Marrow transplantation from related donors other than HLA-identical siblings

Bone marrow transplantation for the treatment of genetic diseases

Consideration of a bone marrow transplant (BMT) for a child with a genetic disease depends upon many factors including the pathophysiology of the disorder, the natural history of the disease, whether an alternative therapy exists and whether a donor is available. Children with disorders such as severe combined immunodeficiency disease (SCID), in which life expectancy is minimal, are obviously candidates for a BMT, even with less than optimal donors, while those with disorders such as beta-thalassemia major, in which an alternative therapy exists, must be considered more carefully and only with an optimal donor. The risks of conditioning therapy, graft-versus-host disease (GVHD), and early death as well as the cost are critical to this decision and must be viewed in light of the potential outcome of a successful BMT and the life expectancy and quality of life with a BMT. For some genetic diseases with multisystem involvement (e.g., Hurler's mucopolysaccharidosis), the efficacy of a BMT has been reasonably demonstrated, providing significant brain damage has not occurred previously. For some other storage-related diseases, there is no place for BMT. Further studies are essential to increase our knowledge as to its potential role in other types of genetic-associated diseases.

Autologous bone marrow transplant in the treatment of acute leukaemia

For a minority of patients with acute leukaemia, usually in children and predominantly with acute lymphoblastic leukaemia, existing chemotherapy protocols are curative. For a minority of the remaining group myeloablative chemoradiotherapy supported by allogeneic marrow from an HLA-matched donor can cure the disease. Major efforts are being made to free the potential benefit of this approach from the limitations imposed by the associated immune-biological complications, and limited donor availability. In the last decade the resurgence of autologous transplantation in remission has been a major new source of hope for further progress. Many groups have produced encouraging results, which now that they have substantial follow-up, suggest that this approach is altering the normal pattern of relapse. Almost all the experience, however, while producing consistent results, at least in AML, is anecdotal. The possibility of selection bias, particularly by the time-censoring effect, cannot be excluded, and prospective controlled trials are needed. The data available suggest which investigations could be expected to yield clear results. Other questions, particularly whether or not to purge the marrow, are only practical to investigate in well-defined patient subgroups. The opportunity to identify predictive parameters in this new clinical setting, using the more powerful techniques now becoming available should not be missed. National and international trials now in progress will yield crucial data in the next 2 or 3 years.

Strong donor mononuclear cell reactivity for herpes simplex virus (HSV) antigen in HSV immune donors combined with recipient seropositivity for HSV is associated with acute graft-versus-host disease

Prior to bone marrow transplantation (BMT) titres of IgG antibodies for cytomegalovirus (CMV), herpes simplex virus (HSV) and varicella zoster virus (VZV) were analysed in 51 donors and recipients of allogeneic bone marrow. Donor mononuclear cells from peripheral blood and bone marrow cells were stimulated with antigen prepared from CMV, HSV and VZV. High IgG titres for HSV in the recipient were associated with grade II-III acute graft-versus-host disease (GVHD) (P = 0.05). Furthermore, the combination of positive IgG titre for HSV antibodies in the recipient, and strong donor blood mononuclear cell reactivity to HSV antigen in HSV immune donors, significantly increased the incidence of grade II-III acute GVHD (P = 0.04). The data suggest that HSV immune donor mononuclear cells may initiate a GVH reaction.

