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Ruiz MA, Junior RLK, Piron-Ruiz L, Saran PS, Castiglioni L, Quadros LGD, Pinho TS, Burt RK. Medical, ethical, and legal aspects of hematopoietic stem cell transplantation for Crohn’s disease in Brazil. World J Stem Cells 2020; 12:1113-1123. [PMID: 33178395 PMCID: PMC7596442 DOI: 10.4252/wjsc.v12.i10.1113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 07/08/2020] [Accepted: 08/26/2020] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease that can affect any part of the gastrointestinal tract. The etiology of CD is unknown; however, genetic, epigenetic, environmental, and lifestyle factors could play an essential role in the onset and establishment of the disease. CD results from immune dysregulation due to loss of the healthy symbiotic relationship between host and intestinal flora and or its antigens. It affects both sexes equally with a male to female ratio of 1.0, and its onset can occur at any age, but the diagnosis is most commonly observed in the range of 20 to 40 years of age. CD diminishes quality of life, interferes with social activities, traumatizes due to the stigma of incontinence, fistulae, strictures, and colostomies, and in severe cases, affects survival when compared to the general population. Symptoms fluctuate between periods of remission and activity in which complications such as fistulas, strictures, and the need for bowel resection, surgery, and colostomy implantation make up the most severe aspects of the disease. CD can be progressive and the complications recurrent despite treatment with anti-inflammatory drugs, corticosteroids, immunosuppressants, and biological agents. However, over time many patients become refractory without treatment alternatives, and in this scenario, hematopoietic stem cell transplantation (HSCT) has emerged as a potential treatment option. The rationale for the use of HSCT for CD is anchored in animal studies and human clinical trials where HSCT could reset a patient's immune system by eliminating disease-causing effector cells and upon immune recovery increase regulatory and suppressive immune cells. Autologous HSCT using a non-myeloablative regimen of cyclophosphamide and anti-thymocyte globulin without CD34+ selection has been to date the most common transplant conditioning regimen adopted. In this review we will address the current situation regarding CD treatment with HSCT and emphasize the medical, ethical, and legal aspects that permeate the procedure in Brazil.
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Affiliation(s)
- Milton Artur Ruiz
- Department of Bone Marrow Transplant, Beneficência Portuguesa Hospital, São José do Rio Preto 15090 470, Brazil
| | | | - Lilian Piron-Ruiz
- Department of Bone Marrow Transplantation, Beneficência Portuguesa Hospital, São José do Rio Preto 15090 470, Brazil
| | - Priscila Samara Saran
- Department of Bone Marrow Transplantation, Beneficência Portuguesa Hospital, São José do Rio Preto 15090 470, Brazil
| | - Lilian Castiglioni
- Genetics and Molecular Biology, FAMERP- Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto 15090 470 Brazil
| | - Luiz Gustavo de Quadros
- Department of Endoscopy, Beneficência Portuguesa Hospital, ABC Medical School, São Bernardo 15015 110, Brazil
| | - Tainara Souza Pinho
- Department of Bone Marrow Transplantation, Beneficência Portuguesa Hospital, São José do Rio Preto 15090 470, Brazil
| | - Richard K Burt
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States
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Immune reconstitution/immunocompetence in recipients of kidney plus hematopoietic stem/facilitating cell transplants. Transplantation 2015; 99:288-98. [PMID: 25594553 DOI: 10.1097/tp.0000000000000605] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Nineteen subjects have more than 18 months' follow-up in a phase IIb tolerance protocol in HLA-mismatched recipients of living donor kidney plus facilitating cell enriched hematopoietic stem cell allografts (FCRx). Reduced intensity conditioning preceded a kidney allograft, followed the next day by FCRx. Twelve have achieved stable donor chimerism and have been successfully taken off immunosuppression (IS). We prospectively evaluated immune reconstitution and immunocompetence. Return of CD4 and CD8 T central and effector memory cell populations was rapid. T-cell receptor (TCR) Excision Circle analysis showed a significant proportion of chimeric cells produced were being produced de novo. The TCR repertoires posttransplant in chimeric subjects were nearly as diverse as pretransplant donors and recipients, and were comparable to subjects with transient chimerism who underwent autologous reconstitution. Subjects with persistent chimerism developed few serious infections when off IS. The majority of infectious complications occurred while subjects were still on conventional IS. BK viruria and viremia resolved after cessation of IS and no tissue-invasive cytomegalovirus infections occurred. Notably, although 2 of 4 transiently or nonchimeric subjects experienced recurrence of their underlying autoimmune disorders, none of the chimeric subjects have, suggesting that self-tolerance is induced in addition to tolerance to alloantigen. No persistently chimeric subject has developed donor-specific antibody, and renal function has remained within normal limits. Patients were successfully vaccinated per The American Society for Blood and Marrow Transplantation guidelines without loss of chimerism or rejection. Memory for hepatitis vaccination persisted after transplantation. Chimeric subjects generated immune responses to pneumococcal vaccine. These data suggest that immune reconstitution and immunocompetence are maintained in persistently chimeric subjects.
