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Kalincik T, Sharmin S, Roos I, Massey J, Sutton I, Withers B, Freedman MS, Atkins H, Krasulova E, Kubala Havrdova E, Trneny M, Kozak T, Burman J, Macdonell R, Torkildsen Ø, Bø L, Lehmann AK, Sharrack B, Snowden J. Effectiveness of autologous haematopoietic stem cell transplantation versus natalizumab in progressive multiple sclerosis. J Neurol Neurosurg Psychiatry 2024; 95:775-783. [PMID: 38538060 DOI: 10.1136/jnnp-2023-332790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/12/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Natalizumab was not shown to modify disability in progressive multiple sclerosis (MS). This matched observational study compared the effectiveness of autologous haematopoietic stem cell transplantation (AHSCT) with natalizumab in progressive MS. METHODS Patients with primary/secondary progressive MS from seven AHSCT MS centres and the MSBase registry, treated with AHSCT or natalizumab, were matched on a propensity score derived from sex, age, Expanded Disability Status Scale (EDSS), number of relapses 12/24 months before baseline, time from MS onset, the most effective prior therapy and country. The pairwise-censored groups were compared on hazards of 6-month confirmed EDSS worsening and improvement, relapses and annualised relapse rates (ARRs), using Andersen-Gill proportional hazards models and conditional negative binomial model. RESULTS 39 patients treated with AHSCT (37 with secondary progressive MS, mean age 37 years, EDSS 5.7, 28% with recent disability progression, ARR 0.54 during the preceding year) were matched with 65 patients treated with natalizumab. The study found no evidence for difference in hazards of confirmed EDSS worsening (HR 1.49, 95% CI 0.70 to 3.14) and improvement (HR 1.50, 95% CI 0.22 to 10.29) between AHSCT and natalizumab over up to 4 years. The relapse activity was also similar while treated with AHSCT and natalizumab (ARR: mean±SD 0.08±0.28 vs 0.08±0.25; HR 1.05, 95% CI 0.39 to 2.82). In the AHSCT group, 3 patients experienced febrile neutropenia during mobilisation, 9 patients experienced serum sickness, 6 patients required intensive care unit admission and 36 patients experienced complications after discharge. No treatment-related deaths were reported. CONCLUSION This study does not support the use of AHSCT to control disability in progressive MS with advanced disability and low relapse activity.
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Affiliation(s)
- Tomas Kalincik
- CORe, Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Sifat Sharmin
- CORe, Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Izanne Roos
- CORe, Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jennifer Massey
- Department of Neurology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Ian Sutton
- Department of Neurology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
- University of Syndey, Sydney, New South Wales, Australia
| | - Barbara Withers
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Haematology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Mark S Freedman
- Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Harold Atkins
- Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Eva Krasulova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital in Prague, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital in Prague, Prague, Czech Republic
| | - Marek Trneny
- General University Hospital in Prague, Prague, Czech Republic
- Department of Haematology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tomas Kozak
- Department of Haematology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
- University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Joachim Burman
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Richard Macdonell
- Department of Neurology, Austin Health, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Basil Sharrack
- Department of Neuroscience and Sheffield NIHR Translational Neuroscience Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Metabolism, Medical School, The University of Sheffield, Sheffield, UK
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Gottschlich KN, Zolic-Karlsson Z, Aas E, Kvistad SAS, Bø L, Torkildsen Ø, Lehmann AK. Healthcare utilization and costs associated with autologous haematopoietic stem cell transplantation in Norwegian patients with relapsing remitting multiple sclerosis. Mult Scler Relat Disord 2024; 84:105507. [PMID: 38412758 DOI: 10.1016/j.msard.2024.105507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/24/2024] [Accepted: 02/15/2024] [Indexed: 02/29/2024]
Abstract
Multiple sclerosis (MS) patients experience long-term deterioration of neurological function, reduced quality of life, long-lasting treatment cycles, and an increased risk of early workability loss imposing an economic burden to society. Autologous haematopoietic stem cell transplantation (AHSCT) has shown promising treatment effects for relapsing remitting MS (RRMS). This study employs a micro-costing approach to estimate healthcare utilization and costs associated with AHSCT in Norwegian RRMS patients. Patient-level data were extracted from medical journals of 30 RRMS patients receiving AHSCT treatment at Haukeland University Hospital in the period from January 2015 to January 2018. The time horizon for the analysis was from the pretransplant screening until one year after AHSCT. A correlation was found between patient body weight and total healthcare cost. The average total healthcare cost of AHSCT for RRMS patients was estimated to EUR 66 304 (95% CI: EUR 63 598 - EUR 69 010) including costs associated with the pre-AHSCT period, AHSCT treatment phases and one-year follow-up. The majority of the costs, EUR 64 329, occurred during the treatment phase and within the first 100 days after AHSCT. The results indicate that long-term healthcare cost savings may be achieved using AHSCT in selected patients with aggressive RRMS. This is due to the high costs of most used disease modifying treatments. Further research including long-term clinical data is needed to determine the cost-effectiveness of this treatment.
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Affiliation(s)
- Katharina Natalie Gottschlich
- Centre for Alcohol and Drug Research (KORFOR), Stavanger University Hospital, PO Box 8100, Stavanger 4068, Norway; Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, PO Box 1089, Blindern, Oslo 0317, Norway; Haukeland University Hospital, Bergen 5021, Norway
| | - Zinajda Zolic-Karlsson
- The Norwegian Medical Products Agency, PO Box 240, Skøyen, Oslo 0213, Norway; Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Eline Aas
- Department of Health Management and Health Economics, Institute for Health and Society, University of Oslo, PO Box 1089, Blindern, Oslo 0317, Norway; Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Lars Bø
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Anne Kristine Lehmann
- Department of Medicine, Section of Haematology, Haukeland University Hospital, Bergen, Norway
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3
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Katsarogiannis E, Axelson H, Berntsson S, Rothkegel H, Burman J. Evoked potentials after autologous hematopoietic stem cell transplantation for multiple sclerosis. Mult Scler Relat Disord 2024; 83:105447. [PMID: 38242050 DOI: 10.1016/j.msard.2024.105447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/14/2023] [Accepted: 01/13/2024] [Indexed: 01/21/2024]
Abstract
OBJECTIVE To investigate the effect of autologous hematopoietic stem cell transplantation (AHSCT) on functional aspects of the nervous system assessed by visual (VEP), somatosensory (SEP), and motor (MEP) evoked potentials in patients with relapsing-remitting multiple sclerosis. BACKGROUND Several studies have demonstrated the efficacy of AHSCT on inflammatory activity and disability progression in patients with multiple sclerosis. However, the impact of AHSCT on evoked potentials has not been evaluated before. METHODS Twelve AHSCT-treated patients from Uppsala University Hospital were consecutively recruited. Evoked potentials (EP) were collected at baseline and two follow-up visits, 3 and 12 months post-AHSCT. We calculated a composite EP score for each participant and compared it between different time points. RESULTS The median total EP score decreased from 5 at baseline, to 2.5 at 12 months post-ASHCT (p = 0.008). A significant improvement in tibial SEP (tSEP) latencies was observed (42.7 vs 41.5 ms, p < 0.001), with a similar trend for MEP latencies 12 months post-ASHCT. No significant changes in median SEP or VEP latencies were observed. CONCLUSIONS Treatment with AHSCT was associated with improved transmission in some central nervous system pathways in multiple sclerosis patients.
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Affiliation(s)
| | - Hans Axelson
- Department of Medical Sciences, Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Shala Berntsson
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Holger Rothkegel
- Department of Medical Sciences, Neurophysiology, Uppsala University, Uppsala, Sweden; Department of Clinical Neurophysiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Joachim Burman
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
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Brittain G, Petrie J, Duffy KEM, Glover R, Hullock K, Papaioannou D, Roldan E, Beecher C, Bursnall M, Ciccarelli O, Coles AJ, Cooper C, Giovannoni G, Gabriel I, Kazmi M, Kyriakou C, Nicholas R, Paling D, Peniket A, Scolding N, Silber E, de Silva T, Venneri A, Walters SJ, Young C, Muraro PA, Sharrack B, Snowden JA. Efficacy and safety of autologous haematopoietic stem cell transplantation versus alemtuzumab, ocrelizumab, ofatumumab or cladribine in relapsing remitting multiple sclerosis (StarMS): protocol for a randomised controlled trial. BMJ Open 2024; 14:e083582. [PMID: 38316583 PMCID: PMC10860024 DOI: 10.1136/bmjopen-2023-083582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/16/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION Autologous haematopoietic stem cell transplantation (aHSCT) is increasingly used as treatment for patients with active multiple sclerosis (MS), typically after failure of disease-modifying therapies (DMTs). A recent phase III trial, 'Multiple Sclerosis International Stem Cell Transplant, MIST', showed that aHSCT resulted in prolonged time to disability progression compared with DMTs in patients with relapsing remitting MS (RRMS). However, the MIST trial did not include many of the current high-efficacy DMTs (alemtuzumab, ocrelizumab, ofatumumab or cladribine) in use in the UK within the control arm, which are now offered to patients with rapidly evolving severe MS (RES-MS) who are treatment naïve. There remain, therefore, unanswered questions about the relative efficacy and safety of aHSCT over these high-efficacy DMTs in these patient groups. The StarMS trial (Autologous Stem Cell Transplantation versus Alemtuzumab, Ocrelizumab, Ofatumumab or Cladribine in Relapsing Remitting Multiple Sclerosis) will assess the efficacy, safety and long-term impact of aHSCT compared with high-efficacy DMTs in patients with highly active RRMS despite the use of standard DMTs or in patients with treatment naïve RES-MS. METHODS AND ANALYSIS StarMS is a multicentre parallel-group rater-blinded randomised controlled trial with two arms. A total of 198 participants will be recruited from 19 regional neurology secondary care centres in the UK. Participants will be randomly allocated to the aHSCT arm or DMT arm in a 1:1 ratio. Participants will remain in the study for 2 years with follow-up visits at 3, 6, 9, 12, 18 and 24 months postrandomisation. The primary outcome is the proportion of patients who achieve 'no evidence of disease activity' during the 2-year postrandomisation follow-up period in an intention to treat analysis. Secondary outcomes include efficacy, safety, cost-effectiveness and immune reconstitution of aHSCT and the four high-efficacy DMTs. ETHICS AND DISSEMINATION The study was approved by the Yorkshire and Humber-Leeds West Research Ethics Committee (20/YH/0061). Participants will provide written informed consent prior to any study specific procedures. The study results will be submitted to a peer-reviewed journal and abstracts will be submitted to relevant national and international conferences. TRIAL REGISTRATION NUMBER ISRCTN88667898.
