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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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2
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Rahman MM, Islam MR, Islam MT, Harun-Or-Rashid M, Islam M, Abdullah S, Uddin MB, Das S, Rahaman MS, Ahmed M, Alhumaydhi FA, Emran TB, Mohamed AAR, Faruque MRI, Khandaker MU, Mostafa-Hedeab G. Stem Cell Transplantation Therapy and Neurological Disorders: Current Status and Future Perspectives. BIOLOGY 2022; 11:147. [PMID: 35053145 PMCID: PMC8772847 DOI: 10.3390/biology11010147] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/26/2021] [Accepted: 12/29/2021] [Indexed: 02/07/2023]
Abstract
Neurodegenerative diseases are a global health issue with inadequate therapeutic options and an inability to restore the damaged nervous system. With advances in technology, health scientists continue to identify new approaches to the treatment of neurodegenerative diseases. Lost or injured neurons and glial cells can lead to the development of several neurological diseases, including Parkinson's disease, stroke, and multiple sclerosis. In recent years, neurons and glial cells have successfully been generated from stem cells in the laboratory utilizing cell culture technologies, fueling efforts to develop stem cell-based transplantation therapies for human patients. When a stem cell divides, each new cell has the potential to either remain a stem cell or differentiate into a germ cell with specialized characteristics, such as muscle cells, red blood cells, or brain cells. Although several obstacles remain before stem cells can be used for clinical applications, including some potential disadvantages that must be overcome, this cellular development represents a potential pathway through which patients may eventually achieve the ability to live more normal lives. In this review, we summarize the stem cell-based therapies that have been explored for various neurological disorders, discuss the potential advantages and drawbacks of these therapies, and examine future directions for this field.
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Affiliation(s)
- Mohammad Mominur Rahman
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.M.R.); (M.R.I.); (M.T.I.); (M.H.-O.-R.); (M.I.); (M.B.U.); (S.D.); (M.S.R.); (M.A.)
| | - Mohammad Rezaul Islam
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.M.R.); (M.R.I.); (M.T.I.); (M.H.-O.-R.); (M.I.); (M.B.U.); (S.D.); (M.S.R.); (M.A.)
| | - Mohammad Touhidul Islam
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.M.R.); (M.R.I.); (M.T.I.); (M.H.-O.-R.); (M.I.); (M.B.U.); (S.D.); (M.S.R.); (M.A.)
| | - Mohammad Harun-Or-Rashid
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.M.R.); (M.R.I.); (M.T.I.); (M.H.-O.-R.); (M.I.); (M.B.U.); (S.D.); (M.S.R.); (M.A.)
| | - Mahfuzul Islam
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.M.R.); (M.R.I.); (M.T.I.); (M.H.-O.-R.); (M.I.); (M.B.U.); (S.D.); (M.S.R.); (M.A.)
| | - Sabirin Abdullah
- Space Science Center, Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia;
| | - Mohammad Borhan Uddin
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.M.R.); (M.R.I.); (M.T.I.); (M.H.-O.-R.); (M.I.); (M.B.U.); (S.D.); (M.S.R.); (M.A.)
| | - Sumit Das
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.M.R.); (M.R.I.); (M.T.I.); (M.H.-O.-R.); (M.I.); (M.B.U.); (S.D.); (M.S.R.); (M.A.)
| | - Mohammad Saidur Rahaman
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.M.R.); (M.R.I.); (M.T.I.); (M.H.-O.-R.); (M.I.); (M.B.U.); (S.D.); (M.S.R.); (M.A.)
| | - Muniruddin Ahmed
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh; (M.M.R.); (M.R.I.); (M.T.I.); (M.H.-O.-R.); (M.I.); (M.B.U.); (S.D.); (M.S.R.); (M.A.)
| | - Fahad A. Alhumaydhi
- Department of Medical Laboratories, College of Applied Medical Sciences, Qassim University, Buraydah 52571, Saudi Arabia;
| | - Talha Bin Emran
- Department of Pharmacy, BGC Trust University Bangladesh, Chittagong 4381, Bangladesh
| | | | | | - Mayeen Uddin Khandaker
- Centre for Applied Physics and Radiation Technologies, School of Engineering and Technology, Sunway University, Bandar Sunway 47500, Selangor, Malaysia;
| | - Gomaa Mostafa-Hedeab
- Pharmacology Department & Health Sciences Research Unit, Medical College, Jouf University, Sakaka 72446, Saudi Arabia;
- Pharmacology Department, Faculty of Medicine, Beni-Suef University, Beni-Suef 62521, Egypt
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3
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Bashir BA, Othman SA, Malik AA. A rare haematological disorder in a Sudanese child: Evans syndrome, case report and literature review. Sudan J Paediatr 2021; 21:89-94. [PMID: 33879949 DOI: 10.24911/sjp.106-1583095341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Evans syndrome is a condition in which autoimmune-mediated red blood cells and platelet destruction happens consecutively. It may be associated with a reduction in neutrophil count as a result of immune neutropenia. No sex preference is known and it presents in all ages and any ethnic cohort. Generally, this syndrome tends to be chronic and is characterised by remission and exacerbation. We document a case of the immune-mediated disease associated with Epstein-Barr virus infection in an 8-year-old boy from eastern Sudan who presented with both immune thrombocytopenia purpura and autoimmune haemolytic anaemia. Complete blood count and peripheral blood picture revealed features consistent with immune haemolytic anaemia (rouleaux formation and spherocytes) and thrombocytopenia. Direct anti-human globulin test and indirect anti-human globulin test were positive. Evans syndrome is a potentially life-threatening condition due to the concomitant existence with antiplatelet and anti-erythrocyte antibodies distinguished by a positive antiglobulin test and possibly linked to other autoimmune or lymphoproliferative diseases.
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Affiliation(s)
- Bashir Abdrhman Bashir
- Department of Hematology, Faculty of Medical Laboratory Sciences, Port Sudan Ahlia College, Port Sudan, Sudan
| | - Suhair A Othman
- Department of Pediatric, Faculty of Medicine, Red Sea University, Port Sudan, Sudan
| | - Amel Aziz Malik
- Department of Pediatric, Faculty of Medicine, Red Sea University, Port Sudan, Sudan
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4
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Haematopoietic stem cell transplantation in systemic sclerosis: Challenges and perspectives. Autoimmun Rev 2020; 19:102662. [PMID: 32942028 DOI: 10.1016/j.autrev.2020.102662] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/07/2020] [Indexed: 12/12/2022]
Abstract
Systemic Sclerosis is chronic progressive autoimmune disease, characterised by microangiopathy and fibrosis. Due to disease heterogeneity, in terms of extent, severity, and rate of progression, optimal therapeutic interventions are still lacking. Haematopoietic stem cells may be a new therapeutic option in this disease and, although the results of the first trials are encouraging, several issues remain to be addressed. On these bases, the stem cells transplantation is an area of active investigation, and an overview of the current available literature may help to define the role of this therapeutic strategy. Although the promising results, some unmet needs remain, including the transplantation protocols and their effects on immune system, the selection of the ideal patient and the pre-transplant cardiopulmonary evaluations. An improvement in these fields will allow us to optimize the haematopoietic stem cell therapies in SSc.
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5
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Silva Riveiro A, Nieto González JC, Martínez Barrio J. Systemic Sclerosis after Bone Marrow Transplantation: A Case with Evidence of Donor-related Disease Transfer. J Rheumatol 2019; 46:1246-1247. [PMID: 31092711 DOI: 10.3899/jrheum.180853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Alicia Silva Riveiro
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | | | - Julia Martínez Barrio
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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6
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Allogeneic hematopoietic stem cell transplantation for severe, refractory juvenile idiopathic arthritis. Blood Adv 2019; 2:777-786. [PMID: 29618462 DOI: 10.1182/bloodadvances.2017014449] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 02/21/2018] [Indexed: 12/13/2022] Open
Abstract
Patients with juvenile idiopathic arthritis (JIA) can experience a severe disease course, with progressive destructive polyarthritis refractory to conventional therapy with disease-modifying antirheumatic drugs including biologics, as well as life-threatening complications including macrophage activation syndrome (MAS). Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative immunomodulatory strategy for patients with such refractory disease. We treated 16 patients in 5 transplant centers between 2007 and 2016: 11 children with systemic JIA and 5 with rheumatoid factor-negative polyarticular JIA; all were either refractory to standard therapy, had developed secondary hemophagocytic lymphohistiocytosis/MAS poorly responsive to treatment, or had failed autologous HSCT. All children received reduced toxicity fludarabine-based conditioning regimens and serotherapy with alemtuzumab. Fourteen of 16 patients are alive with a median follow-up of 29 months (range, 2.8-96 months). All patients had hematological recovery. Three patients had grade II-IV acute graft-versus-host disease. The incidence of viral infections after HSCT was high, likely due to the use of alemtuzumab in already heavily immunosuppressed patients. All patients had significant improvement of arthritis, resolution of MAS, and improved quality of life early following allo-HSCT; most importantly, 11 children achieved complete drug-free remission at the last follow-up. Allo-HSCT using alemtuzumab and reduced toxicity conditioning is a promising therapeutic option for patients with JIA refractory to conventional therapy and/or complicated by MAS. Long-term follow-up is required to ascertain whether disease control following HSCT continues indefinitely.
