factors and their effect on hematopoiesis]

Human serum contains stimulators of hemopoietic precursor cells. Isolation of "factors" from serum is technically more difficult than from supernatants due to interactions of "factors" with the high molecular weight serum proteins. On the other hand, serum factors are naturally occurring activities which are likely to play a role in regulation of hemopoiesis. Two hemopoietic stimulators which differ from the known colony stimulating factor have been found in human serum. One of them is an indirect "releaser" activity, which induces the release of granulocyte colony stimulating factor (G-CSF) from normal peripheral blood lymphocytes. In patients whose cells release abnormally low amounts of G-CSA, this serum activity is elevated, indicating a feedback mechanism between "releaser" activity and the actual release. G-CSA itself does not circulate in serum. Thus, we assume that releaser activity has a local effect in the bone marrow on the release of G-CSF. These observations suggest that hemopoiesis is regulated by multi-step hormonal mechanisms, in analogy to other known hormone systems.

A comparison between ALG and bone marrow transplantation in treatment of severe aplastic anemia

One hundred patients with severe aplastic anemia were treated and evaluated in a prospective study at our hospital between January 1976 and October 1983. 28 patients had a HLA-identical sibling donor and were treated with bone marrow transplantation. 72 patients without a HLA-identical sibling donor were given antilymphocyte globulin followed by oral low dose androgen therapy. One and a half years to nine years after treatment 13 patients (46%) survive in the transplant group and 53 patients (74%) survive in the second group. All except one in the second group have self-sustaining hematopoiesis without need for transfusions. There is one major difference between the two therapies. Marrow transplantation restores bone marrow function completely and no late hematological complications have been seen in this group. The majority of patients treated with antilymphocyte globulin in contrast have residual abnormalities of hemopoiesis: macrocytosis, mild granulocytopenia and mild thrombocytopenia. Relapse (11 of 72 patients) and clonal hematological disorders, such as paroxysmal nocturnal hemoglobinuria (4 patients) and leukemia (one patient) can occur years after complete bone marrow reconstitution with antilymphocyte globulin. These late disorders are of concern. In spite of this we conclude that antilymphocyte globulin treatment is an effective therapy with low early mortality and morbidity and a high chance for a long sustained remission. Results are better or at least equivalent to bone marrow transplantation and patients with donors should be given the option of transplantation or antilymphocyte globulin.

Engraftment of T-cell-depleted rabbit bone marrow

T cell depletion of donor bone marrow prevents graft-versus-host disease (GvHD) but increases the risk of rejection. Rabbit bone marrow was T-cell-depleted using the properties of rabbit T cells to form spontaneous rosettes in the cold and by incubation in methylprednisolone (1 mg/ml, 10(6) cells/ml). New Zealand white rabbits were transplanted with Red Burgundy rabbit bone marrow from the opposite sex after conditioning with 12 Gy total body irradiation. Untreated animals die of GvHD at day 23. Three groups were studied: T cell depletion plus ciclosporin (A), T-cell-depleted bone marrow plus irradiated autologous bone marrow plus irradiated donor buffy coat (B), and T-cell-depleted bone marrow plus irradiated autologous bone marrow plus irradiated donor buffy coat plus ciclosporin (C). Buffy coat cells irradiated with 15 Gy were given for 5 days. Such cells do not form colonies in culture; however, they are able to release interleukin-2. In group A, 9 of 15 animals rejected, 6 survived for 45 days (median, range 16-249 days). In group B, all 5 of 5 animals died of rejection (median survival time 14 days, range 13-20 days). In group C, 8 of 10 animals did engraft, 4 died of GvHD (median survival 48 days, range 26-58 days), and 4 are long-term survivors (greater than 6 months to greater than 1 year), 3 as complete chimeras. We conclude that the combination of irradiated donor buffy coat cells, irradiated autologous bone marrow and ciclosporin restores engraftment of T-cell-depleted mismatched bone marrow without losing the benefit of reduced GvHD.