The role of HLA matching in transplantation

All viable human tissues transplanted from one individual to another are at risk of rejection. The extent of risk depends on the donor HLA-host T cell receptor disparity. Such disparity is now known to involve genetic products coded by both HLA and non-HLA genes. T cell responses to mismatches on transplants are graded: the greater the mismatch the greater the number of clones of T cells responding. Consequently, the more severe the rejection process. Global statistics support this view in that cumulative mismatches at HLA are associated with poorer graft survival. However such studies also suggest that mismatches at different HLA loci vary in potency. The strength of mismatch seems to increase from HLA-A, the weakest, through HLA-B to HLA-DR, the most potent. Analysis of clinical results suggests that the risk associated with HLA mismatches in kidney transplantation dwindles after the first five months post-transplant. Although graft losses tend to occur sporadically thereafter, no major risk associated with HLA mismatches can be discerned. Whether this dwindling impact of HLA mismatches with time post-transplant is a general phenomenon applicable to all transplants, or whether it suggests some form of adaptation of host to graft in kidney transplant recipients alone is a subject for further exploration. Tissues vary widely in their susceptibility to rejection through HLA mismatches.(ABSTRACT TRUNCATED AT 250 WORDS)

Pathogenesis and recent therapeutic approaches to graft-versus-host disease

Effective prophylaxis of acute GVHD should bring about improved patient survival by decreasing severe infections during the first 3 months after transplantation and reducing the incidence of chronic GVHD while not compromising the quality of hematopoietic engraftment or increasing the incidence of leukemic relapse by impairing the graft-versus-leukemia effect. None of the current approaches to prevention of GVHD succeed at meeting these expectations, although postgrafting immunosuppressive therapy comes closest to the ideal. The technique of T cell depletion has been very effective in reducing the incidence of GVHD, but conditioning programs must be developed that will be more successful at eliminating host immune and malignant cells. It is doubtful that this will be achieved with systemic chemotherapy and total body irradiation. Innovative approaches such as the use of monoclonal antibodies, either alone or linked to short-lived radioactive isotopes with short linear energy transfer, promise to result in less toxic but more efficient programs, not only providing better eradication of malignant disease but also ameliorating the problem of graft failure. It is conceivable, however, that it will never be possible to kill all leukemic cells with chemoradiotherapy of any form, and the graft-versus-leukemia effect may be essential. Perhaps in the future it will be possible to distinguish lymphocytes causing the graft-versus-leukemia effect from those causing GVHD, isolate them, and use them in attempts at therapy. In the meantime, postgrafting immunosuppressive drugs are used most frequently to prevent and treat GVHD, and steadily improving survival statistics can be expected.

Hematopoietic stem cell processing and storage

The techniques to collect, process, and store HSC in anticipation of transplantation are now widely available. Important unresolved issues revolve around the as yet imperfect identification and classification of totipotential progenitors. However, much progress has been and will continue to be made despite this limitation. Research priorities of present and future stem cell processing laboratories should include: 1. Optimization of liquid (nonfrozen) storage techniques. This will permit more complex cell-specific manipulations, such as T-lymphocyte subset selection, isolation of CD34+ populations, treatment in vitro with growth factors, gene transfer experiments, and long-range transport of HSC, to be performed while preserving HSC integrity. 2. A better understanding of the regulation and kinetics of peripheral blood and umbilical cord HSC, to allow optimum collection procedures that do not require marrow harvesting. 3. An intensive study into the optimum conditions of collection, processing, and storage of megakaryocytic progenitors to decrease the long platelet-transfusion dependency of the myeloablated patient. 4. A search for a simple in vitro correlate of engraftment potential of a stem cell preparation. This will greatly improve the quality control functions of the laboratory as well as contribute to better patient selection for transplantation.

The use of unrelated bone marrow transplantation in the treatment of chronic myelogenous leukemia

Although marrow transplantation is the treatment of choice for chronic myelogenous leukemia, its full application is limited by donor availability. It now appears that the use of volunteer unrelated donors will be feasible and efficacious, albeit with a higher likelihood of complications. Thus, marrow grafting from unrelated donors should be considered in most instances where transplantation from a matched sibling would be contemplated.

