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Doglio M, Alexander T, Del Papa N, Snowden JA, Greco R. New insights in systemic lupus erythematosus: From regulatory T cells to CAR-T-cell strategies. J Allergy Clin Immunol 2022; 150:1289-1301. [PMID: 36137815 DOI: 10.1016/j.jaci.2022.08.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/11/2022] [Accepted: 08/02/2022] [Indexed: 12/14/2022]
Abstract
Systemic lupus erythematous is a heterogeneous autoimmune disease with potentially multiorgan damage. Its complex etiopathogenesis involves genetic, environmental, and hormonal factors, leading to a loss of self-tolerance with autoantibody production and immune complex formation. Given the relevance of autoreactive B lymphocytes, several therapeutic approaches have been made targeting these cells. However, the disease remains incurable, reflecting an unmet need for effective strategies. Novel therapeutic concepts have been investigated to provide more specific and sustainable disease modification compared with continued immunosuppression. Autologous hematopoietic stem cell transplantation has already provided the proof-of-concept that immunodepletion can lead to durable treatment-free remissions, albeit with significant treatment-related toxicity. In the future, chimeric antigen receptor-T-cell therapies, for example, CD19 chimeric antigen receptor-T, may provide a more effective lymphodepletion and with less toxicity than autologous hematopoietic stem cell transplantation. An emerging field is to enhance immune tolerance by exploiting the suppressive capacities of regulatory T cells, which are dysfunctional in patients with systemic lupus erythematous, and thus resemble promising candidates for adoptive cell therapy. Different approaches have been developed in this area, from polyclonal to genetically engineered regulatory T cells. In this article, we discuss the current evidence and future directions of cellular therapies for the treatment of systemic lupus erythematous, including hematopoietic stem cell transplantation and advanced regulatory T-cell-based cellular therapies.
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Affiliation(s)
- Matteo Doglio
- Experimental Hematology Unit, Department of Immunology Transplantations and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy; Unit of Pediatric Immunohematology, San Raffaele Hospital, Milan, Italy
| | - Tobias Alexander
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Rheumatology and Clinical Immunology, Berlin, Germany; Deutsches Rheuma-Forschungszentrum (DRFZ), an Institute of the Leibniz Association, Berlin, Germany.
| | | | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals Foundation NHS Trust, Sheffield, United Kingdom
| | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Mila, Italy.
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2
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Achini-Gutzwiller FR, Snowden JA, Corbacioglu S, Greco R. Haematopoietic stem cell transplantation for severe autoimmune diseases in children: A review of current literature, registry activity and future directions on behalf of the autoimmune diseases and paediatric diseases working parties of the European Society for Blood and Marrow Transplantation. Br J Haematol 2022; 198:24-45. [PMID: 37655707 DOI: 10.1111/bjh.18176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 11/27/2022]
Abstract
Although modern clinical management strategies have improved the outcome of paediatric patients with severe autoimmune and inflammatory diseases over recent decades, a proportion will experience ongoing or recurrent/relapsing disease activity despite multiple therapies often leading to irreversible organ damage, and compromised quality of life, growth/development and long-term survival. Autologous and allogeneic haematopoietic stem cell transplantation (HSCT) have been used successfully to induce disease control and often apparent cure of severe treatment-refractory autoimmune diseases (ADs) in children. However, transplant-related outcomes are disease-dependent and long-term outcome data are limited in respect to efficacy and safety. Moreover, balancing risks of HSCT against AD prognosis with continually evolving non-transplant options is challenging. This review appraises published literature on HSCT strategies and outcomes in individual paediatric ADs. We also provide a summary of the European Society for Blood and Marrow Transplantation (EBMT) Registry, where 343 HSCT procedures (176 autologous and 167 allogeneic) have been reported in 326 children (<18 years) for a range of AD indications. HSCT is a promising treatment modality, with potential long-term disease control or cure, but therapy-related morbidity and mortality need to be reduced. Further research is warranted to establish the position of HSCT in paediatric ADs via registries and prospective clinical studies to support evidence-based interspeciality guidelines and recommendations.
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Affiliation(s)
- Federica R Achini-Gutzwiller
- Division of Paediatric Stem Cell Transplantation and Haematology, Children's Research Centre (CRC), University Children's Hospital of Zurich, Zurich, Switzerland
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Selim Corbacioglu
- Department of Paediatric Oncology, Haematology and Stem Cell Transplantation, University Children's Hospital Regensburg, Regensburg, Germany
| | - Raffaella Greco
- Unit of Haematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Ginoux E, Kottler D, Anglaret B, Balme B, Bulabois CE, Skowron F. Remission of a long-lasting sarcoidosis after allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia. JAAD Case Rep 2016; 2:408-410. [PMID: 27766304 PMCID: PMC5065641 DOI: 10.1016/j.jdcr.2016.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Emmanuelle Ginoux
- Department of Dermatology, Centre Hospitalier de Valence, Valence, France
| | - Diane Kottler
- Department of Dermatology, Centre Hospitalier de Valence, Valence, France
| | - Bruno Anglaret
- Department of Hematology, Centre Hospitalier de Valence, Valence, France
| | - Brigitte Balme
- Department of Dermatopathology, CHU Lyon sud, Pierre Bénite, France
| | | | - François Skowron
- Department of Dermatology, Centre Hospitalier de Valence, Valence, France
- Correspondence to: François Skowron, MD, Service de Dermatologie, Centre Hospitalier de Valence, 179 Bd Maréchal JUIN, 26000 Valence, France.Service de DermatologieCentre Hospitalier de Valence179 Bd Maréchal JUINValence26000France
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Kelsey PJ, Oliveira MC, Badoglio M, Sharrack B, Farge D, Snowden JA. Haematopoietic stem cell transplantation in autoimmune diseases: From basic science to clinical practice. Curr Res Transl Med 2016; 64:71-82. [PMID: 27316390 DOI: 10.1016/j.retram.2016.03.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 03/31/2016] [Indexed: 12/20/2022]
Abstract
Based on animal studies and serendipitous clinical cases, haematopoietic stem cell transplantation (HSCT) has been used since 1995 as a specific treatment for patients with severe treatment-resistant autoimmune disease (ADs). Despite other clinical developments for autoimmune diseases, including biological therapies, there has been an ongoing requirement for HSCT in some diseases and several thousand procedures have been registered in databases for a wide variety of diseases, predominantly for treatment with autologous HSCT. Currently, the main indications are multiple sclerosis, systemic sclerosis and Crohn's disease, which are supported by large series and randomised controlled trials (RCTs), whereas retrospective registry analyses support benefit in a range of rarer indications. Research into mechanisms of action has provided insight into how tolerance may be achieved with an intensive one-off treatment. In addition to the profound anti-inflammatory and immunosuppressive effects provided by the cytotoxic regimen, long-term responses in some diseases may be explained by 'resetting' the immune system through thymic reprocessing and generation of increased T-regulatory cell activity. This review aims to summarise the gradual evolution of HSCT in severe autoimmune diseases over the last 20 years, focussing on the recent publication of clinical and scientific studies, as well as evidence-based guidelines and recommendations.