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Affiliation(s)
- Gavin Brittain
- Neuroscience Institute, The University of Sheffield, Sheffield, UK
- Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jennifer Petrie
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - Kate E M Duffy
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - Rachel Glover
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - Katie Hullock
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - Diana Papaioannou
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - Elisa Roldan
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | | | - Matthew Bursnall
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - Olga Ciccarelli
- Queen Square Institute of Neurology, University College London, London, UK
| | - Alasdair J Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | | | - Ian Gabriel
- Imperial College Healthcare NHS Trust, London, UK
| | | | | | | | - David Paling
- Department of Clinical Neurology, Royal Hallamshire Hospital, Sheffield, UK
| | - Andy Peniket
- Department of Haematology, Churchill Hospital, Oxford, UK
| | - Neil Scolding
- Neurology, University of Bristol Institute of Clinical Neurosciences, Bristol, UK
- Department of Neurology, Gloucestershire Royal Hospital, Gloucester, UK
| | - Eli Silber
- Department of Neurology, King's College Hospital NHS Foundation Trust, London, UK
| | - Thushan de Silva
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- South Yorkshire Regional Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Annalena Venneri
- Brunel University London, London, UK
- University of Parma, Parma, Italy
| | - Stephen J Walters
- Division of Population Health, The University of Sheffield, Sheffield, UK
| | - Carolyn Young
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- University of Liverpool Institute of Systems Molecular and Integrative Biology, Liverpool, UK
| | - Paolo A Muraro
- Department of Brain Sciences, Imperial College London, London, UK
| | - Basil Sharrack
- Neuroscience Institute, The University of Sheffield, Sheffield, UK
- Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
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5
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Ross LA, Stropp LM, Cohen JA. Autologous Hematopoietic Stem Cell Transplantation to Treat Multiple Sclerosis. Neurol Clin 2024; 42:165-184. [PMID: 37980114 DOI: 10.1016/j.ncl.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
In aggregate, the available data suggest autologous hematopoietic stem cell transplantation (AHSCT) has potent, durable efficacy to treat relapsing multiple sclerosis (MS). Safety issues and financial costs are significant but largely associated with the procedure itself. AHSCT is a reasonable option for patients with highly active relapsing MS and an inadequate response to the available disease therapies. The key question is where to place AHSCT in the overall relapsing MS algorithm relative to other high-efficacy therapies. Ongoing randomized trials will better characterize the benefit and risk of AHSCT compared with currently available high-efficacy disease therapies.
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Affiliation(s)
- Lindsay A Ross
- Mellen Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Lisa M Stropp
- Mellen Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Jeffrey A Cohen
- Mellen Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Silfverberg T, Zjukovskaja C, Ljungman P, Nahimi A, Ahlstrand E, Dreimane A, Einarsdottir S, Fagius J, Iacobaeus E, Hägglund H, Lange N, Lenhoff S, Lycke J, Mellergård J, Piehl F, Svenningsson A, Tolf A, Cherif H, Carlson K, Burman J. Haematopoietic stem cell transplantation for treatment of relapsing-remitting multiple sclerosis in Sweden: an observational cohort study. J Neurol Neurosurg Psychiatry 2024; 95:125-133. [PMID: 37748927 PMCID: PMC10850659 DOI: 10.1136/jnnp-2023-331864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/26/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND A growing evidence base supports the use of autologous haematopoietic stem cell transplantation (aHSCT) for treatment of relapsing-remitting multiple sclerosis (RRMS), but it has not yet been integrated into most national clinical guidelines. The objective of this study was to assess efficacy and safety when aHSCT is implemented in routine healthcare. METHODS We assessed 231 patients and the final analysis included 174 RRMS patients who were treated with aHSCT in Sweden before 1 January 2020. Efficacy was evaluated by performing a retrospective analysis of prospectively collected data from the Swedish MS registry. Procedure-related safety was assessed by analysing data from electronic patient records covering a period of 100 days following aHSCT. RESULTS With a median follow-up time of 5.5 (IQR: 3.4-7.5) years, the Kaplan-Meier estimate for no evidence of disease activity was 73% (95% CI 66% to 81%) at 5 years and 65% (95% CI 57% to 75%) at 10 years. Out of the 149 patients with baseline disability, 80 (54%) improved, 55 (37%) were stable and 14 (9%) deteriorated. The mean number of adverse events per patient was 1.7 (±SD: 1.5) for grade 3 events and 0.06 (±SD: 0.3) for grade 4 events. Febrile neutropenia was the most common adverse event, affecting 68% of patients. There was no treatment-related mortality. CONCLUSIONS Treatment with aHSCT for RRMS is associated with freedom from disease activity in a majority of patients, with acceptable adverse events. This procedure should be considered a standard of care for patients with highly active RRMS.
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Affiliation(s)
- Thomas Silfverberg
- Medical Sciences, Uppsala universitet Medicinska och farmaceutiska vetenskapsomradet, Uppsala, Sweden
- Center for Clinical Research Dalarna, Falun, Sweden
| | | | - Per Ljungman
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska Comprehensive Cancer Center, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Adjmal Nahimi
- Department of Neurology, Rehabilitation Medicine, Memory Disorders, and Geriatrics, Skåne University Hospital Lund, Lund, Sweden
| | - Erik Ahlstrand
- Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Arta Dreimane
- Department of Hematology, Linköping University Hospital, Linkoping, Sweden
| | - Sigrun Einarsdottir
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Hematology and Coagulation, Sahlgrenska Sjukhuset, Gothenburg, Sweden
| | - Jan Fagius
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Ellen Iacobaeus
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Hans Hägglund
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska Comprehensive Cancer Center, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Niclas Lange
- Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Stig Lenhoff
- Department of Hematology, Oncology & Radiophysics, Skåne University Hospital Lund, Lund, Sweden
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Johan Mellergård
- Department of Neurology, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Svenningsson
- Department of Clinical Sciences, Karolinska Institutet Institutionen för kliniska vetenskaper Danderyds sjukhus, Stockholm, Sweden
- Department of Neurology, Karolinska Institutet Institutionen för kliniska vetenskaper Danderyds sjukhus, Stockholm, Sweden
| | - Andreas Tolf
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Honar Cherif
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Kristina Carlson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Joachim Burman
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Msheik A, Assi F, Hamed F, Jibbawi A, Nakhl AM, Khoury A, Mohanna R, Gerges T, Atat R. Stem Cell Transplantation for Multiple Sclerosis: A 2023 Review of Published Studies. Cureus 2023; 15:e47972. [PMID: 38034162 PMCID: PMC10686127 DOI: 10.7759/cureus.47972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
This comprehensive literature review underscores the potential of stem cell transplantation (SCT) as a therapeutic intervention for multiple sclerosis (MS). By amalgamating evidence from various sources, including randomized controlled trials (RCTs), observational, retrospective, and comparative studies, this review offers a holistic understanding of SCT's effectiveness, safety, and feasibility in diverse contexts of MS management. SCT has shown promise in mitigating disease activity and progression, particularly in relapsing-remitting MS (RRMS). RCTs like the high dose immunoablation and autologous hematopoietic stem cell transplantation in MS (ASTIMS) versus mitoxantrone therapy in severe multiple sclerosis and multiple sclerosis international stem cell transplant (MIST) trials reveal SCT's capacity to reduce new lesion occurrences and inflammatory activity. However, variability exists in disability score improvements among these studies. Observational and retrospective investigations further affirm SCT's potential, highlighting decreased relapse rates, enhanced expanded disability status scale (EDSS) scores, and a noteworthy proportion of patients achieving no evidence of disease activity (NEDA). The initial literature search using all of the search items produced a total of 3,636 articles. After title, abstract, and article type screening and article retrieving, 147 articles were assessed for eligibility using the inclusion criteria. At the end of the literature search, 37 articles met the eligibility criteria. They were included in our review according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Patients treated with hematopoietic stem cell transplantation (HSCT) present lower progression and relapse rates, suppression of inflammatory activity, and a greater reduction in T2 lesions on MRI than those treated with disease-modifying therapies (DMTs). In summary, while SCT presents promise as a therapeutic option for MS, its deployment should be tailored to individual patient characteristics, disease stages, and responses.