Bone marrow transplantation: a review of a programme and its first 100 patients

We review the first 100 patients receiving a bone marrow transplant as definitive therapy for their underlying disease. These patients were treated between May 1975 and June 1988. Median age was 8 years (range, 1 month to 43 years). Initially, patients were given transplants late in their disease but, as the programme progressed, patients were given transplants earlier and while in remission from their disease. The types of disease considered for treatment by bone marrow transplantation (BMT) expanded from leukaemia, and aplastic anaemia to include neuroblastoma, thalassaemia and immune deficiency. Initially matched donors were used but the source of marrow broadened to include mismatched family members, matched unrelated donors and autologous marrow. Problems after BMT were rejection (11%), acute graft-versus-host disease (GVHD) (45%), interstitial pneumonitis (22%) and relapse (36%). Recurrence of disease was the cause of half the deaths. GVHD was less frequent with the use of methotrexate and cyclosporin, T-cell depleted marrow or matched donors. Interstitial pneumonitis was more commonly associated with the use of mismatched donors and the development of GHVD. Relapse was less likely when BMT was undertaken in the first remission. At least one long-term side effect was seen in all patients treated with total body irradiation whereas no patient treated without irradiation had long-term side effects. The rate of disease free survival of patients at 24 months was 56% for matched, 48% for closely matched, 46% for autologous and 29% for mismatched transplants. For matched transplants mortality within the first 6 months after transplantation decreased from 28% before 1984 to 5% since 1984. Fifty-one patients have survived to June 1989, 49 of them disease free, for periods ranging from 12 to 123 months (median 29 months).

HLA-DP incompatibilities induce significant proliferation in primary mixed lymphocyte cultures in HLA-A, -B, -DR and -DQ compatible individuals: implications for allogeneic bone marrow transplantation

The major part of the proliferative response in primary mixed lymphocyte cultures (MLC) is caused by HLA-DRB1 incompatibilities. In DRB1-matched pairs the proliferation induced by HLA-DRB3, -DQ and -DP mismatches may be unmasked. In most previous studies the influence of HLA-DP incompatibilities in primary MLC has been investigated in homozygous typing cells representing only a few Dw specificities. We were interested in determining the stimulatory capacity of isolated HLA-DP mismatches, ascertained by RFLP analysis, in primary MLC in HLA-A, -B, -DR and -DQ compatible, unrelated heterozygous individuals of many different Dw specificities. Thirty-eight MLCs performed with cells from related pairs and 67 with cells from unrelated pairs were evaluated. All but nine of the MLCs were analyzed in both directions, giving a total of 201 investigated reactions. The relative responses (RR) in the three MLCs performed between DP incompatible, related pairs were all positive (RR greater than or equal to 8%). Eighty of 82 MLCs performed with cells from DP incompatible, unrelated individuals were positive, whereas 37 of 46 MLCs between DP compatible, unrelated pairs were negative (RR less than 8%) (p less than 10(-10)). The magnitude of the RR was influenced by the number of DP mismatches. Thus, the mean RR was approximately twice as high in MLCs in which responder and stimulator cells differed by two DP antigens (mean RR 60.5%) compared with reactions with only one DP mismatch (mean RR 35.4%) (p less than 10(-3)). RFLP-defined HLA-DP incompatibilities predict a positive primary MLC in HLA-A, -B, -DR and -DQ matched individuals with a high degree of accuracy (98%).(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous complete remission of chronic myeloid leukaemia following haematological relapse after allogeneic bone marrow transplantation