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Affiliation(s)
- P J Kelsey
- Departments of Haematology and Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield, UK.
| | - M-C Oliveira
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | - B Sharrack
- Departments of Haematology and Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield, UK
| | - D Farge
- St. Louis hospital, Internal Medicine and Vascular Diseases Unit, Paris, France; INSERM 1160 Unit, Paris 7 Diderot University, Sorbonne Paris Cite 1, Paris, France
| | - J A Snowden
- Departments of Haematology and Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield, UK
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Mamez AC, Souchet L, Roos-Weil D, Uzunov M, Brun AL, Algrin C, Leblond V, Nguyen S. Graft-versus-T-cell lymphoma effect: a sustained CR after tapering immunosuppressive drugs in a patient with angioimmunoblastic T-cell lymphoma in relapse after allogeneic transplantation. Bone Marrow Transplant 2014; 50:304-6. [PMID: 25365069 DOI: 10.1038/bmt.2014.243] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- A C Mamez
- Service d'Hématologie, Hôpital Pitié Salpêtrière, Paris, France
| | - L Souchet
- Service d'Hématologie, Hôpital Pitié Salpêtrière, Paris, France
| | - D Roos-Weil
- Service d'Hématologie, Hôpital Pitié Salpêtrière, Paris, France
| | - M Uzunov
- Service d'Hématologie, Hôpital Pitié Salpêtrière, Paris, France
| | - A L Brun
- Service de Radiologie, Hôpital Pitié Salpêtrière, Paris, France
| | - C Algrin
- Service d'Hématologie, Hôpital Pitié Salpêtrière, Paris, France
| | - V Leblond
- Service d'Hématologie, Hôpital Pitié Salpêtrière, Paris, France
| | - S Nguyen
- Service d'Hématologie, Hôpital Pitié Salpêtrière, Paris, France
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6
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Rosario C, Seguro L, Vasconcelos C, Shoenfeld Y. Is there a cure for systemic lupus erythematosus? Lupus 2014; 22:417-21. [PMID: 23554031 DOI: 10.1177/0961203313479839] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The morbidity and mortality of systemic lupus erythematosus (SLE) is a subject of intense relevance in the literature, yet descriptions of prolonged and sustained remissions or even cure are barely reported. In recent decades the life expectancy in SLE patients has improved, but the quality of life seems to be poor compared with other chronic diseases and with the general population. The immunopathogenesis of SLE is complex and not fully understood, so patients have been treated with nonspecific immunosuppressive therapies. But in recent years, because of advances in basic science, targeted therapies have been developed. Despite the progress made in treating SLE, currently a cure in SLE seems to be a myth. SLE it seems, remains incurable. A specific treatment has not emerged to directly abrogate a disease-specific autoimmune response. Relapsing manifestations and complications of treatment still remain important markers of morbidity.
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Affiliation(s)
- C Rosario
- Internal Medicine Department, Hospital de Pedro Hispano, Portugal
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7
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Marmont du Haut Champ AM. Hematopoietic stem cell transplantation for systemic lupus erythematosus. Clin Dev Immunol 2012; 2012:380391. [PMID: 22969816 PMCID: PMC3437314 DOI: 10.1155/2012/380391] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 06/06/2012] [Accepted: 07/03/2012] [Indexed: 12/29/2022]
Abstract
Two streams of research are at the origin of the utilization of hematopoietic stem cell transplantation (HSCT) for severe autoimmune diseases (SADs). The allogeneic approach came from experimental studies on lupus mice, besides clinical results in coincidental diseases. The autologous procedure was encouraged by researches on experimental neurological and rheumatic disorders. At present the number of allogeneic HSCT performed for human SADs can be estimated to not over 100 patients, and the results are not greatly encouraging, considering the significant transplant-related mortality (TRM) and the occasional development of a new autoimmune disorder and/or relapses notwithstanding full donor chimerism. Autologous HSCT for refractory SLE has become a major target. Severe cases have been salvaged, TRM is low and diminishing, and prolonged clinical remissions are obtainable. Two types of immune resetting have been established, "re-education" and regulatory T cell (Tregs) normalization. Allogeneic HSCT for SLE seems best indicated for patients with disease complicated by an oncohematologic malignancy. Autologous HSCT is a powerful salvage therapy for otherwise intractable SLE. The duration of remission in uncertain, but a favorable response to previously inactive treatments is a generally constant feature. The comparison with new biological agents, or the combination of both, are to be ascertained.
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Affiliation(s)
- Alberto M Marmont du Haut Champ
- Division of Hematology and Stem Cell Transplantation, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy.
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8
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Pession A, Zama D, Masetti R, Gasperini P, Prete A. Hematopoietic stem cell transplantation for curing children with severe autoimmune diseases: is this a valid option? Pediatr Transplant 2012; 16:413-25. [PMID: 22519456 DOI: 10.1111/j.1399-3046.2012.01691.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The cure of children with severe AD, especially patients with severe, progressive, and therapy-resistant autoimmunity, represents a challenge for current medical practice. The idea of HSCT as a promising therapeutic opportunity was borne accidentally from finding patients who, after undergoing HSCT for a hematological indication, were cured of a concomitant AD. Thus, over the last two decades, HSCT has been extensively investigated, and it has become an appealing therapy for rheumatological (juvenile rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis) and hematological diseases (immune cytopenias). Recently, interesting results have been also described in type 1 diabetes mellitus and Crohn's disease. Although the use of HSCT has been steadily rising in the last few years, many questions are still open, especially after the discoveries of many new biological agents. Given the low incidence of ADs in children, most of the data about the use of the HSCT for these diseases are taken from a mixed cohort of adults and children. The aim of this review is to summarize the published studies and to try to answer the question as to whether this procedure can be considered a promising approach.
