Graft-versus-leukemia effect in allogeneic marrow transplant recipients with acute leukemia is maintained using cyclosporin A combined with methotrexate as prophylaxis. Acute Leukemia Working Party of the European Group for Blood and Marrow Transplantation

A total of 1634 recipients of HLA-identical sibling bone marrow with acute leukemia were treated with the combination of cyclosporin A (CsA) and methotrexate as prophylaxis against graft-versus-host disease (GVHD). The probability of relapse decreased with an increasing grade of acute GVHD, especially in patients grafted in first remission (CR-1): P < 0.01 and P < 0.001 for acute lymphoblastic leukemia and acute myeloid leukemia, respectively. Among patients surviving at least 3 months without a relapse, chronic GVHD was associated with a decreased incidence of relapse in CR-1 (P < 0.0001 for both diagnoses), and a better LFS. Among patients in CR-1, the probability of relapse was the same in those with limited or with extensive chronic GVHD. However, in patients with intermediate stage of the disease (> or = 2nd remission or 1st relapse) with previous acute GVHD, those with extensive chronic GVHD had a reduced probability of relapse (P = 0.05). The graft-versus-leukemia effect of acute and especially chronic GVHD was confirmed by multivariate analyses. Overall, the highest LFS was seen in patients with chronic GVHD and no or grades I-II acute GVHD. The lowest LFS was seen in patients having acute GVHD grades III-IV without chronic GVHD.

In utero haematopoietic stem cell transplantation: current perspectives and future potential

In utero transplantation (IUT) of haematopoietic cells is a new therapeutic option for families with increased risk of having a child with an inherited disorder. Immunological naiveté and the rapidly expanding haematopoietic system in the first trimester human fetus, make therapeutic intervention by IUT a real possibility for those disorders which can be diagnosed early in gestation. Fewer cells are required than in postnatal BMT and therapy can be offered before the pathological sequelae of a disorder become manifested. However, only a few cases of IUT have been performed in humans and it is imperative that consensus is reached quickly on issues such as cell numbers/cell types so that the benefits of this approach to treatment can be realised. This review presents the current status of IUT, the cases thus far recorded and offers a prospective view of developments in this rapidly expanding area.

Treatment of hepatic venoocclusive disease with recombinant human tissue plasminogen activator or orthotopic liver transplantation after allogeneic bone marrow transplantation

Ten allogeneic bone marrow transplant (BMT) recipients with hepatic venoocclusive disease (VOD) were treated with recombinant human tissue plasminogen activator (rt-PA). Two of them subsequently underwent orthotopic liver transplantation (OLT). One additional patient with VOD underwent OLT without prior rt-PA treatment. Treatment with rt-PA was started a median of 14 (1--35) days after BMT. The dose of rt-PA given to adults was 10-50 mg i.v. and that given to children was 3-10 mg i.v. Treatment was given for 2-4 days. In three patients, the dose was administered over a longer period or it was repeated. Four patients responded to rt-PA therapy and six did not. Eight patients suffered from hemorrhages, one intracranial and three gastrointestinal. Four patients required blood transfusions. Four had minor subcutaneous hemorrhages and/or epistaxis. One patient died of intracranial hemorrhage and five from hepatic and/or multiorgan failure. Two patients treated with rt-PA, 10 mg/day for 4 days, are alive; one is alive and well 3 months after BMT, the other has relapsed after 7 months. The three patients undergoing OLT died of chronic hepatic failure, cerebral edema, and pneumonia. Our experience suggests that rt-PA should not be administered in high doses and that the treatment should not be given over a longer period, because of the risk of severe hemorrhages.