A 31-year-old woman with Philadelphia (Ph) chromosome-positive chronic myeloid leukaemia (CML) underwent allogenic bone marrow transplantation during accelerated phase. Non-T-cell-depleted marrow from a male sibling mismatched at one Class 2 histocompatibility locus was infused after conditioning with total body irradiation and intravenous cyclophosphamide. Cyclosporin and methotrexate were given for prevention of graft-versus-host disease (GVHD). Prompt engraftment occurred with donor karyotype cells, followed by transient moderate acute GVHD. However, by day 60 after BMT, haematological relapse occurred with increasing splenomegaly, leucocytosis, increasing marrow fibrosis, and cytogenetic mosaicism, consisting of 47% donor metaphases with 53% Ph-positive host metaphases, some containing additional structural changes. Thirty days later further cytogenetic progression was evident. A slowly progressive fungal pneumonia concurrently present was treated with intravenous amphotericin and gradual reduction of cyclosporin. Subsequently, without further cytotoxic chemotherapy, pancytopenia and bone marrow hypoplasia developed, and on day 144 only donor karyotype marrow cells were seen. Chromosomes have remained of donor type on subsequent occasions, and the patient has a normal performance status 25 months after BMT. The patient's course illustrates that factors operating after allogeneic BMT contribute to longterm control of CML. The factors potentially responsible for this spontaneous remission, after early relapse, are discussed.

Effect of HLA incompatibility on graft-versus-host disease, relapse, and survival after marrow transplantation for patients with leukemia or lymphoma

We analyzed the relevance of HLA incompatibility to acute graft-versus-host disease, relapse, and survival in 281 patients with hematologic neoplasms who underwent bone marrow transplantation. Each patient received marrow from a family member who shared one HLA haplotype with the patient but differed to a variable degree for the HLA-A, -B, and -D antigens of the haplotype not shared; 29 were phenotypically identical, 119 were incompatible for one locus, 104 for two loci, and 29 for three loci. These 281 patients were compared with 967 patients who received marrow from siblings with identical HLA genotypes. All patients were treated with cyclophosphamide and total-body irradiation followed by the infusion of unmodified donor marrow cells. Occurrence of severe acute graft-versus-host disease was evaluated in patients who achieved sustained engraftment. In recipients of haploidentical grafts occurrence of severe acute graft-versus-host disease was associated with (1) graft-versus-host disease prophylaxis containing the combination of methotrexate plus cyclosporine versus standard methotrexate, relative risk = 0.35; 95% confidence interval, 0.21-0.57, p less than 0.0001; and (2) the degree of recipient HLA incompatibility, relative risk = 1.95 for each locus incompatible; 95% confidence interval, 1.52-2.50, p less than 0.0001; (3) patient age, relative risk = 1.23 per decade; 95% confidence interval, 1.05-1.44, p = 0.0094. Acute graft-versus-host disease was associated with lower leukemic relapse after transplant in patients with acute lymphocytic leukemia, and chronic graft-versus-host disease was associated with lower relapse after transplant for acute nonlymphocytic leukemia in relapse or chronic myelogenous leukemia in blast crisis. After transplantation for acute nonlymphocytic leukemia in remission, the rate of leukemic relapse was 22% in 61 recipients of "one-locus" (A, B, or D)-incompatible grafts compared to 37% in 561 recipients of HLA-identical sibling grafts. Survival was decreased as the degree of HLA disparity increased. Survival of "one-locus"-incompatible transplant recipients, however, was equivalent to that of HLA-identical sibling transplant recipients.

Immunomodulatory and antimicrobial efficacy of intravenous immunoglobulin in bone marrow transplantation

BACKGROUND

Graft-versus-host disease (GVHD) and infection are major complications of allogeneic bone marrow transplantation. Since intravenous immunoglobulin has shown benefit in several immunodeficiency and autoimmune disorders, we studied its antimicrobial and immunomodulatory role after marrow transplantation.

METHODS

In a randomized trial of 382 patients, transplant recipients given immunoglobulin (500 mg per kilogram of body weight weekly to day 90, then monthly to day 360 after transplantation) were compared with controls not given immunoglobulin. By chance, the immunoglobulin group included more patients with advanced-stage neoplasms; otherwise, the study groups were balanced for prognostic factors.