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Affiliation(s)
- Andrea Pession
- Paediatric Oncology and Haematology Unit Lalla Seràgnoli, Department of Paediatrics, University of Bologna Sant'Orsola-Malpighi Hospital, Bologna, Italy
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9
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Snowden JA, Saccardi R, Allez M, Ardizzone S, Arnold R, Cervera R, Denton C, Hawkey C, Labopin M, Mancardi G, Martin R, Moore JJ, Passweg J, Peters C, Rabusin M, Rovira M, van Laar JM, Farge D. Haematopoietic SCT in severe autoimmune diseases: updated guidelines of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 2012; 47:770-90. [PMID: 22002489 PMCID: PMC3371413 DOI: 10.1038/bmt.2011.185] [Citation(s) in RCA: 212] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 07/04/2011] [Accepted: 07/04/2011] [Indexed: 12/13/2022]
Abstract
In 1997, the first consensus guidelines for haematopoietic SCT (HSCT) in autoimmune diseases (ADs) were published, while an international coordinated clinical programme was launched. These guidelines provided broad principles for the field over the following decade and were accompanied by comprehensive data collection in the European Group for Blood and Marrow Transplantation (EBMT) AD Registry. Subsequently, retrospective analyses and prospective phase I/II studies generated evidence to support the feasibility, safety and efficacy of HSCT in several types of severe, treatment-resistant ADs, which became the basis for larger-scale phase II and III studies. In parallel, there has also been an era of immense progress in biological therapy in ADs. The aim of this document is to provide revised and updated guidelines for both the current application and future development of HSCT in ADs in relation to the benefits, risks and health economic considerations of other modern treatments. Patient safety considerations are central to guidance on patient selection and HSCT procedural aspects within appropriately experienced and Joint Accreditation Committee of International Society for Cellular Therapy and EBMT accredited centres. A need for prospective interventional and non-interventional studies, where feasible, along with systematic data reporting, in accordance with EBMT policies and procedures, is emphasized.
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Affiliation(s)
- J A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
- Department of Oncology, University of Sheffield, Sheffield, UK
| | - R Saccardi
- Department of Haematology, Careggi University Hospital, Firenze, Italy
| | - M Allez
- Service de Gastroentérologie, INSERM U 662, Hôpital St Louis, Paris, France
| | - S Ardizzone
- Department of Gastroenterology, Sacco University Hospital, Milan, Italy
| | - R Arnold
- Charite Hospital Berlin, Berlin, Germany
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - C Denton
- Centre for Rheumatology, Royal Free and University College Medical School, Hampstead, London, UK
| | - C Hawkey
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - M Labopin
- Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, AP-HP, UPMC Univ Paris 06, Paris, France
| | - G Mancardi
- Department of Neuroscience, Ophthalmology and Genetics, University of Genova, Genova, Italy
| | - R Martin
- Institute for Neuroimmunology and Clinical MS Research, Hamburg, Germany
| | - J J Moore
- St Vincent's Hospital, Sydney, NSW, Australia
| | - J Passweg
- Universitaetsspital Basel, Basel, Switzerland
| | - C Peters
- BMT Unit, St Anna Children's Hospital, Vienna, Austria
| | - M Rabusin
- BMT Unit, Department of Pediatrics, Institute of Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - M Rovira
- SCT Unit, Hematology Department, Hospital Clinic, Barcelona, Spain
| | | | - D Farge
- Department of Internal Medicine, INSERM U 796, Hôpital St Louis, Paris, France
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Benesch M, Urban C, Platzbecker U, Passweg J. Stem cell transplantation for patients with Evans syndrome. Expert Rev Clin Immunol 2010; 5:341-8. [PMID: 20477011 DOI: 10.1586/eci.09.9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Evans syndrome (ES) is a chronic hematological disorder characterized by autoimmune hemolytic anemia and immune-mediated thrombocytopenia that often requires profound and long-term immunosuppression. Only a few small case series or single case studies of autologous and allogeneic hematopoietic stem cell transplantation (HSCT) in patients with ES have been reported in the literature, with long-term remissions being observed after both autologous and allogeneic HSCT. Patients with ES suffering from refractory disease, multiple relapses and serious disease-related complications should be offered allogeneic HSCT, which is the only treatment with curative potential. Autologous HSCT might be preferable in patients with serious pre-existing comorbidities lacking an HLA-identical donor. Owing to the rarity of this disease and the small number of patients receiving HSCT for ES, prospective controlled studies on this approach are not available. A prospective registration of patients transplanted for ES would allow the development of optimal transplant strategies.
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Affiliation(s)
- Martin Benesch
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 30, A-8036 Graz, Austria.
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Marmont AM, Saccardi R. This issue reports the results of HSCT. Concluding remarks. Autoimmunity 2010; 41:686-90. [PMID: 18958749 DOI: 10.1080/08916930802200240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Snowden JA, Martin-Rendon E, Watt SM. Clinical stem cell therapies for severe autoimmune diseases. Transfus Med 2009; 19:223-34. [DOI: 10.1111/j.1365-3148.2009.00927.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Passweg JR, Rabusin M. Hematopoetic stem cell transplantation for immune thrombocytopenia and other refractory autoimmune cytopenias. Autoimmunity 2009; 41:660-5. [DOI: 10.1080/08916930802198436] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Nonmyeloablative allogeneic bone marrow transplantation of a child with systemic autoimmune disease and lung vasculitis. Immunol Res 2008; 41:26-33. [PMID: 18360745 DOI: 10.1007/s12026-007-0015-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Hematopoietic stem cell transplantation for autoimmune diseases: What have we learned? J Autoimmun 2008; 30:116-20. [DOI: 10.1016/j.jaut.2007.12.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Marmont AM. Will hematopoietic stem cell transplantation cure human autoimmune diseases? J Autoimmun 2008; 30:145-50. [DOI: 10.1016/j.jaut.2007.12.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Deane S, Meyers FJ, Gershwin ME. On reversing the persistence of memory: Hematopoietic stem cell transplant for autoimmune disease in the first ten years. J Autoimmun 2008; 30:180-96. [DOI: 10.1016/j.jaut.2007.12.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Gualandi F, Bruno B, Van Lint MT, Luchetti S, Uccelli A, Capello E, Mancardi GL, Bacigalupo A, Marmont A. Autologous stem cell transplantation for severe autoimmune diseases: a 10-year experience. Ann N Y Acad Sci 2007; 1110:455-64. [PMID: 17911461 DOI: 10.1196/annals.1423.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The first autologous hematopoietic stem cell transplantation in Europe for a patient with severe refractory systemic lupus erythematosus (SLE) was performed in Genoa in 1996. Since then, 32 patients with a wide spectrum of autoimmune diseases (ADs) received autologous transplants, 22 of them with multiple sclerosis (MS). There were no fatal adverse events. All patients had complete or very good partial remissions, but relapses were frequent, especially in SLE, though never as aggressive as pretransplant. The mechanism of action of this intervention remains not completely understood, as briefly discussed here.
