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Mehta JM, Hiremath SC, Chilimba C, Ghasemi A, Weaver JD. Translation of cell therapies to treat autoimmune disorders. Adv Drug Deliv Rev 2024; 205:115161. [PMID: 38142739 PMCID: PMC10843859 DOI: 10.1016/j.addr.2023.115161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/05/2023] [Accepted: 12/15/2023] [Indexed: 12/26/2023]
Abstract
Autoimmune diseases are a diverse and complex set of chronic disorders with a substantial impact on patient quality of life and a significant global healthcare burden. Current approaches to autoimmune disease treatment comprise broadly acting immunosuppressive drugs that lack disease specificity, possess limited efficacy, and confer undesirable side effects. Additionally, there are limited treatments available to restore organs and tissues damaged during the course of autoimmune disease progression. Cell therapies are an emergent area of therapeutics with the potential to address both autoimmune disease immune dysfunction as well as autoimmune disease-damaged tissue and organ systems. In this review, we discuss the pathogenesis of common autoimmune disorders and the state-of-the-art in cell therapy approaches to (1) regenerate or replace autoimmune disease-damaged tissue and (2) eliminate pathological immune responses in autoimmunity. Finally, we discuss critical considerations for the translation of cell products to the clinic.
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Affiliation(s)
- Jinal M Mehta
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
| | - Shivani C Hiremath
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
| | - Chishiba Chilimba
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
| | - Azin Ghasemi
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
| | - Jessica D Weaver
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA.
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2
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Spadea M, Saglio F, Ceolin V, Barone M, Zucchetti G, Quarello P, Fagioli F. Immune-mediated cytopenias (IMCs) after HSCT for pediatric non-malignant disorders: epidemiology, risk factors, pathogenesis, and treatment. Eur J Pediatr 2023; 182:2471-2483. [PMID: 36967419 PMCID: PMC10257634 DOI: 10.1007/s00431-023-04912-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 06/11/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) represents a curative option for pediatric patients affected by malignant and non-malignant disorders. Several complications may arise during the post-transplantation period, including immune-mediated disorders. Immune-mediated cytopenias (IMCs) account for up to 22% of pediatric HSCT complications, representing an important cause of morbidity and mortality post-HSCT. So far, their pathogenesis is not well-understood, and their management may be very challenging. Further, most patients are refractory to first-line treatment which is based on high-dose intravenous steroids, immunoglobulin, and the monoclonal anti-CD20 antibody - rituximab. No clear consensus has been reached for second- and third-line therapeutic options. CONCLUSION We reviewed the epidemiology, risk factors, pathogenesis, and treatment of IMCs, aiming to offer a deeper understanding of these complications as a guide to improving the management of these fragile patients and a cue for the design of tailored clinical trials. WHAT IS KNOWN • IMCs arising in the post-HSCT setting represent a rare but potentially life-threatening complication. Younger patients affected by non-malignant disorders are at the greatest risk of IMCs arising after HSCT. Corticosteroids, intravenous immunoglobulin, and rituximab represent the undiscussed first-line therapeutic approach. WHAT IS NEW • This review highlitghts how children present unique risk factors for post HSCT IMCs, which are the result of the complex relationship between the immaturity of their infantile immune system and all the perturbing agents and factors which characterize the post-HSCT setting. Future efforts are warranted to establish the best option for refractory patients, for whom a standard and validated approach is not currently available. Among new agents, ibrutinib or bortezomib and fostamatinib or low-dose IL-2 could represent a good therapeutic option for patients with graft-versus-host disease and hemolytic anemia or graft-versus-host disease and thrombocytopenia, respectively.
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Affiliation(s)
- Manuela Spadea
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
- University of Torino, Turin, Italy
| | - Francesco Saglio
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - Valeria Ceolin
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
- Erasmus University MC-Sophia Childrens Hospital, Rotterdam, Netherlands
| | - Marta Barone
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - Giulia Zucchetti
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - Paola Quarello
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy.
- University of Torino, Turin, Italy.
| | - Franca Fagioli
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
- University of Torino, Turin, Italy
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Fukui Y, Honda A, Takano H, Obo T, Mizuno H, Masamoto Y, Kurokawa M. Severe autoimmune pancytopenia after autologous hematopoietic stem cell transplantation for Hodgkin lymphoma. J Clin Exp Hematop 2022; 62:217-221. [PMID: 36261334 PMCID: PMC9898711 DOI: 10.3960/jslrt.22006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Autoimmune pancytopenia is rarely seen with Hodgkin lymphoma, and only one pediatric case of pancytopenia after autologous hematopoietic stem cell transplantation (HSCT) has been reported. We herein report a case of autoimmune pancytopenia that developed after autologous HSCT for nodular lymphocyte predominant Hodgkin lymphoma (NLPHL). A 56-year-old Japanese woman underwent autologous HSCT for NLPHL. She developed autoimmune pancytopenia seven months after autologous HSCT. In this case, PSL was effective, and the blood cell counts normalized completely. However, the patient suffered from a fatal infection, probably because of immunosuppression caused by prolonged administration of PSL, as well as a history of several chemotherapies and autologous HSCT. To our knowledge, this is the first adult case of autoimmune pancytopenia after autologous HSCT for Hodgkin lymphoma. To further validate the optimal treatment strategy for autoimmune cytopenia after autologous HSCT, more cases are necessary.
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Affiliation(s)
- Yuta Fukui
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Akira Honda
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Hirofumi Takano
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Takafumi Obo
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Hideaki Mizuno
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Yosuke Masamoto
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Mineo Kurokawa
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
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4
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Acquired hemophilia A following allogeneic stem cell transplantation for acute lymphoblastic leukemia. Ann Hematol 2022; 101:1861-1863. [PMID: 35312797 PMCID: PMC8935119 DOI: 10.1007/s00277-022-04819-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/13/2022] [Indexed: 12/02/2022]
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Burt RK, Muraro PA, Farge D, Oliveira MC, Snowden JA, Saccardi R, Han X, Quigley K, Bueno V, Frasca D, Fedorenko D, Burman J. New autoimmune diseases after autologous hematopoietic stem cell transplantation for multiple sclerosis. Bone Marrow Transplant 2021; 56:1509-1517. [PMID: 33911200 DOI: 10.1038/s41409-021-01277-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/01/2021] [Accepted: 03/19/2021] [Indexed: 02/02/2023]
Abstract
Secondary autoimmune diseases (2ndADs), most frequently autoimmune cytopenias (AICs), were first described after allogeneic hematopoietic stem cell transplantation (HSCT) undertaken for malignant and hematological indications, occurred at a prevalence of ~5-6.5%, and were attributed to allogeneic immune imbalances in the context of graft versus host disease, viral infections, and chronic immunosuppression. Subsequently, 2ndADs were reported to complicate roughly 2-14% of autologous HSCTs performed for an autoimmune disease. Alemtuzumab in the conditioning regimen has been identified as a risk for development of 2ndADs after either allogeneic or autologous HSCT and is consistent with the high rates of 2ndADs when using alemtuzumab as monotherapy. Due to the significant consequences but variable incidence, depending on conditioning regimen, of 2ndADs and similarity in known immune reconstitution kinetics after autologous HSCT for autoimmune diseases and after alemtuzumab monotherapy, we propose that an imbalance between B and T lineage regeneration early after HSCT may underlie the pathogenesis of 2ndADs.
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Affiliation(s)
- Richard K Burt
- Division of Immunotherapy, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Paolo A Muraro
- Neuroimmunology and Immunotherapy, Department of Brain Sciences, Imperial College London, London, UK
| | - Dominique Farge
- Unité de Médecine Interne: Maladies Auto-immunes et Pathologie Vasculaire (UF 04), IRSL, EA-3518, Université de Paris, MATHEC, Centre de Référence des Maladies auto-immunes systémiques Rares d'Ile-de-France, Filière FAI2R, Hôpital St-Louis, AP-HP, Paris, France
| | - Maria Carolina Oliveira
- Divisão de Imunologia Clínica, Departamento de Clínica Médica, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals, NHS Foundation Trust and the University of Sheffield, Sheffield, UK
| | - Riccardo Saccardi
- Department of Hematology, Careggi University Hospital, Florence, Italy
| | - Xiaoqiang Han
- Division of Immunotherapy, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kathleen Quigley
- Division of Immunotherapy, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Valquiria Bueno
- Department of Microbiology, Immunology and Parasitology DMIP Federal University of São Paulo UNIFESP, São Paulo, Brasil
| | - Daniela Frasca
- Department of Microbiology and Immunology, and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Denis Fedorenko
- The A.A. Maximov Department of Hematology and Cellular Therapy, National Pirogov Medical Surgical Center, Moscow, Russian Federation
| | - Joachim Burman
- Department of Neurology, Uppsala University, Uppsala, Sweden
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Giardino S, Bava C, Arrigo S, Pierri F, Gandullia P, Coccia C, Faraci M. Thalidomide as treatment of crohn-like disease occurred after allogeneic hematopoietic stem cell transplantation in a pediatric patient. Pediatr Transplant 2021; 25:e13941. [PMID: 33314581 DOI: 10.1111/petr.13941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/11/2020] [Accepted: 11/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Autoimmune diseases may occur after allogeneic hematopoietic stem cell transplantation (allo-HSCT) and inflammatory bowel disease (IBD or Crohn disease) is rarely described. We describe a child who developed CD after allo-HSCT, successfully treated with thalidomide. CASE REPORT A child affected by mucopolysaccharidosis type I received two allogeneic HSCTs for rejection after the first one. After cutaneous and intestinal chronic GvHD and 6 months after HSCT, the patients developed a trilinear autoimmune cytopenia successfully treated with rituximab and sirolimus. Due to persisting intestinal symptoms, colonoscopies were performed and histological findings demonstrated a picture of CD. Based on this observation and according to the recommendations for the treatment of CD, thalidomide was started. A complete stable clinical response was obtained 8 weeks after start of thalidomide. Colonoscopy performed 4.8 years later demonstrated a complete endoscopic and histological remission of CD. DISCUSSION In this case, the diagnosis of CD after HSCT was based on histological findings. Indeed, repeated colonscopies were necessary for diagnosis, since both clinical and endoscopic features are often common to chronic GvHD and CD. Thalidomide was started at the dose of 1.7 mg/Kg/day, and it was well tolerated. Mild peripheral neurotoxicity occurred 5 years later but disappeared completely with the dose reduction. Currently, the patient is in complete remission from CD, despite the discontinuation of all the immunosuppressive therapies. CONCLUSIONS Thalidomide could represent a therapeutic option to treat CD as autoimmune disease after allogeneic HSCT.