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Zandi S, Kanfar S, Cserti-Gazdewich C, Lipton JH, Pendergrast J. Resolution of celiac disease, IgA deficiency and platelet refractoriness after allogeneic bone marrow transplantation for acute leukemia. Haematologica 2019; 104:e121-e123. [PMID: 30655374 DOI: 10.3324/haematol.2018.203943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Sasan Zandi
- University Health Network (UHN), Laboratory Medicine Program (LMP), Department of Laboratory Hematology (Blood Transfusion Laboratory [BTL]).,University of Toronto, Faculty of Medicine; Department of Laboratory Medicine - Pathobiology (LMP)
| | - Solaf Kanfar
- University Health Network (UHN), Department of Medical Oncology & Hematology (DMOH), Bone Marrow Transplant Program.,University of Toronto, Faculty of Medicine; Department of Medicine - Division of Hematology, Toronto, ON, Canada
| | - Christine Cserti-Gazdewich
- University Health Network (UHN), Laboratory Medicine Program (LMP), Department of Laboratory Hematology (Blood Transfusion Laboratory [BTL]).,University of Toronto, Faculty of Medicine; Department of Laboratory Medicine - Pathobiology (LMP).,University Health Network (UHN), Department of Medical Oncology & Hematology (DMOH), Bone Marrow Transplant Program.,University of Toronto, Faculty of Medicine; Department of Medicine - Division of Hematology, Toronto, ON, Canada
| | - Jeffrey H Lipton
- University Health Network (UHN), Department of Medical Oncology & Hematology (DMOH), Bone Marrow Transplant Program.,University of Toronto, Faculty of Medicine; Department of Medicine - Division of Hematology, Toronto, ON, Canada
| | - Jacob Pendergrast
- University Health Network (UHN), Laboratory Medicine Program (LMP), Department of Laboratory Hematology (Blood Transfusion Laboratory [BTL]) .,University of Toronto, Faculty of Medicine; Department of Laboratory Medicine - Pathobiology (LMP).,University Health Network (UHN), Department of Medical Oncology & Hematology (DMOH), Bone Marrow Transplant Program.,University of Toronto, Faculty of Medicine; Department of Medicine - Division of Hematology, Toronto, ON, Canada
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8
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Alexander T, Farge D, Badoglio M, Lindsay JO, Muraro PA, Snowden JA. Hematopoietic stem cell therapy for autoimmune diseases - Clinical experience and mechanisms. J Autoimmun 2018; 92:35-46. [PMID: 29934135 DOI: 10.1016/j.jaut.2018.06.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/07/2018] [Accepted: 06/08/2018] [Indexed: 12/13/2022]
Abstract
With accumulating evidence and improved outcomes along with recognition that modern biological therapies are not universally effective, require chronic administration and have high acquisition costs, hematopoietic stem cell transplantation (HSCT) has become an emerging direction for cell therapy in autoimmune diseases (ADs). The goal of this therapy is to induce medication-free remissions by resetting the immune system into a naïve and self-tolerant state through eradication of the autoreactive immunologic memory and profound re-configuration of the immune system induced by the transplant procedure. Safety of HSCT has generally improved by implementing internal quality management and external accreditation. Inter-disciplinary guidelines for patient selection, transplant technique and supportive care along with greater center experience should optimize safe and appropriate delivery of HSCT in specific ADs. In this review, we discuss the current role and future perspectives of HSCT in AD, focusing on recent published clinical and scientific studies and recommendations in the field.
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Affiliation(s)
- Tobias Alexander
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Germany.
| | - Dominique Farge
- Unité de Médecine Interne, Maladies Auto-immunes et Pathologie Vasculaire (UF 04), Hôpital St-Louis, AP-HP, 1 avenue Claude Vellefaux, 75010 Paris, Université Denis Diderot, France; Centre de Référence des Maladies auto-immunes systémiques Rares d'Ile-de-France (site constitutif), Filière FAI2R, France
| | - Manuela Badoglio
- EBMT Paris Study Office / CEREST-TC, Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Université Pierre et Marie Curie, Paris, France
| | - James O Lindsay
- The Royal London Hospital, Barts Health NHS Trust, London, E1 1BB UK; Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT, UK
| | - Paolo A Muraro
- Division of Brain Sciences, Department of Medicine, Imperial College London, London, UK
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2JF, UK
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9
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Paketçi A, Demir K, Tüfekçi Ö, Acar S, Abacı A, Yılmaz Ş, Böber E. Graves' disease following allogenic hematopoietic stem cell transplantation for severe aplastic anemia: case report and literature review. J Pediatr Endocrinol Metab 2018; 31:589-593. [PMID: 29708883 DOI: 10.1515/jpem-2017-0358] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/29/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Similar autoimmune processes (defective T-cell function) take place during the pathogenesis of aplastic anemia (AA) and Graves' disease (GD). Antithyroid drugs used for the management of GD may induce AA and GD may occur following treatment of severe aplastic anemia (SAA). CASE PRESENTATION Clinical and laboratory investigations were performed for an 11-year-and-2-month-old girl who was referred for bilateral exophthalmus and abnormal thyroid function tests. She had been diagnosed as having severe acquired AA at the age of 8 years and had been treated with allogenic hematopoietic stem cell transplantation from her healthy human leukocyte antigen-matched sibling donor. Clinical examination revealed a weight of 32.6 kg (-0.88 standard deviation [SD] score); height, 145.7 cm (-0.14 SD score); body mass index 15.5 kg/m2 (-1.01 SD score); heart rate, 110/min; blood pressure, 128/74 mmHg; bilateral exophthalmos and an enlarged thyroid gland. The laboratory workup showed hemoglobin of 11.1 g/dL; white blood cells, 7500/mL; platelets, 172,000/mL; free thyroxine (FT4), 4.80 ng/dL (normal, 0.5-1.51); free triiodothyronine (FT3), 17.7 pg/mL (normal, 2.5-3.9); thyrotropin (TSH), 0.015 mIU/mL (normal, 0.38-5.3); antithyroglobulin peroxidase (TPO) antibody, 61.7 IU/mL (normal, 0-9); antithyroglobulin (TG) antibody, <0.9 IU/mL (normal, 0-4) and thyrotropin (TSH) receptor antibodies 14 U/L (normal, 0-1). Doppler ultrasonography showed diffuse enlargement of the thyroid gland and increased vascularity. She was treated with methimazole (0.6 mg/kg/day). L-thyroxine treatment was also needed (50 μg/day). Thrombocytopenia developed during follow-up. A thyroidectomy was performed for definitive treatment at the 14th month of treatment. CONCLUSIONS The association of hyperthyroidism and AA in the pediatric age group is rare. The long-term use of antithyroid drugs and radioactive iodine should be avoided due to their hematologic toxic side effects.