[Adverse effects of total body irradiation for bone marrow transplantation: prevention and therapy. Experience at Basel, July 1979-March 1986]

Acute toxicity, delayed complications and the incidence of interstitial pneumonitis (IP) after total body irradiation (TBI) are reviewed. Between July 1979 and March 1986 118 patients with hematological malignancies underwent bone marrow transplantation (BMT): all were conditioned with cyclophosphamide and TBI. 106 patients received single dose irradiation (18 with lung-shielding) and 12 had fractionated TBI. Except for mucositis all other symptoms of acute toxicity such as fever, vomiting, parotitis, headache and abdominal pain were usually of short duration. Fractionated TBI did not produce less acute side effects than single dose irradiation. Irradiation, and particularly the maximum lung dose, plays an important role in the multifactorial pathogenesis of IP. Delayed complications may appear several months or years after TBI. The majority of men suffer definitive sterility caused by azoospermia. In women primary ovarian failure and permanent sterility is a common sequela of BMT with TBI. The risk of developing cataracts after single dose TBI is about 80%, and surgical repair was necessary in 43% of these cases. Secondary tumors after TBI have been reported. So far we have observed no secondary malignancies in our patients after BMT. Rampant dental decay can be avoided by careful dental prophylaxis.

Immunoadsorption for removal of anti-A and anti-B blood group antibodies in ABO-incompatible bone marrow transplantation

About 10-15 percent of all patients undergoing allogeneic bone marrow transplantation have a major ABO-incompatibility with their donors. The risk of acute hemolytic reactions due to the infusion of an incompatible donor marrow into the recipient can basically be prevented by recipient antibody depletion or by donor marrow red cell depletion. Nine patients were treated by immunoadsorption using a cartridge with chemically synthesized human blood group A and B antigen as immunoadsorbent for antibody depletion. Within a four-hour-procedure about 2-4 times the patient plasma volume could be processed, thus lowering the anti-A and -B hemagglutinins by 2 to 3 tubes. There was a tendency of better IgG removal when titers initially were high, showing a high antibody clearing capacity. There was no significant correlation between starting titer or amount of plasma volume processed and titer reduction. No decrease in titers were observed in one case. We propose repeated immunoadsorption procedures over 2-3 consecutive days before BMT. The procedure is largely safe and without serious side effects. A major advantage is the avoidance of nonautologous human blood products compared to the conventional plasma exchange. All 8 patients surviving long enough had prompt and stable engraftment of all three cell lines post BMT. No late serological complications occurred when patients were regularly monitored and in vivo adsorption was used when titers increased.

Acquired aplastic anaemia: a PNH-like disease?

Bone marrow from 20 patients with aplastic anaemia at different stages of disease and from three patients with paroxysmal nocturnal haemoglobinuria (PNH) was incubated in isosmolar sucrose with 5% autologous serum prior to culture in methylcellulose. If fresh serum was used, colony formation by granulocyte-macrophage colony forming cells (GM-CFC) and immature erythroid precursors (BFU-E) was reduced to approximately 50% in all patients tested, at any stage of disease, including complete autologous bone marrow recovery. Heat inactivation and complement inactivation with EDTA completely abrogated this inhibitory serum effect. Selective inactivation of the classical, antibody dependent complement pathway with Mg2+ EGTA reduced the inhibitory effect by 50%. Complement sensitivity of haemopoietic precursors is a known feature of PNH. Since the majority of our patients did not have PNH as judged by a negative sucrose-test on mature erythrocytes, we conclude that, in aplastic anaemia, haemopoietic cells express a PNH-like defect at a primitive level.

Characteristics and clinical relevance of autolymphocytotoxins in patients with aplastic anemia

Serum of 68 patients with aplastic anemia was tested for the presence of autolymphocytotoxins (auto-LTs). Prior to specific disease treatment, 16 patients (24%) displayed antibodies cytotoxic to their own lymphocytes. These antibodies had the characteristics of cold-reactive lymphocytotoxins. Their detection in patients' sera was found unrelated to a viral or toxic cause of the disease or the patients' HLA genotype. Broadly reactive anti-HLA antibodies were less frequent in pretreatment sera containing auto-LTs, suggesting that these autoantibodies could modulate alloantibody production. However, after specific disease treatment, the alloantibody frequency was comparable in patients with or without auto-LTs. We found no significant difference in response to antilymphocyte serum or bone marrow graft outcome in the patients in relation to the presence or absence of pretreatment auto-LTs. This observation suggests that the detection of these autoantibodies in aplastic anemia has no clinical relevance.

Increased frequency of DR2 in patients with aplastic anaemia and increased DR sharing in their parents

68 patients with aplastic anaemia, their parents and healthy siblings were typed for HLA-A, B and DR antigens. Among the patients there is an overrepresentation of DR2. The parents of affected children show an increased compatibility at the DR locus. This situation could favour the expression of recessive gene(s) involved in haematopoiesis and located in the HLA locus.