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Affiliation(s)
- Stefano Giardino
- Hematopoetic Stem Cell Transplant Unit, Hematology-Oncology, IRCSS, Institute G. Gaslini, Genova, Italy
| | - Cecilia Bava
- Pediatric Department, IRCSS, Institute G. Gaslini, Genova, Italy
| | - Serena Arrigo
- Gastroenterology and Digestive Endoscopy Unit, IRCSS, Institute G. Gaslini, Genova, Italy
| | - Filomena Pierri
- Hematopoetic Stem Cell Transplant Unit, Hematology-Oncology, IRCSS, Institute G. Gaslini, Genova, Italy
| | - Paolo Gandullia
- Gastroenterology and Digestive Endoscopy Unit, IRCSS, Institute G. Gaslini, Genova, Italy
| | - Cristina Coccia
- Department of Pathology, IRCSS, Institute G. Gaslini, Genova, Italy
| | - Maura Faraci
- Hematopoetic Stem Cell Transplant Unit, Hematology-Oncology, IRCSS, Institute G. Gaslini, Genova, Italy
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7
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Galvin RT, Cao Q, Miller WP, Knight-Perry J, Smith AR, Ebens CL. Characterizing Immune-Mediated Cytopenias After Allogeneic Hematopoietic Cell Transplantation for Pediatric Nonmalignant Disorders. Transplant Cell Ther 2021; 27:316.e1-316.e8. [PMID: 33836874 PMCID: PMC8036237 DOI: 10.1016/j.jtct.2021.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 01/12/2021] [Accepted: 01/17/2021] [Indexed: 11/30/2022]
Abstract
Immune-mediated cytopenias (IMC)-isolated or combined hemolytic anemia, thrombocytopenia, or neutropenia-are increasingly recognized as serious complications after allogeneic hematopoietic cell transplantation (HCT) for nonmalignant disorders (NMD). However, IMC incidence, duration, response to therapy, and risk factors are not well defined. This retrospective chart review identified cases of IMC with serologic confirmation among patients who underwent HCT for NMD at a single institution between 2010 and 2017. IMC after HCT for NMD in a large pediatric cohort (n = 271) was common with a cumulative incidence of 18%, identified at a median of 136 days after HCT. Treatment included prolonged immune suppression (>3 months) in 58% of all IMC cases, 91% when multiple cell lines were affected. Multiple therapeutic agents were used for the majority affected, and median time to resolution of IMC was 118 days from diagnosis. Fine-Gray competing risk multivariate regression analysis identified a combined risk factor of younger age (<3 years) and inherited metabolic disorder, as well as hemoglobinopathy (at any age) associated with 1-year incidence of IMC (P < .01). We expand these findings with the observation of declining donor T-lymphoid chimerism from day 60 to 100 and lower absolute CD4+ counts at day 100 (P < .01), before median onset of IMC, for patients with IMC compared to those without. In this cohort, 4 deaths (8%) were associated with IMC, including 2 requiring second transplantation for secondary graft failure. Although the pathogenesis of IMC post-HCT for NMD remains elusive, further research may identify approaches to prevent and better treat this HCT complication.
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Affiliation(s)
- Robert T Galvin
- University of Minnesota, Department of Pediatrics; Minneapolis, MN, USA
| | - Qing Cao
- University of Minnesota, Biostatistics Core at Masonic Cancer Center; Minneapolis, MN, USA
| | | | - Jessica Knight-Perry
- University of Colorado, Department of Pediatric Hematology, Oncology, and Bone Marrow Transplantation; Denver, CO, USA
| | - Angela R Smith
- University of Minnesota, Department of Pediatric Blood and Marrow Transplant; Minneapolis, MN, USA
| | - Christen L Ebens
- University of Minnesota, Department of Pediatric Blood and Marrow Transplant; Minneapolis, MN, USA.
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8
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Consensus opinion on immune-mediated cytopenias after hematopoietic cell transplant for inherited metabolic disorders. Bone Marrow Transplant 2021; 56:1238-1247. [PMID: 33441980 DOI: 10.1038/s41409-020-01179-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/04/2020] [Accepted: 11/25/2020] [Indexed: 12/23/2022]
Abstract
Hematopoietic stem cell transplantation (HCT) has been increasingly used for patients with inherited metabolic disorders (IMD). Immune mediated cytopenias (IMCs) after HCT, manifesting as hemolytic anemia, thrombocytopenia, and/or neutropenia, are recognized as a significant complication in this patient population, yet our understanding of the incidence, risk factors, and pathophysiology is currently limited. Review of the published literature demonstrates a higher incidence in younger patients who undergo HCT for a nonmalignant disease indication. However, a few reports suggest that the incidence is even higher among those with IMD (incidence ranging from 10 to 56%). This review summarizes the literature, provides an approach to better understanding of the possible etiology of IMCs, and proposes a diagnostic and management plan for patients with IMD who develop single or multi-lineage cytopenias after HCT.
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9
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George E, Manrai M. Response to 'Profile of Hepatobiliary Dysfunction in Hematopoietic Stem Cell Transplant Recipients: Autoimmune Diseases Also Contribute'. J Clin Exp Hepatol 2021; 11:632. [PMID: 34511828 PMCID: PMC8414419 DOI: 10.1016/j.jceh.2021.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Manish Manrai
- Department of Internal Medicine, Armed Forces Medical College, Pune, India
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10
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Outcome of Non-hematological Autoimmunity After Hematopoietic Cell Transplantation in Children with Primary Immunodeficiency. J Clin Immunol 2020; 41:171-184. [PMID: 33141919 DOI: 10.1007/s10875-020-00895-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Knowledge of post-hematopoietic cell transplantation (HCT) non-hematological autoimmune disease (AD) is far from satisfactory. METHOD This multicenter retrospective study focuses on incidence, risk factors, and outcomes of post-HCT AD in 596 children with primary immunodeficiency (PID) who were transplanted from 2009 to 2018. RESULTS The indications of HCT were severe combined immunodeficiency (SCID, n = 158, 27%) and non-SCID PID (n = 438, 73%). The median age at HCT was 2.3 years (range, 0.04 to 18.3 years). The 5-year overall survival for the entire cohort was 79% (95% cumulative incidence (CIN), 74-83%). The median follow-up of surviving patients was 4.3 years (0.08 to 14.7 years). The CIN of post-HCT AD was 3% (2-5%) at 1 year post-HCT, 7% (5-11%) at 5 years post-HCT, and 11% (7-17%) at 8 years post-HCT. The median onset of post-HCT AD was 2.2 years (0.12 to 9.6 years). Autoimmune thyroid disorder (n = 19, 62%) was the most common post-HCT AD, followed by neuromuscular disorders (n = 7, 22%) and rheumatological manifestations (n = 5, 16%). All patients but one required treatment for post-HCT AD. After multivariate analysis, age at transplant (p = 0.01) and T cell-depleted graft (p < 0.001) were significant predictors of post-HCT AD. None of the T cell-depleted graft recipients developed post-HCT AD. Patients with a lower CD3+ count at 6 months post-HCT had a significant higher incidence of post-HCT AD compared to disease controls. Graft-versus-host disease, viral infection, and donor chimerism had no association with post-HCT AD. CONCLUSION Post-HCT AD occurred in 11% at 8 years post-HCT and its occurrence was associated with older age at HCT and unmanipulated graft.
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11
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Bradford KL, Pearl M, Kohn DB, Weng P, Yadin O, Bowles LV, De Oliveira SN, Moore TB. AT1R Activating Autoantibodies in Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2020; 26:2061-2067. [PMID: 32736008 PMCID: PMC8128374 DOI: 10.1016/j.bbmt.2020.07.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/18/2020] [Accepted: 07/21/2020] [Indexed: 12/25/2022]
Abstract
Angiotensin II type 1 receptor activating autoantibodies (AT1R-AAs) have gained attention in solid organ transplant as non-HLA antibodies associated with rejection, vasculopathy, and graft dysfunction. These antibodies have also been reported in the context of pre-eclampsia, scleroderma, and isolated hypertension. Here, we present 3 post-hematopoietic stem cell transplant (HSCT) cases with patients demonstrating elevated levels of AT1R-AAs detected within the first year post-HSCT. All patients had hypertension, and 2 patients exhibited profound diarrhea and hypokalemia. The hypertension, in all cases, was refractory to multiple classes of antihypertensives. Upon autoantibody identification, an angiotensin receptor blocker, losartan, was promptly initiated, and all patients showed blood pressure improvement. The 2 patients with electrolyte disturbances had rapid normalization of these levels and resolution of the diarrhea. These cases demonstrate a previously unreported association of elevated AT1R-AA levels in post-HSCT patients with a rapid response to angiotensin receptor blockade initiation.
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Affiliation(s)
- Kathryn L Bradford
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of California, Los Angeles, Los Angeles, California
| | - Meghan Pearl
- Department of Pediatrics, Division of Pediatric Nephrology, University of California, Los Angeles, Los Angeles, California
| | - Donald B Kohn
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of California, Los Angeles, Los Angeles, California; Department of Molecular & Medical Pharmacology, University of California, Los Angeles, Los Angeles, California; The Eli & Edythe Broad Stem Cell Research Center, University of California, Los Angeles, Los Angeles, California; Pediatric Blood and Marrow Transplant Program, University of California, Los Angeles, Los Angeles, California
| | - Patricia Weng
- Department of Pediatrics, Division of Pediatric Nephrology, University of California, Los Angeles, Los Angeles, California
| | - Ora Yadin
- Department of Pediatrics, Division of Pediatric Nephrology, University of California, Los Angeles, Los Angeles, California
| | - La Vette Bowles
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of California, Los Angeles, Los Angeles, California; Pediatric Blood and Marrow Transplant Program, University of California, Los Angeles, Los Angeles, California
| | - Satiro N De Oliveira
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of California, Los Angeles, Los Angeles, California; The Eli & Edythe Broad Stem Cell Research Center, University of California, Los Angeles, Los Angeles, California; Pediatric Blood and Marrow Transplant Program, University of California, Los Angeles, Los Angeles, California
| | - Theodore B Moore
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of California, Los Angeles, Los Angeles, California; Pediatric Blood and Marrow Transplant Program, University of California, Los Angeles, Los Angeles, California.
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12
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Das J, Gill A, Lo C, Chan-Lam N, Price S, Wharton SB, Jessop H, Sharrack B, Snowden JA. A Case of Multiple Sclerosis-Like Relapsing Remitting Encephalomyelitis Following Allogeneic Hematopoietic Stem Cell Transplantation and a Review of the Published Literature. Front Immunol 2020; 11:668. [PMID: 32431694 PMCID: PMC7214636 DOI: 10.3389/fimmu.2020.00668] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/24/2020] [Indexed: 12/21/2022] Open
Abstract
Complications involving the central nervous system (CNS) occur in 9–14% of patients following allogeneic hematopoietic stem cell transplantation (HSCT), including stroke-like episodes, demyelination, encephalitis, and nonspecific neurological symptoms. Here we report a case of multiple sclerosis (MS) like relapsing remitting encephalomyelitis following allogeneic HSCT, which did not respond to disease modifying therapies (DMTs) and “domino” autologous HSCT. A 53-year-old male was treated with allogeneic HSCT for lymphoid blast transformation of chronic myeloid leukemia. Ten months later he presented with confusion, slurred speech, left sided facial weakness and ataxia. A magnetic resonance imaging brain scan showed multiple enhancing tumefactive lesions. Neuromyelitis optica (NMO) and myelin oligodendrocyte glycoprotein (MOG) antibodies were negative. After extensive investigations for infections, autoimmune disorders and recurrence of malignancy, he underwent brain biopsy, which showed a macrophage rich lesion with severe myelin loss but axonal preservation indicating a demyelinating pathology. Although his symptoms improved with corticosteroids, he relapsed five months later. In the absence of any systemic features suggesting graft versus host disease (GvHD), his presentation was thought to be compatible with MS. The illness followed an aggressive course that did not respond to glatiramer acetate and natalizumab. He was therefore treated with “domino” autologous HSCT, which also failed to induce long-term remission. Despite further treatment with ocrelizumab, he died of progressive disease. An autopsy limited to the examination of brain revealed multifocal destructive leukoencephalopathy with severe myelin and axonal loss. Immunohistochemistry showed macrophage located in the perivascular area, with no T or B lymphocytes. The appearance was unusual and not typical for chronic MS plaques. Reported cases of CNS demyelination following allogeneic HSCT are very limited in the literature, especially in relation to histopathological examination. Although the clinical disease course of our patient following allogeneic HSCT resembled an “MS-like” relapsing remitting encephalomyelitis, the autopsy examination did not show any evidence of active inflammation. The impact of DMTs and HSCT on the histological appearance of “MS-like” CNS pathologies is unknown. Therefore, reporting this and similar cases will improve our awareness and understanding of underlying disease mechanisms.