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Hamerschlak N, Rodrigues M, Moraes DA, Oliveira MC, Stracieri ABPL, Pieroni F, Barros GMN, Madeira MIA, Simões BP, Barreira AA, Brum DG, Ribeiro AAF, Kutner JM, Tylberi CP, Porto PP, Santana CL, Neto JZ, Barros JC, Paes AT, Burt RK, Oliveira EA, Mastropietro AP, Santos AC, Voltarelli JC. Brazilian experience with two conditioning regimens in patients with multiple sclerosis: BEAM/horse ATG and CY/rabbit ATG. Bone Marrow Transplant 2009; 45:239-48. [DOI: 10.1038/bmt.2009.127] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Blanco Y, Saiz A, Carreras E, Graus F. Autologous haematopoietic-stem-cell transplantation for multiple sclerosis. Lancet Neurol 2005; 4:54-63. [PMID: 15620857 DOI: 10.1016/s1474-4422(04)00966-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Intense immunosuppression followed by autologous haematopoietic-stem-cell transplantation (HSCT) is being assessed as a potential treatment for patients with severe multiple sclerosis (MS). The treatment was developed from research that showed autologous HSCT was as effective as allogeneic HSCT in the treatment of experimental autoimmune encephalomyelitis. The treatment is thought to eradicate the defective immune system, and the infused haematopoietic stem cells reconstitute an immune system that is more tolerant to the nervous system. About 250 patients with MS have been treated with autologous HSCT as part of phase I and phase II open trials. Autologous HSCT seems feasible in MS and assessment with clinical and MRI measures suggests it induces a profound and long-lasting suppression of inflammation. The course of MS seems to be stabilised after autologous HSCT, especially in ambulatory patients with evidence of active disease. Autologous HSCT deserves further study in randomised controlled trials.
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Affiliation(s)
- Yolanda Blanco
- Service of Neurology, Hospital Clínic, Institut d'Investigació Biomèdica August Pi i Sunyer, University of Barcelona, Spain
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Popat U, Krance R. Haematopoietic stem cell transplantation for autoimmune disorders: the American perspective. Br J Haematol 2004; 126:637-49. [PMID: 15327514 DOI: 10.1111/j.1365-2141.2004.05076.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The hypothesis that haematopoietic stem cell transplantation (HSCT) might be useful in treating refractory autoimmune diseases (AID) was suggested by studies in animal models and by the improvement of concurrent autoimmune diseases in patients who had undergone transplantation for haematological disorders. This concept has now been tested in a substantial number of phase I/II clinical trials of autologous HSCT. These early results are promising, even in patients who have failed on multiple standard therapies for AID. Transplantation-related toxicity has decreased with growing experience in the application of this procedure, better patient selection and the modification of treatment protocols. Randomized trials currently under way or under consideration should clarify the role of HSCT in patients with autoimmune disorders.
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Affiliation(s)
- Uday Popat
- Department of Medicine, Baylor College of Medicine, 6565 Fannin M 964, Houston, TX 77030, USA.
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Porta C, Caporali R, Epis O, Ramaioli I, Invernizzi R, Rovati B, Comolli G, Danova M, Montecucco C. Impaired bone marrow hematopoietic progenitor cell function in rheumatoid arthritis patients candidated to autologous hematopoietic stem cell transplantation. Bone Marrow Transplant 2004; 33:721-8. [PMID: 14743200 DOI: 10.1038/sj.bmt.1704407] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We have evaluated bone marrow morphology, percentage of bone marrow CD34(+) cells, proliferative activity of bone marrow precursors, clonogenic assay (BFU-E and CFU-GM) in short-term bone marrow cultures, and bone marrow cell apoptosis, together with serum TNF-alpha and IL-6, in 16 chronic, refractory RA patients, as well as in five healthy controls. Of 16 RA patients (68.7%), 11 showed a reduced bone marrow cellularity, while it was normal in all the controls. In RA patients, the median percentage of CD34(+) bone marrow cells, the median percentage of proliferating bone marrow myeloid precursors, and the median number of both BFU-E and CFU-GM colonies were significantly lower than observed in the controls. As far as TNF-alpha and IL-6 titers is concerned, the latter did not significantly differ from controls' values, while TNF-alpha titers were significantly lower in healthy controls. Finally, the median apoptotic index of early bone marrow myeloid cells of RA patients was significantly higher compared with controls. These observations may identify the biological risk factors for impaired mobilization and/or engraftment when RA patients are candidates for autologous hematopoietic stem cell grafting.
