Hematopoietic stem cell transplantation for autoimmune disorders

Interstitial lung disease in systemic sclerosis

Interstitial lung disease (ILD) is a common manifestation of systemic sclerosis (SSc) and mainly encountered in patients with diffuse disease and/or anti-topoisomerase 1 antibodies. ILD develops in up to 75% of patients with SSc overall. However, SSc-ILD evolves to end-stage respiratory insufficiency in only a few patients. Initial pulmonary function tests (PFT) with measurement of carbon monoxide diffusing capacity, together with high-resolution computed tomography, allows for early diagnosis of SSc-ILD, before the occurrence of dyspnea. Unlike idiopathic ILD, SSc-ILD corresponds to non-specific interstitial pneumonia in most cases, whereas usual interstitial pneumonia is less frequently encountered. Therefore, the prognosis of SSc-ILD is better than that for idiopathic ILD. Nevertheless, ILD represents one of the two main causes of death in SSc patients. To detect SSc-ILD early, PFT must be repeated regularly, every 6 months to 1 year, depending on disease worsening. Conversely, broncho-alveolar lavage is not needed to evaluate disease activity in SSc-ILD but may be of help in diagnosing opportunistic infection. The treatment of SSc-ILD is not well established. Cyclophosphamide, which has been used for 20 years, has recently been evaluated in two prospective randomized studies that failed to demonstrate a major benefit for lung function. Open studies reported mycophenolate mofetil, azathioprine and rituximab as alternatives to cyclophosphamide. On failure of immunosuppressive agent treatment, lung transplantation can be proposed in the absence of other major organ involvement or severe gastro-esophageal reflux.

Hematopoietic SCT for the treatment of multiple sclerosis

Multiple sclerosis (MS) is the leading autoimmune indication for autologous hematopoietic SCT (aHSCT). Patient selection criteria and transplant interventions have been refined through a series of cohort and registry studies. High- and low-intensity chemotherapy-based conditioning regimens have been used, creating trade-offs between toxicity and effectiveness. TBI has been associated with greater toxicity and poor outcomes. aHSCT stops MS relapses and lessens the disability in malignant MS, which otherwise rapidly incapacitates patients. Better responses occur in progressive MS earlier in the disease when it has a more inflammatory nature. aHSCT prevents further disability in many patients, but some actually recover from their infirmities. Current regimens and supportive care result in very low morbidity and mortality. MS patients experience unique complications in addition to the expected toxicities. Cytokines used alone for stem-cell mobilization may induce MS flares but are safe to be used in combination with steroids or cytotoxic agents. Urinary tract infections, herpes virus reactivation and an engraftment syndrome may occur early after aHSCT. Rarely secondary autoimmune diseases have been reported late after HSCT. Increasing experience in caring for patients with MS has reduced the frequency and severity of toxicity. Conceived as an opportunity to 'reboot' a tolerant immune system, aHSCT is successful in treating patients with MS that is refractory to conventional immunomodulatory drugs.

[Interstitial lung disease in systemic sclerosis]

INTRODUCTION

Interstitial lung diseases (ILD) in systemic sclerosis (SSc) are mainly encountered in patients with diffuse disease although they may occur less frequently in patients with limited cutaneous disease.

BACKGROUND

In SSc early detection of ILD should be achieved by high resolution computed tomography and pulmonary function tests, including measurement of DLCO. In total up to 75% of patients with SSc develop ILD but it is progressive in only a minority of patients. Unlike idiopathic ILD, SSc associated ILD corresponds to non-specific interstitial pneumonia rather than usual interstitial pneumonia in the majority of cases. This explains the better prognosis of SSc associated ILD compared with idiopathic ILD. Nevertheless ILD represents one of the two main causes of death in SSc.

VIEWPOINT

The treatment of SSc associated ILD is not well established. Anti-fibrosing treatments have failed to demonstrate benefit and cyclophosphamide, which has been used for about 15 years in the treatment of this condition, has recently been evaluated in two prospective randomised studies which showed a significant but modest effect on respiratory function.