Colony formation of human fetal CD34+ hematopoietic cells

Manipulations to enhance engraftment of donated cells may be advantageous in transplantation of fetal hematopoietic cells (FHC). By assessing the formation of colonies, CD34+ enrichment was evaluated with and without cytokine stimulation (interleukins 3 and 6, stem cell factor, granulocyte-macrophage colony-stimulating factor). Cord blood cells and bone marrow cells served as controls. In FHC, cytokine stimulation and CD34+ enrichment always enhanced the formation of CFU-GM (colony-forming units--granulocytes, macrophages) and CFU-GEMM (colony-forming units-granulocytes, erythroid cells, macrophages, megakaryocytes). However, BFU-E (burst-forming units--erythroid cells) in FHC remained unchanged after cytokine stimulation and CD34+ enrichment. In FHC, the addition of cytokines and the enrichment of CD34+ cells usually contributed equally to enhance CFU-GM and CFU-GEMM colony formation. CD34-negative FHC produced the same number or more BFU-E and half the number of CFU-GM and CFU-GEMM as compared with crude cells. This CD34-negative cell population also responded to cytokine stimulation. Such findings may indicate that purification of CD34+ cells is not meaningful in fetal transplantation.

Cytokine stimulation of human fetal hematopoietic cells

The effects of interleukins 3 and 6, stem cell factor, and granulocyte-macrophage colony-stimulating factor on human fetal hematopoietic, bone marrow, and cord blood cells were studied on the basis of the colony-forming capacity. Fetal hematopoietic cells from 28 elective abortions, three bone marrow samples, and three cord blond samples were incubated with cytokines and investigated for the presence of BFU-E (burst-forming units--erythroid), CFU-GM (colony-forming units--granulocytes, macrophages), and CFU-GEMM (colony-forming units--granulocytes, erythrocytes, macrophages, megakaryocytes). Single and combined cytokines and preincubation versus adding cytokines in culture were investigated. Interleukin-6 alone had the most pronounced effect on BFU-E formation. All four cytokines in combination yielded the highest scores for CFU-GM (p < 0.05) and CFU-GEMM (p < 0.05), whereas BFU-E was not enhanced. The mode of cytokine exposure was not a determinant of colony formation.

Loss of seroreactivity against human papillomavirus (HPV) in bone marrow transplant recipients

Sera from 19 autologous and 35 allogeneic bone marrow transplant (BMT) patients at Huddinge University Hospital were analyzed by different ELISA assays before and 1 year after BMT for the presence of IgG antibodies towards human papillomavirus (HPV). One assay was a peptide-based enzyme-linked immunoadsorbent assay (ELISA). These peptides were derived from the amino acid sequences of the two major viral capsid proteins of HPV 16, p(31) L1 and (p49) L2. The other was an ELISA using HPV-type 16 virus-like particles (VLPs) as antigens. Before BMT 13/19 autologous and 14/35 allogeneic BMT patients were IgG positive towards p49 (L2). Reactivity to p31 (L1) was less frequent and was only observed in 7/19 autologous and 3/35 allogeneic BMT patients. One year after BMT 1/4 of the autologous and 2/3 of the allogeneic BMT patients who were IgG positive to p49 (L2) lost these antibodies as measured by the peptide ELISA assay. Regarding IgG reactivity to p31 (L1), one of the seven p31 (L1) positive autologous BMT patients and all three of the p31 (L1) positive allogeneic BMT patients lost this reactivity 1 year after BMT. Of all the 19 autologous and the 35 allogeneic BMT patients only two allogeneic BMT patients were weakly IgG reactive towards VLPs and 1 year after BMT this activity was lost in one of the two patients.

Oral ribavirin for prevention of severe liver disease caused by hepatitis C virus during allogeneic bone marrow transplantation

Four allogeneic bone marrow transplant patients who were infected with hepatitis C virus (HCV) before bone marrow transplantation (BMT) were treated with oral ribavirin during and after transplantation. None of the patients had severe liver complications. One patient died early. Polymerase chain reaction analysis revealed that two patients who were HCV RNA-positive before BMT became HCV RNA-negative during therapy and remained HCV RNA-negative during 6 and 12 months of follow-up, respectively. No severe side effects of ribavirin were documented. Ribavirin therapy can be given safely to patients undergoing BMT and can result in clearance of HCV RNA.