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Affiliation(s)
- Ali Msheik
- Neurological Surgery, Faculty of Medicine Lebanese University, Hadath, LBN
| | - Farah Assi
- Infectious Diseases, Faculty of Medicine Lebanese University, Beirut, LBN
| | - Faten Hamed
- Pharmacology, Lebanese International University, Beirut, LBN
| | - Ali Jibbawi
- Pediatric Medicine, Saint Georges Hospital, Beirut, LBN
| | - Anna-Marina Nakhl
- Medicine and Surgery, Faculty of Medicine Lebanese University, Beirut, LBN
| | - Anthony Khoury
- Medicine and Surgery, Faculty of Medicine Lebanese University, Beirut, LBN
| | - Rami Mohanna
- Medicine and Surgery, Faculty of Medicine Saint-Joseph University, Beirut, LBN
| | - Teddy Gerges
- Anesthesia, Winchester Anesthesia Associates, Boston, USA
| | - Rami Atat
- Neurology, Faculty of Medical Sciences Lebanese University, Beirut, LBN
- Neurology, Al Zahraa University Medical Center, Beirut, LBN
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8
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Bayas A, Berthele A, Blank N, Dreger P, Faissner S, Friese MA, Gerdes LA, Grauer OM, Häussler V, Heesen C, Janson D, Korporal-Kuhnke M, Kowarik M, Kröger N, Lünemann JD, Martin R, Meier U, Meuth S, Muraro P, Platten M, Schirmer L, Stürner KH, Stellmann JP, Scheid C, Bergh FT, Warnke C, Wildemann B, Ziemssen T. Autologous haematopoietic stem cell transplantation for multiple sclerosis: a position paper and registry outline. Ther Adv Neurol Disord 2023; 16:17562864231180730. [PMID: 37780055 PMCID: PMC10540601 DOI: 10.1177/17562864231180730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/21/2023] [Indexed: 10/03/2023] Open
Abstract
Background While substantial progress has been made in the development of disease-modifying medications for multiple sclerosis (MS), a high percentage of treated patients still show progression and persistent inflammatory activity. Autologous haematopoietic stem cell transplantation (AHSCT) aims at eliminating a pathogenic immune repertoire through intense short-term immunosuppression that enables subsequent regeneration of a new and healthy immune system to re-establish immune tolerance for a long period of time. A number of mostly open-label, uncontrolled studies conducted over the past 20 years collected about 4000 cases. They uniformly reported high efficacy of AHSCT in controlling MS inflammatory disease activity, more markedly beneficial in relapsing-remitting MS. Immunological studies provided evidence for qualitative immune resetting following AHSCT. These data and improved safety profiles of transplantation procedures spurred interest in using AHSCT as a treatment option for MS. Objective To develop expert consensus recommendations on AHSCT in Germany and outline a registry study project. Methods An open call among MS neurologists as well as among experts in stem cell transplantation in Germany started in December 2021 to join a series of virtual meetings. Results We provide a consensus-based opinion paper authored by 25 experts on the up-to-date optimal use of AHSCT in managing MS based on the Swiss criteria. Current data indicate that patients who are most likely to benefit from AHSCT have relapsing-remitting MS and are young, ambulatory and have high disease activity. Treatment data with AHSCT will be collected within the German REgistry Cohort of autologous haematopoietic stem CeLl trAnsplantation In MS (RECLAIM). Conclusion Further clinical trials, including registry-based analyses, are urgently needed to better define the patient characteristics, efficacy and safety profile of AHSCT compared with other high-efficacy therapies and to optimally position it as a treatment option in different MS disease stages.
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Affiliation(s)
- Antonios Bayas
- Department of Neurology and Clinical Neurophysiology, Faculty of Medicine, University of Augsburg, Augsburg
| | - Achim Berthele
- Department of Neurology, School of Medicine, Technical University of Munich, Munich
| | - Norbert Blank
- Rheumatology Section, Interdisciplinary Centre for Chronic Inflammatory Diseases, Heidelberg University Hospital, Heidelberg
| | - Peter Dreger
- Spokesman German Working Group for Haematopoietic Stem Cell Transplantation and Cellular Therapy e.V., Heidelberg University Hospital, Heidelberg
| | - Simon Faissner
- Department of Neurology, University Hospital of Ruhr-University Bochum, St. Josef-Hospital, Bochum
| | - Manuel A. Friese
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS) and Department of Neurology, University Medical Center Hamburg-Eppendorf
| | - Lisa-Ann Gerdes
- Institut für Klinische Neuroimmunologie am Klinikum der Ludwig-Maximilians-Universität München, München
| | - Oliver Martin Grauer
- Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster
| | - Vivien Häussler
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS) and Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Christoph Heesen
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS) and Department of Neurology University Medical Center Hamburg-Eppendorf
- Clinical and Rehabilitative MS Research, Institute for Neuroimmunology and Multiple Sclerosis (INIMS), University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, D-20246 Hamburg, Germany
| | - Dietlinde Janson
- Clinic for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg
| | | | - Markus Kowarik
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Kröger
| | - Nikolaus Kröger
- Clinic for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Jan D. Lünemann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster
| | - Roland Martin
- Institute of Experimental Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Uwe Meier
- Chairman of the Professional Association of German Neurologists, Neurocentrum Grevenbroich, Grevenbroich
| | - Sven Meuth
- Medical Faculty, Department of Neurology, University Hospital Düsseldorf, Düsseldorf
| | - Paolo Muraro
- Department of Brain Sciences, Imperial College London, London, UK
| | - Michael Platten
- Department of Neurology, Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Heidelberg
| | - Lucas Schirmer
- Department of Neurology, Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Heidelberg
| | | | - Jan Patrick Stellmann
- Centre de Résonance Magnétique Biologique et Médicale, Aix-Marseille Université, Marseille
| | - Christof Scheid
- Clinic I for Internal Medicine, University Hospital Cologne, Cologne
| | | | - Clemens Warnke
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic and Polyclinic of Neurology, Cologne
| | - Brigitte Wildemann
- AG Neuroimmunology, Neurological Clinic, Heidelberg University Hospital, Heidelberg
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, University Clinic Carl Gustav Carus Dresden, Technische Universität Dresden
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9
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Kalincik T, Sharmin S, Roos I, Freedman MS, Atkins H, Burman J, Massey J, Sutton I, Withers B, Macdonell R, Grigg A, Torkildsen Ø, Bo L, Lehmann AK, Havrdova EK, Krasulova E, Trněný M, Kozak T, van der Walt A, Butzkueven H, McCombe P, Skibina O, Lechner-Scott J, Willekens B, Cartechini E, Ozakbas S, Alroughani R, Kuhle J, Patti F, Duquette P, Lugaresi A, Khoury SJ, Slee M, Turkoglu R, Hodgkinson S, John N, Maimone D, Sa MJ, van Pesch V, Gerlach O, Laureys G, Van Hijfte L, Karabudak R, Spitaleri D, Csepany T, Gouider R, Castillo-Triviño T, Taylor B, Sharrack B, Snowden JA. Comparative Effectiveness of Autologous Hematopoietic Stem Cell Transplant vs Fingolimod, Natalizumab, and Ocrelizumab in Highly Active Relapsing-Remitting Multiple Sclerosis. JAMA Neurol 2023; 80:702-713. [PMID: 37437240 PMCID: PMC10186210 DOI: 10.1001/jamaneurol.2023.1184] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/12/2023] [Indexed: 07/14/2023]
Abstract
Importance Autologous hematopoietic stem cell transplant (AHSCT) is available for treatment of highly active multiple sclerosis (MS). Objective To compare the effectiveness of AHSCT vs fingolimod, natalizumab, and ocrelizumab in relapsing-remitting MS by emulating pairwise trials. Design, Setting, and Participants This comparative treatment effectiveness study included 6 specialist MS centers with AHSCT programs and international MSBase registry between 2006 and 2021. The study included patients with relapsing-remitting MS treated with AHSCT, fingolimod, natalizumab, or ocrelizumab with 2 or more years study follow-up including 2 or more disability assessments. Patients were matched on a propensity score derived from clinical and demographic characteristics. Exposure AHSCT vs fingolimod, natalizumab, or ocrelizumab. Main outcomes Pairwise-censored groups were compared on annualized relapse rates (ARR) and freedom from relapses and 6-month confirmed Expanded Disability Status Scale (EDSS) score worsening and improvement. Results Of 4915 individuals, 167 were treated with AHSCT; 2558, fingolimod; 1490, natalizumab; and 700, ocrelizumab. The prematch AHSCT cohort was younger and with greater disability than the fingolimod, natalizumab, and ocrelizumab cohorts; the matched groups were closely aligned. The proportion of women ranged from 65% to 70%, and the mean (SD) age ranged from 35.3 (9.4) to 37.1 (10.6) years. The mean (SD) disease duration ranged from 7.9 (5.6) to 8.7 (5.4) years, EDSS score ranged from 3.5 (1.6) to 3.9 (1.9), and frequency of relapses ranged from 0.77 (0.94) to 0.86 (0.89) in the preceding year. Compared with the fingolimod group (769 [30.0%]), AHSCT (144 [86.2%]) was associated with fewer relapses (ARR: mean [SD], 0.09 [0.30] vs 0.20 [0.44]), similar risk of disability worsening (hazard ratio [HR], 1.70; 95% CI, 0.91-3.17), and higher chance of disability improvement (HR, 2.70; 95% CI, 1.71-4.26) over 5 years. Compared with natalizumab (730 [49.0%]), AHSCT (146 [87.4%]) was associated with marginally lower ARR (mean [SD], 0.08 [0.31] vs 0.10 [0.34]), similar risk of disability worsening (HR, 1.06; 95% CI, 0.54-2.09), and higher chance of disability improvement (HR, 2.68; 95% CI, 1.72-4.18) over 5 years. AHSCT (110 [65.9%]) and ocrelizumab (343 [49.0%]) were associated with similar ARR (mean [SD], 0.09 [0.34] vs 0.06 [0.32]), disability worsening (HR, 1.77; 95% CI, 0.61-5.08), and disability improvement (HR, 1.37; 95% CI, 0.66-2.82) over 3 years. AHSCT-related mortality occurred in 1 of 159 patients (0.6%). Conclusion In this study, the association of AHSCT with preventing relapses and facilitating recovery from disability was considerably superior to fingolimod and marginally superior to natalizumab. This study did not find evidence for difference in the effectiveness of AHSCT and ocrelizumab over a shorter available follow-up time.