RESULTS

Control patients seronegative for cytomegalovirus who received seronegative blood products remained seronegative, but seronegative patients who received immunoglobulin and screened blood had a passive transfer of cytomegalovirus antibody (median titer, 1:64). Among the 61 seronegative patients who could be evaluated, none contracted interstitial pneumonia; among the 308 seropositive patients evaluated, 22 percent of control patients and 13 percent of immunoglobulin recipients had this complication (P = 0.021). Control patients had an increased risk of gram-negative septicemia (relative risk = 2.65, P = 0.0039) and local infection (relative risk = 1.36, P = 0.029) and received 51 more units of platelets than did immunoglobulin recipients. Neither survival nor the risk of relapse was altered by immunoglobulin. However, among patients greater than or equal to 20 years old, there was a reduction in the incidence of acute GVHD (51 percent in controls vs. 34 percent in immunoglobulin recipients; P = 0.0051) and a decrease in deaths due to transplant-related causes after transplantation of HLA-identical marrow (46 percent vs. 30 percent; P = 0.023).

CONCLUSIONS

Passive immunotherapy with intravenous immunoglobulin decreases the risk of acute GVHD, associated interstitial pneumonia, and infections after bone marrow transplantation.

The influence of allogeneic cells on the human T and B cell repertoire

Clinical transplantation is often complicated by rejection episodes, in which the immune system of the recipient reacts to the foreign transplantation (HLA) antigens on the graft. This immune response includes humoral and cellular components. In the first, B lymphocytes form antibodies to the HLA alloantigens. In the second, CD8+ T lymphocytes recognize and react to HLA class I antigens, and CD4+ T cells react to HLA class II antigens. The frequency and severity of these rejection episodes can be diminished by immunosuppressive drugs, HLA matching between donor and recipient, and immune modulation by blood transfusion. Effective HLA matching between donor and recipient is not always possible and often not necessary. Insight into the factors that influence the T and B cell repertoire after blood transfusion might lead to new approaches to improve graft survival.

An unusual presentation of chronic graft-versus-host disease in an unrelated bone marrow transplantation

The case described is that of an unrelated bone marrow transplantation in a 43-year-old man. Although the major histocompatibility complex met the criteria for a perfect genotypic match, de novo graft-versus-host disease developed with unusual manifestations involving structures of the oral cavity and associated areas. The loss of taste and smell, as well as profound xerostomia, was treated by stimulating salivary flow. Synergistic sialagogues were used with the hope that an increase in salivary production would mediate an improvement in taste and smell.

Bone marrow transplantation for childhood acute lymphoblastic leukaemia after marrow relapse

Children with acute lymphoblastic leukaemia in whom relapse in bone marrow occurs have a poor outlook when treated with chemotherapy alone. Twenty-seven patients with childhood acute lymphoblastic leukaemia were treated for marrow relapse with high-dose chemotherapy with or without total body irradiation followed by bone marrow transplantation (BMT). Twenty patients received allogeneic marrow from partially or completely matched histocompatible donors. In this group, nine patients (45%) were free of disease with a median follow-up of 57 months (range, 22 to 126 months) after transplantation, four (20%) died from interstitial pneumonitis and seven (35%) died after a further relapse. Seven patients received autologous marrow collected while they were in remission. In this group, one patient died from infection and six died after a further relapse. We conclude that allogeneic BMT is more effective than autologous transplantation and results in long-term disease-free survival in a significant number of patients. New methods are needed to eradicate residual disease in the patient and to purge marrow ex vivo.

Successful allogeneic transplantation of T-cell-depleted bone marrow from closely HLA-matched unrelated donors