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Affiliation(s)
- C Porta
- Istituto di Medicina Interna ed Oncologia Medica, Università degli Studi di Pavia e I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.
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Marty MC, Alliot F, Rutin J, Fritz R, Trisler D, Pessac B. The myelin basic protein gene is expressed in differentiated blood cell lineages and in hemopoietic progenitors. Proc Natl Acad Sci U S A 2002; 99:8856-61. [PMID: 12084930 PMCID: PMC124388 DOI: 10.1073/pnas.122079599] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Myelin basic proteins (MBP) are major constituents of the myelin sheath of oligodendrocytes and Schwann cells in the central nervous system and the peripheral nervous system, respectively. We previously showed that MBP-related transcripts are present in the bone marrow and the immune system. These mRNAs are transcribed from a region called 0', consisting of three exons, located upstream of the classical MBP exons; these three exons belong to the long MBP gene otherwise called "Golli-MBP." The most abundant of these mRNAs, now called HMBP (hemopoietic MBP), encompasses the sequence encoded by the region 0' plus exon 1 and part of intron 1 of the classic MBP gene. Antisera to recombinant HMBP proteins are immunoreactive with proteins of about 26-28 kDa in brain, thymus, and spleen. This report demonstrates that HMBP proteins are present in the vast majority (>95%) of thymic T cells, which express the corresponding transcripts, as do mature T cells from lymph nodes and spleen. HMBP mRNAs and proteins are also manifest in the majority of spleen B lymphocytes and in B cell lines. In addition to lymphoid cells, HMBP proteins are in all types of myeloid lineage cells, i.e., macrophages, dendritic cells, and granulocytes, as well as in megakaryocytes and erythroblasts. Finally, HMBP proteins are present in CD34+ bone marrow cells, and, furthermore, in highly proliferative cultures, these CD34+ cells express HMBP RNAs and proteins. Thus, MBP gene products are present both in the nervous system and in the entire hemopoietic system.
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Affiliation(s)
- M C Marty
- Centre National de la Recherche Scientifique, 15 rue de l'Ecole de Médecine 75270 Paris CEDEX 06 France
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Moore J, Tyndall A, Brooks P. Stem cells in the aetiopathogenesis and therapy of rheumatic disease. Best Pract Res Clin Rheumatol 2001; 15:711-26. [PMID: 11812017 DOI: 10.1053/berh.2001.0189] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Animal models of autoimmune disease and case reports of patients with these diseases who have been involved in bone marrow transplants have provided important data implicating the haemopoietic stem cell in rheumatic disease pathogenesis. Animal and human examples exist for both cure and transfer of rheumatoid arthritis, systemic lupus erythematosus (SLE) and other organ-specific diseases using allogeneic haemopoietic stem cell transplantation. This would suggest that the stem cell in these diseases is abnormal and could be cured by replacement of a normal stem cell although more in vitro data are required in this area. Given the morbidity and increased mortality in some patients with severe autoimmune diseases and the increasing safety of autologous haemopoietic stem cell transplantation (HSCT), pilot studies have been conducted using HSCT in rheumatic diseases. It is still unclear whether an autologous graft will cure these diseases but significant remissions have been obtained which have provided important data for the design of randomized trials of HSCT versus more conventional therapy. Several trials are now open to accrual under the auspices of the European Bone Marrow Transplant Group/European League Against Rheumatism (EBMT/EULAR) registry. Future clinical and laboratory research will need to document the abnormalities of the stem cell of a rheumatic patient because new therapies based on gene therapy or stem cell differentiation could be apllied to these diseases. With increasing safety of allogeneic HSCT it is not unreasonable to predict cure of some rheumatic diseases in the near future.