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Affiliation(s)
- Ahu Paketçi
- Department of Pediatric Endocrinology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Korcan Demir
- Department of Pediatric Endocrinology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Özlem Tüfekçi
- Department of Pediatric Hematology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Sezer Acar
- Department of Pediatric Endocrinology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Ayhan Abacı
- Department of Pediatric Endocrinology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Şebnem Yılmaz
- Department of Pediatric Hematology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
| | - Ece Böber
- Department of Pediatric Endocrinology, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
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Snowden JA, Badoglio M, Labopin M, Giebel S, McGrath E, Marjanovic Z, Burman J, Moore J, Rovira M, Wulffraat NM, Kazmi M, Greco R, Snarski E, Kozak T, Kirgizov K, Alexander T, Bader P, Saccardi R, Farge D. Evolution, trends, outcomes, and economics of hematopoietic stem cell transplantation in severe autoimmune diseases. Blood Adv 2017; 1:2742-2755. [PMID: 29296926 PMCID: PMC5745133 DOI: 10.1182/bloodadvances.2017010041] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/27/2017] [Indexed: 02/06/2023] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) has evolved for >20 years as a specific treatment of patients with autoimmune disease (AD). Using European Society for Blood and Marrow Transplantation registry data, we summarized trends and identified factors influencing activity and outcomes in patients with AD undergoing first autologous HSCT (n = 1951; median age, 37 years [3-76]) and allogeneic HSCT (n = 105; median age, 12 years [<1-62]) in 247 centers in 40 countries from 1994 to 2015. Predominant countries of activity were Italy, Germany, Sweden, the United Kingdom, The Netherlands, Spain, France, and Australia. National activity correlated with the Human Development Index (P = .006). For autologous HSCT, outcomes varied significantly between diseases. There was chronological improvement in progression-free survival (PFS, P < 10-5), relapse/progression (P < 10-5), and nonrelapse mortality (P = .01). Health care expenditure was associated with improved outcomes in systemic sclerosis and multiple sclerosis (MS). On multivariate analysis selecting adults for MS, systemic sclerosis, and Crohn disease, better PFS was associated with experience (≥23 transplants for AD, P = .001), learning (time from first HSCT for AD ≥6 years, P = .01), and Joint Accreditation Committee of the International Society for Cellular Therapy and European Society for Blood and Marrow Transplantation accreditation status (P = .02). Despite improved survival over time (P = .02), allogeneic HSCT use remained low and largely restricted to pediatric practice. Autologous HSCT has evolved into a treatment modality to be considered alongside other modern therapies in severe AD. Center experience, accreditation, interspecialty networking, and national socioeconomic factors are relevant for health service delivery of HSCT in AD.
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Affiliation(s)
- John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Manuela Badoglio
- European Society for Blood and Marrow Transplantation (EBMT) Paris Study Office and
| | - Myriam Labopin
- Department of Haematology, Saint Antoine Hospital, INSERM Unité Mixte de Recherche 938, Université Pierre et Marie Curie, Paris, France
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute-Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Eoin McGrath
- Joint Accreditation Committee of the International Society for Cellular Therapy and EBMT (JACIE) Office, Barcelona, Spain
| | - Zora Marjanovic
- Service d'Hematologie clinique et Therapie Cellulaire, Hopital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - John Moore
- Haematology Department, St. Vincent's Health Network, Darlinghurst, NSW, Australia
| | | | - Nico M Wulffraat
- Divisie Kinderen, Cluster Immunologie, Reumatologie, Hematologie en Infectiologie, Wilhelmina Kinderziekenhuis, Utrecht, The Netherlands
| | - Majid Kazmi
- Kings Health Partners, Department of Haematology, Guys Hospital, London, United Kingdom
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Emilian Snarski
- Department of Hematology, Oncology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Tomas Kozak
- Přednosta Interní hematologické kliniky, Univerzity Karlovy a Fakultní nemocnice Královské Vinohrady, Prague, Czech Republic
| | - Kirill Kirgizov
- Department of Scientific Studies and Clinical Technologies, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Tobias Alexander
- Klinik für Rheumatologie und Klinische Immunologie, Charité-Universitätsmedizin, Berlin, Germany
| | - Peter Bader
- Stammzelltransplantation und Immunologie Klinik für Kinder und Jugendmedizin, Frankfurt am Main, Germany
| | - Riccardo Saccardi
- Haematology Department, Careggi University Hospital, Florence, Italy
| | - Dominique Farge
- Unité Clinique de Médecine Interne, Maladies Auto-immunes et Pathologie Vasculaire, Unité Fonctionnelle 04, Hôpital Saint-Louis, AP-HP, INSERM Unité Mixte de Recherche Scientifique 1160, Paris Denis Diderot University, Paris, France; and
- Centre de Référence des Maladies auto-immunes systémiques Rares d'Ile-de-France (site constitutif), Filière FAI2R, Paris, France
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11
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Hill QA, Stamps R, Massey E, Grainger JD, Provan D, Hill A. Guidelines on the management of drug-induced immune and secondary autoimmune, haemolytic anaemia. Br J Haematol 2017; 177:208-220. [PMID: 28369704 DOI: 10.1111/bjh.14654] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | | | - John D Grainger
- Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Drew Provan
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
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12
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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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Worel N, Buser A, Greinix HT, Hägglund H, Navarro W, Pulsipher MA, Nicoloso de Faveri G, Bengtsson M, Billen A, Espino G, Fechter M, Giudice V, Hölig K, Kanamori H, Kodera Y, Leitner G, Netelenbos T, Niederwieser D, van Walraven SM, Rocha V, Torosian T, Vergueiro C, Weisdorf D, Yabe H, Halter JP. Suitability Criteria for Adult Related Donors: A Consensus Statement from the Worldwide Network for Blood and Marrow Transplantation Standing Committee on Donor Issues. Biol Blood Marrow Transplant 2015; 21:2052-2060. [PMID: 26271194 DOI: 10.1016/j.bbmt.2015.08.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 08/05/2015] [Indexed: 12/20/2022]
Abstract
The number of allogeneic hematopoietic stem cell (HSC) transplants performed globally each year continues to increase. Advances in HLA typing, better supportive care, and administration of reduced-intensity conditioning regimens allow treatment of older patients with older sibling donors. Pretransplant donor assessment and testing are very important processes affecting the quality and safety of donation. For unrelated HSC donors detailed recommendations for health assessment have been published, allowing donation only if they are unrestrictedly healthy. Eligibility criteria for related donors are less strict and vary significantly between centers. In situations where a family donor does not meet the suitability criteria for unrelated donors, involved physicians often struggle with the decision whether the matched relative is suitable for donation or not. On behalf of the Worldwide Network for Blood and Marrow Transplantation Standing Committee on Donor Issues, we intended to develop a consensus document with recommendations for donor workup and final clearance of family donors who would not be able to serve as unrelated donors because of their age or pre-existing diseases. This article covers different topics intending to support decision-making, with the goal of minimizing medical risk to the donor and protection of the recipient from transmissible diseases.
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Affiliation(s)
- Nina Worel
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria.
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland; Department of Hematology, University Hospital Basel, Basel, Switzerland
| | | | - Hans Hägglund
- Division of Hematology, Department of Medical Sciences Uppsala University, Uppsala, Sweden
| | | | - Michael A Pulsipher
- Division of Hematology and Hematological Malignancies, Huntsman Cancer Institute/University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | | | - Mats Bengtsson
- Tobias Registry of Swedish Bone Marrow Donors and Uppsala University, Department of Immunology, Genetics and Pathology, Uppsala, Sweden
| | | | - German Espino
- Department of Internal Medicine, Hematology and Bone Marrow Transplantation Section, University Hospital Caja del Seguro Social, Panama City, Panama
| | - Mirjam Fechter
- Europdonor Foundation Leiden, Leiden University Medical Centre, Leiden, The Netherlands
| | - Valeria Giudice
- Department of Immunohematology and Transfusion Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Kristina Hölig
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Heiwa Kanamori
- Department of Hematology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Yoshihisa Kodera
- Asia-Pacific Blood and Marrow Transplantation Group and Department of Promotion for Blood and Marrow Transplantation, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Gerda Leitner
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Tanja Netelenbos
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Suzanna M van Walraven
- Europdonor Foundation Leiden, Leiden University Medical Centre, Leiden, The Netherlands; Ethics Working Group of the World Marrow Donor Association, Leiden, The Netherlands
| | - Vanderson Rocha
- Oxford University Hospitals NHS Trust, British Bone Marrow Donor Registry and Cord Blood Banks, NHS-BT, Oxford, United Kingdom
| | | | - Carmen Vergueiro
- FCM Santa Casa de São Paulo, Disciplina de Hematologia e Oncologia, São Paulo, Brasil
| | - Daniel Weisdorf
- Bone Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Hiromasa Yabe
- Department of Cell Transplantation and Regenerative Medicine, Tokai University School of Medicine, Tokyo, Japan
| | - Jörg P Halter
- Department of Hematology, University Hospital Basel, Basel, Switzerland
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14
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Abstract
The presence of autoimmune diseases, including Systemic Sclerosis (SSc), suggest failure of the normal immune regulatory processes leading to activation and expansion of autoreactive effector immune cells. Recently, stem cell transplantation emerged as a novel rescue therapy for a variety of refractory autoimmune diseases. The therapeutic strategy involves the ablation of the aberrant self-reactive immune cells by chemotherapy and the regeneration of a new self-tolerant immune system formed by the transplanted stem cells. In the last few years, thousands of patients worldwide have received haematopoietic stem cell transplantation (HSCT), mostly autologous, as treatment for severe irreversible autoimmune diseases, with promising results. Here we review the results of published small series of SSc patients treated with allogeneic and autologous HSCT, as well as three randomized trials, exploring the safety and efficacy of autologous HSCT in SSc. Although the results are encouraging, nonetheless, the correct application of stem cell transplantation remains an area of active investigation. Results of larger randomized, double blind clinical trials, will certainly improve our knowledge of the appropriate clinical use of stem cell therapy in SSc patients.