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Affiliation(s)
- F Gualandi
- Division of Hematology and Stem Cell Transplantation Center, Azienda Ospedaliera-Universitaria S. Martino, Italy
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Verda L, Kim DA, Ikehara S, Statkute L, Bronesky D, Petrenko Y, Oyama Y, He X, Link C, Vahanian NN, Burt RK. Hematopoietic mixed chimerism derived from allogeneic embryonic stem cells prevents autoimmune diabetes mellitus in NOD mice. Stem Cells 2007; 26:381-6. [PMID: 17975228 DOI: 10.1634/stemcells.2006-0262] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Embryonic stem cell (ESC)-derived hematopoietic stem cells (HSC), unlike HSC harvested from the blood or marrow, are not contaminated by lymphocytes. We therefore evaluated whether ESC-derived HSC could produce islet cell tolerance, a phenomenon termed graft versus autoimmunity (GVA), without causing the usual allogeneic hematopoietic stem cell transplant complication, graft-versus-host disease (GVHD). Herein, we demonstrate that ESC-derived HSC may be used to prevent autoimmune diabetes mellitus in NOD mice without GVHD or other adverse side effects. ESC were cultured in vitro to induce differentiation toward HSC, selected for c-kit expression, and injected either i.v. or intra-bone marrow (IBM) into sublethally irradiated NOD/LtJ mice. Nine of 10 mice from the IBM group and 5 of 8 from the i.v. group did not become hyperglycemic, in contrast to the control group, in which 8 of 9 mice developed end-stage diabetes. All mice with >5% donor chimerism remained free of diabetes and insulitis, which was confirmed by histology. Splenocytes from transplanted mice were unresponsive to glutamic acid decarboxylase isoform 65, a diabetic-specific autoantigen, but responded normally to third-party antigens. ESC-derived HSC can induce an islet cell tolerizing GVA effect without GVHD. This study represents the first instance, to our knowledge, of ESC-derived HSC cells treating disease in an animal model.
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Affiliation(s)
- Larissa Verda
- Division of Immunotherapy, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Kapoor S, Wilson AG, Sharrack B, Lobo A, Akil M, Sun L, Dalley CD, Snowden JA. Haemopoietic stem cell transplantation--an evolving treatment for severe autoimmune and inflammatory diseases in rheumatology, neurology and gastroenterology. ACTA ACUST UNITED AC 2007; 12:179-91. [PMID: 17558693 DOI: 10.1080/10245330701255106] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The concept of haemopoietic stem cell transplantation (HSCT) to treat severe autoimmune diseases has been around for several decades. Advances in the safety of HSCT have made it a clinical reality since 1995. Databases have registered around a thousand patients treated specifically for a wide range of diseases, predominantly multiple sclerosis (MS), systemic sclerosis (SSc), rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Phase I/II prospective and retrospective studies have supported the potential of autologous HSCT as a treatment option in severely affected patients, with profound and prolonged clinical responses in some diseases, although procedures are generally not curative. Allogeneic HSCT appears to offer curative potential, but the potential of high toxicity has limited its use in this context. The exact role of HSCT remains to be defined, particularly in the context of other advances in the treatment of autoimmune disease. Along with other groups, the European Group for Blood and Marrow Transplantation (EBMT) are overseeing several phase III trials in autologous transplantation. Given the risks of the HSCT, eligibility is restricted to patients who have severe, treatment resistant disease, in whom the prognosis is otherwise poor. This review aims to summarise the current published data in this evolving treatment for relatively rare patients with resistant or rapidly progressive disease where treatment options are otherwise limited. This cross-fertilization of knowledge between many specialties may provide increasing therapeutic opportunities in otherwise untreatable diseases. Moreover, destroying and rebuilding immune systems may provide insights into autoimmune diseases.
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Affiliation(s)
- Sabrina Kapoor
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
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Marmont AM, Gualandi F, Occhini D, Morandi F, Ferretti E, Pezzolo A, Strada P, Ravetti JL, Pistoia V, Falanga A, Bacigalupo A. Catastrophic relapse of Evans syndrome five years after allogeneic BMT notwithstanding full donor chimerism. Terminal hemolytic-uremic syndrome. Autoimmunity 2007; 39:505-11. [PMID: 17060030 DOI: 10.1080/08916930600847598] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A patient with severe Evans syndrome received an allo-BMT from his HLA-identical sister on November, 2000. Full marrow and blood donor chimerism were achieved only after 5 donor lymphocyte infusions (DLI), and coincided with complete clinical remission and disappearence of auto-antibodies. Five years later, hemolytic anemia recurred with rapid increase of serum bilirubin to over 50 mg%: he responded to combined therapy, but died on day +17 from admission of an acute hemolytic uremic syndrome (HUS). All circulating blood cells, including erythrocytes, were 100% donor. Ex vivo cultured and expanded T and B cells from the peripheral blood were also 100% donor. The supernatants from B cell cultures, containing either IgM or IgG, did not react with a panel of erythrocytes. Thus in this typical autoimmune disease with a predominant B cell pathogenesis the donor immune system resulted "innocent of autoimmunity". The persistence of long-lived recipient autoreactive plasma-cell lines in survival niches, still producing autoantibodies, may be hypothesized for this and similar cases. The postulated graft-versus-autoimmunity (GVA) effect was apparently not sufficient to eradicate autoimmunity in this patient.
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Affiliation(s)
- A M Marmont
- Division of Hematology and Stem Cell Transplantation Center, Istituto G. Gaslini, Genova, Italy.
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25
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Loh Y, Oyama Y, Statkute L, Verda L, Quigley K, Yaung K, Barr W, Jovanovic B, Burt RK. Non-myeloablative allogeneic hematopoietic stem cell transplantation for severe systemic sclerosis: graft-versus-autoimmunity without graft-versus-host disease? Bone Marrow Transplant 2007; 39:435-7. [PMID: 17310133 DOI: 10.1038/sj.bmt.1705611] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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26
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Marmont AM, Dominietto A, Gualandi F, Piaggio G, van Lint MT, Bacigalupo A. Pure white cell aplasia (PWCA) relapsing after allogeneic BMT and successfully treated with nine DLIs. Biol Blood Marrow Transplant 2006; 12:987-9. [PMID: 16920566 DOI: 10.1016/j.bbmt.2006.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Accepted: 04/21/2006] [Indexed: 12/29/2022]
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27
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Kunitomi A, Ishikawa T, Tajima K, Konaka Y, Yagita M. Bone marrow transplantation with a reduced-intensity conditioning regimen in a patient with Wegener granulomatosis and therapy-related leukemia. Int J Hematol 2006; 83:262-5. [PMID: 16720560 DOI: 10.1532/ijh97.05148] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We describe a patient with Wegener granulomatosis (WG) who underwent long-term cyclophosphamide treatment and thereafter developed acute myelogenous leukemia (AML). After the AML was induced into remission, the patient received an allogeneic stem cell transplant (allo-SCT) from his sibling after undergoing a reduced-intensity conditioning regimen. His clinical course shortly after allo-SCT was uneventful. No clinically apparent acute or chronic graft-versus-host disease developed. Repeated analysis of the peripheral blood lymphocytes after transplantation showed complete donor chimerism. The level of proteinase 3 antineutrophil cytoplasmic antibody (PR3-ANCA) remained undetectable until 4 months after transplantation, when it began to increase. When the level of PR3-ANCA peaked, the patient suddenly presented with fever and joint pain, which later spontaneously resolved in parallel with the declining titer of PR3-ANCA. He is now in remission for both AML and WG at 22 months after transplantation. The patient's clinical course after allo-SCT may provide us with valuable information regarding the establishment of allo-SCT as a therapeutic option for WG.