We describe a four-year experience with bone marrow transplantation involving closely HLA-matched unrelated donors and 55 consecutive patients with hematologic disease who were seven months to 48.6 years old (median, 18 years). An intensive pretransplantation conditioning regimen and graft-versus-host disease (GVHD) prophylaxis with CD3-directed T-cell depletion and cyclosporine were employed. Durable engraftment was achieved in 50 of 53 patients who could be evaluated (94 percent; 95 percent confidence interval, 83 to 98 percent). Acute GVHD of Grade II to IV developed in 46 percent of the patients (confidence interval, 27 to 66 percent). The incidence and severity of acute GVHD were increased in recipients of HLA-mismatched marrow as compared with recipients of phenotypically matched marrow (incidence of 53 percent [confidence interval, 37 to 68 percent] vs. 17 percent [confidence interval, 5 to 45 percent]; P less than 0.05). Extensive chronic GVHD and deaths not due to relapse also tended to be more frequent when HLA-mismatched marrow was used, but not significantly so. With a median follow-up of more than 19 months (range, greater than 9 to greater than 39), the actuarial disease-free survival of transplant recipients with leukemia and a relatively good prognosis (acute leukemia in first remission and chronic myelogenous leukemia in chronic phase) was 48 percent (confidence interval, 24 to 73 percent), and that of recipients with more aggressive leukemia was 32 percent (confidence interval, 18 to 51 percent); the actuarial survival of recipients with non-neoplastic disease was 63 percent (confidence interval, 31 to 86 percent). We conclude that marrow transplantation with closely HLA-matched unrelated donors can be effective treatment for neoplastic and non-neoplastic diseases. Although transplants from phenotypically HLA-matched unrelated donors appear to be most effective, transplants with limited HLA disparity can also be successful in some patients.

Bone marrow transplantation in hematologic malignancies. Current status

Bone marrow transplantation (BMT) after supralethal cytoreductive therapy in the acute leukemias, chronic myelogenous leukemia (CML), and the lymphomas may be curative in 50% to 60% of patients. The donor may be a human leukocyte antigen (HLA) matched family member (allogeneic), an identical twin (syngeneic), or the patient (autologous). In general, the outcome is best in younger patients and those transplanted early in their disease (i.e., in the first remission for acute leukemia and in the chronic phase of the disease in CML). Solutions to the major problems of allogeneic BMT, such as graft-versus-host disease and viral infections, are being actively pursued. Syngeneic and autologous BMT avoids some of the above problems, but relapses appear to be greater. Despite this problem, a significant number of cures have been accomplished. Newer methods of purging autologous marrow and newer preparative regimens promise to reduce the problem of relapses.

Cost effectiveness of bone marrow transplantation in acute nonlymphocytic leukemia

To compare the cost effectiveness of bone marrow transplantation and conventional chemotherapy, we evaluated the resources used in the care of adult patients with acute nonlymphocytic leukemia who were enrolled in a prospective trial and received induction chemotherapy at a single university hospital. Nineteen patients were subsequently treated with chemotherapy and 17 with transplantation. Cost accounting began with induction chemotherapy and extended over a five-year period. Costs were estimated by means of a resource-based, multivariate prediction model. The transplantation and chemotherapy groups had virtually equivalent use of resources (hospital days, laboratory tests, blood products, and radiologic and operative procedures) over five years, except for a 10-fold increase in the use of the intensive care unit for the patients who underwent transplantation (P less than 0.001). The total costs over five years were estimated at $193,000 per patient for transplantation and $136,000 per patient for chemotherapy (P = 0.02). At five years, the costs per year of life saved ("life-year") were nearly equal ($62,500 per life-year for transplantation vs. $64,000 per life-year for chemotherapy) because of the better rate of disease-free survival in patients who underwent bone marrow transplantation. We conclude that the cost effectiveness of bone marrow transplantation to treat acute nonlymphocytic leukemia compares favorably with that of chemotherapy and could be further enhanced if intensive care resources were used more selectively.