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Affiliation(s)
- Paola Cipriani
- Clinical Immunology and Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, "San Salvatore" University Hospital, University of L'Aquila, L'Aquila, Italy
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15
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Snowden JA, Ansari A, Sachchithanantham S, Jackson G, Thompson N, Lobo A, Sanderson J, Kazmi M. Autologous stem cell transplantation in severe treatment-resistant Crohn's disease: long-term follow-up of UK patients treated on compassionate basis. QJM 2014; 107:871-7. [PMID: 24803477 DOI: 10.1093/qjmed/hcu095] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although autologous stem cell transplantation (ASCT) may achieve disease control in severe treatment-resistant Crohn's disease (CD), relapse is frequent, and there is little information regarding long-term outcomes in terms of response to subsequent treatments and complications of ASCT. DESIGN Retrospective evaluation of UK patients treated on a compassionate basis from three UK tertiary centres. METHODS We summarize long-term outcomes of six previously unreported patients with severe treatment-resistant CD treated with ASCT according to international guidelines between 2003 and 2009. Median duration of CD before ASCT was 14 (7-22) years. Following stem cell mobilization, patients were treated with high-dose cyclophosphamide (200 mg/kg) and rabbit anti-thymocyte globulin (7.5 mg/kg) followed by ASCT. RESULTS All patients tolerated ASCT with routine toxicities and no treatment-related mortality and are alive at 50-123 months post-ASCT. Clinical and endoscopic remissions of CD were confirmed at 3 months post-ASCT in five patients, although median time to next treatment for inflammatory disease was 10 months (range: 3-16 months). Subsequently, disease control was achieved with previously ineffective and newer treatments, with surgery performed predominantly for pre-existing fibrotic strictures. Two patients became independent of home total parenteral nutrition (TPN). Reported late complications of ASCT included hypothyroidism and ovarian failure. CONCLUSION Long-term follow-up supports the safety and feasibility of ASCT as a means of achieving short-term control of severe CD whilst potentially re-sensitizing the disease to medical therapy and reducing requirements for surgery and TPN. Given the inevitability of relapse, pre-emptive salvage and/or maintenance treatments post-ASCT should be the focus of future trials.
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Affiliation(s)
- J A Snowden
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - A Ansari
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - S Sachchithanantham
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - G Jackson
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - N Thompson
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - A Lobo
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - J Sanderson
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - M Kazmi
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
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Ferrara JLM. Blood and Marrow Transplant Clinical Trials Network: progress since the State of the Science Symposium 2007. Biol Blood Marrow Transplant 2014; 20:149-53. [PMID: 24239651 PMCID: PMC4957643 DOI: 10.1016/j.bbmt.2013.11.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 11/07/2013] [Indexed: 11/30/2022]
Abstract
Outcomes of hematopoietic cell transplantation continue to improve. New techniques have reduced transplant toxicities, and there are new sources of hematopoietic stem cells from related and unrelated donors. In June 2007, the Blood and Marrow Transplant Clinical Trials Network (BMT CTN) convened a State of the Science Symposium (SOSS) in Ann Arbor and identified 11 high priority clinical trials for the network to pursue. This article reviews both the status of those trials and the record of achievement of the BMT CTN as it convenes another SOSS in Grapevine, Texas in February 2014.
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Affiliation(s)
- James L M Ferrara
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.
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17
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Kato H, Onishi Y, Nakajima S, Okitsu Y, Fukuhara N, Fujiwara T, Yamada-Fujiwara M, Kameoka J, Ishizawa K, Harigae H. Significant improvement of Takayasu arteritis after cord blood transplantation in a patient with myelodysplastic syndrome. Bone Marrow Transplant 2013; 49:458-9. [DOI: 10.1038/bmt.2013.198] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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18
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Papanastasiou AD, Chatzantoni K, Mouzaki A. Current therapeutic leads for the treatment of autoimmune diseases: stem cell transplantation and inhibition of post-translational modifications of autoantigens. Expert Opin Drug Discov 2013; 3:1255-65. [PMID: 23489081 DOI: 10.1517/17460441.3.10.1255] [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
BACKGROUND The complexity of autoimmune diseases is reflected on their clinicopathological heterogeneity and the failure to find treatments that cure them after over a century of research. Conventional treatments help ameliorate disease activity but they treat the symptoms whereas the diseases remain incurable in the vast majority of patients. OBJECTIVE To confront diseases of such nature it is essential to discover therapeutics that will lead to the induction of tolerance or the specific deletion of autoreactive lymphocytes. Current basic and clinical research strategies focus on the better identification of self-antigens, the induction of T regulatory cells that can suppress autoreactive cell activities or, more radically, the 'reformatting' of the immune system through hematopoietic stem cell transplantation (HSCT). METHODS We analyzed literature on autoimmune disease therapeutics, focusing on new antigens that may arise from post-translational modifications of common proteins and, also, the area of HSCT. RESULTS/CONCLUSIONS With the recent discovery that citrullination of self-epitopes may be a major pathogenic mechanism for, at least, certain types of autoimmune diseases, it becomes apparent that potentially any self-antigen in the body can be a target of an autoimmune attack. In addition, although the available data on HSCT applied to patients suffering from severe refractory autoimmune diseases do not allow for the determination of the efficacy of the various methods employed to re-educate the immune system, they contribute to our understanding of disease pathogenesis and the improvement on the therapeutic approaches.
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Affiliation(s)
- Anastasios D Papanastasiou
- University of Patras, Medical School, Division of Hematology, Department of Internal Medicine, Patras, GR-261 10, Greece +30 2610 969123 ; +30 2610 969123 ;
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19
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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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20
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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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Snowden JA, Pearce RM, Lee J, Kirkland K, Gilleece M, Veys P, Clark RE, Kazmi M, Abinun M, Jackson GH, Mackinnon S, Russell NH, Cook G. Haematopoietic stem cell transplantation (HSCT) in severe autoimmune diseases: analysis of UK outcomes from the British Society of Blood and Marrow Transplantation (BSBMT) data registry 1997-2009. Br J Haematol 2012; 157:742-6. [DOI: 10.1111/j.1365-2141.2012.09122.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 03/06/2012] [Indexed: 12/29/2022]
Affiliation(s)
- John A. Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust and Department of Oncology; University of Sheffield; Sheffield; UK
| | | | - Julia Lee
- BSBMT Data Registry; Guy's Hospital; London; UK
| | | | | | - Paul Veys
- Great Ormond Street Hospital NHS Trust; London; UK
| | | | - Majid Kazmi
- Guy's & St Thomas' NHS Foundation Trust (Kings Healthcare Partners); London; UK
| | - Mario Abinun
- Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne; UK
| | - Graham H. Jackson
- Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne; UK
| | | | | | - Gordon Cook
- Leeds Teaching Hospitals NHS Trust; London; UK
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22
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Complete resolution of guttate psoriasis following autologous SCT for Ewing's sarcoma in a pediatric patient. Bone Marrow Transplant 2012; 47:1585-6. [PMID: 22522571 DOI: 10.1038/bmt.2012.68] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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Clerici M, Cassinotti A, Onida F, Trabattoni D, Annaloro C, Della Volpe A, Rainone V, Lissoni F, Duca P, Sampietro G, Fociani P, Vago G, Foschi D, Ardizzone S, Deliliers GL, Porro GB. Immunomodulatory effects of unselected haematopoietic stem cells autotransplantation in refractory Crohn's disease. Dig Liver Dis 2011; 43:946-52. [PMID: 21907652 DOI: 10.1016/j.dld.2011.07.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 07/08/2011] [Accepted: 07/27/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Autologous haematopoietic stem cells transplantation (HSCT) has been shown to be effective in refractory Crohn's disease. AIM We analysed the effects of HSCT on the immune response of patients treated for moderate-severe Crohn's disease, refractory or intolerant to multiple drugs. METHODS Unselected peripheral blood stem cells were collected after mobilisation with cyclophosphamide (CTX) and G-CSF. The conditioning regimen included CTX and rabbit antithymocyte globulin. Blood samples for immunological analyses were collected at baseline, after mobilisation, and 3, 6 and 12 months after transplantation. Immunological analyses evaluated: (1) CD4(+)/CD25(high+)/FoxP3(+) regulatory T cells (T-regs); (2) Toll-like receptor 2-(TLR2) and TRL4-expressing monocytes (CD14(+) cells); (3) IL-12, IL-10, TNF-alpha-production by mitogen-stimulated CD14(+) cells and IFN-gamma production by CD4(+) T cells. Immunological results were compared with healthy donors and associated with clinical and endoscopic response during 12 months of follow-up. RESULTS Overall, T-regs increased, whilst TLR4-expressing cells, as well as TNF-alpha and IL-10, all higher than healthy donors at baseline, significantly decreased after transplantation. Full responders at T(3) had higher T-regs and lower IFN-gamma and IL12. T-regs decreased and IL12 and TLR2 increased in the only relapsed patient. CONCLUSIONS HSCT can induce and maintain clinical and endoscopic remission in refractory Crohn's disease, which is associated with immunomodulation.