A comparison of busulphan versus total body irradiation combined with cyclophosphamide as conditioning for autograft or allograft bone marrow transplantation in patients with acute leukaemia. Acute Leukaemia Working Party of the European Group for Blood and Marrow Transplantation (EBMT)

We retrospectively compared the outcome in patients in the EBMT database transplanted for acute leukaemia from January 1987 to January 1994 who received busulphan and cyclophosphamide (BU/CY) as a pretransplant regimen versus those who received cyclophosphamide and total-body irradiation (CY/TBI). The patients were matched for type of transplant (autologous bone marrow transplantation (ABMT) versus allogeneic (BMT)), diagnosis (acute lymphoblastic leukaemia (ALL) or acute myeloid leukaemia (AML)), status (early (first complete remission, CR-1) versus intermediate (second or later remission, first relapse)), age, FAB classification for AML, prevention of graft-versus-host disease and year of transplantation. In ABMT recipients (matched paired 530 x 2) with ALL CR-1, AML CR-1 and AML intermediate disease, transplant-related mortalities (TRM) relapse incidence (RI) and leukaemia-free survival (LFS) did not differ significantly in patients treated with BU/CY or CY/TBI. However, in ABMT recipients with ALL intermediate disease, the probability of relapse was 82 +/- 5% (+/- 95% confidence interval) in the BU/CY group compared to 62 +/- 6% in the CY/TBI group (P = 0.002) and the 2-year leukaemia-free survival 14 +/- 4% and 34 +/- 6%, respectively (P = 0.002). In BMT recipients of bone marrow from HLA-identical siblings (matched paired 391 x 2), the TRM, RI and LFS did not differ significantly between the two treatments in all groups. In particular, the 2-year LFS in patients with AML CR-1 was 64 +/- 3% in those treated with BU/CY (n = 237) compared to 66 +/- 3% in those given CY/TBI (n = 237). In all groups the findings were confirmed in a multivariate analysis of prognostic factors. Veno-occlusive disease (VOD) of the liver (P < 0.05) and haemorrhagic cystitis (P < 0.001) was more common in the BU/CY group compared to the CY/TBI group for ABMT and BMT patients. In conclusion, BU/CY and CY/TBI as pretransplant regimens gave similar results in all situations, except ABMT for ALL intermediate stages with more than 2 years from diagnosis to transplantation, where a lower RI and a higher LFS were associated with CY/TBI.

Clinical outcome in four children with metachromatic leukodystrophy treated by bone marrow transplantation

Four children with metachromatic leukodystrophy (MLD) underwent allogeneic bone marrow transplantation between 1988 and 1993. No effect on the natural course of the disease was observed in two children with late infantile and juvenile MLD. They had moderate neurological symptoms at the time of BMT and were followed for 7 and 6 years, respectively. The third child with the juvenile form of MLD was mildly to moderately affected when transplanted. She had lost some gross motor functions as well as speech and mental abilities at follow-up 3 years later. The fourth case, diagnosed biochemically and presymptomatically as late infantile MLD, had a subtle gait disturbance when grafted at 18 months of age. Demyelination, not observed before BMT, was visualized 1 year later on MRI. This boy's condition has continued to deteriorate 2 years after transplantation. We have adopted recent recommendations that BMT should be considered only in presymptomatic children with late infantile MLD or early in the course of juvenile MLD. In such children, still longer follow-up periods are necessary to evaluate the benefit of BMT.