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Affiliation(s)
- Akane Kunitomi
- Division of Hematology and Rheumatology, Department of Medicine, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Osaka, Japan.
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28
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Marmont AM. Allogeneic haematopoietic stem cell transplantation for severe autoimmune diseases: great expectations but controversial evidence. Bone Marrow Transplant 2006; 38:1-4. [PMID: 16788682 DOI: 10.1038/sj.bmt.1705394] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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29
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Caselli D, Farruggia P, Trizzino A, Cannella S, Santoro A, Locatelli F, Aricò M. Split chimerism may be enough to cure Evans syndrome. Bone Marrow Transplant 2006; 38:311. [PMID: 16785863 DOI: 10.1038/sj.bmt.1705427] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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30
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Urban C, Lackner H, Sovinz P, Benesch M, Schwinger W, Dornbusch HJ, Moser A. Successful unrelated cord blood transplantation in a 7-year-old boy with Evans syndrome refractory to immunosuppression and double autologous stem cell transplantation. Eur J Haematol 2006; 76:526-30. [PMID: 16529601 DOI: 10.1111/j.0902-4441.2006.t01-1-ejh2549.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Evans syndrome is an autoimmunopathy characterized by thrombocytopenia and autoimmune hemolytic anemia with poor response to immunosuppression. A 2-yr-old boy with Evans syndrome showed only short-lasting responses to immunosuppressive treatment including double autologous peripheral stem cell transplantation (SCT). Intracranial bleeding required emergency splenectomy and external ventricular drainage. Unrelated umbilical cord blood was given following conditioning with busulfan, thiotepa, etoposide and antithymocyte globulin. One year after SCT the patient shows stable blood counts without immunosuppression. This is the first child reported with Evans syndrome successfully treated by means of unrelated cord blood transplantation.
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MESH Headings
- Adrenal Cortex Hormones/adverse effects
- Adrenal Cortex Hormones/therapeutic use
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/surgery
- Cerebral Hemorrhage/etiology
- Cerebral Hemorrhage/pathology
- Child, Preschool
- Cord Blood Stem Cell Transplantation
- Danazol/therapeutic use
- Drug Resistance
- Female
- Humans
- Immunoglobulins, Intravenous/therapeutic use
- Immunosuppressive Agents/therapeutic use
- Magnetic Resonance Imaging
- Male
- Peripheral Blood Stem Cell Transplantation
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/surgery
- Remission Induction
- Splenectomy
- Transplantation Conditioning
- Transplantation, Autologous
- Transplantation, Homologous
- Vincristine/therapeutic use
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Affiliation(s)
- Christian Urban
- Division of Pediatric Hematology/Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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31
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Abstract
Evans syndrome is an uncommon condition defined by the combination (either simultaneously or sequentially) of immune thrombocytopenia (ITP) and autoimmune haemolytic anaemia (AIHA) with a positive direct antiglobulin test (DAT) in the absence of known underlying aetiology. This condition generally runs a chronic course and is characterised by frequent exacerbations and remissions. First-line therapy is usually corticosteroids and/or intravenous immunoglobulin, to which most patients respond; however, relapse is frequent. Options for second-line therapy include immunosuppressive drugs, especially ciclosporin or mycophenolate mofetil; vincristine; danazol or a combination of these agents. More recently a small number of patients have been treated with rituximab, which induces remission in the majority although such responses are often sustained for <12 months and the long-term effects in children are unclear. Splenectomy may also be considered although long-term remissions are less frequent than in uncomplicated ITP. For very severe and refractory cases stem cell transplantation (SCT) offers the only chance of long-term cure. The limited data available suggest that allogeneic SCT may be superior to autologous SCT but both carry risks of severe morbidity and of transplant-related mortality. Cure following reduced-intensity conditioning has now been reported and should be considered for younger patients in the context of controlled clinical trials.
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Affiliation(s)
- Alice Norton
- Paediatric Haematology, Department of Paediatrics, St Mary's Hospital, Paddington, London, UK
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32
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Blouin P, Auvrignon A, Pagnier A, Thuret I, Antoni G, Bader-Meunier B, Le Deist F, Chastagner P, Aladjidi N, Pellier I, Bertrand Y, Behar C, Landmann-Parker J, Leverger G, Perel Y. Syndrome d'Evans : étude rétrospective de la société d'hématologie et d'immunologie pédiatrique (36 cas). Arch Pediatr 2005; 12:1600-7. [PMID: 16185853 DOI: 10.1016/j.arcped.2005.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2004] [Accepted: 07/07/2005] [Indexed: 10/25/2022]
Abstract
UNLABELLED Evans' Syndrome (ES) is defined as the combination of immune thrombocytopenia (ITP) and autoimmune haemolytic anemia (AIHA), in the absence of any known underlying etiology. Pathophysiology, epidemiology and outcome remain unclear. POPULATION Thirty-six children (20 male, 16 female), who were diagnosed in the SHIP french centres (Société d'hématologie et d'immunologie pédiatrique) between 1990 and 2002 with ES, were included in this retrospective study. RESULTS Median age at diagnosis was 4 years. In 21 children, ES occurred in the setting of consanguinity, family history of autoimmune/inflammatory disease, associated autoimmune disorder or immunoregulatory abnormalities (serum imunoglobulins, peripheral blood lymphocytes subsets, low level of the C3-C4 complement components, nuclear antibodies). Several successive treatments were used in this serie (median: 3, range: 0-10) including corticosteroid therapy (35/36), intravenous immunoglobulins (32/36), immunosuppressive agents (14/36), splenectomy (9/36) and anti CD 20 monoclonal antibodies (6/36). Patients with a low level of serum immunoglobulins were more often non-responders to corticosteroidtherapy/intravenous immunoglobulins and required more frequently further therapy (P=0.03). Three patients died (intracranial bleeding, N=2, Guillain-Barre syndrome; N=1). CONCLUSION ES was a severe, life-threatening disease, requiring aggressive immunosuppressive therapy in as many as half the patients. Our forthcoming study aims to (i) describe homogeneously-studied and prospectively-analysed cohort of childhood ES, (ii) separate ES from specific immune deficiency (especially fas gene mutations), generalised autoimmune/inflammatory disorders and genetic diseases, (iii) identify well-defined ES subsets, (iv) establish prognostic factors and optimal treatment within these subsets.