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Affiliation(s)
- Mario Clerici
- Chair of Immunology, Department of Biomedical Sciences and Technologies, University of Milano, Milano, Italy.
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Hosseini H, Oh DY, Chan ST, Chen XT, Nasa Z, Yagita H, Alderuccio F, Toh BH, Chan J. Non-myeloablative transplantation of bone marrow expressing self-antigen establishes peripheral tolerance and completely prevents autoimmunity in mice. Gene Ther 2011; 19:1075-84. [DOI: 10.1038/gt.2011.179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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25
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Annaloro C, Onida F, Lambertenghi Deliliers G. Autologous hematopoietic stem cell transplantation in autoimmune diseases. Expert Rev Hematol 2011; 2:699-715. [PMID: 21082959 DOI: 10.1586/ehm.09.60] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The term 'autoimmune diseases' encompasses a spectrum of diseases whose clinical manifestations and, possibly, biological features vary widely. The results of conventional treatment are considered unsatisfactory in aggressive forms, with subsets of patients having short life expectancies. Relying on wide experimental evidence and more feeble clinical data, some research groups have used autologous hematopoietic stem cell transplantation (HSCT) in the most disabling autoimmune diseases with the aim of resetting the patient's immune system. Immunoablative conditioning regimens are preferred over their myeloablative counterparts, and some form of in vivo and/or ex vivo T-cell depletion is generally adopted. Despite 15 years' experience, published controlled clinical trials are still lacking, with the evidence so far available coming from pilot studies and registry surveys. In multiple sclerosis, clinical improvement, or at least lasting disease stabilization, can be achieved in the majority of the patients; nevertheless, the worst results are observed in patients with progressive disease, where no benefit can be expected from conventional therapy. Concerning rheumatologic diseases, wide experience has been acquired in systemic sclerosis, with long-term improvements in cutaneous disease being frequently reported, although visceral involvement remains unchanged at best. Autografting has proved to be barely effective in rheumatoid arthritis and quite toxic in juvenile idiopathic arthritis, whereas it leads to clinical remission and the reversal of visceral impairment in the majority of patients with systemic lupus erythematosus. A promising indication is Crohn's disease, in which long-term endoscopic remission is frequently observed. Growing experience with autologous HCST in autoimmune diseases has progressively reduced concerns about transplant-related mortality and secondary myelodysplasia/leukemia. Therefore, a sustained complete remission seems to be within the reach of autografting in some autoimmune diseases; in others, the indications, risks and benefits of autografting need to be better defined. Consequently, the search for new drugs should also be encouraged.
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Affiliation(s)
- Claudio Annaloro
- Bone Marrow Transplantation Center-Hematology I, Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, University of Milan, Via Francesco Sforza 35, Milan, Italy
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Tsukamoto H, Nagafuji K, Horiuchi T, Mitoma H, Niiro H, Arinobu Y, Inoue Y, To K, Miyamoto T, Iwasaki H, Teshima T, Harada M, Akashi K. Analysis of immune reconstitution after autologous CD34+ stem/progenitor cell transplantation for systemic sclerosis: predominant reconstitution of Th1 CD4+ T cells. Rheumatology (Oxford) 2010; 50:944-52. [DOI: 10.1093/rheumatology/keq414] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Wulffraat NM, van Rooijen EM, Tewarie R, Brinkman D, Prakken B, Kuis W. Current perspectives of autologous stem cell transplantation for severe Juvenile Idiopathic Arthritis. Autoimmunity 2010; 41:632-8. [PMID: 19117174 DOI: 10.1080/08916930802200224] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The majority of children with Juvenile Idiopathic Arthritis can nowadays be treated adequately. However despite the use of combinations of antirheumatic drugs, corticosteroids and the newer so called biologicals (blocking the TNF, Interleukin 1 or Interleukin 6 pathways) a proportion of children with arthritis remain resistant also to these therapies and suffer from a very severe, debilitating and potentially fatal disease. For such children autologous stem cell transplantation (ASCT) is successfully performed since 1997. Here we describe the long term outcome of the initial cohort of children with resistant Juvenile Idiopathic arthritis, treated with ASCT. The initial cohort of children was treated with a conditioning regimen containing Cyclophosphamide, anti thymocyte globulins and low dose Total Body irradiation. Overall favourable responses were seen, with a drug free remission rate of 50-55 %. In the more recent years late relapses were noted with lower percentages for drug free long term outcome. Special emphasis is given on 2 cases showing very late relapses, occurring after 7 and 9 years. The observed relapses are often less severe compared to the situation before SCT and can be treated successfully with conventional drugs in the majority of cases. More recently, ASCT was performed in 4 JIA children with a fludarabin containing regimen in stead of low dose TBI. With a 4 to 5 year follow up, these 4 patients are all in drug free full remission. Allogeneic transplant with an HLA matched family donor was reported in 2 JIA cases. Follow up of 1 and 3 year is sofar show clinical disease remission and tapering of medition. In conclusion, given the favourable long term outcome, SCT remains a valuable treatment option for children with drug resistant JIA.
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Affiliation(s)
- N M Wulffraat
- Department of Pediatric Immunology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.
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28
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Holzer U, van Royen-Kerkhof A, van der Torre P, Kuemmerle-Deschner J, Well C, Handgretinger R, Mueller I, Wulffraat N. Successful autologous stem cell transplantation in two patients with juvenile dermatomyositis. Scand J Rheumatol 2010; 39:88-92. [PMID: 20132077 DOI: 10.3109/03009740903096622] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Juvenile dermatomyositis (JDM) is a chronic inflammatory disorder of unknown aetiology that affects muscle and skin. We report on two patients with severe progressive JDM who developed contractures and were wheelchair dependent despite therapy including methotrexate (MTX), steroids, immunoglobulins, cyclosporin A, and rituximab. On account of the refractory disease, autologous stem cell transplantation (ASCT) was performed using a CD3/CD19-depleted graft after immunoablative conditioning with fludarabine, cyclophosphamide, and anti-thymocyte globulin. This induced a dramatic improvement and sustained remission of the disease in both patients. We demonstrate that ASCT is a therapeutic option with low toxicity for patients with severe, refractory JDM.
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Affiliation(s)
- U Holzer
- Department of General Paediatrics, Haematology, and Oncology, University Children's Hospital Tübingen, Tübingen, Germany.