Inhibition of immunoglobulin production in vitro by IgG and F(ab')2 fragments, but not by the Fc portion

Antibody-secreting B cells were measured as plaque-forming cells (PFC) in a modified haemolysis-in-gel assay, using protein A coupled sheep erythrocytes as targets. Human lymphocytes from blood (PBL), bone marrow or spleen were stimulated in vitro by various polyclonal B-cell activators and incubated with intravenous immunoglobulin (IVIG) or peptide fragments of IVIG. IgG and IgM production from PBL and bone marrow cells, measured as PFC, was inhibited more than 50% by IVIG 2.5 mg/ml, compared to controls without IVIG. Inhibition of the IgG and IgM response of spleen cells by IVIG varied depending on the stimuli. Using Staphylococcus aureus protein A (SPA), inhibition was almost 90% (P < 0.001). The inhibition of the IgG and IgM responses to lipopolysaccharide from Escherichia coli (LPS) were 70% (P < 0.01) and 28% (P < 0.05), respectively. IgG stimulation by pokeweed mitogen (PWM) was inhibited by 57% (P < 0.01), but the IgM response was inhibited only by the higher IVIG concentration of 5.0 mg/ml. In mixed lymphocyte cultures of spleen cells, IgG and IgM production were inhibited by more than 60% (P < 0.05). The effect of IgG, IgG-F(ab')2 and IgG-Fc on LPS or PWM-stimulated spleen cells were compared, using equimolar concentrations of the various preparations. IgG- and IgM-producing PFC were significantly (P < 0.05) inhibited in a dose-dependent fashion by IgG and F(ab')2, but not by Fc. LPS-induced IgG and IgM production was inhibited also when IgG and F(ab')2 were added up to 48 h after the stimulator. A comparison of IgG, F(ab')2 and Fc products from different companies showed that all IgG and F(ab')2 preparations significantly inhibited IgG and IgM production of LPS-stimulated spleen cells. No significant inhibition was obtained with any of the purified Fc products.

Safety and efficacy of liposomal amphotericin B in allogeneic bone marrow transplant recipients

In a retrospective analysis, 79 allogeneic bone marrow recipients treated with AmBisome prophylactically or because of proven or suspected invasive fungal infection (IFI) were evaluated in 92 episodes. The median duration of treatment was 14 (range 1-112) days. The mean maximum dose given was 1.64 +/- 0.8 mg kg-1 day-1 and the mean total dose was 1.29 +/- 2.28 g. The overall incidence of reported adverse events was 194, of which none had a serious outcome. In six cases, the drug was withdrawn as a result of toxic or allergic reactions: dyspnoea and flush (3), urticaria (1), cholecystitis (1) and disorientation (one case, probably not related to AmBisome). No anaphylactoid reactions were seen. Laboratory findings, including low serum potassium (48% of the episodes), increased serum creatinine (38%) and increased serum sodium levels (7%), caused no major clinical problems. Thirteen cases of verified IFI were evaluated regarding the efficacy of AmBisome. Survival or cure of the mycotic infection occurred in 5/13 patients (38%). Two patients were treated with AmBisome (3.6 and 3.3 mg kg-1 day-1) because of verified IFI before BMT. One died of IFI. The other died of venoocclusive disease of the liver (VOD) without histological evidence of active IFI. We found a significant (P < 0.05) reduction in autopsy-proven IFI, 12/199 (6%) compared to the period when only conventional doses of amphotericin B were used, 26/227 (11%).

Use of a semi-quantitative PCR for cytomegalovirus DNA as a basis for pre-emptive antiviral therapy in allogeneic bone marrow transplant patients

The aim of this study was to evaluate the efficacy of pre-emptive antiviral therapy, based on a semi-quantitative nested PCR for cytomegalovirus (CMV) DNA in leukocytes, for the prevention of CMV disease after allogeneic BMT. Fifty-eight patients were prospectively followed with PCR for CMV DNA and antiviral therapy with ganciclovir was initiated after two consecutive positive tests. The levels of CMV DNA were determined by serial dilutions of the positive samples. The probability of detection of CMV DNA was 48.3% and the probability of CMV disease 6% at 100 days after BMT. Patients with CMV disease had higher CMV DNA levels compared with patients without CMV disease (P = 0.001). In comparison to 58 matched historical controls detection of CMV DNA was 5 days earlier (NS) and antiviral therapy could be initiated 10 days earlier in patients followed by PCR (P = 0.05). Pre-emptive antiviral therapy was given to 28 patients in a total of 36 courses. Patients became negative in PCR after 28 of 36 courses (77%). We conclude that PCR for CMV DNA can be used for early detection of CMV infection and as the basis of initiation of pre-emptive antiviral therapy in BMT patients.