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Affiliation(s)
- Joyutpal Das
- Department of Neurology, Salford Royal NHS Foundation Trust, Manchester, United Kingdom.,Department of Neurology, Royal Hallamshire Hospital, Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Atta Gill
- Department of Haematology, Royal Hallamshire Hospital, Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Christine Lo
- Department of Neurology, Royal Hallamshire Hospital, Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom.,Sheffield Institute of Translational Neuroscience, University of Sheffield, Sheffield, United Kingdom
| | - Natalie Chan-Lam
- Department of Haematology, Royal Hallamshire Hospital, Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Siân Price
- Department of Neurology, Royal Hallamshire Hospital, Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Stephen B Wharton
- Sheffield Institute of Translational Neuroscience, University of Sheffield, Sheffield, United Kingdom.,Department of Histopathology, Royal Hallamshire Hospital, Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Helen Jessop
- Department of Haematology, Royal Hallamshire Hospital, Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Basil Sharrack
- Department of Neurology, Royal Hallamshire Hospital, Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom.,Sheffield Institute of Translational Neuroscience, University of Sheffield, Sheffield, United Kingdom
| | - John A Snowden
- Department of Haematology, Royal Hallamshire Hospital, Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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13
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Lv W, Qu H, Wu M, Fan Z, Huang F, Xu N, Xuan L, Lin R, Zhao K, Sun J, Lai Y, Xu Y, Liu Q. Autoimmune hemolytic anemia after allogeneic hematopoietic stem cell transplantation in adults: A southern China multicenter experience. Cancer Med 2019; 8:6549-6558. [PMID: 31502764 PMCID: PMC6825994 DOI: 10.1002/cam4.2539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/22/2019] [Accepted: 08/22/2019] [Indexed: 01/06/2023] Open
Abstract
To investigate the incidence and risk factors as well as prognosis of autoimmune hemolytic anemia (AIHA) following allogeneic hematopoietic stem cell transplantation (allo‐HSCT), a total of 1377 adult hematological malignancies at three institutions were enrolled in this study. The 3‐year cumulative incidence of AIHA was 2.2 ± 0.4%. Multivariate analysis showed that haploidentical donors (HRDs) and chronic graft vs host disease (cGVHD) were the independent risk factors for AIHA. Patients with AIHA treated initially with corticosteroids combined with cyclosporine A (CsA) had a higher complete response rate than those with corticosteroids monotherapy (66.7% vs 11.1%; P = .013). The 3‐year cumulative incidence of malignant diseases relapse was 4.4 ± 4.3% and 28.0 ± 1.3% (P = .013), treatment‐related mortality (TRM) was 8.9 ± 6.3% and 17.4 ± 1.2% (P = .431), disease‐free survival (DFS) was 56.1 ± 1.5% and 86.7 ± 7.2% (P = .011), and overall survival (OS) was 86.3 ± 7.4% and 64.1 ± 1.5% (P = .054), respectively, in the patients with AIHA and those without AIHA. Our results indicate that HRDs and cGVHD are risk factors for AIHA and corticosteroids combined with CsA are superior to corticosteroids as initial treatment for AIHA. Autoimmune hemolytic anemia does not contribute to increase TRM and could reduce the malignant diseases relapse and increase DFS.
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Affiliation(s)
- Weiran Lv
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Hong Qu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Hematology, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Meiqing Wu
- Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Ren Lin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Ke Zhao
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yongrong Lai
- Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yajing Xu
- Hematology, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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14
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Neunert CE, Despotovic JM. Autoimmune hemolytic anemia and immune thrombocytopenia following hematopoietic stem cell transplant: A critical review of the literature. Pediatr Blood Cancer 2019; 66:e27569. [PMID: 30537439 DOI: 10.1002/pbc.27569] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/29/2018] [Accepted: 11/02/2018] [Indexed: 01/19/2023]
Abstract
Autoimmune cytopenias (AIC) post-hematopoietic stem cell transplant (HSCT) are rare but exceptionally challenging complication. We conducted a comprehensive literature review and identified a pooled incidence of post-HSCT autoimmune hemolytic anemia and/or immune thrombocytopenia of 2.66% (SE = 0.27) in pediatric patients. Nonmalignant disease, unrelated donor transplant, peripheral or cord blood stem cell source, conditioning regimen without total body irradiation, and presence of chronic graft-versus-host disease were prominent risk factors. Treatment was highly variable, and cytopenias were commonly refractory. AIC represent a significant post-HSCT complication. We report here the incidence, risk factors, and possible biology behind the development of AIC in pediatric post-HSCT patients.
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Affiliation(s)
- C E Neunert
- Department of Pediatrics, Hematology/Oncology/Bone Marrow Transplant, Columbia University School of Medicine, New York, New York
| | - J M Despotovic
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, Texas
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15
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Shargian-Alon L, Raanani P, Rozovski U, Siegal T, Yust-Katz S, Yeshurun M. Immune Mediated Cerebellar Ataxia: An Unknown Manifestation of Graft-versus-Host Disease. Acta Haematol 2018; 141:19-22. [PMID: 30439710 DOI: 10.1159/000494423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/01/2018] [Indexed: 11/19/2022]
Abstract
Neurologic complications of allogeneic hematopoietic cell transplantation (allo-HCT) include infections, cerebrovascular events, therapy-induced neurotoxicity, recurrent malignancies, and neurologic manifestations of graft-versus-host disease (GVHD). Anti-glutamic acid decarboxylase (GAD) antibody-associated cerebellar ataxia is a well-established disorder of autoimmune origin, but there are no reports in the literature of its occurrence following allo-HCT. We describe a middle-aged woman with chronic GVHD after allo-HCT who presented with a rapidly progressive cerebellar syndrome. Thorough investigation revealed only cerebellar atrophy on brain imaging and positive anti-GAD65 antibodies in serum and cerebrospinal fluid suggesting the diagnosis of anti-GAD antibody-associated cerebellar ataxia. Despite prompt treatment with high-dose corticosteroids, intravenous immunoglobulins, and rituximab, the patient's condition rapidly deteriorated, and she died 4 months later. This case suggests that anti-GAD antibody-associated cerebellar ataxia may be a rare manifestation of chronic GVHD.
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Affiliation(s)
- Liat Shargian-Alon
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Rozovski
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Siegal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neuro-Oncology Center, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Shlomit Yust-Katz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neuro-Oncology Center, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Moshe Yeshurun
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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16
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Del Papa N, Pignataro F, Zaccara E, Maglione W, Minniti A. Autologous Hematopoietic Stem Cell Transplantation for Treatment of Systemic Sclerosis. Front Immunol 2018; 9:2390. [PMID: 30386340 PMCID: PMC6198074 DOI: 10.3389/fimmu.2018.02390] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/26/2018] [Indexed: 12/29/2022] Open
Abstract
Systemic Sclerosis (SSc) is a complex autoimmune disease, characterized by high mortality and morbidity. The heterogeneity in terms of extent, severity, and rate of progression of skin and internal organ involvement gives rise to many difficulties in finding the optimal therapeutic interventions for SSc and, to date, no disease-modifying agents are available. In this scenario, it is not surprising that SSc was one of the first autoimmune diseases challenged with high-dose immunosuppressive treatment followed by autologous hematopoietic stem cell transplantation (AHSCT). In the last decades, AHSCT has emerged as a treatment option for refractory SSc through a reduction of the aberrant immune cells, followed by re-constitution of a new, self-tolerant immune system. After several case series and pilot studies, more recently three randomized controlled trials have shown a benefit in skin involvement, organ functions and quality of life measures in AHSCT compared to monthly cyclophosphamide. In addition, although AHSCT presents a certain risk of mortality, it has been shown that the overall survival is better, compared to the cyclophosphamide group. Current evidence suggests that SSc patients who are most likely to benefit from AHSCT are early, active, with rapidly progressing diffuse skin disease, and mild involvement of internal organs. As the studies have progressed, it has become evident the need for a more rigorous patient selection, the optimization of transplant and post-transplant procedures, and the intervention of multidisciplinary teams of specialists to increase the safety and efficacy of AHSCT in SSc.
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Affiliation(s)
- Nicoletta Del Papa
- Dipartimento di Fisiatria e Reumatologia, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - Francesca Pignataro
- Dipartimento di Fisiatria e Reumatologia, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - Eleonora Zaccara
- Dipartimento di Fisiatria e Reumatologia, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - Wanda Maglione
- Dipartimento di Fisiatria e Reumatologia, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - Antonina Minniti
- Dipartimento di Fisiatria e Reumatologia, Istituto Ortopedico Gaetano Pini, Milan, Italy
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17
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Pariani N, Willis M, Muller I, Healy S, Nasser T, McGowan A, Lyons G, Jones J, Chatterjee K, Dayan C, Robertson N, Coles A, Moran C. Alemtuzumab-Induced Thyroid Dysfunction Exhibits Distinctive Clinical and Immunological Features. J Clin Endocrinol Metab 2018; 103:3010-3018. [PMID: 29878256 PMCID: PMC6097600 DOI: 10.1210/jc.2018-00359] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/01/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Alemtuzumab, a highly effective treatment for multiple sclerosis (MS), predisposes to Graves disease (GD), with a reportedly indolent course. OBJECTIVE To determine the type, frequency, and course of thyroid dysfunction (TD) in a cohort of alemtuzumab-treated patients with MS in the United Kingdom. DESIGN Case records of alemtuzumab-treated patients who developed TD were reviewed. RESULTS A total of 41.1% (102 out of 248; 80 female and 22 male) of patients developed TD, principally GD (71.6%). Median onset was 17 months (range 2 to 107) following the last dose, with the majority (89%) within 3 years. Follow-up data (range 6 to 251 months) were available in 71 case subjects, of whom 52 (73.2%) developed GD: 10 of these (19.2%) had fluctuating TD. All 52 patients with GD commenced antithyroid drugs (ATDs): 3 required radioiodine (RAI) due to ATD side effects, and drug therapy is ongoing in 2; of those who completed a course, 16 are in remission, 1 developed spontaneous hypothyroidism, and 30 (64%) required definitive or long-term treatment (RAI, n = 17; thyroidectomy, n = 5; and long-term ATDs, n = 8). Three cases of thyroiditis and 16 cases of hypothyroidism were documented: 5 with antithyroid peroxidase antibody positivity only, 10 with positive TSH receptor antibody (TRAb), and 1 of uncertain etiology. Bioassay confirmed both stimulating and blocking TRAb in a subset of fluctuating GD cases. CONCLUSIONS Contrary to published literature, we recorded frequent occurrence of GD that required definitive or prolonged ATD treatment. Furthermore, fluctuating thyroid status in GD and unexpectedly high frequency of TRAb-positive hypothyroidism suggested changing activity of TRAb in this clinical context; we have documented the existence of both blocking and stimulating TRAb in these patients.