The release of interleukin-2 (IL-2) and colony stimulating activity (CSA) in aplastic anemia patients: opposite behaviour with improvement of bone marrow function

Peripheral blood cells from patients with aplastic anemia were tested for their ability to release interleukin-2 (IL-2) and colony stimulating activity (CSA) before treatment. IL-2 release--as measured in the mouse thymocyte assay--was abnormally high in 18/34, and abnormally low in 10/34 patients. "Low" release was due to simultaneous release of thymocyte inhibitors. In 18 patients who achieved self-sustaining hemopoiesis after high dose immunosuppressive therapy, excess IL-2 release decreased to low levels (p less than 0.001), and the release of inhibitors disappeared. In contrast, the release of CSA by patient cells--which did not correlate with peripheral blood monocyte counts--either remained high or increased to excessively high values in 24/24 patients tested before and after successful immunosuppressive treatment. Patients with stable hemopoietic grafts after bone marrow transplantation for aplastic anemia, did not release excess CSA. It is concluded that IL-2 and CSA play opposite roles in aplastic anemia. High IL-2 release seems associated with disease activity, whereas high CSA-release appears to reflect a repair mechanism.

Influence of graft-versus-host disease prophylaxis on early T-lymphocyte regeneration following allogeneic bone marrow transplantation

An early decrease in the ratio between T4+ and T8+ T lymphocytes has been shown to correlate with the development of grade II-IV GVHD in allogeneic bone marrow transplant (BMT) recipients receiving methotrexate (MTX) as prophylaxis for acute graft-versus-host disease (GVHD). This study compares the onset of T-cell regeneration in patients receiving cyclosporin A (CyA) with those receiving MTX. Firstly, lymphoid recovery occurred at a significantly faster rate in the patients on CyA. Secondly, in those patients, the repopulation of T4+ and T8+ T cells started simultaneously, whereas in patients on MTX the repopulation of the T8+ subset lagged about a week behind that of the T4+ subset. Thirdly, the decrease in the T4/T8 ratios as a function of the lymphocyte counts occurred at a significantly slower rate in the patients on CyA than in those on MTX. Thus, the differences in the onset of T-cell regeneration in BMT recipients on CyA as compared with those on MTX abolished the correlation of the T4/T8 ratio changes with grades II-IV GVHD as described in patients receiving MTX.

Treatment of severe aplastic anemia

A total of 100 patients with severe aplastic anemia were treated and evaluated in a prospective study at our hospital between January 1976 and October 1983: 28 patients had an HLA-identical sibling donor and were treated with bone marrow transplantation, and 72 patients without an HLA-identical sibling donor were given antilymphocyte globulin followed by oral low-dose androgen therapy. At 1 1/2-9 years after treatment, 13 patients (46%) survive in the transplant group and 45 patients (75%) survive in the second group. All except one in the second group have self-sustaining hematopoiesis without need for transfusions. There is one major difference between the two therapies. Marrow transplantation restores bone marrow function completely and no late hematologic complications have been seen in this group. The majority of patients treated with antilymphocyte globulin in contrast have residual abnormalities of hematopoiesis: macrocytosis, mild granulocytopenia, and mild thrombopenia. Relapse (11 of 72 patients) and clonal hematologic disorders, such as paroxysmal nocturnal hemoglobinuria (four patients) and leukemia (one patient) can occur years after complete bone marrow reconstitution with antilymphocyte globulin. These late disorders are of concern. Despite this, we conclude that antilymphocyte globulin treatment is an effective therapy with low early mortality and morbidity and a high chance for a long, sustained remission. Results are better or at least equivalent to bone marrow transplantation and patients with donors should be given the option of transplant or antilymphocyte globulin.

The effect of cytomegalovirus infection on T lymphocytes after allogeneic bone marrow transplantation

The influence of cytomegalovirus (CMV) infection on peripheral T lymphocyte repopulation was studied in 59 bone marrow transplant (BMT) recipients who received either cyclosporin A (CyA) or methotrexate (MTX) as prophylaxis for acute graft-versus-host disease. We used monoclonal antibodies and single- or double-marker immunofluorescence for the quantitation of T4+, T8+ and HNK1+ T cell subpopulations. CMV infection was serologically diagnosed by an enzyme-linked immunosorbent assay (ELISA), and by viral cultures and histological studies. Among the 52 patients who were evaluable for CMV infection, one had a primary infection and 24 had CMV reactivation/reinfection after BMT. In the latter patients, increases to supranormal levels were observed in T8+ T cells and HNK1+ T cells, both in patients on CyA and in patients on MTX. Double-marker immunofluorescence revealed that the two markers were largely expressed by the same cells, which therefore had the T8+ HNK1+ phenotype. In addition, the very small subset of T4+ HNK+ T cells was slightly, but consistently, increased in the patients with CMV reactivation/reinfection. CMV infection did not influence the numbers of T4+ HNK1- and T8+ HNK1- T cells. The long-lasting presence of large numbers of T8+ HNK1+ T cells in patients who had CMV reactivation/reinfection suggests a continuing interaction between the virus and the immune system of its host.