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Affiliation(s)
- Tomas Kalincik
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Sifat Sharmin
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Izanne Roos
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Mark S. Freedman
- University of Ottawa, Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Harold Atkins
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Joachim Burman
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Jennifer Massey
- Department of Neurology, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
- St Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Ian Sutton
- Department of Neurology, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Barbara Withers
- St Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Haematology, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - Richard Macdonell
- Department of Neurology, Austin Health, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Grigg
- University of Melbourne, Melbourne, Victoria, Australia
- Department of Haematology, Austin Health, Melbourne, Victoria, Australia
| | - Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bo
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Eva Krasulova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Marek Trněný
- Department of Haematology, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Tomas Kozak
- Department of Haematology, 3rd Faculty of Medicine, Charles University in Prague, and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Anneke van der Walt
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Helmut Butzkueven
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Pamela McCombe
- University of Queensland, Brisbane, Queensland, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Olga Skibina
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Box Hill Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Jeannette Lechner-Scott
- School of Medicine and Public Health, University Newcastle, Newcastle, New South Wales, Australia
- Department of Neurology, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia
| | - Barbara Willekens
- Department of Neurology, Antwerp University Hospital, Edegem, Belgium
- Translational Neurosciences Research Group, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | | | | | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, Catania, Italy
- Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Pierre Duquette
- CHUM MS Center and Universite de Montreal, Montreal, Quebec, Canada
| | - Alessandra Lugaresi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Samia J. Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mark Slee
- Flinders University, Adelaide, South Australia, Australia
| | - Recai Turkoglu
- Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | | | - Nevin John
- Monash Medical Centre, Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Maria Jose Sa
- Department of Neurology, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
| | - Vincent van Pesch
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Université Catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium
| | - Oliver Gerlach
- Academic MS Center Zuyderland, Department of Neurology, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Guy Laureys
- Department of Neurology, University Hospital Ghent, Ghent, Belgium
| | | | - Rana Karabudak
- Department of Neurology, Hacettepe University Hospitals, Ankara, Turkey
| | - Daniele Spitaleri
- Azienda Ospedaliera di Rilievo Nazionale San Giuseppe Moscati Avellino, Avellino, Italy
| | - Tunde Csepany
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Riadh Gouider
- Department of Neurology, Razi University Hospital, Manouba, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | | | - Bruce Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Basil Sharrack
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - John A. Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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10
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Jespersen F, Petersen SL, Andersen P, Sellebjerg F, Magyari M, Sørensen PS, Blinkenberg M. Autologous hematopoietic stem cell transplantation of patients with aggressive relapsing-remitting multiple sclerosis: Danish nation-wide experience. Mult Scler Relat Disord 2023; 76:104829. [PMID: 37364374 DOI: 10.1016/j.msard.2023.104829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/28/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Autologous hematopoietic stem cell treatment (AHSCT) is considered an effective treatment option for patients with aggressive relapsing-remitting multiple sclerosis (RRMS). Still there are few randomized and controlled studies of AHSCT to shed light on the safety and efficacy of the treatment, and therefore experiences from single centers are important. AIM To describe the Danish experience with AHSCT regarding patient characteristics, safety, and efficacy. METHOD Nationwide retrospective single center study of patients with multiple sclerosis (MS) treated with AHSCT. RESULTS A total of 32 patients were treated with AHSCT from May 2011 to May 2021. Seven were treated with carmustine, etoposide, cytarabine arabinoside, and melphalan (BEAM) as well as antithymocyte globulin (ATG). Twenty-five patients were treated with cyclophosphamide (CY) and ATG. In the whole cohort, relapse-free survival (RFS) was 77% (95% CI: 64-94%), worsening-free survival (WFS) was 79% (95% CI: 66-96%), MRI event-free survival (MFS) was 93% (95% CI: 85-100%), and no evidence of disease (NEDA-3) was 69% (95% CI: 54-89%) at the end of year two post-AHSCT. We had no treatment related mortality and only few severe adverse events (AEs). CONCLUSION AHSCT of patients with aggressive RRMS was an effective and relatively safe treatment with few serious AEs and no mortality in Danish patients.
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Affiliation(s)
- Freja Jespersen
- Danish Multiple Sclerosis Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Søren Lykke Petersen
- Department of Hematology Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Pernille Andersen
- Blood bank, Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Blinkenberg
- Danish Multiple Sclerosis Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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11
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Brittain G, Coles AJ, Giovannoni G, Muraro PA, Palace J, Petrie J, Roldan E, Scolding NJ, Snowden JA, Sharrack B. Autologous haematopoietic stem cell transplantation for immune-mediated neurological diseases: what, how, who and why? Pract Neurol 2023; 23:139-145. [PMID: 36162855 DOI: 10.1136/pn-2022-003531] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/04/2022]
Abstract
In carefully selected patients, autologous haematopoietic stem cell transplantation (HSCT) is a safe, highly effective and cost-saving treatment modality for treatment-resistant, and potentially treatment-naïve, immune-mediated neurological disorders. Although the evidence base has been growing in the last decade, limited understanding has led to confusion, mistrust and increasing use of health tourism. In this article, we discuss what autologous HSCT is, which immune-mediated conditions can be treated with it, how to select patients, what are the expected outcomes and potential adverse effects, and how cost-effective this treatment is.
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Affiliation(s)
- Gavin Brittain
- Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
| | - Alasdair J Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - G Giovannoni
- Neuroscience and Trauma, Blizard Institute of Cell and Molecular Science, London, UK
| | | | | | - Jennifer Petrie
- Clinical Trials Research Unit, The University of Sheffield, Sheffield, UK
| | - Elisa Roldan
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N J Scolding
- Institute of Clinical Neurosciences, University of Bristol, Bristol, UK
- Department of Neurology, Gloucestershire Royal Hospital, Gloucester, UK
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Basil Sharrack
- Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
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12
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Zayed MA, Sultan S, Alsaab HO, Yousof SM, Alrefaei GI, Alsubhi NH, Alkarim S, Al Ghamdi KS, Bagabir SA, Jana A, Alghamdi BS, Atta HM, Ashraf GM. Stem-Cell-Based Therapy: The Celestial Weapon against Neurological Disorders. Cells 2022; 11:3476. [PMID: 36359871 PMCID: PMC9655836 DOI: 10.3390/cells11213476] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/15/2022] [Accepted: 10/24/2022] [Indexed: 09/01/2023] Open
Abstract
Stem cells are a versatile source for cell therapy. Their use is particularly significant for the treatment of neurological disorders for which no definitive conventional medical treatment is available. Neurological disorders are of diverse etiology and pathogenesis. Alzheimer's disease (AD) is caused by abnormal protein deposits, leading to progressive dementia. Parkinson's disease (PD) is due to the specific degeneration of the dopaminergic neurons causing motor and sensory impairment. Huntington's disease (HD) includes a transmittable gene mutation, and any treatment should involve gene modulation of the transplanted cells. Multiple sclerosis (MS) is an autoimmune disorder affecting multiple neurons sporadically but induces progressive neuronal dysfunction. Amyotrophic lateral sclerosis (ALS) impacts upper and lower motor neurons, leading to progressive muscle degeneration. This shows the need to try to tailor different types of cells to repair the specific defect characteristic of each disease. In recent years, several types of stem cells were used in different animal models, including transgenic animals of various neurologic disorders. Based on some of the successful animal studies, some clinical trials were designed and approved. Some studies were successful, others were terminated and, still, a few are ongoing. In this manuscript, we aim to review the current information on both the experimental and clinical trials of stem cell therapy in neurological disorders of various disease mechanisms. The different types of cells used, their mode of transplantation and the molecular and physiologic effects are discussed. Recommendations for future use and hopes are highlighted.
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Affiliation(s)
- Mohamed A. Zayed
- Physiology Department, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Physiology Department, Faculty of Medicine, Menoufia University, Menoufia 32511, Egypt
| | - Samar Sultan
- Medical Laboratory Technology Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Regenerative Medicine Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Hashem O. Alsaab
- Department of Pharmaceutics and Pharmaceutical Technology, College of Pharmacy, Taif University, Taif 21944, Saudi Arabia
| | - Shimaa Mohammad Yousof
- Physiology Department, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Medical Physiology Department, Faculty of Medicine, Suez Canal University, Ismailia 41522, Egypt
| | - Ghadeer I. Alrefaei
- Department of Biology, College of Science, University of Jeddah, Jeddah 21589, Saudi Arabia
| | - Nouf H. Alsubhi
- Department of Biological Sciences, College of Science & Arts, King Abdulaziz University, Rabigh 21911, Saudi Arabia
| | - Saleh Alkarim
- Embryonic and Cancer Stem Cell Research Group, King Fahad Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Biology Department, Faculty of Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Embryonic Stem Cells Research Unit, Biology Department, Faculty of Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Kholoud S. Al Ghamdi
- Department of Physiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia
| | - Sali Abubaker Bagabir
- Genetic Unit, Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Jazan University, Jazan 45142, Saudi Arabia
| | - Ankit Jana
- School of Biotechnology, Kalinga Institute of Industrial Technology (KIIT) Deemed to be University, Campus-11, Patia, Bhubaneswar 751024, Odisha, India
| | - Badrah S. Alghamdi
- Department of Physiology, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Pre-Clinical Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Hazem M. Atta
- Clinical Biochemistry Department, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Cairo University, Cairo 11562, Egypt
| | - Ghulam Md Ashraf
- Department of Medical Laboratory Sciences, College of Health Sciences, University of Sharjah, University City, Sharjah 27272, United Arab Emirates
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13
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Willison AG, Meuth SG. [Multiple sclerosis: interventions to halt disease : Which patients can be considered for autologous stem cell transplantation]. DER NERVENARZT 2022; 93:987-999. [PMID: 35951049 DOI: 10.1007/s00115-022-01358-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Autologous hematopoietic stem cell transplantation (aHSCT) for treatment of multiple sclerosis (MS) is gaining increasing prominence in the therapeutic landscape. This review article focuses on describing the evidence and European guidelines for aHSCT so that neurologists in Germany can consider this treatment option for appropriate MS patients. In this context, it must be taken into consideration that in every case a cost transfer must be individually applied for. AIM To provide information for neurologists considering aHSCT for patients with MS. MATERIAL AND METHODS In this narrative review articles from PubMed were pooled and analyzed. RESULTS AND DISCUSSION High quality data from randomized, controlled clinical trials are required to compare the efficacy of aHSCT to the currently available highly effective disease-modifying therapies (DMT) so that reliable conclusions can be drawn regarding the relationship between the risks and benefits of aHSCT in MS; however, the studies discussed in this review provide important points of reference for patient selection and the transplantation protocol. Further advice is available from the European Society for Blood and Marrow Transplantation (EBMT) for experienced centers considering aHSCT. The available data and the European guidelines suggest that patients aged less than 45 years, an expanded disability status scale (EDSS) ≤ 5.5, highly active MS, a disease duration of less than 10 years, an ineffective course of DMT or rapidly progressive MS may be eligible for aHSCT and should be referred to an experienced center for further assessment.