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MESH Headings
- Adolescent
- Adrenal Cortex Hormones/therapeutic use
- Age of Onset
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/genetics
- Anemia, Hemolytic, Autoimmune/immunology
- Anemia, Hemolytic, Autoimmune/pathology
- Child
- Child, Preschool
- Cohort Studies
- Consanguinity
- Female
- France
- Humans
- Immunoglobulins, Intravenous/therapeutic use
- Infant
- Male
- Prognosis
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/genetics
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/pathology
- Retrospective Studies
- Severity of Illness Index
- Syndrome
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Affiliation(s)
- P Blouin
- Service de pédiatrie, Hôtel-Dieu, BP 69, 63003 Clermont-Ferrand cedex, France.
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33
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Griffith LM, Pavletic SZ, Tyndall A, Bredeson CN, Bowen JD, Childs RW, Gratwohl A, van Laar JM, Mayes MD, Martin R, McSweeney PA, Muraro PA, Openshaw H, Saccardi R, Sandmaier BM, Forman SJ, Nash RA. Feasibility of Allogeneic Hematopoietic Stem Cell Transplantation for Autoimmune Disease: Position Statement from a National Institute of Allergy and Infectious Diseases and National Cancer Institute–Sponsored International Workshop, Bethesda, MD, March 12 and 13, 2005. Biol Blood Marrow Transplant 2005; 11:862-70. [PMID: 16275589 DOI: 10.1016/j.bbmt.2005.07.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2005] [Accepted: 07/14/2005] [Indexed: 12/29/2022]
Affiliation(s)
- Linda M Griffith
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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34
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Tyndall A, Saccardi R. Haematopoietic stem cell transplantation in the treatment of severe autoimmune disease: results from phase I/II studies, prospective randomized trials and future directions. Clin Exp Immunol 2005; 141:1-9. [PMID: 15958063 PMCID: PMC1809422 DOI: 10.1111/j.1365-2249.2005.02806.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Around 700 patients have received an autologous haematopoietic stem cell transplant (HSCT) as treatment for a severe autoimmune disease (AD). The majority of these have been within the context of phase I/II clinical trials and following international guidelines proposed 7 years ago. In general, a positive benefit/risk ratio has led to phase III prospective randomized controlled trials in multiple sclerosis (MS), systemic sclerosis (SSc) and rheumatoid arthritis (RA) in Europe. In the US, similar trials are being planned for SSc, MS and systemic lupus erythematosus (SLE). Transplant related mortality (TRM) has fallen in all disease subgroups since the inception due to more appropriate patient selection, and so far a clear advantage of the more intense myeloablative regimens in terms of remission induction and relapse rate has not emerged. Although each AD has a different profile, over a third of patients have sustained a durable remission, often with no further need for immunosuppressive drugs. In those who relapsed, many responded to agents which pre transplant had been ineffective. The study of immune reconstitution and gene expression pre and post HSCT is being undertaken to further understand the mechanism of autoimmunity.
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Affiliation(s)
- A Tyndall
- Department of Rheumatology, University Hospital Basle, Basle, Switzerland.
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35
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Abstract
Transplantation of haematopoietic stem cells--cells capable of self renewing and reconstituting all types of blood cell--can treat numerous lethal diseases, including leukaemias and lymphomas. It may now be applicable for the treatment of severe autoimmune diseases, such as therapy-resistant rheumatoid arthritis and multiple sclerosis. Studies in animal models show that the transfer of haematopoietic stem cells can reverse autoimmunity, and several mechanistic pathways may explain this phenomenon. The outcome of ongoing clinical trials, as well as of studies in patients and animal models, will help to determine the role that stem-cell transplantation can play in the treatment of autoimmune diseases.
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Affiliation(s)
- Megan Sykes
- Bone Marrow Transplantation Section, Transplantation Biology Research Center, Massachusetts General Hospital/Harvard Medical School, MGH East, Building 149-5102, 13th Street, Boston, Massachusetts 02129, USA.
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36
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Tyndall A, Farge D. Progress in hematopoietic stem cell transplantation for autoimmune diseases. Expert Rev Clin Immunol 2005; 1:159-67. [PMID: 20477663 DOI: 10.1586/1744666x.1.1.159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
An international co-ordinated Phase I/II program commenced 8 years ago to study the role of profound immunoablation with hematopoietic stem cell transplantation in the treatment of severe, refractory autoimmune disease. Almost 700 patients have been treated for a variety of autoimmune diseases, mostly multiple sclerosis, systemic sclerosis, also referred to as scleroderma, systemic lupus erythematosis, rheumatoid arthritis and juvenile idiopathic arthritis. An overall treatment-related mortality of 7% was observed, with significant differences between diseases; 11% in systemic lupus erythematosis and only one patient with rheumatoid arthritis. Although outcomes are disparate in different diseases, there were significant durable, clinically useful remissions, relapses, and nonresponders in all groups. Although different protocols were employed, a clear advantage from the more intensive myeloablative regimens was not observed, although an increased toxicity did occur. The Phase I/II data was exploited in designing the Phase III randomized, comparative trials that are running in systemic sclerosis, multiple sclerosis and rheumatoid arthritis in Europe, and at the advanced planning stage in systemic sclerosis, multiple sclerosis and systemic lupus erythematosis in the USA. In parallel, a basic science program is proceeding with the prospective studies to improve understanding of the mechanisms of autoimmune disease activity and remission.
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Affiliation(s)
- Alan Tyndall
- University Hospital, Department of Rheumatology, Felix-Platter Spital, Basel, Switzerland.
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37
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Hough RE, Snowden JA, Wulffraat NM. Haemopoietic stem cell transplantation in autoimmune diseases: a European perspective. Br J Haematol 2005; 128:432-59. [PMID: 15686452 DOI: 10.1111/j.1365-2141.2004.05298.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The potential of haemopoietic stem cell transplantation (HSCT) for the treatment of autoimmune and inflammatory diseases was originally supported by almost three decades of animal experiments and by the serendipitous remissions of autoimmune disease observed in patients undergoing transplantation for haematological disorders. Improved safety of both autologous and allogeneic HSCT over the last decade has been followed by increasing acceptance of HSCT as an experimental treatment for severe autoimmune diseases that are resistant to conventional treatment. International databases have collated over 700 procedures performed specifically for a variety of autoimmune diseases. Phase III clinical trials are in progress for some diseases. This review provides a comprehensive update on the efficacy and toxicity of HSCT in severe autoimmune disease. Future directions in the context of other evolving therapies are discussed.