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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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30
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Farge D, Labopin M, Tyndall A, Fassas A, Mancardi GL, Van Laar J, Ouyang J, Kozak T, Moore J, Kötter I, Chesnel V, Marmont A, Gratwohl A, Saccardi R. Autologous hematopoietic stem cell transplantation for autoimmune diseases: an observational study on 12 years' experience from the European Group for Blood and Marrow Transplantation Working Party on Autoimmune Diseases. Haematologica 2009; 95:284-92. [PMID: 19773265 DOI: 10.3324/haematol.2009.013458] [Citation(s) in RCA: 249] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Autologous hematopoietic stem cell transplantation has been used since 1996 for the treatment of severe autoimmune diseases refractory to approved therapies. We evaluated the long-term outcomes of these transplants and aimed to identify potential prognostic factors. DESIGN AND METHODS In this observational study we analyzed all first autologous hematopoietic stem cell transplants for autoimmune diseases reported to the European Group for Blood and Marrow Transplantation (EBMT) registry between 1996-2007. The primary end-points for analysis were overall survival, progression-free survival and transplant-related mortality at 100 days. RESULTS Nine hundred patients with autoimmune diseases (64% female; median age, 35 years) who underwent a first autologous hematopoietic stem cell transplant were included. The main diseases were multiple sclerosis (n=345), systemic sclerosis (n=175), systemic lupus erythematosus (n=85), rheumatoid arthritis (n=89), juvenile arthritis (n=65), and hematologic immune cytopenia (n=37). Among all patients, the 5-year survival was 85% and the progression-free survival 43%, although the rates varied widely according to the type of autoimmune disease. By multivariate analysis, the 100-day transplant-related mortality was associated with the transplant centers' experience (P=0.003) and type of autoimmune disease (P=0.03). No significant influence of transplant technique was identified. Age less than 35 years (P=0.004), transplantation after 2000 (P=0.0015) and diagnosis (P=0.0007) were associated with progression-free survival. CONCLUSIONS This largest cohort studied worldwide shows that autologous hematopoietic stem cell transplantation can induce sustained remissions for more than 5 years in patients with severe autoimmune diseases refractory to conventional therapy. The type of autoimmune disease, rather than transplant technique, was the most relevant determinant of outcome. Results improved with time and were associated with the transplant centers' experience. These data support ongoing and planned phase III trials to evaluate the place of autologous hematopoietic stem cell transplantation in the treatment strategy for severe autoimmune diseases.
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Affiliation(s)
- Dominique Farge
- Service de Médecine Interne et Unité INSERM U 976, Hôpital Saint-Louis, Assistance-Publique Hôpitaux de Paris, Paris-7 Université Denis Diderot, 1 avenue Claude Vellefaux, 75 010 Paris France.
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31
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Snowden JA, Kapoor S, Wilson AG. Stem cell transplantation in rheumatoid arthritis. Autoimmunity 2009; 41:625-31. [DOI: 10.1080/08916930802198550] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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32
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Cohen A. Hematopoietic stem cell transplantation and diabetes mellitus: the paradox between treatment and cause of a disease. Pediatr Transplant 2009; 13:3-6. [PMID: 18785911 DOI: 10.1111/j.1399-3046.2008.01006.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fagius J, Lundgren J, Öberg G. Early highly aggressive MS successfully treated by hematopoietic stem cell transplantation. Mult Scler 2008; 15:229-37. [DOI: 10.1177/1352458508096875] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background During the last 15 years, high-dose chemotherapy with autologous hematopoietic stem cell transplantation (HSCT) has globally been performed for severe multiple sclerosis (MS). Most patients have been in progressive phase with long disease duration. As a rule, treatment effect has been minor or moderate. Patients Since 2004, we have performed HSCT in nine young patients with “malignant” relapsing–remitting MS. Criteria for treatment were short duration of disease; very frequent, severe relapses; recent improvement periods indicating potential for recovery after strong immunosuppression. Findings Median age at treatment was 27 (range 9–34) years, MS duration 26 (4–100) months, and annualized relapse rate 10 (4–12). Median Disability Status Scale (extended disability status scale, EDSS) at HSCT was 7.0 (3.5–8.0). Median follow-up time April 2008 is 29 (23–47) months. Median EDSS improvement is 3.5 (1.0–7.0), clearly surpassing most previous reports. One patient relapsed mildly with rapid recovery 7 months after HSCT. All patients are otherwise stable, median EDSS being 2.0 (0–6.0). Before HSCT, 61 relapses occurred in 82 patient months; during follow-up, one relapse in 289 patient months. Conclusion This small series of patients with “malignant” relapsing–remitting MS suggests HSCT to be an effective treatment option for this relatively rare disease course. It further suggests that future criteria for HSCT in MS should be close to the present ones.
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Affiliation(s)
- J Fagius
- Department of Neurology, University Hospital, Uppsala, Sweden
| | - J Lundgren
- Department of Paediatrics, Lund University Hospital, Lund, Sweden
| | - G Öberg
- Department of Haematology, University Hospital, Uppsala, Sweden
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Wiesendanger M, Stanevsky A, Kovsky S, Diamond B. Novel therapeutics for systemic lupus erythematosus. Curr Opin Rheumatol 2008; 18:227-35. [PMID: 16582684 DOI: 10.1097/01.bor.0000218941.04613.85] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW This review provides an update on recently explored therapies in systemic lupus erythematosus and introduces novel therapeutic approaches under consideration. Recent advances in our understanding of systemic lupus are highlighted as well, as these must now inform consideration of therapeutics. RECENT FINDINGS Many therapeutic strategies have been shown to be beneficial in murine models of lupus. Compounds that inhibit cellular signaling in response to autoantigens or other triggers and protocols that reconstitute the immune repertoire to diminish autoreactivity are now entering clinical trials. SUMMARY Requirements for novel approaches in lupus include improved efficacy and lower toxicity than current therapies, with the goal to reduce tissue damage while preserving immunocompetence.
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Affiliation(s)
- Margrit Wiesendanger
- Department of Medicine, Columbia University Medical Center, New York, New York 10032, USA
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35
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Rabusin M, Andolina M, Maximova N. Haematopoietic SCT in autoimmune diseases in children: rationale and new perspectives. Bone Marrow Transplant 2008; 41 Suppl 2:S96-9. [DOI: 10.1038/bmt.2008.64] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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36
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Axelson HW, Oberg G, Askmark H. No benefit of treatment with cyclophosphamide and autologous blood stem cell transplantation in multifocal motor neuropathy. Acta Neurol Scand 2008; 117:432-4. [PMID: 18081911 DOI: 10.1111/j.1600-0404.2007.00970.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Patients with multifocal motor neuropathy (MMN) usually respond to intravenous immunoglobulin (IVIG), but because of the short-lasting effect the treatment must be given repeatedly. Remission after treatment with high-dose cyclophosphamide has recently been reported in one patient refractory to IVIG. CASE REPORT Here we report on a patient who responded to IVIG, but temporarily deteriorated dramatically after treatment with high-dose cyclophosphamide and autologous blood stem cell transplantation. Today the situation is the same as before the treatment with cyclophosphamide and blood stem cell transplantation, i.e. IVIG is given every 4 weeks. CONCLUSION Our patient did not benefit from the treatment with high-dose cyclophosphamide and autologous blood stem cell transplantation. The effect of treatment with high-dose cyclophosphamide in MMN seems to be difficult to predict and that should be paid attention to if this type of treatment is considered.
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Affiliation(s)
- H W Axelson
- Department of Neurophysiology, University Hospital, Uppsala, Sweden.
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37
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[Stem cell transplantation in autoimmune diseases]. Rev Med Interne 2007; 29:80-3. [PMID: 18096275 DOI: 10.1016/j.revmed.2007.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Accepted: 11/04/2007] [Indexed: 12/29/2022]
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38
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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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39
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Ferrara JLM, Anasetti C, Stadtmauer E, Antin J, Wingard J, Lee S, Levine J, Schultz K, Appelbaum F, Negrin R, Giralt S, Bredeson C, Heslop H, Horowitz M. Blood and Marrow Transplant Clinical Trials Network State of the Science Symposium 2007. Biol Blood Marrow Transplant 2007; 13:1268-85. [PMID: 17950914 DOI: 10.1016/j.bbmt.2007.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Accepted: 08/20/2007] [Indexed: 11/16/2022]
Abstract
Outcomes of hematopoietic cell transplantation are steadily improving. New techniques have reduced transplant toxicities, and there are new sources of hematopoietic stem cells from unrelated donors. In June 2007 the Blood and Marrow Transplant Clinical Trials Network convened a State of the Science Symposium of more than 200 participants in Ann Arbor to identify the most compelling clinical research opportunities in the field. This report summarizes the symposium's discussions and identifies eleven high priority clinical trials that the network plans to pursue over the course of the next several years.
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40
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[Haematopoietic stem cell transplantation in the treatment of autoimmune diseases]. Rev Med Interne 2007; 29:115-21. [PMID: 17976871 DOI: 10.1016/j.revmed.2007.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 08/13/2007] [Indexed: 12/29/2022]
Abstract
PURPOSE During the past ten years, more than 1000 patients suffering from severe autoimmune disease have received an autologous haematopoietic stem cell transplant. These new therapeutic have been used in systemic sclerosis (scleroderma), multiple sclerosis, rheumatoid arthritis, juvenile idiopathic arthritis and systemic lupus erythematosus. CURRENT KNOWLEDGE AND KEY POINTS Autologous haematopoietic stem cell transplantation has become a curative option for condition with very poor prognosis as severe systemic sclerosis, lupus erythematosus or other systemic diseases. This review summarizes the current experience in the phase I and II clinical trials in Europe and North America. We describe the main results and the limits of stem cell transplantation in systemic diseases. FUTURE PROSPECTS AND PROJECTS Autologous haematopoietic stem cell transplant in the treatment of autoimmune disease has evolved from a experimental concept to a clinically feasible and powerful therapy for selected patients with severe disease.