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Affiliation(s)
- A G Willison
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - S G Meuth
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
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14
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Kvistad SAS, Burman J, Lehmann AK, Tolf A, Zjukovskaja C, Melve GK, Bø L, Torkildsen Ø. Impact of previous disease-modifying treatment on safety and efficacy in patients with MS treated with AHSCT. J Neurol Neurosurg Psychiatry 2022; 93:844-848. [PMID: 35508373 PMCID: PMC9304086 DOI: 10.1136/jnnp-2022-328797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/18/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Autologous haematopoietic stem cell transplantation (AHSCT) is a highly effective treatment for multiple sclerosis (MS). The impact of previous long-lasting disease-modifying treatments (DMT) for safety and efficacy of AHSCT is unknown. OBJECTIVE To explore whether previous DMTs with long-lasting effects on the immune system (anti-CD20 therapy, alemtuzumab and cladribine) affect treatment-related complications, long-term outcome and risk of new MS disease activity in patients treated with AHSCT. METHODS Retrospective observational study of 104 relapsing remitting patients with MS treated by AHSCT in Sweden and Norway from 2011 to 2021, grouped according to the last DMT used ≤6 months prior to AHSCT. The primary outcomes were early AHSCT-related complications (mortality, neutropenic fever and hospitalisation length), long-term complications (secondary autoimmunity) and proportion of patients with No Evidence of Disease Activity (NEDA-3 status): no new relapses, no MRI activity and no disease progression during the follow-up. RESULTS The mean follow-up time was 39.5 months (range 1-95). Neutropenic fever was a common AHSCT-related complication affecting 69 (66%) patients. There was no treatment-related mortality. During the follow-up period, 20 patients (19%) were diagnosed with autoimmunity. Occurrence of neutropenic fever, hospitalisation length or secondary autoimmunity did not vary dependent on the last DMT used prior to AHSCT. A total of 84 patients (81%) achieved NEDA-3 status, including all patients (100%) using rituximab, alemtuzumab or cladribine before AHSCT. CONCLUSION This study provides level 4 evidence that AHSCT in patients previously treated with alemtuzumab, cladribine or rituximab is safe and efficacious.
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Affiliation(s)
- Silje Agnethe Stokke Kvistad
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway .,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Joachim Burman
- Department of Neuroscience, Uppsala Universitet, Uppsala, Sweden
| | - Anne Kristine Lehmann
- Department of Medicine, Section of Hematology, Haukeland University Hospital, Bergen, Norway
| | - Andreas Tolf
- Department of Neuroscience, Uppsala Universitet, Uppsala, Sweden.,Department of Neurology, Akademiska sjukhuset, Uppsala, Sweden
| | | | - Guro Kristin Melve
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Norwegian Multiple Sclerosis Competence Centre, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neurology, Norwegian Multiple Sclerosis Competence Centre, Bergen, Norway
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15
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Alexander T, Greco R. Hematopoietic stem cell transplantation and cellular therapies for autoimmune diseases: overview and future considerations from the Autoimmune Diseases Working Party (ADWP) of the European Society for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2022; 57:1055-1062. [PMID: 35578014 PMCID: PMC9109750 DOI: 10.1038/s41409-022-01702-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/26/2022] [Accepted: 04/29/2022] [Indexed: 02/06/2023]
Abstract
Autoimmune diseases (ADs) represent a heterogenous group of complex diseases with increasing incidence in Western countries and are a major cause of morbidity. Hematopoietic stem cell transplantation (HSCT) has evolved over the last 25 years as a specific treatment for patients with severe ADs, through eradication of the pathogenic immunologic memory and profound immune renewal. HSCT for ADs is recently facing a unique developmental phase across transplant centers. This review provides a comprehensive overview of the recent evidence and developments in the area, including fundamentals of preclinical research, clinical studies in neurologic, rheumatologic and gastroenterologic diseases, which represent major indications at present, along with evidence of HSCT for rarer indications. Moreover, we describe the interwoven challenges of delivering more advanced cellular therapies, exploiting mesenchymal stem cells, regulatory T cells and potentially CAR-T cell therapies, in patients affected by ADs. Overall, we discuss past and current indications, efficacy, associated risks and benefits, and future directions of HSCT and advanced cellular therapies in the treatment of severe/refractory ADs, integrating the available literature with European Society for Blood and Marrow Transplantation (EBMT) registry data.
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Affiliation(s)
- Tobias Alexander
- Department of Rheumatology and Clinical Immunology, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
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16
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The current standing of autologous haematopoietic stem cell transplantation for the treatment of multiple sclerosis. J Neurol 2022; 269:3937-3958. [PMID: 35399125 PMCID: PMC8995166 DOI: 10.1007/s00415-022-11063-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/01/2022]
Abstract
AbstractAutologous haematopoietic stem cell transplantation (aHSCT) is gaining traction as a valuable treatment option for patients affected by severe multiple sclerosis (MS), particularly the relapsing–remitting form. We describe the current literature in terms of clinical trials, observational and retrospective studies, as well as immune reconstitution following transplantation, with a focus on the conditioning regimens used for transplantation. The evidence base predominantly consists of non-randomised, uncontrolled clinical trials or data from retrospective or observational cohorts, i.e. very few randomised or controlled trials. Most often, intermediate-intensity conditioning regimens are used, with promising results from both myeloablative and lymphoablative strategies, as well as from regimens that are low and high intensity. Efficacy of transplantation, which is likely secondary to immune reconstitution and restored immune tolerance, is, therefore, not clearly dependent on the intensity of the conditioning regimen. However, the conditioning regimen may well influence the immune response to transplantation. Heterogeneity of conditioning regimens among studies hinders synthesis of the articles assessing post-aHSCT immune system changes. Factors associated with better outcomes were lower Kurtzke Expanded Disability Status Scale, relapsing–remitting MS, younger age, and shorter disease duration at baseline, which supports the guidance for patient selection proposed by the European Society for Blood and Marrow Transplantation. Interestingly, promising outcomes were described for patients with secondary progressive MS by some studies, which may be worth taking into account when considering treatment options for patients with active, progressive disease. Of note, a significant proportion of patients develop autoimmune disease following transplantation, with alemtuzumab-containing regimens associated with the highest incidence.
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17
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Cencioni MT, Genchi A, Brittain G, de Silva TI, Sharrack B, Snowden JA, Alexander T, Greco R, Muraro PA. Immune Reconstitution Following Autologous Hematopoietic Stem Cell Transplantation for Multiple Sclerosis: A Review on Behalf of the EBMT Autoimmune Diseases Working Party. Front Immunol 2022; 12:813957. [PMID: 35178046 PMCID: PMC8846289 DOI: 10.3389/fimmu.2021.813957] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/29/2021] [Indexed: 12/18/2022] Open
Abstract
Multiple sclerosis (MS) is a central nervous system (CNS) disorder, which is mediated by an abnormal immune response coordinated by T and B cells resulting in areas of inflammation, demyelination, and axonal loss. Disease-modifying treatments (DMTs) are available to dampen the inflammatory aggression but are ineffective in many patients. Autologous hematopoietic stem cell transplantation (HSCT) has been used as treatment in patients with a highly active disease, achieving a long-term clinical remission in most. The rationale of the intervention is to eradicate inflammatory autoreactive cells with lympho-ablative regimens and restore immune tolerance. Immunological studies have demonstrated that autologous HSCT induces a renewal of TCR repertoires, resurgence of immune regulatory cells, and depletion of proinflammatory T cell subsets, suggesting a "resetting" of immunological memory. Although our understanding of the clinical and immunological effects of autologous HSCT has progressed, further work is required to characterize the mechanisms that underlie treatment efficacy. Considering that memory B cells are disease-promoting and stem-like T cells are multipotent progenitors involved in self-regeneration of central and effector memory cells, investigating the reconstitution of B cell compartment and stem and effector subsets of immunological memory following autologous HSCT could elucidate those mechanisms. Since all subjects need to be optimally protected from vaccine-preventable diseases (including COVID-19), there is a need to ensure that vaccination in subjects undergoing HSCT is effective and safe. Additionally, the study of vaccination in HSCT-treated subjects as a means of evaluating immune responses could further distinguish broad immunosuppression from immune resetting.