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Affiliation(s)
- Nadia Pariani
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Mark Willis
- Division of Psychological Medicine and Clinical Neuroscience, Department of Neurology, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Ilaria Muller
- Thyroid Research Group, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Sarah Healy
- Division of Psychological Medicine and Clinical Neuroscience, Department of Neurology, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Taha Nasser
- Division of Psychological Medicine and Clinical Neuroscience, Department of Neurology, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Anne McGowan
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Greta Lyons
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Joanne Jones
- Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Krishna Chatterjee
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Colin Dayan
- Thyroid Research Group, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Neil Robertson
- Division of Psychological Medicine and Clinical Neuroscience, Department of Neurology, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Alasdair Coles
- Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Carla Moran
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
- Correspondence and Reprint Requests: Carla Moran, MB, PhD, University of Cambridge, Metabolic Research Laboratories, Institute of Metabolic Science, Level 4, Box 289, Addenbrooke’s Hospital, Cambridge, CB2 0QQ, United Kingdom. E-mail:
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18
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Penger T, Albrecht A, Marx M, Stachel D, Metzler M, Dörr HG. Adrenal crisis in a 14-year-old boy 12 years after hematopoietic stem cell transplantation. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM180034. [PMID: 29899990 PMCID: PMC5993059 DOI: 10.1530/edm-18-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 05/18/2018] [Indexed: 11/21/2022] Open
Abstract
We report on a boy of Albanian descent with the history of juvenile myelomonocytic leukemia (JMML). JMML was diagnosed at the age of 17 months and treated by hematopoietic stem cell transplantation (HSCT). At the age of 14.3 years, about 12 years after HSCT, he was hospitalized with an adrenal crisis. Hormone findings were consistent with primary adrenal insufficiency. Autoimmune adrenalitis was confirmed by positive autoantibodies against 21-hydroxylase and adrenal tissue. Since autoimmune Hashimoto thyroiditis was already known from the age of 9 years, we assume that both diseases are part of the spectrum of autoimmune polyglandular syndrome (APS) type 2. APS type 2 is a rare endocrine disease characterized by Addison’s disease along with autoimmune thyroid disease and/or type 1 diabetes.
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Affiliation(s)
- Theresa Penger
- Divisions of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, University Hospital of Erlangen, Erlangen, Germany
| | - Andrea Albrecht
- Divisions of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, University Hospital of Erlangen, Erlangen, Germany
| | - Michaela Marx
- Divisions of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, University Hospital of Erlangen, Erlangen, Germany
| | - Daniel Stachel
- Pediatric Hematology & Oncology, Department of Pediatric and Adolescent Medicine, University Hospital of Erlangen, Erlangen, Germany
| | - Markus Metzler
- Pediatric Hematology & Oncology, Department of Pediatric and Adolescent Medicine, University Hospital of Erlangen, Erlangen, Germany
| | - Helmuth G Dörr
- Divisions of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, University Hospital of Erlangen, Erlangen, Germany
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19
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Yanir AD, Hanson IC, Shearer WT, Noroski LM, Forbes LR, Seeborg FO, Nicholas S, Chinn I, Orange JS, Rider NL, Leung KS, Naik S, Carrum G, Sasa G, Hegde M, Omer BA, Ahmed N, Allen CE, Khaled Y, Wu MF, Liu H, Gottschalk SM, Heslop HE, Brenner MK, Krance RA, Martinez CA. High Incidence of Autoimmune Disease after Hematopoietic Stem Cell Transplantation for Chronic Granulomatous Disease. Biol Blood Marrow Transplant 2018; 24:1643-1650. [PMID: 29630926 DOI: 10.1016/j.bbmt.2018.03.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/31/2018] [Indexed: 12/24/2022]
Abstract
There is a lack of consensus regarding the role and method of hematopoietic stem cell transplantation (HSCT) on patients with chronic granulomatous disease (CGD). Long-term follow-up after HSCT in these patient population is essential to know its potential complications and decide who will benefit the most from HSCT. We report the outcome of HSCT and long-term follow-up in 24 patients with CGD, transplanted in our center from either related (n = 6) or unrelated (n = 18) donors, over a 12-year period (2003 to 2015), using high-dose alemtuzumab in the preparative regimen. We evaluated the incidence and timing of adverse events and potential risk factors. We described in detailed the novel finding of increased autoimmunity after HSCT in patients with CGD. At a median follow-up of 1460 days, 22 patients were full donor chimeras, and 2 patients had stable mixed chimerism. All assessable patients showed normalization of their neutrophil oxidative burst test. None of the patients developed grades II to IV acute graft-versus-host disease, and no patient had chronic graft-versus-host disease. Twelve of 24 patients developed 17 autoimmune diseases (ADs). Severe ADs (cytopenia and neuropathy) occurred exclusively in the unrelated donor setting and mainly in the first year after HSCT, whereas thyroid AD occurred in the related donor setting as well and more than 3 years after HSCT. Two patients died due to infectious complications after developing autoimmune cytopenias. One additional patient suffered severe brain injury. The remaining 21 patients have long-term Lansky scores ≥ 80. The outcome of HSCT from unrelated donors is comparable with related donors but might carry an increased risk of developing severe AD. A lower dose of alemtuzumab may reduce this risk and should be tested in further studies.
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Affiliation(s)
- Asaf D Yanir
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Imelda C Hanson
- Section of Immunology Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - William T Shearer
- Section of Immunology Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Lenora M Noroski
- Section of Immunology Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Lisa R Forbes
- Section of Immunology Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Feliz O Seeborg
- Section of Immunology Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Sarah Nicholas
- Section of Immunology Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Ivan Chinn
- Section of Immunology Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Jordan S Orange
- Section of Immunology Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Nicholas L Rider
- Section of Immunology Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Kathryn S Leung
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Swati Naik
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - George Carrum
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Ghadir Sasa
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Meenakshi Hegde
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Bilal A Omer
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Nabil Ahmed
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Carl E Allen
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Yassine Khaled
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Meng-Fen Wu
- The Division of Biostatistics, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Hao Liu
- The Division of Biostatistics, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Stephen M Gottschalk
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Helen E Heslop
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Malcolm K Brenner
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Robert A Krance
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas
| | - Caridad A Martinez
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center and Houston Methodist Hospital, Houston, Texas.
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20
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Biology and Potential Use of Chicken Bone Marrow-derived Cells. JOURNAL OF ANIMAL REPRODUCTION AND BIOTECHNOLOGY 2018. [DOI: 10.12750/jet.2018.33.1.31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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21
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Randall A, Huda S, Jacob A, Larner AJ. Autoimmune encephalitis (NMDAR antibody) in a patient receiving chronic post-transplant immunosuppression. Pract Neurol 2018; 18:320-322. [PMID: 29588384 DOI: 10.1136/practneurol-2018-001923] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 11/04/2022]
Abstract
Autoimmune encephalitis associated with antibodies (Abs) directed against the synaptic ligand-gated ion channel NMDA receptor (NMDAR) was first described as a paraneoplastic disorder in association with ovarian teratoma. Other forms of neoplasia have subsequently been reported although many patients do not have a tumour. Tumour removal, where applicable, and immunotherapy form the mainstays of treatment. We present a patient who developed NMDAR-Ab encephalitis despite being chronically immunosuppressed following organ transplantation, and who was eventually found to have an occult malignancy in the form of non-Hodgkin's lymphoma.
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Affiliation(s)
- Anna Randall
- Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Saif Huda
- Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Anu Jacob
- Walton Centre for Neurology and Neurosurgery, Liverpool, UK
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22
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Bittencourt MCB, Atanazio MJ, Xavier EM, Costa SF. Postsurgical pyoderma gangrenosum after an autologous stem cell transplantation for multiple myeloma. BMJ Case Rep 2018; 2018:bcr-2017-222286. [PMID: 29305364 DOI: 10.1136/bcr-2017-222286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a man who underwent autologous stem cell transplantation (ASCT) for multiple myeloma. Two months after ASCT, he presented with necrotising cholecystitis due to gallbladder stones and was submitted to laparoscopic cholecystectomy. About a week later, he developed progressive skin ulcers at sites where trochanters had been inserted. Progressive enlargement and necrotic aspect of these ulcers took place despite debridement and large spectrum antibiotics. New ulcers developed at the site of enoxaparin injection at the right arm (pathergy phenomenon). A skin biopsy and clinical evaluation favoured the diagnosis of pyoderma gangrenosum (PG). He was treated with daily methylprednisolone and dapsone with improvement of the lesions. This is the first case in the literature of PG after ASCT. Despite the risk factors, the onset of an autoinflammatory disease right after the transplant is intriguing since PG is extremely rare in immunocompromised patients.
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Affiliation(s)
| | | | - Erick Menezes Xavier
- Department of Hematology, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Brazil
| | - Silvia Figueiredo Costa
- Department of Infectious Diseases, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Brazil
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23
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Cicalese MP, Ferrua F, Castagnaro L, Rolfe K, De Boever E, Reinhardt RR, Appleby J, Roncarolo MG, Aiuti A. Gene Therapy for Adenosine Deaminase Deficiency: A Comprehensive Evaluation of Short- and Medium-Term Safety. Mol Ther 2018; 26:917-931. [PMID: 29433935 PMCID: PMC5910668 DOI: 10.1016/j.ymthe.2017.12.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 12/20/2017] [Accepted: 12/24/2017] [Indexed: 12/22/2022] Open
Abstract
Loss of adenosine deaminase activity leads to severe combined immunodeficiency (ADA-SCID); production and function of T, B, and natural killer (NK) cells are impaired. Gene therapy (GT) with an autologous CD34+-enriched cell fraction that contains CD34+ cells transduced with a retroviral vector encoding the human ADA cDNA sequence leads to immune reconstitution in most patients. Here, we report short- and medium-term safety analyses from 18 patients enrolled as part of single-arm, open-label studies or compassionate use programs. Survival was 100% with a median of 6.9 years follow-up (range, 2.3 to 13.4 years). Adverse events were mostly grade 1 or grade 2 and were reported by all 18 patients following GT. Thirty-nine serious adverse events (SAEs) were reported by 15 of 18 patients; no SAEs were considered related to GT. The most common adverse events reported post-GT include upper respiratory tract infection, gastroenteritis, rhinitis, bronchitis, oral candidiasis, cough, neutropenia, diarrhea, and pyrexia. Incidence rates for all of these events were highest during pre-treatment, treatment, and/or 3-month follow-up and then declined over medium-term follow-up. GT did not impact the incidence of neurologic/hearing impairments. No event indicative of leukemic transformation was reported.