Technical modifications in hyperfractionated total body irradiation for T-lymphocyte deplete bone marrow transplant

The Medical College of Wisconsin implemented a major bone marrow transplant (BMT) program in July 1985. The type of transplants to be focused on were allogeneic T-lymphocyte deplete. Total body irradiation (TBI) was initially patterned after the Memorial method. Patients received total body irradiation in a sitting position at a dose rate of 20-25 cGy/minute with 50% attenuation lung blocks used both anterior/posterior and posterior/anterior. Electron boosting was utilized for the ribs beneath the lung blocks. Occasionally, lower extremity boosting was required because of the sitting position. A dose of 14 Gy was chosen since T-lymphocyte deplete bone marrow transplant data suggest the need for higher total doses to consistently obtain engraftment. This dose was given in 3 equal daily fractions over 3 days following conditioning chemotherapy. Six of 11 patients treated in this manner developed lethal pulmonary events. In response to the pulmonary toxicity, partial lung shielding was increased to 60% attenuation. In the next 107 patients receiving this program of total body irradiation there was a reduced incidence of fatal pulmonary events (10 cases of fatal idiopathic interstitial pneumonitis and 12 cases of fatal pulmonary infections) after a median follow-up of 9 months. This was an obvious improvement over the initial group. A significant level of hepato-renal toxicity was also observed with 14 Gy total body irradiation when no liver or kidney blocking was used. Of the first 20 patients treated, three cases of fatal veno-occlusive disease resulted. Subsequently, a 10% attenuation right sided liver block was added. Five of 98 patients treated with this block have developed fatal hepatic dysfunction, (median follow-up of 7.2 months). This incidence is not statistically different from the initial group but favors the use of the liver block. Some renal toxicity was also detected with the earlier regimen, especially in pediatric patients. Partial kidney blocking has been implemented to minimize this toxicity. Our current dose rate has been reduced to 8 cGy/minute in a further attempt to reduce organ toxicity. To date, this selective blocking has not adversely affected the excellent rate (96%) of first time engraftments.

Syngeneic or autologous graft-versus-host disease

Graft-versus-host disease (GVHD) until recently was supposed to occur only when immunocompetent T lymphocytes are infused into immunoincompetent allogeneic hosts that possess histocompatibility antigens not possessed by the donor that could act as targets for cell-mediated cytotoxicity. A syndrome clinically and histologically identical to mild allogeneic GVHD occurs infrequently, following syngeneic or autologous bone marrow transplantation (BMT). This syndrome called syngeneic or autologous GVHD can be regularly produced with Cyclosporine (CsA) in animals undergoing syngeneic or autologous BMT. Animals with this syndrome develop T cells that are autocytotoxic to Ia antigen-bearing cells. The presence of an irradiated thymus and CsA administration is necessary to produce this disease. Operationally, this disease results from a disturbance of balance between a normally present autoregulatory cell and an autocytotoxic T cell. The study of mechanisms involved in the generation of this disease will add to our fundamental understanding of the cellular regulation of autocytotoxic T cell-medicated reactions and diseases. Most recently, we have been able to induce this disease in man with the aim of investigating its therapeutic effect in autologous BMT in patients with Ia-bearing tumors.

Acute renal failure following bone marrow transplantation: a retrospective study of 272 patients

To assess the incidence, risk factors, and course of acute renal failure (ARF) following bone marrow transplantation (BMT), a retrospective analysis of 272 patients receiving transplants at the Fred Hutchinson Cancer Research Center during 1986 was undertaken. The patients were divided into three groups: group 1, hemodialysis requiring ARF; group 2, mild renal insufficiency (doubling of serum creatinine, Scr, but no dialysis); group 3, relatively normal post-BMT renal function (no doubling of Scr). Fifty-three percent of patients at least doubled their Scr (Groups 1 and 2), and 24% required dialysis. The degree of renal functional impairment had a dramatic impact on patient mortality rates (84%, 37%, and 17% in groups 1, 2, and 3, respectively). Jaundice (bilirubin greater than or equal to 2.0 mg/dL), weight gain (greater than or equal to 2.0 kg), amphotericin B use, and a pretransplant Scr greater than or equal to 0.7 mg/dL were independently associated with the subsequent development of dialysis-requiring ARF (P less than 0.001; relative risks, 3.0 to 7.7). Neither aminoglycoside/vancomycin/cyclosporine A use nor acute graft v host disease correlated with the development of ARF. A mismatched graft was a significant risk factor for ARF by univariate but not by multivariate analysis. Within 48 hours before doubling the Scr, 63% of group 1 patients had positive blood cultures and 39% developed hypotension. Of the 26 group 1 patients who had urine Na concentrations measured, 85% had values less than or equal to 40 mEq/L. Autopsy kidney specimens provided no clear explanation for ARF in the vast majority of patients in group 1.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of HLA compatibility on engraftment of bone marrow transplants in patients with leukemia or lymphoma