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Affiliation(s)
- R E Hough
- Department of Haematology, Sheffield Teaching Hospitals NHS Trust, University of Sheffield, Sheffield, UK
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38
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Marmont AM. Stem cell transplantation for autoimmune disorders. Coincidental autoimmune disease in patients transplanted for conventional indications. Best Pract Res Clin Haematol 2004; 17:223-32. [PMID: 15302336 DOI: 10.1016/j.beha.2004.04.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The practice of stem cell transplantation for severe autoimmune diseases refractory to conventional therapy originated from two landmark discoveries: the excellent results of animal experiments, and serendipitous observations in human coincidental diseases. The latter include patients with an often long-standing autoimmune disease who have developed a haematological condition (aplasia, leukaemia, lymphoma) requiring stem cell transplantation (from marrow as well as from blood). Allogeneic and autologous transplants have been performed. The initial information deriving from both procedures is their feasibility, even more convincing since the patients were affected by two simultaneous severe diseases. The information derived from autologous transplants has, however, now been superseded by the considerable and increasing number of those transplants performed for primary autoimmune diseases. On the other hand, allogeneic stem cell transplantation for very severe autoimmune diseases is being cautiously explored in current protocols. Allogeneic transplants in coincidental disease have also suggested a graft-versus-autoimmunity effect, which may become relevant in conjunction with non-myeloablative, less toxic condition regimens.
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Affiliation(s)
- Alberto M Marmont
- Division of Hematology and Stem Cell Transplantation Centre, S Martino's Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy.
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39
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Jones OY, Good RA, Cahill RA. Nonmyeloablative allogeneic bone marrow transplantation for treatment of childhood overlap syndrome and small vessel vasculitis. Bone Marrow Transplant 2004; 33:1061-3. [PMID: 15048144 DOI: 10.1038/sj.bmt.1704482] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A 13-year-old Caucasian female with a systemic connective tissue disease (overlap syndrome with pulmonary vasculitis) underwent nonmyeloablative allogeneic BMT after failure of prolonged combination immunosuppressives to induce remission. The procedure also included cotransplantation of donor bone chips as a source of stromal cells. The unique protocol allowed good engraftment of hematopoietic (>95%) and bone core stromal cells (>60%). The patient was clinically improved, stable, and off all immunosuppressive medications 36 months post-transplant. To our knowledge, this is the first pediatric nonmyeloablative BMT with cotransplantation of stromal cells solely for treatment of an autoimmune disease.
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Affiliation(s)
- O Y Jones
- Department of Pediatrics, Division of Allergy, Immunology & Rheumatology, University of South Florida/All Children's Hospital, 801 Sixth Street South, St Petersburg, FL 33701, USA.
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40
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Musso M, Porretto F, Crescimanno A, Polizzi V, Scalone R. Donor lymphocyte infusions for refractory pure red cell aplasia relapsing after both autologous and nonmyeloablative allogeneic peripheral stem cell transplantation. Bone Marrow Transplant 2004; 33:769-71. [PMID: 14755320 DOI: 10.1038/sj.bmt.1704419] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Pure red cell aplasia (PRCA) is characterized by a selective marrow aplasia of the erythroid compartment. Immunosuppressive therapy achieves good results in about 25% of cases, but relapses are frequent. Autologous or allogeneic haematopoietic stem cell transplantation (HSCT) may be valuable in selected patients. Here, we report details of a 29-year-old woman treated successfully by donor lymphocyte infusions (DLIs) following allogeneic HSCT for acquired refractory relapsed PRCA. The nonmyeloablative conditioning regimen consisted of cyclophosphamide 60 mg/kg/day for 2 days and fludarabine 30 mg/m(2) daily for 4 days. Haematopoiesis was still completely 'recipient' 1 month after allo-HSCT, but progressed to full donor engraftment after three doses of 'escalating' DLI. The possible role of a graft-versus-autoimmunity effect induced by allogeneic HSCT followed by DLI infusions in the treatment of the disease is discussed.
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Affiliation(s)
- M Musso
- UO Oncoematologia e Trapianto di Midollo, Dipartimento Oncologico, La Maddalena, Palermo, Italy.
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41
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Ford CD, Asch J, Pulsipher M, Petersen FB. Successful reduced-intensity allogeneic transplantation utilizing a fludarabine-based preparative regimen in a patient with chronic lymphocytic leukaemia and a history of fludarabine-associated autoimmune haemolytic anaemia. Br J Haematol 2004; 126:623-4. [PMID: 15287959 DOI: 10.1111/j.1365-2141.2004.05088.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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42
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Passweg JR, Rabusin M, Musso M, Beguin Y, Cesaro S, Ehninger G, Espigado I, Iriondo A, Jost L, Koza V, Lenhoff S, Lisukov I, Locatelli F, Marmont A, Philippe P, Pilatrino C, Quartier P, Stary J, Veys P, Vormoor J, Wahlin A, Zintl F, Bocelli-Tyndall C, Tyndall A, Gratwohl A. Haematopoetic stem cell transplantation for refractory autoimmune cytopenia. Br J Haematol 2004; 125:749-55. [PMID: 15180864 DOI: 10.1111/j.1365-2141.2004.04978.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study describes the outcome of patients receiving haematopoietic stem cell transplantation (HSCT) to treat severe refractory autoimmune cytopenia. The registry of the European Group of Blood and Marrow Transplantation holds data on 36 patients receiving 38 transplants, the first transplant was autologous for 27 and allogeneic for nine patients. Patients had autoimmune haemolytic anaemia (autologous: 5; allogeneic: 2), Evans's syndrome (autologous: 2; allogeneic: 5); immune thrombocytopenia (autologous: 12), pure red cell aplasia (autologous: 4; allogeneic: 1), pure white cell aplasia (autologous: 1; allogeneic 1), or thrombotic thrombocytopenic purpura (autologous: 3). Patients had longstanding disease having failed multiple prior treatments. Among 26 evaluable patients mobilized for autologous HSCT, three died of treatment-related causes, one died of disease progression, seven were non-responders, six patients had transient responses and nine had continuous partial or complete remission. Of the seven evaluable patients receiving allogeneic HSCT, one died of treatment-related complications, one with transient response died of progressive disease and five had a continuous response. Autologous and allogeneic HSCT may induce a response in a subset of patients with autoimmune cytopenia of long duration albeit at the price of considerable toxicity.
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Affiliation(s)
- J R Passweg
- Basel University Hospitals, Basel, Switzerland.