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Affiliation(s)
- Maria Teresa Cencioni
- Division of Neurology, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Angela Genchi
- Department of Neurology, Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gavin Brittain
- South Yorkshire Regional Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals National Health Service (NHS) Foundation Trust, Sheffield, United Kingdom.,Institute for Translational Neuroscience and Sheffield Neuroscience Biomedical Research Centre (BRC), Sheffield, United Kingdom
| | - Thushan I de Silva
- South Yorkshire Regional Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals National Health Service (NHS) Foundation Trust, Sheffield, United Kingdom.,Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
| | - Basil Sharrack
- South Yorkshire Regional Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals National Health Service (NHS) Foundation Trust, Sheffield, United Kingdom.,Institute for Translational Neuroscience and Sheffield Neuroscience Biomedical Research Centre (BRC), Sheffield, United Kingdom
| | - John Andrew Snowden
- Department of Haematology, Sheffield Teaching Hospitals National Health Service (NHS) Foundation Trust, Sheffield, United Kingdom.,Department of Oncology and Metabolism, The University of Sheffield, Sheffield, United Kingdom
| | - Tobias Alexander
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Rheumatology and Clinical Immunology, Berlin, Germany.,Deutsches Rheuma-Forschungszentrum, ein Leibniz Institut, Berlin, Germany
| | - Raffaella Greco
- Unit of Haematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Paolo A Muraro
- Division of Neurology, Department of Brain Sciences, Imperial College London, London, United Kingdom
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18
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Patti F, Chisari CG, Toscano S, Arena S, Finocchiaro C, Cimino V, Milone G. Autologous Hematopoietic Stem Cell Transplantation in Multiple Sclerosis Patients: Monocentric Case Series and Systematic Review of the Literature. J Clin Med 2022; 11:jcm11040942. [PMID: 35207216 PMCID: PMC8875789 DOI: 10.3390/jcm11040942] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 02/05/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, inflammatory and immune-mediated disease of the central nervous system (CNS), commonly affecting young adults and potentially associated with life-long disability. About 14 disease-modifying treatments (DMTs) are currently approved for the treatment of MS. However, despite the use of highly effective therapies, some patients exhibit a highly active disease with an aggressive course from onset and a higher risk of long-term disability accrual. In the last few years, several retrospective studies, clinical trials, meta-analyses and systematic reviews have investigated autologous hematopoietic stem cell transplantation (AHSCT) as a possible therapeutic option in order to address this unmet clinical need. These studies demonstrated that AHSCT is a highly efficacious and relatively safe therapeutic option for the treatment of highly active MS. Particularly, over recent years, the amount of evidence has grown, with significant improvements in the development of patient selection criteria, choice of the most suitable transplant technique and clinical experience. In this paper, we present six patients who received AHSCT in our MS center and we systematically reviewed recent evidence about the long-term efficacy and safety of AHSCT and the placement of AHSCT in the rapidly evolving therapeutic armamentarium for MS.
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Affiliation(s)
- Francesco Patti
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Clara Grazia Chisari
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Simona Toscano
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Sebastiano Arena
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Chiara Finocchiaro
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Vincenzo Cimino
- IRCCS Centro Neurolesi “Bonino Pulejo”, 98124 Messina, Italy;
| | - Giuseppe Milone
- Hematology and Bone Marrow Transplant Unit, Azienda Policlinico-Vittorio Emanuele, 95124 Catania, Italy;
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19
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Real-world application of autologous hematopoietic stem cell transplantation in 507 patients with multiple sclerosis. J Neurol 2021; 269:2513-2526. [PMID: 34633525 PMCID: PMC8503710 DOI: 10.1007/s00415-021-10820-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/19/2021] [Accepted: 09/24/2021] [Indexed: 12/29/2022]
Abstract
Objective To investigate the results of real-world application of non-myeloablative autologous HSCT for multiple sclerosis (MS). Methods Between July 2003 and October 2019 at a single center (Northwestern University), 414 patients with relapsing remitting MS (RRMS) and 93 patients with newly diagnosed secondary progressive MS (SPMS) underwent non-myeloablative HSCT. Results There was one treatment-related death (0.19%) due to hospital-acquired legionella pneumonia, and one patient developed neutropenic bacteremia (Klebsiella pneumonia) without sepsis. Overall 5-year survival was 98.8%. Post HSCT secondary autoimmune diseases (2nd ADs) were idiopathic thrombocytopenia (ITP) and hypo or hyperthyroidism. ITP was highest with alemtuzumab (14%) and 0 to 2.8% for the non-alemtuzumab regimens. After HSCT, 16 patients developed hypothyroidism (3.5%) and 15 developed hyperthyroidism / Grave’s disease (3.3%). Relapse free survival (RFS) at 5 years for RRMS and SPMS was 80.1% and 98.1%, respectively, while progression free survival (PFS) at 4 years for RRMS and SPMS was 95% versus 66%, respectively. For patients with RRMS, the EDSS significantly improved (p < 0.0001) at each follow-up from a pre-HSCT mean of 3.87 to 2.51, 2.50, 2.41, 2.33, and 2.19 at 1, 2, 3, 4, and 5 years, respectively. For SPMS, the EDSS improved significantly only at 1 year but not thereafter. For SPMS, the mean baseline EDSS of 5.09 changed post-HSCT to 4.85 (p = 0.04), 4.88 (p = 0.2), 4.92 (p = .27), 4.72 (p = 0.07), and 4.2 (p = 0.21) at 1, 2, 3, 4, 5 years, respectively. Conclusion In patients with RRMS, autologous non-myeloablative HSCT is an effective one-time therapy, while HSCT appears of less benefit for newly diagnosed SPMS.
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20
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Made to Measure: Patient-Tailored Treatment of Multiple Sclerosis Using Cell-Based Therapies. Int J Mol Sci 2021; 22:ijms22147536. [PMID: 34299154 PMCID: PMC8304207 DOI: 10.3390/ijms22147536] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 12/14/2022] Open
Abstract
Currently, there is still no cure for multiple sclerosis (MS), which is an autoimmune and neurodegenerative disease of the central nervous system. Treatment options predominantly consist of drugs that affect adaptive immunity and lead to a reduction of the inflammatory disease activity. A broad range of possible cell-based therapeutic options are being explored in the treatment of autoimmune diseases, including MS. This review aims to provide an overview of recent and future advances in the development of cell-based treatment options for the induction of tolerance in MS. Here, we will focus on haematopoietic stem cells, mesenchymal stromal cells, regulatory T cells and dendritic cells. We will also focus on less familiar cell types that are used in cell therapy, including B cells, natural killer cells and peripheral blood mononuclear cells. We will address key issues regarding the depicted therapies and highlight the major challenges that lie ahead to successfully reverse autoimmune diseases, such as MS, while minimising the side effects. Although cell-based therapies are well known and used in the treatment of several cancers, cell-based treatment options hold promise for the future treatment of autoimmune diseases in general, and MS in particular.
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21
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Lee H, Nakamura K, Narayanan S, Brown RA, Nash RA, Griffith LM, Steinmiller KC, Devine SM, Hutton GJ, Popat U, Racke MK, Georges GE, Bowen JD, Arnold DL. Brain volume change after high-dose immunosuppression and autologous hematopoietic cell transplantation for relapsing-remitting multiple sclerosis. Mult Scler Relat Disord 2021; 54:103149. [PMID: 34284316 DOI: 10.1016/j.msard.2021.103149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 06/09/2021] [Accepted: 07/08/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Brain volume loss (BVL) is commonly observed after high-dose immunosuppression and autologous hematopoietic cell transplantation (HDIT/HCT) for treatment of multiple sclerosis (MS). To better understand the mechanisms of underlying BVL associated with this treatment, we characterized the time courses of whole-brain (WB), grey-matter (GM) and white-matter (WM) volume loss in relapsing-remitting MS (RRMS) patients who received BEAM-based HDIT/HCT. METHODS We used Jacobian integration to measure MRI-based WB, GM and WM volume changes up to 5 years after transplant in twenty-four RRMS participants who underwent BEAM-based HDIT/HCT. Using a two-piecewise mixed-effects model, we estimated the short-term (baseline to 1 year) and long-term (beyond 1 year) rates of BVL after HDIT/HCT. We also compared the rates based on the presence of gadolinium-enhancing lesions at baseline, and the maintenance of event-free survival during follow-up. RESULTS On average, accelerated short-term BVL of -1.37% (SE: 0.21), -0.86% (SE: 0.28) and -2.18% (SE: 0.26) occurred in WB, GM and WM, respectively. Baseline T1-weighted MRI WM lesion volume was a significant predictor in the WB (short-term) and the WM (short-term and long-term). The average rates of BVL after the initial acceleration were -0.22%/y (SE: 0.10), -0.13%/y (SE: 0.11) and -0.36%/y (SE: 0.11) in the WB, GM and WM, respectively. Participants with gadolinium-enhancing lesions at baseline had significantly higher short-term rates of GM (-1.56% vs. -0.27%, p = 0.01) and WB volume loss (-1.94% vs. -0.81%, p = 0.006) at 1 year follow-up as compared to those without gadolinium-enhancing lesions. WM volume loss was not significantly different (-2.59% vs. -1.66%, p = 0.16). Participants who maintained event-free survival had similar rates of BVL compared to those who did not. CONCLUSIONS BVL may accelerate for months after HDIT/HCT. However, over the long-term, adequate HDIT/HCT may reduce BVL rates to those similar to normal aging at the WB level.
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Affiliation(s)
- Hyunwoo Lee
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Kunio Nakamura
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | - Sridar Narayanan
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; NeuroRx Research Inc., Montreal, QC, Canada
| | - Robert A Brown
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; ShadowLab Research Inc., Toronto, ON, Canada
| | | | - Linda M Griffith
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Steven M Devine
- Be The Match BioTherapies, National Marrow Donor Program (NMDP)/Be The Match, Center for International Blood and Marrow Transplant Research (CIBMTR), Minneapolis, MN, USA
| | - George J Hutton
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael K Racke
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; NeuroRx Research Inc., Montreal, QC, Canada
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22
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Nicholas RS, Rhone EE, Mariottini A, Silber E, Malik O, Singh-Curry V, Turner B, Scalfari A, Ciccarelli O, Sormani MP, Olavarria E, Mehra V, Gabriel I, Kazmi MA, Muraro P. Autologous Haematopoietic Stem Cell Transplantation in Active Multiple Sclerosis: a Real-world Case Series. Neurology 2021; 97:e890-e901. [PMID: 34253634 DOI: 10.1212/wnl.0000000000012449] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 06/11/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE to examine outcomes in people with multiple sclerosis (PwMS) treated with autologous hematopoietic stem cell transplantation (AHSCT) in a real-world setting. METHODS retrospective cohort study on PwMS treated with AHSCT at two centers in London, UK, consecutively between 2012 and 2019 who had ≥ 6 months of follow-up or died at any time. Primary outcomes were survival free of MS relapses, MRI new lesions and worsening of expanded disability status scale (EDSS). Adverse events rates were also examined. RESULTS the cohort includes 120 PwMS; 52% had progressive MS (primary or secondary) and 48% had relapsing-remitting MS (RRMS). At baseline, the median expanded disability status scale (EDSS) was 6.0; 90% of the evaluable cases showed MRI activity in the 12 months preceding AHSCT. Median follow-up after AHSCT was 21 months (range 6-85). MS relapse-free survival was 93% at 2 years and 87% at 4 years after AHSCT. No new MRI lesions were detected in 90% of subjects at 2 years and 85% at 4 years. EDSS progression-free survival (PFS) was 75% at 2 years and 65% at 4 years. EBV reactivation and monoclonal paraproteinemia were associated with worse PFS. There were 3 transplant-related deaths within 100 days (2.5%), all following fluid overload and cardiac or respiratory failure. CONCLUSIONS efficacy outcomes of AHSCT in this real-world cohort are similar to those reported in more stringently selected clinical trial populations, although the risks may be higher. CLASSIFICATION OF EVIDENCE this study is rated Class IV because of the uncontrolled, open-label design.