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41
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Rosa SB, Voltarelli JC, Chies JAB, Pranke P. The use of stem cells for the treatment of autoimmune diseases. Braz J Med Biol Res 2007; 40:1579-97. [PMID: 17713674 DOI: 10.1590/s0100-879x2006005000166] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Accepted: 07/02/2007] [Indexed: 12/13/2022] Open
Abstract
Autoimmune diseases constitute a heterogeneous group of conditions commonly treated with anti-inflammatory, immunosuppressant and immunomodulating drugs, with satisfactory results in most cases. Nevertheless, some patients become resistant to conventional therapy. The use of high doses of drugs in such cases results in the need for bone marrow reconstitution, a situation which has stimulated research into the use of hematopoietic stem cells in autoimmune disease therapy. Stem cell transplantation in such diseases aims to destroy the self-reacting immune cells and produce a new functional immune system, as well as substitute cells for tissue damaged in the course of the disease. Significant results, such as the reestablishment of tolerance and a decrease in the recurrence of autoimmune disease, have been reported following stem cell transplantation in patients with autoimmune disease in Brazil and throughout the world. These results suggest that stem cell transplantation has the potential to become an important therapeutic approach to the treatment of various autoimmune diseases including rheumatoid arthritis, juvenile idiopathic arthritis, systemic lupus erythematosus, multiple sclerosis, systemic sclerosis, Crohn's disease, autoimmune blood cytopenias, and type I diabetes mellitus.
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Affiliation(s)
- S B Rosa
- Laboratório de Hematologia, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
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42
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Morris ES, Sharrack B, Dalley CD, Snowden JA. The Uhthoff phenomenon: a potential post transplant complication in advanced progressive multiple sclerosis. Bone Marrow Transplant 2007; 40:1003-4. [PMID: 17891188 DOI: 10.1038/sj.bmt.1705854] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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43
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Reményi P, Masszi T, Borbényi Z, Soós J, Siklós L, Engelhardt JI. CIDP cured by allogeneic hematopoietic stem cell transplantation. Eur J Neurol 2007; 14:e1-2. [PMID: 17661987 DOI: 10.1111/j.1468-1331.2007.01615.x] [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: 11/26/2022]
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44
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Fousteri G, Hayek A, von Herrath M. Stopping diabetes in its tracks: autologous non-myeloablative stem cell transplantation. Regen Med 2007; 2:845-51. [PMID: 17907936 DOI: 10.2217/17460751.2.5.845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
A recent report in this year’s April issue of Journal of the American Medical Association describes an unprecedented success in delaying insulin dependence in patients with recent-onset Type 1 diabetes after non-myeloablative immune suppression with cyclophosphamide and antithymocyte globulin followed by autologous stem cell transplantation. In this study, 14 out of 15 patients became insulin-independent, which lasted up to 35 months. Concomitantly, C-peptide levels increased substantially compared with preintervention values. Treatment of autoimmune disorders, and in particular Type 1 diabetes, constitutes a complex balancing act between suppressing autoaggressive responses strongly and permanently enough, while circumventing much-feared long-term side effects from chronic immunosuppression. This clinical Phase I/II trial is relevant to fine-tuning interventive protocols and contributing to the further development of suitable combination therapies to prevent and treat Type 1 diabetes.
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Affiliation(s)
- Georgia Fousteri
- La Jolla Institute for Allergy and Immunology, 9420 Athena Circle, La Jolla, CA 92037, USA.
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45
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Lytton SD, Denton CP, Nutzenberger AM. Treatment of Autoimmune Disease with Rabbit Anti-T Lymphocyte Globulin: Clinical Efficacy and Potential Mechanisms of Action. Ann N Y Acad Sci 2007; 1110:285-96. [PMID: 17911443 DOI: 10.1196/annals.1423.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The rabbit anti-T lymphocyte globulins (rATGs) are immune-suppressive anti-T cell agents with beneficial effects in solid organ and hematological transplantation. The present review evaluates the potential mechanisms of rATGs and their impact on pilot and exploratory studies of diffuse cutaneous systemic sclerosis (scleroderma-SSc), inclusion body myositis (IBM), vasculitis, and type 1 diabetes mellitus (T1DM). The rATGs are associated with improvements in well-defined parameters of clinical autoimmunity: insulin usage, tissue inflammation, and systemic organ functions. Meta-analysis of a retrospective database of SSc, N = 196 and two prospective randomized pilot studies; IBM, N = 11 and T1DM, N = 17 shows a two- to ninefold increase in the relative response to treatments with intravenous infusions of rATG. The rATGs deplete T cells and are associated with increases in the percentage of CD25+ T cell subsets. This may underlie the apparent long-lasting immunomodulation associated with these agents. The future optimization of rATG adjunct therapy requires statistically powered-controlled prospective trials of rATG dose-finding and timing of administration. The potential mechanisms of rATGs:depletion of autoreactive T cells, generation CDCD25+Foxp3+ regulatory T cells (Tregs), and the acquisition of regulatory immune cell functions, need to be examined in patients prior to rATG infusion and at time intervals following rATG treatment to identify those mechanisms relevant to the improvement of their clinical outcome.
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Affiliation(s)
- Simon D Lytton
- SeraDiaLogistics, Hertlingstr 1, 81545 München, Germany.
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46
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Brinkman DMC, Jol-van der Zijde CM, ten Dam MM, te Boekhorst PAW, ten Cate R, Wulffraat NM, Hintzen RQ, Vossen JM, van Tol MJD. Resetting the adaptive immune system after autologous stem cell transplantation: lessons from responses to vaccines. J Clin Immunol 2007; 27:647-58. [PMID: 17690955 PMCID: PMC2075528 DOI: 10.1007/s10875-007-9120-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Accepted: 07/06/2007] [Indexed: 12/29/2022]
Abstract
Autologous stem cell transplantation (ASCT) to treat autoimmune diseases (AID) is thought to reset immunological memory directed against autoantigens. This hypothesis can only be studied indirectly because the exact nature of the pathogenetic autoantigens is unknown in most AID. Therefore, 19 children with juvenile idiopathic arthritis (JIA) or systemic lupus erythematodes (SLE) and 10 adults with multiple sclerosis (MS) were vaccinated with the T-cell-dependent neoantigen rabies and the recall antigen tetanus toxoid after, respectively before, bone marrow harvest. Both vaccinations were repeated after ASCT. All except two of the responders mounted a primary antibody response to rabies after revaccination, and 44% of the responders mounted a primary antibody response to tetanus boost after ASCT. These data show that immunological memory to a neoantigen is lost in most patients with AID after immunoablative pretreatment; however, memory to a recall antigen boosted before bone marrow harvest is only lost in part of the patients. Disease progression was arrested in all patients with JIA/SLE except one, but only in a minority of MS patients. Clinical outcome on a per case basis was not associated with the profile of the immune response toward the vaccination antigens after ASCT.
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Affiliation(s)
- D M C Brinkman
- Department of Pediatrics, Leiden University Medical Center, 2300 RC, Leiden, The Netherlands.
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47
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Augello A, Tasso R, Negrini SM, Cancedda R, Pennesi G. Cell therapy using allogeneic bone marrow mesenchymal stem cells prevents tissue damage in collagen-induced arthritis. ACTA ACUST UNITED AC 2007; 56:1175-86. [PMID: 17393437 DOI: 10.1002/art.22511] [Citation(s) in RCA: 432] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Mesenchymal stem cells (MSCs) are precursors of tissue of mesenchymal origin, but they also have the capacity to regulate the immune response by suppressing T and B lymphocyte proliferation in a non-major histocompatibility complex-restricted manner. Use of MSCs as immunosuppressant agents in autoimmune diseases has been proposed and successfully tested in animal models. We explored the feasibility of using allogeneic MSCs as therapy for collagen-induced arthritis, a mouse model for human rheumatoid arthritis. METHODS DBA/1 mice were immunized with type II collagen in Freund's complete adjuvant, and some of the animals received an intraperitoneal injection of allogeneic MSCs. RESULTS A single injection of MSCs prevented the occurrence of severe, irreversible damage to bone and cartilage. MSCs induced hyporesponsiveness of T lymphocytes as evidenced by a reduction in active proliferation, and modulated the expression of inflammatory cytokines. In particular, the serum concentration of tumor necrosis factor alpha was significantly decreased. MSCs exerted their immunomodulatory function by educating antigen-specific Tregs. CONCLUSION Our results suggest an effective new therapeutic approach to target the pathogenic mechanism of autoimmune arthritis using allogeneic MSCs. However, further studies are required before these results can be translated to clinical settings.