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Affiliation(s)
- J Moore
- Haematology Department, St Vincents Hospital, NSW, Australia
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Papadaki HA, Boumpas DT, Gibson FM, Jayne DR, Axford JS, Gordon-Smith EC, Marsh JC, Eliopoulos GD. Increased apoptosis of bone marrow CD34(+) cells and impaired function of bone marrow stromal cells in patients with systemic lupus erythematosus. Br J Haematol 2001; 115:167-74. [PMID: 11722430 DOI: 10.1046/j.1365-2141.2001.03076.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The changes in bone marrow (BM) stem cell reserve and function and stromal cell function in patients with active systemic lupus erythematosus (SLE) were investigated. The study was carried out on seven SLE patients and 28 healthy controls using flow cytometry and in vitro cell culture assays. We found that patients had low CD34(+) cells, compared with the control group, reflecting the decrease of both CD34(+)/CD38(-) and CD34(+)/CD38(+) cells. Patient CD34(+)/Fas(+) but not CD34(-)/Fas(+) cells were significantly increased. Apoptotic (7AAD(dim)) cells were higher among CD34(+)/Fas(+) than among CD34(+)/Fas(-) cells, and individual values of apoptotic CD34+ cells strongly correlated with the number of CD34(+)/Fas(+) cells. These findings are suggestive of a Fas-mediated apoptosis accounting for the low CD34(+) cells in SLE patients. Moreover, we found that patients had low numbers of granulocyte-macrophage colony-forming units (CFU-GM) and erythroid burst-forming units (BFU-E), compared with the control group, and that the generation of colony-forming cells in long-term BM cultures was significantly reduced. Patient BM stroma failed to support allogeneic progenitor cell growth. In one patient, CD34(+) cells were increased, apoptotic CD34(+)/Fas(+) cells were normalized and defective stromal cell function was restored after autologous stem cell transplantation. We concluded that defective haemopoiesis in SLE patients is probably caused, at least in part, to the presence of autoreactive lymphocytes in BM.
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Affiliation(s)
- H A Papadaki
- Department of Haematology, University of Crete School of Medicine, Crete, Greece.
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Abstract
Remarkable advances have been made in bone marrow transplantation (BMT), which now has become a powerful strategy for the treatment of leukemia, aplastic anemia, congenital immunodeficiency disorders, and autoimmune diseases. Using various animal models, allogeneic BMT has been found to be useful in the treatment of autoimmune diseases. In MRL/lpr mice, which are radiosensitive (<8.5 Gy) and are an animal model for autoimmune disorders, conventional BMT resulted in only transient effects; the manifestations of the autoimmune diseases recurred 3 months after BMT. However, the combination of BMT plus bone grafts (to recruit donor stromal cells) was capable of preventing the recurrence of autoimmune diseases in MRL/lpr mice. This strategy was found to be ineffective in the treatment of MRL/lpr mice that had developed autoimmune diseases, because these mice were more sensitive to the effects of radiation after the onset of lupus nephritis due to uremic enterocolitis. We have recently discovered a safer strategy for treatment of autoimmune diseases, which includes fractionated irradiation (5.5 Gy x 2) (day -1) followed by portal venous injection (day 0) plus intravenous injection (day 5) of donor unfractionated bone marrow cells. We successfully treated autoimmune diseases in MRL/lpr mice using this strategy; 100% of MRL/lpr mice treated in this fashion survive >1 year after treatment. We identified the mechanisms underlying the components of this approach and have found that stromal cells play a crucial role in successful BMT. In this review, the conditions essential for successful allogeneic BMT are discussed.
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Affiliation(s)
- S Ikehara
- First Department of Pathology, Transplantation Center, Kansai Medical University, Osaka, Japan.
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Moore J, Brooks P. Stem cell transplantation for autoimmune diseases. SPRINGER SEMINARS IN IMMUNOPATHOLOGY 2001; 23:193-213. [PMID: 11455856 DOI: 10.1007/s002810100059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- J Moore
- Haematology Department, St. Vincents Hospital, NSW, Australia.
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Viganego F, Nash R, Furst DE. Bone marrow transplantation in the treatment of systemic sclerosis. Curr Rheumatol Rep 2000; 2:492-500. [PMID: 11123103 DOI: 10.1007/s11926-000-0026-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Systemic sclerosis (SSc) is an uncommon, progressive, sometimes lethal fibrotic disease whose pathogenesis probably includes immunologic elements, especially early in its course. There is no proven therapy for this disease, although some promising results have been obtained with the use of immunosuppressive drugs such as cyclophosphamide. There exists a subgroup of patients who have rapidly progressive disease or who are not responsive to conventional treatment, and who may benefit from intensive immunosuppression with stem cell rescue (stem cell transplantation). The rationale for bone marrow transplantation (BMT), and, more recently, peripheral blood stem cell transplantation (SCT), has been validated by studies on animal models of autoimmunity. Autologous transplantation has shown encouraging anecdotal results, and it is now being evaluated in phase I/II studies in patients with predictably poor outcome. In this light, reliably identifying patients early in the course of SSc is extremely important in order to establish correct eligibility criteria. For patients unable to tolerate transplant regimens, other approaches may be feasible. In this regard, nonmyeloablative approaches, such as immunosuppression without rescue and mixed chimerism, are also discussed.
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Affiliation(s)
- F Viganego
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, D1-100, Seattle, WA 98109-4417, USA.
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Hematotherapy literatureWatch. JOURNAL OF HEMATOTHERAPY & STEM CELL RESEARCH 1999; 8:565-71. [PMID: 10791907 DOI: 10.1089/152581699320018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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