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Affiliation(s)
- Richard S Nicholas
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | | | - Alice Mariottini
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK.,Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
| | - Eli Silber
- Department of Neurology, King's College Hospital, London, UK
| | - Omar Malik
- Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Antonio Scalfari
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Olga Ciccarelli
- Queen Square MS Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genova, Genova, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Eduardo Olavarria
- Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Faculty of Medicine, Imperial College London
| | - Varun Mehra
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Ian Gabriel
- Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Faculty of Medicine, Imperial College London
| | - Majid A Kazmi
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Paolo Muraro
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK .,Imperial College Healthcare NHS Trust, London, UK
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23
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Burt RK, Muraro PA, Farge D, Oliveira MC, Snowden JA, Saccardi R, Han X, Quigley K, Bueno V, Frasca D, Fedorenko D, Burman J. New autoimmune diseases after autologous hematopoietic stem cell transplantation for multiple sclerosis. Bone Marrow Transplant 2021; 56:1509-1517. [PMID: 33911200 DOI: 10.1038/s41409-021-01277-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/01/2021] [Accepted: 03/19/2021] [Indexed: 02/02/2023]
Abstract
Secondary autoimmune diseases (2ndADs), most frequently autoimmune cytopenias (AICs), were first described after allogeneic hematopoietic stem cell transplantation (HSCT) undertaken for malignant and hematological indications, occurred at a prevalence of ~5-6.5%, and were attributed to allogeneic immune imbalances in the context of graft versus host disease, viral infections, and chronic immunosuppression. Subsequently, 2ndADs were reported to complicate roughly 2-14% of autologous HSCTs performed for an autoimmune disease. Alemtuzumab in the conditioning regimen has been identified as a risk for development of 2ndADs after either allogeneic or autologous HSCT and is consistent with the high rates of 2ndADs when using alemtuzumab as monotherapy. Due to the significant consequences but variable incidence, depending on conditioning regimen, of 2ndADs and similarity in known immune reconstitution kinetics after autologous HSCT for autoimmune diseases and after alemtuzumab monotherapy, we propose that an imbalance between B and T lineage regeneration early after HSCT may underlie the pathogenesis of 2ndADs.
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Affiliation(s)
- Richard K Burt
- Division of Immunotherapy, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Paolo A Muraro
- Neuroimmunology and Immunotherapy, Department of Brain Sciences, Imperial College London, London, UK
| | - Dominique Farge
- Unité de Médecine Interne: Maladies Auto-immunes et Pathologie Vasculaire (UF 04), IRSL, EA-3518, Université de Paris, MATHEC, Centre de Référence des Maladies auto-immunes systémiques Rares d'Ile-de-France, Filière FAI2R, Hôpital St-Louis, AP-HP, Paris, France
| | - Maria Carolina Oliveira
- Divisão de Imunologia Clínica, Departamento de Clínica Médica, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals, NHS Foundation Trust and the University of Sheffield, Sheffield, UK
| | - Riccardo Saccardi
- Department of Hematology, Careggi University Hospital, Florence, Italy
| | - Xiaoqiang Han
- Division of Immunotherapy, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kathleen Quigley
- Division of Immunotherapy, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Valquiria Bueno
- Department of Microbiology, Immunology and Parasitology DMIP Federal University of São Paulo UNIFESP, São Paulo, Brasil
| | - Daniela Frasca
- Department of Microbiology and Immunology, and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Denis Fedorenko
- The A.A. Maximov Department of Hematology and Cellular Therapy, National Pirogov Medical Surgical Center, Moscow, Russian Federation
| | - Joachim Burman
- Department of Neurology, Uppsala University, Uppsala, Sweden
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24
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Ramalingam S, Shah A. Stem Cell Therapy as a Treatment for Autoimmune Disease-Updates in Lupus, Scleroderma, and Multiple Sclerosis. Curr Allergy Asthma Rep 2021; 21:22. [PMID: 33759038 DOI: 10.1007/s11882-021-00996-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Evidence for hematopoietic stem cell transplantation (HCT) in autoimmune disease has been building since the 1990s; however, many clinicians may not yet be aware of its applications to autoimmune disease. We review the basic tenets of HCT and evidence for autologous HCT in multiple sclerosis (MS), systemic sclerosis (SSc), and lupus with an emphasis on recent advanced phase trials. RECENT FINDINGS In MS, the phase 3 randomized MIST trial and the phase 2 randomized ASTIMS trial demonstrated the efficacy of autologous HCT in refractory MS over disease-modifying therapies and mitoxantrone, respectively. In SSc, the phase 3 randomized ASTIS trial and the phase 2 randomized SCOT trial demonstrated the efficacy of autologous HCT in advanced SSc compared to cyclophosphamide. The evidence for HCT in autoimmune diseases continues to grow, particularly in MS and SSc. In lupus, large, comparative trials are still needed. Across autoimmune diseases, questions that still remain to be answered include optimizing patient selection to limit TRM, the appropriate use of MAC, and the necessity for graft manipulation. Furthermore, collaboration between disease-specific and transplant physicians is imperative to expand the appropriate use of HCT in routine clinical practice.
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Affiliation(s)
- Sendhilnathan Ramalingam
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, NC, USA
| | - Ankoor Shah
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3874, Durham, NC, 27710, USA.
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Mohammadi R, Aryan A, Omrani MD, Ghaderian SMH, Fazeli Z. Autologous Hematopoietic Stem Cell Transplantation (AHSCT): An Evolving Treatment Avenue in Multiple Sclerosis. Biologics 2021; 15:53-59. [PMID: 33688164 PMCID: PMC7936693 DOI: 10.2147/btt.s267277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/23/2021] [Indexed: 12/03/2022]
Abstract
Autologous hematopoietic stem cell transplantation (AHSCT) is considered as the novel approach to improve multiple sclerosis (MS) patients with disease-modifying therapies (DMTs)-resistance. The results obtained from different studies indicate that AHSCT increases the life quality of MS patients. Several factors are known to be influenced on the successful rate of AHSCT in patients with MS. The individuals aged <40 years with a short duration of MS disease have been demonstrated to show a better response to AHSCT administration. Furthermore, this treatment approach was more effective in relapsing remitting MS (RRMS) patients than progressive MS (PMS). Different clinical trials revealed that AHSCT with a low density conditioning regimen could be suggested as a suitable candidate approach in the management of MS. Several molecular and cellular mechanisms are known to be involved in the resetting of the immune system following the AHSCT infusion in MS patients. These mechanisms play a role in the depletion of auto-reactive lymphocytes and immune system renewal. In the present review, we discuss different clinical and molecular aspects of AHSCT application in the alleviation of MS symptoms.
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Affiliation(s)
- Reihane Mohammadi
- Department of Medical Genetics, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alisam Aryan
- Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mir Davood Omrani
- Department of Medical Genetics, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Zahra Fazeli
- Department of Medical Genetics, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Murrieta-Álvarez I, Cantero-Fortiz Y, León-Peña AA, Olivares-Gazca JC, Priesca-Marín JM, Ruiz-Delgado GJ, Gómez-De-León A, Gonzalez-Lopez EE, Jaime-Pérez JC, Gómez-Almaguer D, Ruiz-Argüelles GJ. The 1,000th Transplant for Multiple Sclerosis and Other Autoimmune Disorders at the HSCT-México Program: A Myriad of Experiences and Knowledge. Front Neurol 2021; 12:647425. [PMID: 33692748 PMCID: PMC7937693 DOI: 10.3389/fneur.2021.647425] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/01/2021] [Indexed: 12/17/2022] Open
Abstract
After gaining experience conducting both auto and allografts in persons with hematological diseases in the HSCT programs in Puebla and Monterrey, México, this study outlines subsequent program autografting patients with autoimmune conditions. The first transplant in multiple sclerosis was conducted in Puebla on July 5, 2006. From 2015 we increased activity autografting persons with autoimmune conditions in the two campuses of the HSCT-México program: Puebla and Monterrey. By December 6, 2020, patient number 1,000 in the program was autografted. In our experience, a significant reduction in the expanded disability status scale score was achieved in all of the three phenotypes of the disease (from a median of 5.1 to 4.5 points), whereas the response rate (defined as a decrease of at least 0.5 of EDSS score regardless of baseline EDSS, or unchanged EDSS) was 83, 78, and 73% after 12 months in the relapsing-remitting, primary-progressive and secondary-progressive forms of multiple sclerosis, respectively. In addition to analyzing the viability, safety, and efficacy of our method, this study contributes new knowledge to the field of both stem cell transplantation and multiple sclerosis.