Stimulatory serum factors in aplastic anaemia. II. Prognostic significance for patients treated with high dose immunosuppression

Serum from patients with aplastic anaemia contains two distinct stimulatory activities on haemopoiesis in culture. The first is a highly unstable enhancing activity, which mainly stimulates colony formation from BFU-E and macrophage precursors, and only acts when added directly to target bone marrow cultures. It is destroyed by Sephadex G-150 chromatography, and thus differs from colony stimulating activity (CSA) and burst promoting activity (BPA). Its mode of action is unknown. It was elevated in 70/97 patients with severe aplastic anaemia (SAA). 71 of these 97 patients were treated with high dose immunosuppression. 55/71 who achieved self-sustaining haemopoiesis had higher serum stimulating activity on BFU-E than 16/71 who never achieved remission (P = 0.0004). It was predictive of response as an all or none phenomenon, independent of the time required for recovery. It was, however, unsatisfactory as a single prognostic test. Bone marrow reconstitution also occurred in 4/71 patients whose serum inhibited BFU-E in direct culture. The second stimulator acts via enhancement of CSA- and BPA-release by accessory cells and is therefore termed 'releaser' activity. It was elevated in 27 of 51 aplastic anaemia patients and did not correlate with direct stimulatory activity. High 'releaser' activity was not predictive of response in 42 patients treated with high dose immunosuppression. However, the ability of patient cells to respond to autologous 'releaser' activity was a positive risk factor. Patients whose cells released an excess of CSA in the presence of autologous serum had a significantly higher chance of autologous recovery within 3 months than patients who produced little or no CSA in the presence of normal or excess releaser activity (P less than 0.0001). A scoring system which includes these two good risk factors is proposed for estimation of a patient's probability to recover autologous bone marrow reconstitution.

Stimulatory serum factors in aplastic anaemia. I. Serum 'releaser' activity for haemopoietic growth factors, a regulator?

Human serum contains an activity which enhances the release of colony stimulating and burst promoting activity (CSA and BPA). It is low in the majority of normal sera and was found elevated in patients with aplastic anaemia. The patient's 'response' to autologous serum releaser activity was measured by comparing CSA and BPA release by patient cells in percentage of release by normal cells. This 'response' was negatively correlated with serum releaser activity (P = 0.0035 for CSA-release, P less than 0.0001 for BPA-release), i.e. releaser activity was high, when factor release was low. This inverse relationship between releaser activity and the patient's response was also observed in four patients with pancytopenia of causes other than aplastic anaemia. We conclude that elevated serum releaser activity reflects a repair mechanisms which operates when CSA- and BPA-production is inadequate. Thus, releaser activity is likely to be a haemopoietic regulator.

[Invasive pulmonary aspergillosis--a diagnostic and therapeutic problem in patients with severe aplastic anemia]

Three young patients with severe aplastic anemia undergoing intensive immunosuppressive therapy developed fever and pulmonary infiltrates during longlasting severe granulocytopenia, despite multiple broad spectrum antibiotic combinations and granulocyte transfusions. Invasive pulmonary aspergillosis was diagnosed only by thoracotomy. In conjunction with high dose amphotericin-B therapy complete resolution of aspergillosis was achieved in two cases, paralleled by slow recovery of bone marrow function, whereas in the third case only a partial remission was possible together with transient amelioration of granulopoiesis. We suggest early aggressive surgical methods to establish the diagnosis of aspergillosis in these severely menaced patients, so that antifungal therapy with high dose amphotericin-B can be initiated at an early stage.

Unidirectional influx and phosphorylation of glucose analogues in cultured astroblasts

Unidirectional influx of 14C-3OMG (3-O-methyl-D-glucose) and rate of phosphorylation of 14C-2DG (2-deoxy-D-glucose) were determined in primary cultures of astroblasts under conditions with negligible unstirred layers. The influx exhibited rate constants between 7.2 and 8.3 min-1 in the concentration range 2.5-25 mM of unlabeled 3OMG and was considered constant, irrespective of concentration of 3OMG. The rate of phosphorylation of 14C-2DG declined for rising concentrations of 2DG and hence showed saturability. The rate constants ranged from 7.9 to 0.1 min-1 in the concentration range 0.04-25 mM of 2DG. These results are not consistent with the view that the influx limits the rate of phosphorylation. They support the notion that the influx is not rate limiting for the phosphorylation.