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Affiliation(s)
- Maria Pia Cicalese
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy, 20132; Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy, 20132
| | - Francesca Ferrua
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy, 20132; Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy, 20132; Vita-Salute San Raffaele University, Milan, Italy, 20132
| | - Laura Castagnaro
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy, 20132; Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy, 20132
| | - Katie Rolfe
- GSK Research and Development, GlaxoSmithKline, UB11 1BT and SG1 2NY, UK
| | - Erika De Boever
- GSK Research and Development, GlaxoSmithKline, King of Prussia, PA 19406, USA
| | - Rickey R Reinhardt
- GSK Research and Development, GlaxoSmithKline, King of Prussia, PA 19406, USA
| | - Jonathan Appleby
- GSK Research and Development, GlaxoSmithKline, UB11 1BT and SG1 2NY, UK
| | - Maria Grazia Roncarolo
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy, 20132; Vita-Salute San Raffaele University, Milan, Italy, 20132; Department of Pediatrics, Division of Stem Cell Transplantation and Regenerative Medicine, Stanford University, Stanford, CA 94305, USA; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA 94305, USA
| | - Alessandro Aiuti
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy, 20132; Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy, 20132; Vita-Salute San Raffaele University, Milan, Italy, 20132.
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Havrdova E, Cohen JA, Horakova D, Kovarova I, Meluzinova E. Understanding the positive benefit:risk profile of alemtuzumab in relapsing multiple sclerosis: perspectives from the Alemtuzumab Clinical Development Program. Ther Clin Risk Manag 2017; 13:1423-1437. [PMID: 29081658 PMCID: PMC5652900 DOI: 10.2147/tcrm.s143509] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The introduction of high-efficacy therapies for relapsing–remitting multiple sclerosis has driven re-evaluation of treatment goals and benefit:risk considerations in treatment choice. In the alemtuzumab Phase II and III clinical trials, patients treated with alemtuzumab 12 mg versus subcutaneous interferon beta-1a demonstrated significantly reduced annualized relapse rates and improved magnetic resonance imaging outcomes, and were significantly more likely to achieve no evidence of disease activity and reduction in brain volume loss. In two of the studies, alemtuzumab-treated patients had a significantly reduced risk of 6-month confirmed disease worsening, compared with subcutaneous interferon beta-1a. Benefits were maintained throughout 5 years, with a majority of patients receiving no alemtuzumab retreatment or other disease-modifying therapy. Trial results support alemtuzumab’s manageable, consistent safety profile in relapsing–remitting multiple sclerosis. Infusion-associated reactions, the most frequent adverse events (AEs), can be minimized by corticosteroid pretreatment, monitoring, and symptomatic management. Other AEs include infections and autoimmune events. Oral anti-herpes prophylaxis should be initiated on the first day of each alemtuzumab treatment course and continued according to local guidelines. Overall cancer risk was lower in the alemtuzumab clinical trials than in a reference population; however, continuing surveillance will determine if alemtuzumab may be associated with certain malignancies such as thyroid papillary carcinoma and melanoma, which are currently identified as potential risks. The post-approval risk management strategy includes a safety monitoring program. Autoimmune AEs (thyroid events, immune thrombocytopenia, nephropathies) can be detected in a timely manner with the monitoring program, which includes physician and patient education about the signs and symptoms, monthly renal and hematologic monitoring, and quarterly thyroid function monitoring for 48 months after the last alemtuzumab course. Education, vigilance by physicians and patients, and monthly laboratory monitoring are recommended to maintain alemtuzumab’s positive benefit:risk profile.
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Affiliation(s)
- Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Jeffrey A Cohen
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Ivana Kovarova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Eva Meluzinova
- Department of Neurology, Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
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Hwang-Bo S, Kim SK, Lee JW, Jang PS, Chung NG, Jeong DC, Cho B, Kim HK. Treatment and response of autoimmune cytopenia occurring after allogeneic hematopoietic cell transplantation in children. Blood Res 2017; 52:119-124. [PMID: 28698848 PMCID: PMC5503889 DOI: 10.5045/br.2017.52.2.119] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 03/30/2017] [Accepted: 04/11/2017] [Indexed: 11/29/2022] Open
Abstract
Background Autoimmune cytopenia (AIC) is a rare complication of allogeneic hematopoietic cell transplantation (HCT). In this study, we reviewed the diagnosis, treatment and response to therapy for pediatric patients with post-HCT AIC at our institution. Methods Of the 292 allogeneic HCTs performed from January, 2011 to December, 2015 at the Department of Pediatrics, The Catholic University of Korea, seven were complicated by post-HCT AIC, resulting in an incidence of 2.4%. Results All seven patients with post-HCT AIC had received unrelated donor transplant. Six of seven patients had a major donor-recipient blood type mismatch. The subtypes of AIC were as follows: immune thrombocytopenia (ITP) 2, autoimmune hemolytic anemia (AIHA) 2, Evans syndrome 3. Median time from HCT to AIC diagnosis was 3.6 months. All but one patient responded to first line therapy of steroid±intravenous immunoglobulin (IVIG), but none achieved complete response (CR) with this treatment. After a median duration of treatment of 15.3 months, two patients with ITP achieved CR and five had partial response (PR) of AIC. Five patients were treated with rituximab, resulting in the following response: 2 CR, 2 PR, 1 no response (NR). Median time to response to rituximab was 26 days from first infusion. All patients are alive without event. Conclusion Post-HCT AIC is a rare complication that may not resolve despite prolonged therapy. Rapid initiation of second line agents including but not limited to B cell depleting treatment should be considered for those that fail to achieve CR with first line therapy.
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Affiliation(s)
- Seok Hwang-Bo
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Seong-Koo Kim
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Jae Wook Lee
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Pil-Sang Jang
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Nack-Gyun Chung
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Dae-Chul Jeong
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Bin Cho
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Hack-Ki Kim
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
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26
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Simonsen CS, Hansen G, Piehl F, Edland A. Chronic inflammatory demyelinating polyradiculoneuropathy occurring after autologous haematopoietic stem cell transplantation for multiple sclerosis. Mult Scler J Exp Transl Clin 2017; 2:2055217316658304. [PMID: 28607734 PMCID: PMC5433337 DOI: 10.1177/2055217316658304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/15/2016] [Indexed: 11/25/2022] Open
Abstract
We describe the case of a man in his 40 s with aggressive multiple sclerosis (MS) who received autologous haematopoietic stem cell transplantation (AHSCT) and subsequently developed probable, if not definite, Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) and haematological complications. Autoimmune conditions occurring as a side effect of allogenic transplantations are well known in the context of haematological malignancies, but only rarely reported for autologous transplantations. Our case demonstrates that although AHSCT may be effective for suppressing MS inflammatory activity, the profound changes to the immune repertoire may lead to other clinically relevant autoimmune phenomena. A careful benefit-risk evaluation should be conducted in all cases where AHSCT is considered.
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Affiliation(s)
| | - Gunnar Hansen
- Department of Neurology, Drammen Hospital, Vestre Viken HF, Norway
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institut, Sweden
| | - Astrid Edland
- Department of Neurology, Drammen Hospital, Vestre Viken HF, Norway
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27
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Rawlings DJ, Metzler G, Wray-Dutra M, Jackson SW. Altered B cell signalling in autoimmunity. Nat Rev Immunol 2017; 17:421-436. [PMID: 28393923 DOI: 10.1038/nri.2017.24] [Citation(s) in RCA: 185] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Recent work has provided new insights into how altered B cell-intrinsic signals - through the B cell receptor (BCR) and key co-receptors - function together to promote the pathogenesis of autoimmunity. These combined signals affect B cells at two distinct stages: first, in the selection of the naive repertoire; and second, during extrafollicular or germinal centre activation responses. Thus, dysregulated signalling can lead to both an altered naive BCR repertoire and the generation of autoantibody-producing B cells. Strikingly, high-affinity autoantibodies predate and predict disease in several autoimmune disorders, including type 1 diabetes and systemic lupus erythematosus. This Review summarizes how, rather than being a downstream consequence of autoreactive T cell activation, dysregulated B cell signalling can function as a primary driver of many human autoimmune diseases.
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Affiliation(s)
- David J Rawlings
- Seattle Children's Research Institute, 1900 9th Avenue, Seattle, Washington 98101, USA.,Department of Immunology, University of Washington School of Medicine.,Department of Pediatrics, University of Washington School of Medicine, 750 Republican Street, Seattle, Washington 98109, USA
| | - Genita Metzler
- Seattle Children's Research Institute, 1900 9th Avenue, Seattle, Washington 98101, USA.,Department of Immunology, University of Washington School of Medicine
| | - Michelle Wray-Dutra
- Seattle Children's Research Institute, 1900 9th Avenue, Seattle, Washington 98101, USA.,Department of Immunology, University of Washington School of Medicine
| | - Shaun W Jackson
- Seattle Children's Research Institute, 1900 9th Avenue, Seattle, Washington 98101, USA.,Department of Pediatrics, University of Washington School of Medicine, 750 Republican Street, Seattle, Washington 98109, USA
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Leone A, Radin M, Almarzooqi AM, Al-Saleh J, Roccatello D, Sciascia S, Khamashta M. Autologous hematopoietic stem cell transplantation in Systemic Lupus Erythematosus and antiphospholipid syndrome: A systematic review. Autoimmun Rev 2017; 16:469-477. [PMID: 28279836 DOI: 10.1016/j.autrev.2017.03.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/10/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) has been proposed as a therapeutic option for patients with Systemic Lupus Erythematosus (SLE) refractory to standard therapy. This therapeutic approach has been applied to other severe autoimmune diseases refractory to standard therapy with promising results. AIM To systematically review the literature and analyze the available evidence on HSCT therapy in patients with SLE and antiphospholipid syndrome (APS), with a focus on therapy efficacy and occurrence of adverse events. METHODS A detailed literature search, applied to Ovid MEDLINE, In-Process and Other Non-Indexed Citation and Ovid Medline 1986 to 2014, has been developed a priori to identify articles that reported findings from clinical and laboratory studies that investigated the effect of HCT in patients with SLE. RESULTS Twenty-five studies met all inclusion criteria, including a total of 279 SLE patients; of those, 54 patients also fulfilled the classification criteria of APS. The majority of the studies reported an improvement after HSCT in terms of diseases activity control (assessed with SLEDAI, or time-free from diseases) or overall survival. However, one study reported no net benefit of HSCT when compared to immunosuppression alone. One retrospective study reported an overall survival at 5years of 81% in 28 SLE patients. Of note, 5 cases (9.3%) of aPL negativization were reported after HSCT in the APS patients. When combining these studies and analyzing these patients with APS, 32 out of 44 (73%) were able to discontinue anticoagulation after HSCT. Our findings also demonstrate a total of 86 infections in the pool of patients (30.8%), 3 of which resulted in the death of the patient (1.3%). We observed an annual incidence of infection of 11.9% with a mean follow up of 36.2months. CONCLUSION Preliminary results of HSCT as a therapeutic option for SLE appear promising. Further studies are warranted in order to assess the safety of the procedure for both the occurrence of secondary autoimmune disease and the rate of infection. However, the rate of adverse effects confines this option to very selected cases of SLE patients resistant or refractory to standard approaches.