Bone marrow transplantation in children using unrelated donors at Huddinge Hospital

Twenty-eight out of 31 children that underwent bone marrow transplantation (BMT) from unrelated donors between 1984 and 1995 received HLA-A, HLA-B and HLA-DR matched unrelated donor (MUD) marrows as defined by serologic HLA class I and genomic HLA class II typing. Compared with 28 case-matched controls transplanted with HLA identical sibling donors, MUD patients received a more intensive conditioning. Twenty-six patients (93%) engrafted while two died of septicaemia during the aplastic phase. Two patients rejected their grafts and four developed Evans syndrome. All controls engrafted without incidents of rejection or Evans syndrome. The probability of acute graft-versus-host disease (GVHD) of grade II or above was 27% after MUD-BMT and 7% in the controls. The 5-year probability of survival was 60% in MUD patients and 89% after sibling BMT (p = 0.03). Leukaemia-free survival was 60% with one relapse in the MUD patients, and 59% with five relapses in the sibling group. Three children who received a mismatched donor marrow died, two of severe GVHD and one after graft rejection. In conclusion, today, a matched unrelated donor BMT is an acceptable alternative for many children who need a BMT but lack a suitable related donor.

Transplantation of peripheral blood progenitor cells from unrelated donors

Six patients with high risk haematological malignancies received peripheral blood progenitor cells (PBPC) from unrelated donors. Four patients received PBPC as primary treatment and 2 following graft failure. Five donors were HLA-A, -B and -DR identical and one had a one antigen mismatch. PBPC were mobilised by treatment with G-CSF for 4-6 days. The patients received a range of 3.4 to 11.4 x 10(8) mononuclear cells/kg and 1.0 to 15.0 x 10(6) CD34 positive cells/kg. Four patients were given Campath 1G and 2 ATG prior to transplantation. The patient with one antigen mismatch received in vitro T-cell depleted PBPC using Campath 1M. All received cyclosporin and 5 in addition methotrexate. All recipients were given G-CSF and all engrafted. The patients developed no or mild acute GVHD. Two patients had limited chronic GVHD of the skin. The recipient of the mismatched graft died from extensive chronic GVHD. Three patients have had a relapse and two are alive and free of leukaemia.

Does high-dose intravenous immune globulin treatment after bone marrow transplantation increase mortality in veno-occlusive disease of the liver?

Forty-five recipients of bone marrow from HLA-identical siblings were given intravenous immune globulin (IVIG) 0.5 g/kg once a week during the first 3 months after transplantation. Fifty-three consecutive previously transplanted HLA-identical siblings were included as controls. Only patients who were cytomegalovirus (CMV) seropositive or had a CMV-seropositive donor were included. There were no major differences in patient characteristics between the two groups. However, more patients in the IVIG group received individualized graft-versus-host disease (GVHD) prophylaxis with less cyclosporine (P < 0.01), more controls received liposomal amphotericin B (P = 0.01), and more patients in the IVIG group received low-dose heparin as prophylaxis against veno-occlusive disease of the liver (P < 0.001). Median follow-up was 21 months in the IVIG group and 47 months in the control group. There were no differences between the groups with regard to time to engraftment, hospitalization time, or days with fever. No differences between the IVIG group and control group were detected in the incidence of acute GVHD grade II-IV (17% vs. 23%) or chronic GVHD (30% vs. 42%). The incidence of bacterial septicemias (53% vs. 63%) and invasive fungal infections (9% vs. 6%) was unaffected by IVIG treatment. The incidence of symptomatic CMV infection was the same in the two groups (14% vs. 16%). One control patient died of CMV interstitial pneumonitis, and 1 patient from each group died from viral interstitial pneumonitis of other origin. The incidence of veno-occlusive disease (VOD) was 16% in the IVIG group versus 6% in the controls (P = NS). Fatal VOD occurred in 11% of the IVIG group compared with none of the controls (P = 0.02). Other transplant-related complications did not differ between the two groups. Two-year survival was 62% in the IVIG group and 60% in the controls (P = NS). No significant beneficial effect was seen with IVIG, which may increase mortality in VOD. The use of high dose IVIG as prophylaxis in marrow transplant recipients is questioned.