[Current status of allogenic bone marrow transplantation in chronic myelocytic leukemia]

Bone marrow transplants were carried out in 18 patients with chronic myelogenous leukemia (CML) in the chronic phase (CP). 12 (67%) are still alive, 11 without evidence of leukemia after a mean observation period of 24 (3-44) months, 1 relapsed and 6 died. The most frequent cause of death was GvHD and interstitial pneumonia (5). 1 patient died of septicemia. 2 grafts were performed in patients with CML in the accelerated phase (AP); both died, one from leukemic relapse and one from GvHD. The authors also participated in an international study in which 117 patients were evaluated. In CP there was a survival plateau at 63%, in AP at 36% and in blastic crisis at 12%. In CP mortality was primarily age-dependent and relapses occurred in only 7%. It is concluded that bone marrow transplantation (BMT) is a highly successful treatment for CML, with the CP the optimum moment for grafting. Longlasting cytogenetic and clinical remissions with potential for cure are possible in a high percentage of patients. The incidence of transplant-related mortality is acceptable. The incidence of leukemic relapse is low in CP. Patients under age 40 with HLA-identical siblings should be transplanted in CP. At present BMT is the only treatment with curative potential for CML.

[Acyclovir in the therapy of herpesvirus infections]

Intravenous acyclovir was tested both prophylactically and therapeutically in herpes infections in 48 patients undergoing bone marrow transplantation. Pretransplant prophylaxis only partly eliminated reactivated infections. Treatment of established mucocutaneous infections was usually successful, also in relapsing cases, when initiated within hours of the appearance of lesions. Extensive lesions, superinfections and dissemination could thus be prevented in this group of severely immunocompromised patients.

Bone marrow cell dose and kinetics of recovery following allogeneic marrow transplantation in man

In 50 patients transplanted for acute or chronic leukemia we studied the correlation between the number of infused bone marrow cells/kg recipient body weight and the time needed for engraftment. Engraftment was arbitrarily defined as the first day of 1 X 10(9) leukocytes/l and of 20 X 10(9) reticulocytes/l after the posttransplantation nadir. There is a negative non-linear correlation between the duration of leukopenia following marrow transplantation and the amount of transfused nucleated cells (p = 0.01). Since the incidence of infectious or hemorrhagic complications depends directly on the duration of aplasia it is justifiable to give a maximal cell dose.

[Bone marrow transplantation in acute lymphatic leukemia during the first remission]

9 patients with acute lymphoblastic leukaemia (ALL) were transplanted in first remission. There were no leukaemic relapses and 6 patients became longterm survivors. Causes of death were GvHD in 2 and interstitial pneumonia in 1. 14 patients with ALL were grafted in later stages of the disease. 10 had a leukaemic relapse. One attained longlasting remission with chemotherapy, while 9 died. One patient died of CMV infection. Cotton wool lesions and haemorrhages in the retina posed a problem in patients with previous cranial irradiation. We recommend transplantation of ALL in first remission if a syngeneic or HLA-identical sibling is available, particularly if the patient has poor risk factors for chemotherapy. Prophylactic cranial irradiation should be replaced by intrathecal methotrexate and/or cytosin arabinoside in these patients.

Haemopoietic stimulators and inhibitors in aplastic anaemia serum

Normal serum and serum from four patients with severe aplastic anaemia was fractionated by Sephadex G-150 gel filtration. Fractions were tested for direct haemopoietic activity on colony forming cells in methylcellulose cultures, and for their indirect influence on haemopoiesis via CSA- and BPA-producing cells. All aplastic anaemia sera contained abnormal inhibitors and stimulators. An inhibitor acting on both haemopoietic and factor producing cells, eluting with the IgM fraction was found in all, variable inhibitors of lower molecular weight in single patients. Stimulatory activity of 10 000-50 000 MW acting on factor producing cells, but not on colony forming cells directly, was found in all, a variable stimulator eluting with the very high MW fraction in single patients. In two patients who achieved complete autologous bone marrow remission after treatment with high dose immunosuppression, Sephadex fractions of serum before treatment and remission serum were simultaneously tested on autologous bone marrow in remission. Inhibitors were detected before treatment and disappeared in remission, stimulators were not detectable before treatment but became strong in remission. It is concluded that the effect of aplastic anaemia serum on haemopoiesis in culture is determined by the balance of inhibitors and stimulators on both haemopoietic and CSA/BPA producing cells.