CONCLUSION

A subgroup of patients with rapidly progressive ILD might benefit from pulsed intravenous cyclophosphamide combined with prednisone 15 mg daily, but this remains to be confirmed.

Complete remission of alopecia universalis after allogeneic hematopoietic stem cell transplantation

This case report is on a 40-year-old male patient with chronic myeloid leukemia (CML) receiving an allogeneic hematopoietic stem cell transplantation (HSCT) in first chronic phase from an HLA-identical sibling brother. He suffered from alopecia universalis occurring 11 years previously. The alopecia involved all body hair, including eyebrows and eyelashes. Between day 40 and day 55 after transplantation, hair started to grow on the chin, eyelashes, and on the top of his head. Immunosuppression was stopped at 6 months because of cytogenetic relapse and incomplete donor chimerism with some renewed hair loss. He returned to full donor chimerism with mild chronic graft-versus-host disease and continued hair growth. With 2 years of follow-up he has remained in continuous remission. Chimerism analyses of hair follicles did not show any donor alleles. Alopecia universalis is probably a chronic autoimmune disorder, curable with replacement of the immune system with an allogeneic HSCT. (Blood. 2005;105:426-427)

Autologous stem cell transplantation for refractory juvenile idiopathic arthritis: analysis of clinical effects, mortality, and transplant related morbidity

OBJECTIVE

To evaluate the safety and efficacy of autologous stem cell transplantation (ASCT) for refractory juvenile idiopathic arthritis (JIA).

DESIGN

Retrospective analysis of follow up data on 34 children with JIA who were treated with ASCT in nine different European transplant centres. Rheumatological evaluation employed a modified set of core criteria. Immunological reconstitution and infectious complications were monitored at three month intervals after transplantation.

RESULTS

Clinical follow up ranged from 12 to 60 months. Eighteen of the 34 patients (53%) with a follow up of 12 to 60 months achieved complete drug-free remission. Seven of these patients had previously failed treatment with anti-TNF. Six of the 34 patients (18%) showed a partial response (ranging from 30% to 70% improvement) and seven (21%) were resistant to ASCT. Infectious complications were common. There were three cases of transplant related mortality (9%) and two of disease related mortality (6%).

CONCLUSIONS

ASCT in severely ill patients with JIA induces a drug-free remission of the disease and a profound increase in general wellbeing in a substantial proportion of patients, but the procedure carries a significant mortality risk. The following adjustments are proposed for future protocols: (1) elimination of total body irradiation from the conditioning regimen; (2) prophylactic administration of antiviral drugs and intravenous immunoglobulins until there is a normal CD4+ T cell count.

Stem cell transplantation in systemic lupus erythematosus

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.

Stem cell transplantation in multiple sclerosis: multiple choices and multiple challenges

Multiple sclerosis (MS) is generally considered as an autoimmune disease of the central nervous system. This concept has led to the idea that profound immunosuppression followed by transplantation of stem cell grafts would stop, or at least slow down, disease activity. Supported by the positive effects of hematopoietic stem cell transplantation (HSCT) on experimental autoimmune encephalomyelitis and by anecdotal reports on the beneficial effect of HSCT on MS patients with concomitant malignant disease, HSCT programs for MS have been initiated worldwide. At this stage, it is impossible to draw general conclusions from the preliminary data reported and therefore overenthusiastic expectations should be tempered. The follow-up periods are too short the groups are too small, the selected patients and protocols too heterogeneous, and publication bias on positive results cannot be excluded. However, there is ample evidence that HSCT is a technically feasible approach in MS, not more dangerous than in the hemato-oncological diseases. For every step in the HSCT procedure, there are many different options. The time has come for a systematic analysis of the safety and efficacy associated with the different methodologies.