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MESH Headings
- Animals
- Arthritis, Experimental/pathology
- Arthritis, Experimental/physiopathology
- Arthritis, Experimental/therapy
- Bone Marrow Cells
- Bone and Bones/drug effects
- Bone and Bones/pathology
- Cartilage, Articular/drug effects
- Cartilage, Articular/pathology
- Cell Proliferation/drug effects
- Cytokines/blood
- Female
- Joints/drug effects
- Joints/pathology
- Male
- Mesenchymal Stem Cell Transplantation
- Mesenchymal Stem Cells/immunology
- Mice
- Mice, Inbred C57BL
- Mice, Inbred DBA
- Mice, Transgenic
- T-Lymphocytes, Regulatory/drug effects
- T-Lymphocytes, Regulatory/metabolism
- T-Lymphocytes, Regulatory/pathology
- Transplantation, Homologous
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Affiliation(s)
- Andrea Augello
- Department of Oncology, Biology, and Genetics, University of Genoa, National Institute for Cancer Research, Genoa, Italy
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Saccardi R, Kozak T, Bocelli-Tyndall C, Fassas A, Kazis A, Havrdova E, Carreras E, Saiz A, Löwenberg B, te Boekhorst PAW, Gualandio F, Openshaw H, Longo G, Pagliai F, Massacesi L, Deconink E, Ouyang J, Nagore FJZ, Besalduch J, Lisukov IA, Bonini A, Merelli E, Slavino S, Gratwohl A, Passweg J, Tyndall A, Steck AJ, Andolina M, Capobianco M, Martin JLD, Lugaresi A, Meucci G, Sáez RA, Clark RE, Fernandez MN, Fouillard L, Herstenstein B, Koza V, Cocco E, Baurmann H, Mancardi GL. Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database. Mult Scler 2007; 12:814-23. [PMID: 17263012 DOI: 10.1177/1352458506071301] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Over the last decade, hematopoietic stem cells transplantation (HSCT) has been increasingly used in the treatment of severe progressive autoimmune diseases. We report a retrospective survey of 183 multiple sclerosis (MS) patients, recorded in the database of the European Blood and Marrow Transplantation Group (EBMT). Transplant data were available from 178 patients who received an autologous graft. Overall, transplant related mortality (TRM) was 5.3% and was restricted to the period 1995-2000, with no further TRM reported since then. Busulphan-based regimens were significantly associated with TRM. Clinical status at the time of transplant and transplant techniques showed some correlations with toxicity. No toxic deaths were reported among the 53 patients treated with the BEAM (carmustine, etoposide, cytosine-arabinoside, melphalan)/antithymocyte globulin (ATG) regimen without graft manipulation, irrespective of their clinical condition at the time of the transplant. Improvement or stabilization of neurological conditions occurred in 63% of patients at a median follow-up of 41.7 months, and was not associated with the intensity of the conditioning regimen. In this large series, HSCT was shown as a promising procedure to slow down progression in a subset of patients affected by severe, progressive MS; the safety and feasibility of the procedure can be significantly improved by appropriate patient selection and choice of transplant regimen.
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Affiliation(s)
- R Saccardi
- BMT Unit Department of Hematology, Ospedale di Careggi, Florence, Italy.
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49
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Statkute L, Verda L, Oyama Y, Traynor A, Villa M, Shook T, Clifton R, Jovanovic B, Satkus J, Loh Y, Quigley K, Yaung K, Gonda E, Krosnjar N, Spahovic D, Burt RK. Mobilization, harvesting and selection of peripheral blood stem cells in patients with autoimmune diseases undergoing autologous hematopoietic stem cell transplantation. Bone Marrow Transplant 2007; 39:317-29. [PMID: 17277794 DOI: 10.1038/sj.bmt.1705579] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Peripheral blood stem cells (PBSC) were mobilized in 130 patients with autoimmune diseases undergoing autologous hematopoietic stem cell transplantation using cyclophosphamide 2 g/m(2) and either granulocyte colony-stimulating factor (G-CSF) 5 mcg/kg/day (for systemic lupus erythematosus (SLE) and secondary progressive multiple sclerosis, SPMS) or G-CSF 10 mcg/kg/day (for relapsing remitting multiple sclerosis (RRMS), Crohn's disease (CD), systemic sclerosis (SSc), and other immune-mediated disorders). Mobilization-related mortality was 0.8% (one of 130) secondary to infection. Circulating peripheral blood (PB) CD34(+) cells/microl differed significantly by disease. Collected CD34(+) cells/kg/apheresis and overall collection efficiency was significantly better using Spectra apheresis device compared to the Fenwall CS3000 instrument. Patients with SLE and RRMS achieved the lowest and the highest CD34(+) cell yields, respectively. Ex vivo CD34(+) cell selection employing Isolex 300iv2.5 apparatus was significantly more efficient compared to CEPRATE CS device. Circulating PB CD34(+) cells/microl correlated positively with initial CD34(+) cells/kg/apheresis and enriched product CD34(+) cells/kg. Mean WBC and platelet engraftment (ANC>0.5 x 10(9)/l and platelet count >20 x 10(9)/l) occurred on days 9 and 11, respectively. Infused CD34(+) cell/kg dose showed significant direct correlation with faster white blood cell (WBC) and platelet engraftment. When adjusted for CD34(+) cell/kg dose, patients treated with a myeloablative regimen had significantly slower WBC and platelet recovery compared to non-myeloablative regimens.
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Affiliation(s)
- L Statkute
- Division of Immunotherapy, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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50
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Brinkman DMC, de Kleer IM, ten Cate R, van Rossum MAJ, Bekkering WP, Fasth A, van Tol MJD, Kuis W, Wulffraat NM, Vossen JM. Autologous stem cell transplantation in children with severe progressive systemic or polyarticular juvenile idiopathic arthritis: Long-term followup of a prospective clinical trial. ACTA ACUST UNITED AC 2007; 56:2410-21. [PMID: 17599770 DOI: 10.1002/art.22656] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of intensive immunosuppression followed by T cell-depleted autologous hematopoietic stem cell transplantation (ASCT) for induction of disease remission in children with refractory progressive juvenile idiopathic arthritis (JIA). METHODS Twenty-two patients with progressive refractory JIA were followed up over a median period of 80 months after pretreatment with intensive immunosuppression followed by ASCT in a multicenter, prospective, phase II clinical trial. Hematopoietic stem cells were harvested from the patients' bone marrow, depleted of T cells, and kept frozen until used for ASCT. Pretreatment of patients consisted of a combination of antithymocyte globulin, cyclophosphamide, and low-dose total body irradiation. Patients were followed up for ASCT-related complications, recovery of hematologic and immune system parameters, and disease outcomes. RESULTS Reconstitution of hematologic values to normal range was rapid. Recovery of immune system parameters, especially normalization of CD4+, CD45RA+ naive T cells, was delayed, occurring at >/=6 months after ASCT. The prolonged period of immune deficiency resulted in a large number of viral infections and may have contributed to the development of macrophage activation syndrome (MAS), leading to death, in 2 patients. After ASCT, 8 of the 20 evaluable patients reached complete clinical remission of their JIA, 7 were partial responders, and 5 experienced a relapse of their disease (occurring 7 years after ASCT in 1 patient). Later during followup, 2 of the patients whose disease relapsed died from infections that developed after restarting immunosuppressive medication. CONCLUSION Intensive immunosuppression followed by ASCT resulted in sustained complete remission or marked improvement in 15 of 22 patients with progressive refractory JIA. The procedure, however, is associated with significant morbidity and risk of mortality due to prolonged and severe depression of T cell immunity. After fatal complications due to MAS were observed in some patients, the protocol was amended in 1999, to ensure less profound depletion of T cells, better control of systemic disease before transplantation, antiviral prophylaxis after transplantation, and slow tapering of corticosteroids. Following these protocol modifications, no additional ASCT-related deaths were observed among the 11 patients who received the modified treatment.
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Affiliation(s)
- D M C Brinkman
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands.
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