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Affiliation(s)
- Alessia Leone
- Ashford and St Peter's Hospitals NHS Foundation Trust, Surrey, UK
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | | | | | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy; SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy; SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy.
| | - Munther Khamashta
- Department of Rheumatology, Dubai Hospital, Dubai, UAE; Lupus Research Unit, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK; Lupus Research Unit, Division of Women's Health, King's College London, London, UK
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Autoimmune hemolysis and immune thrombocytopenic purpura after cord blood transplantation may be life-threatening and warrants early therapy with rituximab. Bone Marrow Transplant 2016; 51:1579-1583. [PMID: 27643868 DOI: 10.1038/bmt.2016.228] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/01/2016] [Accepted: 07/19/2016] [Indexed: 12/19/2022]
Abstract
Autoimmune hemolysis (AH) and immune thrombocytopenic purpura (ITP) are recognized complications after cord blood transplantation (CBT). We evaluated the incidence and characteristics of AH/ITP after double-unit CBT in a day 100 landmark analysis of 152 patients (median age 36 years, range 0.9-70 years) transplanted for hematologic malignancies with myeloablative or nonmyeloablative conditioning and calcineurin inhibitor (CNI)/mycophenolate mofetil. With a median 5.2-year (range 1.6-9.7 years) survivor follow-up, 10 patients developed autoimmune cytopenias (8 AH, 1 ITP, 1 both) at a median of 10.4 months (range 5.8-24.5) post CBT for a 7% cumulative incidence 3 years after the day 100 landmark. Six patients presented with severe disease (hemoglobin ⩽6 g/dL and/or platelets <20 × 109/L). All AH patients were direct antiglobulin test positive. All 10 cases developed during immunosuppression taper with 8 having prior acute GVHD. All 10 patients received rituximab 2-18 days after diagnosis, and corticosteroids combined with rituximab within <7 days was the most effective. No patient died of AH/ITP. AH/ITP occurs infrequently after CBT but may be life-threatening requiring emergency therapy. Rituximab combined with corticosteroids at diagnosis is warranted in patients with severe disease.
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Kato I, Okada H, Nishida T, Konishi Y, Kondo S, Nishisho S, Iwase T, Itoh S, Kusaka T. Evans syndrome after autologous peripheral blood stem cell transplantation for recurrent Hodgkin lymphoma. Pediatr Int 2016; 58:933-6. [PMID: 27577012 DOI: 10.1111/ped.13030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 04/06/2016] [Accepted: 04/14/2016] [Indexed: 12/16/2022]
Abstract
There have been a number of recent reports on the occurrence of autoimmune conditions after autologous hematopoietic stem cell transplantation. We describe a rare case of Evans syndrome (ES) that developed in a 16-year-old patient >1 year after autologous peripheral blood stem cell transplantation for recurrent Hodgkin lymphoma. ES is a rare and frequently refractory condition. No therapy for the condition has been established, and it can often be fatal. In the present case, i.v. cyclosporine A injection was significantly effective against the ES, which has not recurred.
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Affiliation(s)
- Ikuko Kato
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan.
| | - Hitoshi Okada
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tomoko Nishida
- Department of Education for Children with Special Needs, Faculty of Education, Kagawa University, Kagawa, Japan
| | - Yukihiko Konishi
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Sonoko Kondo
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Sae Nishisho
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Takashi Iwase
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Susumu Itoh
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
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31
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Li Z, Rubinstein SM, Thota R, Savani M, Brissot E, Shaw BE, Majhail NS, Mohty M, Savani BN. Immune-Mediated Complications after Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1368-1375. [DOI: 10.1016/j.bbmt.2016.04.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 04/06/2016] [Indexed: 11/27/2022]
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32
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Datta SS, Reddy M, Basu S, Krishnan S. Blood Group Discrepancy-First Sign of Autoimmune Hemolytic Anemia after Hematopoietic Stem Cell Transplantation in a Child. Indian J Hematol Blood Transfus 2016; 32:211-3. [PMID: 27408394 DOI: 10.1007/s12288-015-0630-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/14/2015] [Indexed: 11/25/2022] Open
Abstract
A 12-year-old male child was presented in the emergency with features of anemia and mild icterus on day+67 of HSCT. The child was suffering from Fanconi anemia and undergone HSCT from ABO-matched, fully HLA matched sibling donor. The diagnosis of mixed type AIHA due to cytomegalovirus reactivation was made in the immunohematology laboratory and blood group discrepancy was the first sign of AIHA in this patient. Though the cold agglutinin titer was not significant but the clinical symptoms and laboratory evidences were suggestive of significant hemolysis due to underlying IgG autoantibody. In addition the high complement avidity of IgM autoantibody might also be a contributing factor for clinically significant hemolysis in this case. The patient was successfully treated with phenotype matched blood transfusion, rituximab and oral steroid therapy.
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Affiliation(s)
- Suvro Sankha Datta
- Department of Transfusion Medicine, The Mission Hospital, Sector-2C, Immon Kalyan Sarani, Bidhannagar, Durgapur, WB 713212 India
| | - Mahua Reddy
- Department of Transfusion Medicine, Tata Medical Center, Kolkata, India
| | - Sabita Basu
- Department of Transfusion Medicine, Tata Medical Center, Kolkata, India
| | - Shekhar Krishnan
- Department of Pediatric Oncology, Tata Medical Center, Kolkata, India
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Abstract
Since the start of the international stem cell transplantation project in 1997, over 2000 patients have received a haematopoietic stem cell transplant (HSCT), mostly autologous, as treatment for a severe autoimmune disease, the majority being multiple sclerosis (MS), systemic sclerosis (SSc) and Crohn's disease. There was an overall 85% 5-year survival and 43% progression-free survival. Around 30% of patients in all disease subgroups had a complete response, often durable despite full immune reconstitution. In many cases, e.g. systemic sclerosis, morphological improvement such as reduction of skin collagen and normalization of microvasculature was documented, beyond any predicted known effects of intense immunosuppression alone. It is hoped that the results of the three running large prospective randomized controlled trials will allow modification of the protocols to reduce the high transplant-related mortality which relates to regimen intensity, age of patient, and comorbidity. Mesenchymal stromal cells (MSC), often incorrectly called stem cells, have been the intense focus of in vitro studies and animal models of rheumatic and other diseases over more than a decade. Despite multiple plausible mechanisms of action and a plethora of positive in vivo animal studies, few randomised controlled clinical trials have demonstrated meaningful clinical benefit in any condition so far. This could be due to confusion in cell product terminology, complexity of clinical study design and execution or agreement on meaningful outcome measures. Within the rheumatic diseases, SLE and rheumatoid arthritis (RA) have received most attention. Uncontrolled multiple trial data from over 300 SLE patients have been published from one centre suggesting a positive outcome; one single centre comparative study in 172 RA was positive. In addition, small numbers of patients with Crohn's disease, multiple sclerosis, primary Sjögren's disease, polymyositis/dermatomyositis and type II diabetes mellitus have received MSC therapeutically. The possible reasons for this apparent mismatch between expectation and clinical reality will be discussed.
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Affiliation(s)
- Alan Tyndall
- University of Basel, department of rheumatology, 4, Petersgraben, 4031 Basel, Baseltstadt, Switzerland.
| | - Jacob M van Laar
- University medical center Utrecht, department of rheumatology and clinical immunology, Utrecht, The Netherlands
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Strickland FM, Patel D, Khanna D, Somers E, Robida AM, Pihalja M, Swartz R, Marder W, Richardson B. Characterisation of an epigenetically altered CD4(+) CD28(+) Kir(+) T cell subset in autoimmune rheumatic diseases by multiparameter flow cytometry. Lupus Sci Med 2016; 3:e000147. [PMID: 27099767 PMCID: PMC4823547 DOI: 10.1136/lupus-2016-000147] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/08/2016] [Accepted: 03/09/2016] [Indexed: 12/24/2022]
Abstract
Objectives Antigen-specific CD4+ T cells epigenetically modified with DNA methylation inhibitors overexpress genes normally suppressed by this mechanism, including CD11a, CD70, CD40L and the KIR gene family. The altered cells become autoreactive, losing restriction for nominal antigen and responding to self-class II major histocompatibility complex (MHC) molecules without added antigen, and are sufficient to cause a lupus-like disease in syngeneic mice. T cells overexpressing the same genes are found in patients with active lupus. Whether these genes are co-overexpressed on the same or different cells is unknown. The goal of this study was to determine whether these genes are overexpressed on the same or different T cells and whether this subset of CD4+ T cells is also present in patients with lupus and other rheumatic diseases. Methods Multicolour flow cytometry was used to compare CD11a, CD70, CD40L and KIR expression on CD3+CD4+CD28+ T cells to their expression on experimentally demethylated CD3+CD4+CD28+ T cells and CD3+CD4+CD28+ T cells from patients with active lupus and other autoimmune diseases. Results Experimentally demethylated CD4+ T cells and T cells from patients with active lupus have a CD3+CD4+CD28+CD11ahiCD70+CD40LhiKIR+ subset, and the subset size is proportional to lupus flare severity. A similar subset is found in patients with other rheumatic diseases including rheumatoid arthritis, systemic sclerosis and Sjögren's syndrome but not retroperitoneal fibrosis. Conclusions Patients with active autoimmune rheumatic diseases have a previously undescribed CD3+CD4+CD28+CD11ahiCD70+CD40LhiKIR+ T cell subset. This subset may play an important role in flares of lupus and related autoimmune rheumatic diseases, provide a biomarker for disease activity and serve as a novel therapeutic target for the treatment of lupus flares.