Nutritional and metabolic support in patients undergoing bone marrow transplantation

Bone marrow transplantation (BMT) is a sophisticated procedure consisting of the administration of high-dose chemoradiotherapy followed by intravenous infusion of hemopoietic stem cells to reestablish marrow function when bone marrow is damaged or defective. BMT is used in the treatment of solid tumors, hematologic diseases, and autoimmune disorders. Artificial nutrition, total parenteral nutrition in particular, is provided to patients undergoing BMT to minimize the nutritional consequences of both the conditioning regimens (eg, mucositis of the gastrointestinal tract) and complications resulting from the procedure (eg, graft versus host disease and venoocclusive disease of the liver). Although artificial nutrition is now recognized as the standard of care for BMT patients, defined guidelines for the use of artificial nutrition in this clinical setting are lacking. During the past 2 decades, artificial nutrition in BMT patients has moved from simple supportive care to adjunctive therapy because of the possible benefits, not strictly nutritional, of specialized nutritional intervention. Although data exist documenting the beneficial role of special nutrients, such as lipids and glutamine, in the management of BMT recipients, the results obtained to date are controversial. The reasons for this controversy may reside in the heterogeneity of the patients studied and of the study designs. This review focuses on the need to correctly identify the different patterns of BMT to achieve reproducible and reliable data, which may in turn be used to devise precise guidelines for the use of specialized artificial nutrition in BMT patients.

Treating systemic sclerosis in 2001

Systemic sclerosis (SS) is characterized by sclerosis of the dermis and internal organs and by vascular abnormalities. Although the pathophysiology of the disease has been partly elucidated, the efficacy of long-term treatments remains limited, with no significant increase in survival in prospective studies. Conventional drug treatments are disappointing in clinical practice, and in a recent prospective randomized study standard-dose D-penicillamine was not more effective than mini-dose D-penicillamine. New long-term treatments are emerging for diffuse SS, including cyclophosphamide for patients with progressive interstitial lung disease or stem cell transplantation for those with early organ involvement. The most effective treatments remain symptomatic, such as angiotensin-converting enzyme inhibitors for acute renal crisis, calcium channel antagonists for Raynaud's phenomenon, and proton pump inhibitors for the complications of gastroesophageal reflux. This review article focuses on long-term treatments that are most likely to be effective and suggests symptomatic treatment strategies tailored to specific organ involvements.

Reconstitution of self-reactive antibody repertoires of autologous plasma IgM in patients with non-Hodgkin's lymphoma following myeloablative therapy

In healthy individuals, natural self-reactive antibody repertoires are restricted to a limited subset of autoantigens that is selected early in development and that remains invariant between individuals through aging. In the present study, we addressed the question of whether self-reactive antibody repertoires of plasma IgM change during high-dose chemotherapy (HDCT) with autologous blood stem cell support and whether antibody repertoires generated during immune reconstitution are similar to those present under physiological conditions. We followed the development of antibody repertoires in patients undergoing HDCT for the treatment of B-cell non-Hodgkin's lymphoma (NHL). Antibody repertoires were investigated by quantitative immunoblotting on whole tissue extracts as sources of self-antigens and by multiparametric statistical analysis of the data. We demonstrate that self-reactive antibody repertoires of plasma IgM of NHL patients prior to HDCT differ from those of healthy individuals, that they change during recovery of immune functions, and that antibody repertoires similar to those of healthy individuals are generated during immune reconstitution. We conclude that the mechanisms responsible for the selection of self-reactive repertoires of autologous plasma IgM during immune reconstitution after HDCT may follow those present under physiological conditions and that immune reconstitution may include a shift from altered toward normal patterns of self-reactivity.

Stem cell transplantation for non-malignant disorders

Stem cell transplantation (SCT) can be used to cure or ameliorate a wide variety of non-malignant diseases. These range from inherent defects of haemopoietic cell production or function, through metabolic diseases (where blood cells are providing in vivo enzyme therapy to solid organs), to severe autoimmune diseases. However, although transplantation has revolutionized the treatment of many of the diseases discussed, severe toxicities remain. In some cases these are inherent to the disease concerned but frequently they relate to the conditioning regime or post-transplant complications such as graft-versus-host disease (GvHD). This chapter concentrates on the indications for transplant, outcome statistics and problems inherent in particular conditions, seen in the light of technological improvements during the 1990s and the potential impact of enzyme and gene therapies.