Increased levels of soluble interleukin-2 receptor in veno-occlusive disease of the liver after allogenic bone marrow transplantation

Serum levels of soluble interleukin-2 receptors (sIL-2R), tumor necrosis factor (TNF)-alpha, interferon (IFN)-gamma, and interleukin (IL)-6 were studied in patients who developed veno-occlusive disease of the liver (VOD) after allogenic bone marrow transplantation (BMT). sIL-2R increased by a mean of 366% in 10 VOD patients. This was significantly higher than in control patients (n = 12) undergoing BMT without major complications (103%, P = 0.002) or in patients (n = 10) with grade II or III acute graft-versus-host disease (aGVHD) (139%, P = 0.003). Peak sIL-2R levels occurred on day 17 +/- 4 (mean +/- SD) after BMT in VOD patients versus on day 29 +/- 11 in patients with grades II-III aGVHD (P = 0.006). Mean maximum sIL-2R values in VOD patients were 4548 +/- 1420 (+/- SD, U/ml), which was significantly higher than the value of 2123 +/- 1023 U/ml in control patients undergoing BMT without major complications (P < 0.001). In patients with grade II or III aGVHD, mean maximum sIL-2R levels were 3076 +/- 2264 U/ml. Serum levels of TNF-alpha, IFN-gamma, and IL-6 were also increased during VOD and aGVHD, with peak levels occurring at the same time as peak sIL-2R levels in most patients. We found no difference in peak levels between VOD and acute GVHD patients. To conclude, an early dramatic increase in sIL-2R was seen in patients with VOD. Inflammatory cytokines like IL-6, TNF-alpha, and IFN-gamma also increased during VOD and aGVHD.

Risk factors for acute graft-versus-host disease in 291 consecutive HLA-identical bone marrow transplant recipients

We analysed 35 risk factors for acute GVHD in 291 consecutive recipients of HLA-identical sibling marrow transplants from 1975 to 1993. Of these, 16% developed moderate-to-severe acute GVHD following transplantation. In multivariate analysis, GVHD prophylaxis with monotherapy (MTX or CsA) (P = 0.015) seropositivity for several herpes viruses in the donor (P = 0.015) and seropositivity for CMV in the recipient (P = 0.037) before the transplants as well as early engraftment (P = 0.016), were the principal risk factors for GVHD. A high serum TNF-alpha level during conditioning therapy was also a significant risk factor in 75 recipients (P = 0.005). The risk of grades II-IV acute GVHD increased with the number of risk factors. Thus the cumulative incidence of acute GVHD was 1%, if no risk factor was present, 4% with one, 9% with two, 21% with three and 44% in patients with four risk factors. Factors reported to correlate with acute GVHD, such as age, diagnosis, female donor to male recipient, relative response and donor-responding capacity in MLC, MNS blood group antigen, splenectomy and bone marrow cell dose were not associated with acute GVHD in this study. Five-year survival was 24% in patients with grades II-IV GVHD vs 62% in patients with grades 0-I GVHD (P = 0.0001).