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Affiliation(s)
- Faith M Strickland
- Rheumatology Division, Department of Internal Medicine , The University of Michigan Medical School , Ann Arbor, Michigan , USA
| | - Dipak Patel
- Rheumatology Division, Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor, Michigan, USA; Eli Lilly and Company, San Diego, California, USA
| | - Dinesh Khanna
- Rheumatology Division, Department of Internal Medicine , The University of Michigan Medical School , Ann Arbor, Michigan , USA
| | - Emily Somers
- Rheumatology Division, Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor, Michigan, USA; Department of Environmental Health Sciences, The University of Michigan, Ann Arbor, Michigan, USA; Department of Obstetrics & Gynecology, The University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Aaron M Robida
- Biomedical Research Core, Flow Cytometry, The University of Michigan , Ann Arbor, Michigan , USA
| | - Michael Pihalja
- Biomedical Research Core, Flow Cytometry, The University of Michigan , Ann Arbor, Michigan , USA
| | - Richard Swartz
- Rheumatology Division, Department of Internal Medicine , The University of Michigan Medical School , Ann Arbor, Michigan , USA
| | - Wendy Marder
- Rheumatology Division, Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor, Michigan, USA; Department of Obstetrics & Gynecology, The University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Bruce Richardson
- Rheumatology Division, Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor, Michigan, USA; Department of Medicine, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA
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35
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Prenc E, Pulanic D, Pucic-Bakovic M, Pezer M, Desnica L, Vrhovac R, Nemet D, Pavletic SZ. Potential of glycosylation research in graft versus host disease after allogeneic hematopoietic stem cell transplantation. Biochim Biophys Acta Gen Subj 2016; 1860:1615-22. [PMID: 26923767 DOI: 10.1016/j.bbagen.2016.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 02/21/2016] [Accepted: 02/22/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Glycans, complex oligosaccharides, are directly involved in almost every biological process, have a fundamental role in the immune system, and are probably involved in nearly every human disease. However, glycosylation has been greatly ignored in the area of allogeneic hematopoietic stem cell transplantation (alloHSCT) and graft versus host disease (GVHD). Both acute and chronic GVHD are multisystemic debilitating immunological disturbances arising after alloHSCT. SCOPE OF REVIEW In this paper, we review the glycosylation research already done in the field of alloHSCT and GVHD and evaluate further potential of glycan analysis in GVHD by looking into resembling inflammatory and autoimmune conditions. MAJOR CONCLUSIONS Glycan research could bring significant improvement in alloHSCT procedure with reduction in following complications, such as GVHD. Identifying glycan patterns that induce self-tolerance and the ones that cause the auto- and allo-immune response could lead to innovative and tissue-specific immunomodulative therapy instead of the current immunosuppressive treatment, enabling preservation of the graft-versus-tumor effect. Moreover, improved glycan pattern analyses could offer a more complete assessment and greatly needed dynamic biomarkers for GVHD. GENERAL SIGNIFICANCE This review is written with a goal to encourage glycan research in the field of alloHSCT and GVHD as a perspective tool leading to improved engraftment, discovery of much needed biomarkers for GVHD, enabling an appropriate therapy and improved monitoring of therapeutic response. This article is part of a Special Issue entitled "Glycans in personalised medicine" Guest Editor: Professor Gordan Lauc.
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Affiliation(s)
- Ema Prenc
- Croatian Cooperative Group for Hematologic Diseases, Zagreb, Croatia
| | - Drazen Pulanic
- Division of Haematology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia; University of Zagreb School of Medicine, Zagreb, Croatia; Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek, Croatia.
| | | | - Marija Pezer
- Genos Glycoscience Research Laboratory, Zagreb, Croatia
| | - Lana Desnica
- Division of Haematology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Radovan Vrhovac
- Division of Haematology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia; University of Zagreb School of Medicine, Zagreb, Croatia
| | - Damir Nemet
- Division of Haematology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia; University of Zagreb School of Medicine, Zagreb, Croatia; Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek, Croatia
| | - Steven Z Pavletic
- Graft-versus-Host and Autoimmunity Section, Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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Bolton HA, Zhu E, Terry AM, Guy TV, Koh WP, Tan SY, Power CA, Bertolino P, Lahl K, Sparwasser T, Shklovskaya E, Fazekas de St Groth B. Selective Treg reconstitution during lymphopenia normalizes DC costimulation and prevents graft-versus-host disease. J Clin Invest 2015; 125:3627-41. [PMID: 26301814 DOI: 10.1172/jci76031] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 07/13/2015] [Indexed: 01/03/2023] Open
Abstract
Regulatory T cells (Tregs) have been shown to enhance immune reconstitution and prevent graft-versus-host disease (GVHD) after hematopoietic stem cell transplantation; however, it is unclear how Tregs mediate these effects. Here, we developed a model to examine the mechanism of Treg-dependent regulation of immune reconstitution. Lymphopenic mice were selectively reconstituted with Tregs prior to transfer of conventional CD4+ T cells. Full Treg reconstitution prevented the rapid oligoclonal proliferation that gives rise to pathogenic CD4 effector T cells, while preserving the slow homeostatic form of lymphopenia-induced peripheral expansion that repopulates a diverse peripheral T cell pool. Treg-mediated CTLA-4-dependent downregulation of CD80/CD86 on DCs was critical for inhibition of rapid proliferation and was a function of the Treg/DC ratio achieved by reconstitution. In an allogeneic BM transplant model, selective Treg reconstitution before T cell transfer also normalized DC costimulation and provided complete protection against GVHD. In contrast, cotransfer of Tregs was not protective. Our results indicate that achieving optimal recovery from lymphopenia should aim to improve early Treg reconstitution in order to increase the relative number of Tregs to DCs and thereby inhibit spontaneous oligoclonal T cell proliferation.
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Vaughn JE, Anwer F, Deeg HJ. Treatment of refractory ITP and Evans syndrome by haematopoietic cell transplantation: is it indicated, and for whom? Vox Sang 2015; 110:5-11. [PMID: 26178735 DOI: 10.1111/vox.12314] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 05/27/2015] [Accepted: 05/28/2015] [Indexed: 12/13/2022]
Abstract
Several lines of therapy have been established for patients with immune thrombocytopenia (ITP) and Evans syndrome. However, these therapies generally require prolonged administration, lead to profound immunosuppression and increased infectious risk, and are often poorly tolerated. While most patients with these disorders will respond to first-line steroid therapy, others will prove refractory or intolerant to multiple treatments. In these patients (and possibly even selected patients who are not considered refractory), autologous or allogeneic haematopoietic stem cell transplantation (HCT) may provide definitive therapy. We review the literature on the treatment of ITP and Evans syndrome with HCT and discuss its use in the management of these disorders. We also pose, for the purpose of discussion, research questions that will be important to address if HCT is to be considered a viable option for more patients with these diseases.
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Affiliation(s)
- J E Vaughn
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - F Anwer
- University of Arizona Cancer Center, Tucson, AZ, USA
| | - H J Deeg
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
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Ahmed I, Teruya J, Murray-Krezan C, Krance R. The incidence of autoimmune hemolytic anemia in pediatric hematopoietic stem cell recipients post-first and post-second hematopoietic stem cell transplant. Pediatr Transplant 2015; 19:391-8. [PMID: 25809012 PMCID: PMC4420696 DOI: 10.1111/petr.12455] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 11/26/2022]
Abstract
The reported incidence of post-allogeneic HSCT AIHA was between 4.4% and 6% following a single transplant. Cord blood transplantation, T-cell depletion, and chronic GvHD are significantly associated with post-transplant AIHA. During an 11-yr period, data for 500 pediatric HSCT recipients were eligible for evaluation of the incidence of AIHA post-first and post-second transplants. Demographic, transplant, and post-transplant-related variables were analyzed. Twelve of 500 (2.4%) recipients at a median of 273 days and seven of 72 (9.7%) recipients at a median of 157 days developed AIHA post-first and post-second HSCT, respectively. Post-first HSCT, none of the MRD recipients developed AIHA (0/175 MRD vs. 12/325 other donors, p = 0.04). Four of 12 required a second HSCT to control the AIHA. After the second HSCT, MUD was significantly associated with the development of AIHA. No other variables were associated with the post-second transplant AIHA. The incidence of AIHA post-first and post-second HSCT was less than the reported. The increased incidence of AIHA among recipients of second HSCT is most likely due to the profound immune dysregulation. A much larger, prospective study would be needed to evaluate the incidence, complications, and management of post-transplant AIHA.
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Affiliation(s)
- Ibrahim Ahmed
- Department of Pediatric Hematology/Oncology and BMT, Children's Mercy Hospital; 2401 Gillham Road, Kansas City, Missouri 64108
| | - Jun Teruya
- Department of Pediatrics, Center for Cell and Gene Therapy, Baylor College of Medicine, 1102 Bates Street, Suite 1770, Houston, TX 77030, USA,Departments of Pathology & Immunology, Pediatrics, and Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Cristina Murray-Krezan
- Department of Internal Medicine, Division of Epidemiology, Biostatistics, and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Robert Krance
- Department of Pediatrics, Center for Cell and Gene Therapy, Baylor College of Medicine, 1102 Bates Street, Suite 1770, Houston, TX 77030, USA
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Song MK, Chung JS, Kim SJ, Kim SS, Shin HJ. Diffuse thyroid 18F-FDG uptake after R-CHOP therapy predicts favorable outcome in patients with DLBCL. Ann Hematol 2015; 94:995-1001. [DOI: 10.1007/s00277-015-2311-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/28/2015] [Indexed: 11/28/2022]
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Pulmonary Manifestations of Hematological Malignancies: Focus on Pulmonary Chronic Graft-Versus Host Disease. ORPHAN LUNG DISEASES 2015. [PMCID: PMC7120310 DOI: 10.1007/978-1-4471-2401-6_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Advances in the management of patients in terms of the diagnosis and treatment of hematologic malignancies and treatment-related complications, especially infectious complications, have increased survival time. However, more than half of the patients treated for hematologic malignancies will develop a pulmonary complication during their follow-up, infectious pneumonia remaining the most common diagnosis that should be considered first in regard to its potential severity. Otherwise, new complications that may involve different organs, including the lungs, have been increasingly reported. Currently, over a quarter of lung infiltrates occurring in the context of hematological diseases are due to noninfectious causes. Thus, lung physicians may be increasingly confronted with these lung disorders. Various noninfectious pulmonary complications have been described in the different hematological malignancies; however, these complications are most often studied in the context of allogeneic hematopoietic stem cell transplantation (HSCT). In this chapter, we will briefly review the lung diseases associated with various hematological malignancies before focusing on noninfectious pulmonary complications following allogeneic HSCT.
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Autoimmune Demyelinating Polyneuropathy as a Manifestation of Chronic Graft-versus-Host Disease after Adult Cord Blood Transplantation in a Patient with Chronic Lymphocytic Leukemia. Case Rep Hematol 2014; 2014:758094. [PMID: 25295200 PMCID: PMC4180198 DOI: 10.1155/2014/758094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 08/21/2014] [Indexed: 12/01/2022] Open
Abstract
Immune mediated demyelinating disease after allogeneic stem cell transplantation is a rare entity with unclear etiology. Acute inflammatory demyelinating polyneuropathy (AIDP) has been reported after related and adult unrelated allogeneic stem cell transplantation but no such case has been reported after unrelated cord blood transplantation. We hereby present the first case of AIDP after double umbilical cord blood transplantation (DUCBT). A 55-year-old man with chronic lymphocytic leukemia (CLL) received a cord blood transplant for relapsed refractory disease with high risk cytogenetics. On day 221, patient presented with skin rash, tingling in both lower extremites, and ascending paralysis that progressed rapidly over the course of 2 days. The workup resulted in a diagnosis of AIDP and administration of intravenous immunoglobulins plus steroids was initiated. Motor and sensory powers were fully recovered and his chronic GVHD was managed for several months with single agent sirolimus.
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Wang M, Wang W, Abeywardane A, Adikarama M, McLornan D, Raj K, de Lavallade H, Devereux S, Mufti GJ, Pagliuca A, Potter VT, Mijovic A. Autoimmune hemolytic anemia after allogeneic hematopoietic stem cell transplantation: analysis of 533 adult patients who underwent transplantation at King's College Hospital. Biol Blood Marrow Transplant 2014; 21:60-6. [PMID: 25262883 DOI: 10.1016/j.bbmt.2014.09.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 09/15/2014] [Indexed: 01/08/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is a recognized complication of hematopoietic stem cell transplantation (HSCT); it is often refractory to treatment and carries a high mortality. To improve understanding of the incidence, risk factors, and clinical outcome of post-transplantation AIHA, we analyzed 533 patients who received allogeneic HSCT, and we identified 19 cases of AIHA after HSCT (overall incidence, 3.6%). The median time to onset, from HSCT to AIHA, was 202 days. AIHA was associated with HSCT from unrelated donors (hazard ratio [HR], 5.28; 95% confidence interval [CI], 1.22 to 22.9; P = .026). In the majority (14 of 19; 74%) of AIHA patients, multiple agents for treatment were required, with only 9 of 19 (47%) patients achieving complete resolution of AIHA. Patients with post-transplantation AIHA had a higher overall mortality (HR, 2.48; 95% CI, 1.33 to 4.63; P = .004), with 36% (4 of 11 cases) of deaths attributable to AIHA.