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43
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Urban C, Benesch M, Sovinz P, Schwinger W, Lackner H. Fatal Evans' syndrome after matched unrelated donor transplantation for hyper-IgM syndrome. Eur J Haematol 2004; 72:444-7. [PMID: 15128425 DOI: 10.1111/j.1600-0609.2004.00256.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 3 and 1/2-yr-old boy underwent matched unrelated stem cell transplantation (SCT) for hyper-IgM syndrome. He developed acute and chronic skin graft-vs.-host disease (GVHD). Ten months following SCT he presented with severe hemolytic anemia and thrombocytopenia (Evans' syndrome). Treatment included high-dose steroids, intravenous immunoglobulins, cyclosporine, mycophenolate mofetil, chemotherapeutic agents (cyclophosphamide, vincristine, VP-16), immunoadsorption, and anti-CD20 and anti-CD52 monoclonal antibodies without response. The patient died 16 months after SCT.
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Affiliation(s)
- Christan Urban
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Graz, Graz, Austria
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44
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Abstract
Systemic lupus erythematosus is a heterogeneous, multisystem disease responsive to treatment with corticosteroids and immune suppressives. Many patients fail to achieve treatment-free remissions, and their long-term outcomes remain poor owing to the development of vital organ failure, cumulative drug toxicity and an increased risk of cardiovascular disease and malignancy. Haematopoietic stem cell transplantation (HSCT) offers the potential to improve long-term outcome in those with a poor prognosis. Preliminary phase II and registry studies have usually employed non-myeloablative conditioning with positive CD34 cell selection. They have highlighted the potential efficacy and dangers of HSCT. Patient selection is important but complex, and the influence of HSCT on long-term outcome is unknown. Disease relapse occurs in up to one-third of patients after HSCT, but the consequences of relapse and the role of remission-maintenance strategies are unknown. With the availability of other alternative therapies in refractory disease, there needs to be a clear demonstration of the benefits of HSCT from current randomized trials.
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Affiliation(s)
- David Jayne
- Renal Unit, Addenbrookes Hospital, Box 157, Cambridge CB2 2QQ, UK.
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Abstract
Modern treatments of autoimmune diseases are based on immunological therapies. Rituximab induces a targeted B-cell depletion in the aim of eradicating autoreactive clones in various autoimmune disorders. Several studies are being undertaken and preliminary reports are very encouraging. The mechanism of action is not evident, but appears to be connected with the lowering of autoantibody levels, in the diseases where relevant antibody titres are relievable. Most of the patients treated were affected by idiopathic thrombocytopenic purpura (ITP) and autoimmune haemolytic anaemia, but also very rare diseases like acquired haemophilia are reported. Best results are described in autoimmune haemolytic anaemia, in many others there is clear evidence for efficacy; in all the diseases the number of complete or partial remission, though temporary, is much greater than 50%. Side effects are rarely reported, and immunosuppression is not a great problem. The persistence of clinical improvement for more than 1 year after B-lymphocyte repopulation supports the hypothesis of a stochastic generation of pathogenic B-cell subsets. Other studies and controlled trials are required to establish when and which patients are to be treated, and find the opportunity of the association of others drugs.
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Affiliation(s)
- Luigi Virgolini
- Department of Medicine, U.O. Medicina 2, Azienda Ospedaliera Santa Maria degli Angeli, Pordenone City Hospital, 33170 Pordenone, Italy.
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Passweg JR. Haematopoietic stem cell transplantation for immune thrombopenia and other refractory autoimmune cytopenias. Best Pract Res Clin Haematol 2004; 17:305-15. [PMID: 15302342 DOI: 10.1016/j.beha.2004.04.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This review summarizes data on haematopoietic stem cell transplantation (HSCT) to treat severe, refractory, haematological autoimmune cytopenia. A phase II study by the National Institutes of Health of the USA has presented data on autologous HSCT in 14 patients with immune thrombocytopenia or Evans' syndrome, with no early deaths and a response rate of 57%. The registry of the European Group for Blood and Marrow Transplantation holds data on 38 transplants, autologous for 27 and allogeneic for 9 patients. The disease entities and regimens used were more heterogeneous. The conditions encountered were autoimmune haemolytic anaemia, Evans' syndrome, immune thrombocytopenia, pure red cell aplasia, pure white cell aplasia and thrombotic thrombocytopenic purpura. Patients had long-standing disease, having failed multiple prior treatments. Among 26 evaluable patients mobilized for autologous HSCT, 3 died of treatment-related causes, 1 died of disease progression, 7 were non-responders, 6 patients had transient responses, and 9 had sustained partial or complete remission. Of the 7 evaluable patients receiving allogeneic HSCT, 1 died of treatment-related complications, 1 with a transient response died of progressive disease, and 5 showed a sustained response. Autologous and allogeneic HSCT may induce a response in a considerable proportion of patients with autoimmune cytopenia of long duration.
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Affiliation(s)
- Jakob R Passweg
- Stem Cell Transplant Team, Hematology Division, Basel University Hospitals, Basel, Switzerland.
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47
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Marmont AM. Hematopoietic stem cell transplantation for severe and refractory lupus: comment on the article by Traynor et al. ARTHRITIS AND RHEUMATISM 2003; 48:2696-7; author reply 2697. [PMID: 13130494 DOI: 10.1002/art.11239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Burt RK, Traynor AE, Craig R, Marmont AM. The promise of hematopoietic stem cell transplantation for autoimmune diseases. Bone Marrow Transplant 2003; 31:521-4. [PMID: 12692615 DOI: 10.1038/sj.bmt.1703868] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is being increasingly utilized for the treatment of a whole spectrum of severe autoimmune diseases refractory to conventional therapy. Although allogeneic HSCT has been followed by durable complete remission in a restricted number of patients with coincidental disease, the autologous procedure is generally preferred because of its lesser toxicity. Most autoimmune diseases are the consequence of a multistep process, mainly originating from the interplay of genetic, environmental, and hormonal factors. It has been postulated that if immunosuppressive regimens can eliminate or effectively reduce the level of autoreactive T and B cells, then regeneration of de novo immunity even in the autologous setting may bypass the initial breakdown of self-tolerance and ensure prolonged disease remission. As mentioned in a recent review of this field, protocol design including conditioning regimen, patient selection, stem cell source and final outcome are likely to be disease-specific. The following is a summary of the 2002 International Bone Marrow Transplantation Registry/American Society of Blood and Bone Marrow Transplantation (IBMTR/ASBMT) satellite symposium in Orlando, Florida on 24 February 2002 on 'Expanding the Promise of Hematopoietic Stem Cell Transplantation in Autoimmune Diseases'.
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Affiliation(s)
- R K Burt
- Northwestern University Department of Medicine, Chicago, IL, USA
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