Immunologic reactivity in marrow graft recipients receiving cyclosporine to prevent graft-versus-host disease

In vitro and in vivo immunologic parameters were determined in 26 patients treated continuously with cyclosporine to prevent graft-versus-host-disease (GVHD) after allogeneic bone marrow transplantation (BMT) for acute and chronic leukemia and for aplastic anemia. A group of 18 patients was tested 6 months after BMT and another group of 10 patients was tested after one year. At 6 months after BMT, 94% of the patients had normal serum IgG and IgM levels, whereas at one year 29% of them had low IgA levels. The proportion of patients with normal lymphocyte responses in vitro at 6 months after BMT was 69% and 76% for the responses to concanavalin A and to soluble antigens; 75% and 53% for the responses to allogeneic cells and pokeweed mitogen, respectively; and 89% for the response to phytohemagglutinin. All but one were able to generate suppressor cells upon con A stimulation. At one year after the graft, only one patient had demonstrable multiple abnormalities in in vitro tests. Skin test reactivity at one year was comparable to pre-graft reactivity. After BMT a lymphopenia persisted for 6 months. The rate of infectious complications was high during the first 3 months after BMT, and it diminished progressively as immune functions returned to normal. Infection was the cause of death in two cases (one disseminated cytomegalovirus infection and one septicemia). GHVD occurred in 12 patients; in nine of them the disease was transient and mild, only 1 patient developed severe chronic GVHD. Acute GVHD did not influence the tempo of immunologic reconstitution. In comparison to other studies, it seems that cyclosporine does not delay immune restoration, or increase morbidity from infection, while preventing GVHD and its complications efficiently.

[Bone marrow transplants--quo vadis?]

Early bone marrow transplantation (BMT) in leukaemia has enormously improved the results. Leukaemic relapse is rare, as is transplant-related mortality from interstitial pneumonia and severe graft-versus-host disease (GvHD). In aplastic anaemia the most important development is that treatment with ALG offers a real alternative to BMT which is of crucial importance for all patients without a histo-compatible family donor. The main problems of BMT are the lack of histocompatible donors and GvHD. In leukaemia, relapse is still an additional problem. The new immunosuppressive agent cyclosporin-A (CyA) has made an important contribution to the prophylaxis of severe GvHD. In future the results with CyA are potentially improvable by combination with other immunosuppressive agents. It is important that the use of HLA-semicompatible family donors, unrelated donors or alternative stem cell sources should become feasible. The value of autologous BMT is difficult to judge because in most instances it has been performed in patients with endstage disease. In several congenital diseases there are alternatives to BMT, such as genetic engineering. Although many problems of BMT still have to be solved, this procedure has an important place in modern medicine.

Cyclosporine in human bone marrow transplantation. Serum concentration, graft-versus-host disease, and nephrotoxicity

Serum concentrations of cyclosporine were studied in 42 patients given cyclosporine for the prevention of graft-versus-host-disease (GVHD) following allogeneic bone marrow transplantation (BMT). Serum trough levels for cyclosporine were determined in each patient at least once weekly during the first 3 months and were compared with the occurrence of GVHD and with nephrotoxicity. Cyclosporine was given as 20 mg/kg i.m. or as a 24-hr infusion for the first 5-7 days. This was followed by a single daily oral dose of 12.5 mg/kg for 6 months. Cyclosporine was then gradually reduced and stopped after one year. After a median observation period of 2 years 25 of the 42 patients (59%) are alive. Twenty six patients (62%) developed GVHD, which was stage II or more in 11 (26%) and fatal in 2 patients (5%). Five patients developed GVHD 6-8 weeks after withdrawal of cyclosporine one year after BMT. All patients improved after restarting cyclosporine. No correlation between cyclosporine serum concentration and GVHD was observed, but patients with GVHD had greater fluctuations of their serum trough levels. Serum creatinine increased in all patients soon after BMT and was correlated with cyclosporine serum concentration during the first month. Serum creatinine, however, rose further despite lower cyclosporine concentrations in the second month. These results show that cyclosporine effectively reduces the severity, but not the incidence, of GVHD suggesting that there is a subset of cells resistant to cyclosporine. The therapeutic range, however, between high doses (which are often associated with nephrotoxicity) and the minimal effective dose of cyclosporine, has yet to be defined.