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Affiliation(s)
- Meng Wang
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, and King's College London, London, United Kingdom.
| | - Wenjia Wang
- School of Computing Sciences, University of East Anglia, Norwich, United Kingdom
| | - Ayesha Abeywardane
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, and King's College London, London, United Kingdom
| | - Malinthi Adikarama
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, and King's College London, London, United Kingdom
| | - Donal McLornan
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, and King's College London, London, United Kingdom
| | - Kavita Raj
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, and King's College London, London, United Kingdom
| | - Hugues de Lavallade
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, and King's College London, London, United Kingdom
| | - Stephen Devereux
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, and King's College London, London, United Kingdom
| | - Ghulam J Mufti
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, and King's College London, London, United Kingdom
| | - Antonio Pagliuca
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, and King's College London, London, United Kingdom
| | - Victoria T Potter
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, and King's College London, London, United Kingdom
| | - Aleksandar Mijovic
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, and King's College London, London, United Kingdom
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Tronconi E, Miniaci A, Prete A, Masetti R, Pession A. Juvenile arthritis after haematopoietic stem cell transplantation. Bone Marrow Transplant 2014; 49:1244-5. [DOI: 10.1038/bmt.2014.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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44
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Total leukoderma and leukotrichia in a child after hematopoietic SCT: report of a case and review of the literature. Bone Marrow Transplant 2013; 49:460-2. [PMID: 24335999 DOI: 10.1038/bmt.2013.200] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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45
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Faraci M, Zecca M, Pillon M, Rovelli A, Menconi MC, Ripaldi M, Fagioli F, Rabusin M, Ziino O, Lanino E, Locatelli F, Daikeler T, Prete A. Autoimmune hematological diseases after allogeneic hematopoietic stem cell transplantation in children: an Italian multicenter experience. Biol Blood Marrow Transplant 2013; 20:272-8. [PMID: 24274983 DOI: 10.1016/j.bbmt.2013.11.014] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 11/19/2013] [Indexed: 11/29/2022]
Abstract
Autoimmune hematological diseases (AHDs) may occur after allogeneic hematopoietic stem cell transplantation (HSCT), but reports on these complications in large cohorts of pediatric patients are lacking. Between 1998 and 2011, 1574 consecutive children underwent allogeneic HSCT in 9 Italian centers. Thirty-three children (2.1%) developed AHDs: 15 autoimmune hemolytic anemia (45%), 10 immune thrombocytopenia (30%), 5 Evans' syndrome (15%), 2 pure red cell aplasia (6%), and 1 immune neutropenia (3%). The 10-year cumulative incidence of AHDs was 2.5% (95% confidence interval, 1.7 to 3.6). In a multivariate analysis, the use of alternative donor and nonmalignant disease was statistically associated with AHDs. Most patients with AHDs (64%) did not respond to steroids. Sustained complete remission was achieved in 87% of cases with the anti-CD20 monoclonal antibody (rituximab). Four patients (9%) (1 autoimmune hemolytic anemia, 1 Evans' syndrome, 2 immune thrombocytopenia) died at a median of 87 days after AHD diagnosis as a direct or indirect consequence of their disorder. Our data suggest that AHDs are a relatively rare complication occurring after HSCT that usually respond to treatment with rituximab.
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Affiliation(s)
- Maura Faraci
- Haematopoietic Stem Cell Transplantation Unit, Haematology-Oncology Department, G. Gaslini Children's Research Institute, Genova, Italy.
| | - Marco Zecca
- Paediatric Haematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marta Pillon
- Paediatric Oncology-Haematology Unit, University Hospital of Padova, Padova, Italy
| | - Attilio Rovelli
- Paediatric Haematopoietic Stem Cell Transplantation Unit, MBBM Foundation, University of Milano-Bicocca, Monza, Italy
| | - Maria Cristina Menconi
- Haematopoietic Stem Cell Transplantation Unit, Paediatric Clinic of University of Pisa, Pisa, Italy
| | - Mimmo Ripaldi
- Haematopoietic Stem Cell Transplantation Unit, Haematology-Oncology Department, Pausilipon Hospital, Napoli, Italy
| | - Franca Fagioli
- Haematopoietic Stem Cell Transplantation Unit, Department of Paediatrics, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Marco Rabusin
- Haematopoietic Stem Cell Transplantation Unit, Paediatric Clinic, Burlo Garofolo Research Institute, Trieste, Italy
| | - Ottavio Ziino
- Paediatric Haematology Oncology, Ospedale dei Bambini "G. Di Cristina, Palermo", Palermo, Italy
| | - Edoardo Lanino
- Haematopoietic Stem Cell Transplantation Unit, Haematology-Oncology Department, G. Gaslini Children's Research Institute, Genova, Italy
| | - Franco Locatelli
- Department of Paediatric Haematology-Oncology, IRCCS Bambino Gesù Children's Hospital, Rome, University of Pavia, Pavia, Italy
| | - Thomas Daikeler
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - Arcangelo Prete
- Paediatric Oncology and Haematology Unit Lalla Seràgnoli, Department of Paediatrics, University of Bologna Sant'Orsola-Malpighi Hospital, Bologna, Italy
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Ogura M, Ichikawa M, Masuda A, Kandabashi K, Nannya Y, Kurokawa M. A mixed-type autoimmune hemolytic anemia with immune thrombocytopenia related with myositis and post-transplantation lymphoproliferative disorder. Ann Hematol 2013; 93:869-71. [PMID: 24013519 DOI: 10.1007/s00277-013-1887-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 08/16/2013] [Indexed: 11/25/2022]
MESH Headings
- Adult
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/pathology
- Anemia, Hemolytic, Autoimmune/therapy
- Graft vs Host Disease/complications
- Graft vs Host Disease/pathology
- Graft vs Host Disease/therapy
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Myeloid, Acute/complications
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Male
- Myeloablative Agonists/therapeutic use
- Myositis/complications
- Myositis/pathology
- Myositis/therapy
- Thrombocytopenia/complications
- Thrombocytopenia/pathology
- Thrombocytopenia/therapy
- Transplantation Conditioning
- Transplantation, Homologous
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Affiliation(s)
- Mizuki Ogura
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Fatal immune hemolytic anemia following allogeneic stem cell transplantation: report of 2 cases and review of literature. Transfus Med Rev 2013; 27:166-70. [PMID: 23562007 DOI: 10.1016/j.tmrv.2013.02.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 01/29/2013] [Accepted: 02/18/2013] [Indexed: 01/02/2023]
Abstract
Immune hemolytic anemia is a well-recognized complication after allogeneic hematopoietic stem cell transplantation (HSCT). There are 4 possible causes for this complication. First, antibodies present in the recipient destroy donor cells. Second, donor red cell antibodies at the time of stem cell infusion are transferred to the recipient. Third, sometimes, engrafted donor lymphocytes cause active production of red cell antibodies. Fourth, another cause of hemolysis after allogeneic HSCT is autoimmune hemolytic anemia (AIHA). It is thought to be due to antibodies produced by the donor's immune system against antigens on red cells of donor origin. Autoimmune hemolytic anemia after allogeneic HSCT is rare, it is still not well characterized, and it represents a life-threatening situation. We describe 2 patients with acute myeloid leukemia treated with intensive chemotherapy and umbilical cord blood stem cell transplantation (UCBT). One patient developed AIHA at day +182 and the other at day +212 after receiving UCBT. Patients received 5 and 7 line treatment options, respectively, including continuous corticosteroids, intravenous immunoglobulin, splenectomy, cyclophosphamide, plasma exchange, rituximab, bortezomib, and eculizumab. However, both patients died because of massive hemolysis after 85 and 106 days of intensive treatment, respectively. These cases reflect the extreme difficulty in the therapeutic management of patients with AIHA following UCBT. After an extensive review of the literature, the exact physiopathologic mechanisms of AIHA after allogeneic HSCT in general, and after UCBT in particular, and therefore an effective treatment remain unknown.
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48
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Reading JL, Yang JHM, Sabbah S, Skowera A, Knight RR, Pinxteren J, Vaes B, Allsopp T, Ting AE, Busch S, Raber A, Deans R, Tree TIM. Clinical-Grade Multipotent Adult Progenitor Cells Durably Control Pathogenic T Cell Responses in Human Models of Transplantation and Autoimmunity. THE JOURNAL OF IMMUNOLOGY 2013; 190:4542-52. [DOI: 10.4049/jimmunol.1202710] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Mihalj M, Kellermayer Z, Balogh P. Follicles in gut-associated lymphoid tissues create preferential survival niches for follicular Th cells escaping Thy-1-specific depletion in mice. Int Immunol 2013; 25:423-35. [PMID: 23449667 DOI: 10.1093/intimm/dxt001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Although a substantial number of T cells may escape depletion following in vivo mAb treatment in patients undergoing immunosuppression, their specific tissue location and phenotypic characteristics in different peripheral lymphoid tissues have not been analyzed in detail. Here we investigated the survival of CD4(+) T cells immediately following anti-Thy-1 mAb treatment in mice. We found a preferential survival of CD4(+) T cells expressing Thy-1 antigen in the Peyer's patches (PP) and also in mesenteric lymph nodes (MLN), where the relative majority of the surviving CD4(+) T cells displayed CD44(high)/CD62L(-) phenotype corresponding to effector memory T-cell features. These CD4(+) T cells also expressed CXCR5 and PD-1 (programmed cell death-1) markers characteristic for follicular Th cells (TFH). We also demonstrate that the immediate survival of these cells does not involve proliferation and is independent of IL-7. Induction of germinal center formation in spleen enhanced while the dissolution of follicular architecture by lymphotoxin-β receptor antagonist treatment slightly reduced TFH survival. Our results thus raise the possibility that the follicles within PP and MLN may create natural support niches for the preferential survival of TFH cells of the memory phenotype, thus allowing their escape during T-cell depletion.
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Affiliation(s)
- Martina Mihalj
- Department of Immunology & Biotechnology, Faculty of Medicine, University of Pécs, Szigeti ut 12, Pécs H-7624, Hungary
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50
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New autoimmune diseases after cord blood transplantation: a retrospective study of EUROCORD and the Autoimmune Disease Working Party of the European Group for Blood and Marrow Transplantation. Blood 2013; 121:1059-64. [DOI: 10.1182/blood-2012-07-445965] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Key Points
Autoimmune diseases do occur after CBT in approximately 5% of patients. Of these, AIHA or ITP were observed the most often and were treated with prednisone, CSA, and RTX.
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