We analyzed the relevance of HLA compatibility to sustained marrow engraftment in 269 patients with hematologic neoplasms who underwent bone marrow transplantations. Each patient received marrow from a family member who shared one HLA haplotype with the patient but differed to a variable degree for the HLA-A, B, and D antigens of the haplotype not shared. These 269 patients were compared with 930 patients who received marrow from siblings with identical HLA genotypes. All patients were treated with cyclophosphamide and total-body irradiation followed by the infusion of unmodified donor marrow cells. The rate of graft failure was 12.3 percent among the recipients of marrow from a donor with only one identical haplotype, as compared with 2.0 percent among recipients of marrow from a sibling with the same HLA genotype (both haplotypes inherited from the same parents) (P less than 0.0001). The incidence of graft failure correlated with the degree of donor HLA incompatibility. Graft failure occurred in 3 of 43 transplants (7 percent) from donors who were phenotypically HLA-matched with their recipient (haplotypes similar, but not inherited from the same parents), in 11 of 121 donors (9 percent) incompatible for one HLA locus, in 18 of 86 (21 percent) incompatible for two loci, and in 1 of 19 (5 percent) incompatible for three loci (P = 0.028). In a multivariate binary logistic regression analysis, independent risk factors associated with graft failure were donor incompatibility for HLA-B and D (relative risk = 2.1; 95 percent confidence interval, 1.7 to 2.5; P = 0.0004) and a positive crossmatch for anti-donor lymphocytotoxic antibody (relative risk = 2.3; 95 percent confidence interval, 1.8 to 2.8; P = 0.0038). Residual host lymphocytes were detected in 11 of 14 patients with graft failure, suggesting that the mechanism for graft failure could be host-mediated immune rejection. We conclude that donor HLA incompatibility and prior alloimmunization are significant risk factors for graft failure, and that a more effective immunosuppressive regimen than those currently used is needed for consistent achievement of sustained engraftment of marrow transplanted from donors who are not HLA-identical siblings.

Primary immunodeficiencies in Switzerland: first report of the national registry in adults and children

This first report of a Swiss registry includes 313 patients with primary immunodeficiency syndromes (PIDS) who were observed between January 1975 and January 1985. Diagnosis of specific PIDS was made according to WHO criteria. The most frequent disorders were IgA deficiency (33%) and common variable immunodeficiency (22%), followed by selective deficiency of other immunoglobulin isotypes (9%), severe combined immunodeficiency (9%), infantile sex-linked agammaglobulinemia (7%), and Wiskott-Aldrich syndrome (6%). Frequencies of other types of PIDS varied between 0.3 and 4%. Half of the patients were in the pediatric age group. Male patients predominated (63%). In addition to respiratory and urogenital tract infections, autoimmune disorders were observed in 14 patients with IgA deficiency or common variable immunodeficiency. IgA deficiency was, furthermore, associated with atopic and neurological disorders. A comparison with other national registries revealed some differences: the frequency of severe combined immunodeficiency was high (incidence, 24.3 cases per 10(6) live births), and that of ataxia teleangiectasia was particularly low (1.4 per 10(6) live births) in Switzerland. Frequencies of the three major PIDS groups of (i) predominantly antibody defects, (ii) predominantly cell-mediated defects, and (iii) PIDS associated with other major defects agreed with those reported in the other European studies.