[Bone marrow transplantation in leukemia and aplastic anemia]

In a review of allogeneic bone marrow transplantation (BMT) for leukemia the following points proved to be of crucial importance: (1) combination of cyclophosphamide (Cy) and total body irradiation (TBI) for conditioning, (2) early BMT for acute leukemia (AL) in first remission and for chronic granulocytic leukemia (CGL) in chronic phase, (3) prophylaxis of graft-versus-host disease (GvHD) with cyclosporin-A (CyA). 50 successive BMT for leukemia performed in Basel between July 1979 and September 1982 are analyzed. 7 of 13 acute myelogenous leukemias (AML) and 8 of 9 acute lymphatic leukemias (ALL) grafted in first remission, and 7 of 10 CGL, are alive without signs of leukemia and without chronic problems. Of the patients grafted for AL in second remission or later, 3 of 6 AML and 6 of 12 ALL are alive. Severe GvHD was seen in 5 of 43 BMT between HLD identical siblings, in three of them combined with interstitial pneumonia. Thus the incidence of these two serious complications of allogeneic BMT has been drastically reduced with CyA compared to our previous experience with prophylactic methotrexate (MTX). 4 grafts were performed between HLA-haploidentical siblings. 3 of the 4 patients developed fatal GvHD. This implies that in this histocompatibility setting CyA alone is not sufficient. No problems were encountered in 3 syngeneic BMT. 12 leukemic relapses were observed. Relapse never occurred in ALL in first remission and never in CGL. 4 recurrences were seen in AML in first remission. All other relapses were in patients with AL grafted in stages other than first remission. In 86 successive patients with severe aplastic anemia (SAA) the following important advances were made: (1) it was shown that the majority of patients have sufficient hemopoietic stem cells and that after treatment with antilymphocyte globulin (ALG) over 70% have long-lasting remissions, (2) the combined treatment with ALG and high dose prednisone increases the remission rates to 90% and in addition shortens the supportive care period significantly. These developments are of crucial importance for patients without an HLA-identical sibling, (3) success rates of marrow transplants between HLA-identical siblings could be increased from 36% with prophylactic MTX to 67% using CyA.

Dexamethasone enhances 'CSA' release and depresses 'BPA' release

Dexamethasone 10(-7) M enhanced the release of granulocyte-macrophage colony stimulating activity (GM-CSA) by peripheral blood cells from 15 normals. In 16 patients with hypoplastic marrow failure this effect was more prominent, the release of GM-CSA being increased up to 10-fold by dexamethasone. Dose-response curves of patient cell supernatants indicate that dexamethasone acts by abrogation of an inhibitor on CSA-production. Dexamethasone decreased the release of burst promoting activity (BPA) in all normals and most patients. We conclude that the interaction of glucocorticoid hormones with lymphocyte function results in positive and negative effects on haemopoiesis in vitro. Preliminary experiments in one patient suggest that the steroid effect in vivo correlates with GM-CSA enhancement in vitro.

Differential penetration of DSIP peptides into rat brain

Delta sleep-inducing peptide (DSIP) or five closely related peptides were injected peripherally and the levels of DSIP-like immunoreactivity measured in the brains of 100 g and 500 g rats decapitated a minute later after washout with 0.9% NaCl. Higher concentrations of immunoreactive material were found in brain tissue with injection of des Trp1-DSIP, D-Ala4-DSIP, and, after correction for cross-reactivity, with D-Ala4-DSIP-NH2 than with the other peptides. Both peptides substituted in the fourth position with D-alanine resulted in higher concentrations in 500 g rats than in 100 g rats, indicating a possible effect of age. The 5-10 fold greater brain to blood ratios of radioactivity after 125I-N-Tyr-DSIP than after 125-I radioiodinated serum albumin (RISA) provided additional evidence against non-specific leakage or contamination of the brains with substantial amounts of residual blood. The results suggest that penetration of the blood-brain barrier (BBB) by small amounts of peptides, at least DSIP peptides, may be somewhat selective.

Failure of MIF-1 or naloxone to reverse ischemic-induced neurologic deficits in gerbils

MIF-1 and naloxone exert similar actions in several situations. Since naloxone, at a dose of 1 mg/kg IP, has been reported to reverse the neurologic deficits of gerbils whose right common carotid artery had been occluded, MIF-1 was tested under the same conditions and the effects compared with naloxone. Doses of 0.1, 1.0, and 10.0 mg/kg IP of MIF-1 and naloxone did not significantly alter the signs of either moderate or severe neurologic deficits. Thus, the results of this study with gerbils do not add evidence for the use of these opiate antagonists in strokes.

Allogeneic marrow transplantation for chronic granulocytic leukemia

Six patients with Philadelphia-chromosome (Ph' +)-positive chronic granulocytic leukemia were transplanted from their HLA-identical siblings after conditioning with cyclophosphamide and 1'000 rad total body irradiation. All received cyclosporin-A for prophylaxis of Graft-versus-Host disease. All patients showed prompt engraftment and all are cytogenetically and clinically in complete remission. Two patients had transient mild signs of Graft-versus-Host-disease and one patient had unilateral facial nerve paresis of unknown origin. All are ambulatory and well 6-18 months (median 10 months) after transplantation.

[New development in clinical bone marrow transplantation in leukemia]

39 clinical bone marrow transplants (BMT) for leukemia are described. In a historical control series of 18 patients in whom BMT was performed after all chemotherapeutic resources had been exhausted, there is only 1 long-term survivor (5.5%), 8 patients died from GvH reaction, 6 from interstitial pneumonia and 3 from recurrent leukemia. Since 1979 an attempt has been made to transplant patients under optimal conditions (1st complete remission) and cyclosporin-A (CyA) has been used for prophylaxis of GvH reaction instead of MTX. 11 patients were transplanted according to our original proposal (AML and ALL in first remission, CML in chronic phase): 10 have survived without evidence of leukemia (91%), 1 AML died in relapse. 10 patients were grafted in second or later remissions or early relapse: 5 have leukemia-free survival (50%), 1 is living with a relapse. In this group 3 deaths were due to recurrent leukemia and 1 to CMV-infection. In our experience BMT under optimal circumstances does not involve a risk of early mortality and the chances of recurrent leukemia are reduced. Severe or chronic GvH reaction is not seen under CyA. BMT is the treatment of choice for patients with histocompatible sibling donors.

DSIP-like immunoreactivity in the developing rat brain

Delta sleep-inducing peptide (DSIP) is a naturally occurring nonapeptide that has been reported to affect sleep. The concentration of DSIP-like material was measured by a highly specific radioimmunoassay in brain tissue from developing rats. DSIP-like immunoreactivity was present in fetal brain at increased levels shortly before birth. In one experiment, a significant elevation in the concentration of the peptide occurred at postnatal day 20, but in a second, similar, study the increase occurred later. No marked differences in the levels of DSIP-like immunoreactivity were found in the brains of rats injected 2 months earlier with DSIP or among 10 parts of brains obtained at postnatal day 20. Regardless of the function of DSIP, it is available to the rat throughout early development.

Permeability of blood-brain barrier to DSIP peptides

An improved radioimmunoassay (RIA) for delta sleep-inducing peptide (DSIP) was used to study the permeability of the blood-brain barrier (BBB) to DSIP peptides. Although the synthetic analog [D-Ala3]-DSIP reacts fully in the assay, at least 8 of the 9 amino acids of the naturally occurring DSIP sequence are required for recognition by the antibody. A significant increase in DSIP-like immunoreactivity found in rat brain in one part of the study after peripheral injection of DSIP indicated, therefore, that some peptide crossed the BBB. The much higher levels found in brain tissue after intracarotid administration of [D-Ala3]-DSIP as compared with DSIP made it unlikely that non-specific leakage of peptide across the BBB was the only explanation. Furthermore, the findings after infusion with saline for one minute tended to rule out contamination of brain tissue by peptide remaining in blood. Thus, the results provide additional evidence that one of the ways peptides administered peripherally can influence the brain is by transport across the BBB essentially intact.

[Treatment of severe aplastic anemia]

58 patients with severe aplastic anemia (SAA) were treated and evaluated in a prospective study either by bone marrow transplantation (BMT) or by antilymphocyte globulin (ALG). 19 patients were treated with BMT; 9 are still alive 6 months to 5 years after BMT (47%). 39 patients were treated with ALG; 28 are alive 5 months to 5 years after ALG (72%). 24 of these 28 are self-sustaining and in remission. The results show that treatment with ALG is probably superior to treatment with BMT, and also demonstrate that most patients with SAA have a pool of hematopoietic stem cells able to repopulate the marrow after this type of treatment.

Can whole blood be used instead of separated low density cells for examination of the mitogen response?

The response of whole blood and separated low density cells to 3 mitogenic lectins [Phytohaemagglutinin (PHA), Pokeweed mitogen (PWM) and Concanavalin (Con-A)] was tested in 133 normal individual of all ages, including cord blood. The results obtained with the two methods correlated poorly (r = 0.16 for PHA; 0.47 for PWM and 0.42 for Con-A). Thus, the two methods measure different things and results are not comparable.