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Affiliation(s)
- Iván Murrieta-Álvarez
- Centro de Hematología y Medicina Interna de Puebla, Puebla, Mexico.,Facultad de Medicina, Universidad Popular Autónoma del Estado de Puebla, Puebla, Mexico
| | - Yahveth Cantero-Fortiz
- Centro de Hematología y Medicina Interna de Puebla, Puebla, Mexico.,Escuela de Medicina, Universidad de las Américas Puebla, Puebla, Mexico
| | - Andrés A León-Peña
- Centro de Hematología y Medicina Interna de Puebla, Puebla, Mexico.,Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Juan C Olivares-Gazca
- Centro de Hematología y Medicina Interna de Puebla, Puebla, Mexico.,Facultad de Medicina, Universidad Popular Autónoma del Estado de Puebla, Puebla, Mexico
| | | | - Guillermo J Ruiz-Delgado
- Centro de Hematología y Medicina Interna de Puebla, Puebla, Mexico.,Facultad de Medicina, Universidad Popular Autónoma del Estado de Puebla, Puebla, Mexico.,Laboratorios Clínicos de Puebla, Puebla, Mexico
| | | | | | | | | | - Guillermo J Ruiz-Argüelles
- Centro de Hematología y Medicina Interna de Puebla, Puebla, Mexico.,Facultad de Medicina, Universidad Popular Autónoma del Estado de Puebla, Puebla, Mexico.,Laboratorios Clínicos de Puebla, Puebla, Mexico
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Boffa G, Massacesi L, Inglese M, Mariottini A, Capobianco M, Moiola L, Amato MP, Cottone S, Gualandi F, De Gobbi M, Greco R, Scimè R, Frau J, Zimatore GB, Bertolotto A, Comi G, Uccelli A, Signori A, Angelucci E, Innocenti C, Ciceri F, Repice AM, Sormani MP, Saccardi R, Mancardi G. Long-term Clinical Outcomes of Hematopoietic Stem Cell Transplantation in Multiple Sclerosis. Neurology 2021; 96:e1215-e1226. [PMID: 33472915 DOI: 10.1212/wnl.0000000000011461] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/23/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether autologous hematopoietic stem cell transplantation (aHSCT) is able to induce durable disease remission in people with multiple sclerosis (MS), we analyzed the long-term outcomes after transplantation in a large cohort of patients with MS. METHODS To be included, a minimum dataset (consisting of age, MS phenotype, Expanded Disability Status Scale [EDSS] score at baseline, information on transplantation technology, and at least 1 follow-up visit after transplantation) was required. RESULTS Two hundred ten patients were included (relapsing-remitting [RR] MS 122 [58%]). Median baseline EDSS score was 6 (1-9); mean follow-up was 6.2 (±5.0) years. Among patients with RRMS, disability worsening-free survival (95% confidence interval [CI]) was 85.5% (76.9%-94.1%) at 5 years and 71.3% (57.8%-84.8%) at 10 years. In patients with progressive MS, disability worsening-free survival was 71.0% (59.4%-82.6%) and 57.2% (41.8%-72.7%) at 5 and 10 years, respectively. In patients with RRMS, EDSS significantly reduced after aHSCT (p = 0.001; mean EDSS change per year -0.09 [95% CI -0.15% to -0.04%]). In patients with RRMS, the use of the BCNU+Etoposide+Ara-C+Melphalan (BEAM) + anti-thymocyte globulin (ATG) conditioning protocol was independently associated with a reduced risk of no evidence of disease activity 3 failure (hazard ratio 0.27 [95% CI 0.14-0.50], p < 0.001). Three patients died within 100 days from aHSCT (1.4%); no deaths occurred in patients transplanted after 2007. CONCLUSIONS aHSCT prevents disability worsening in the majority of patients and induces durable improvement in disability in patients with RRMS. The BEAM + ATG conditioning protocol is associated with a more pronounced suppression of clinical relapses and MRI inflammatory activity. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for people with MS, aHSCT induces durable disease remission in most patients.
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Affiliation(s)
- Giacomo Boffa
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Luca Massacesi
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Matilde Inglese
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy.
| | - Alice Mariottini
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Marco Capobianco
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Lucia Moiola
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Maria Pia Amato
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Salvatore Cottone
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Francesca Gualandi
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Marco De Gobbi
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Raffaella Greco
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Rosanna Scimè
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Jessica Frau
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Giovanni Bosco Zimatore
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Antonio Bertolotto
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Giancarlo Comi
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Antonio Uccelli
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Alessio Signori
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Emanuele Angelucci
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Chiara Innocenti
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Fabio Ciceri
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Anna Maria Repice
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Maria Pia Sormani
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Riccardo Saccardi
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
| | - Gianluigi Mancardi
- From the Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (G.B., M.I., A.U., G.M.) and Biostatistics Unit (A.S., M.P.S.), University of Genoa; San Martino Hospital (G.B.), Genoa; Department of Neurosciences Drugs (L. Massacesi, A.M., A.M.R.), Child Health and Department of Neurology 2 (L. Massacesi, A.M., A.M.R.), and Cell Therapy and Transfusion Medicine Unit (C.I., R. Saccardi), Careggi University Hospital, Florence; Ospedale Policlinico San Martino (M.I., A.U., G.M.), IRCCS, Genoa; Department of Neurology (M.C., A.B.), San Luigi Gonzaga Hospital, Orbassano; Department of Neurology (L. Moiola, G.C.) and Department of Haematology and Bone Marrow Transplant (R.G., F.C.), Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan; Department NEUROFARBA (M.P.A.), Section Neurological Sciences, University of Florence IRCCS Fondazione Don Carlo Gnocchi; Department of Neurology (S.C.) and Department of Haematology (R. Scimè), Villa Sofia Hospital, Palermo; Department of Haematology and Bone Marrow Transplant Unit (F.G., E.A.), Policlinico San Martino IRCCS, Genoa; Department of Clinical and Biological Sciences (M.D.G.), Haematopoietic Stem Cell Transplant Unit, University of Turin, San Luigi Gonzaga Hospital, Orbassano; Multiple Sclerosis Center (J.F.), Department of Medical Sciences and Public Health University of Cagliari; Binaghi Hospital (J.F.), Cagliari; Department of Neurology (G.B.Z.), Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, BA; and IRCCS Scientific Clinical Institutes Maugeri (G.M.), Pavia-Genoa Nervi, Italy
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Das J, Snowden JA, Burman J, Freedman MS, Atkins H, Bowman M, Burt RK, Saccardi R, Innocenti C, Mistry S, Laud PJ, Jessop H, Sharrack B. Autologous haematopoietic stem cell transplantation as a first-line disease-modifying therapy in patients with 'aggressive' multiple sclerosis. Mult Scler 2021; 27:1198-1204. [PMID: 33565902 PMCID: PMC8226372 DOI: 10.1177/1352458520985238] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Autologous haematopoietic stem cell transplantation (AHSCT) is an effective treatment for patients with multiple sclerosis (MS) who have highly active disease, despite the use of standard disease-modifying therapies (DMTs). However, the optimal time for offering AHSCT to patients with 'aggressive' MS is yet to be established. OBJECTIVES The objective was to explore the safety and efficacy of AHSCT as a first-line DMT in patients with 'aggressive' MS. METHODS All patients with 'aggressive' MS who received AHSCT as a first-line DMT in five European and North American centres were retrospectively evaluated. RESULTS Twenty patients were identified. The median interval between diagnosis and AHSCT was 5 (1-20) months. All had multiple poor prognostic markers with a median pre-transplant Expanded Disability Status Scale (EDSS) score of 5.0 (1.5-9.5). After a median follow-up of 30 (12-118) months, the median EDSS score improved to 2.0 (0-6.5, p < 0.0001). No patient had further relapses. Three had residual magnetic resonance imaging (MRI) disease activities in the first 6 months post-transplant, but no further new or enhancing lesions were observed in subsequent scans. CONCLUSION AHSCT is safe and effective as a first-line DMT in inducing rapid and sustained remission in patients with 'aggressive' MS.
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Affiliation(s)
- J Das
- Sheffield Institute for Translational Neuroscience, University of Sheffield, UK/Academic Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - J A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - J Burman
- Department of Neurology, Uppsala University Hospital, Uppsala, Sweden
| | - M S Freedman
- Department of Medicine (Neurology), The University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - H Atkins
- Department of Medicine (Neurology), The University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - M Bowman
- Department of Medicine (Neurology), The University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - R K Burt
- Division of Immunotherapy, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - R Saccardi
- Department of Cellular Therapies and Transfusion Medicine, Careggi University Hospital, Florence, Italy
| | - C Innocenti
- Department of Cellular Therapies and Transfusion Medicine, Careggi University Hospital, Florence, Italy
| | - S Mistry
- Academic Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - P J Laud
- Statistical Services Unit, University of Sheffield, Sheffield, UK
| | - H Jessop
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - B Sharrack
- Academic Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Sheffield Institute for Translational Neuroscience, University of Sheffield, UK
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Zhukovsky C, Sandgren S, Silfverberg T, Einarsdottir S, Tolf A, Landtblom AM, Novakova L, Axelsson M, Malmestrom C, Cherif H, Carlson K, Lycke J, Burman J. Autologous haematopoietic stem cell transplantation compared with alemtuzumab for relapsing-remitting multiple sclerosis: an observational study. J Neurol Neurosurg Psychiatry 2021; 92:189-194. [PMID: 33106366 PMCID: PMC7841472 DOI: 10.1136/jnnp-2020-323992] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 09/02/2020] [Accepted: 09/06/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To compare outcomes after treatment with autologous haematopoietic stem cell transplantation (AHSCT) and alemtuzumab (ALZ) in patients with relapsing-remitting multiple sclerosis. METHODS Patients treated with AHSCT (n=69) received a conditioning regimen of cyclophosphamide (200 mg/kg) and rabbit anti-thymocyte globulinerG (6.0 mg/kg). Patients treated with ALZ (n=75) received a dose of 60 mg over 5 days, a repeated dose of 36 mg over 3 days after 1 year and then as needed. Follow-up visits with assessment of the expanded disability status scale score, adverse events and MR investigations were made at least yearly. RESULTS The Kaplan-Meier estimates of the primary outcome measure 'no evidence of disease activity' was 88% for AHSCT and 37% for ALZ at 3 years, p<0.0001. The secondary endpoint of annualised relapse rate was 0.04 for AHSCT and 0.1 for ALZ, p=0.03. At last follow-up, the proportions of patients who improved, were stable or worsened were 57%/41%/1% (AHSCT) and 45%/43%/12% (ALZ), p=0.06 Adverse events grade three or higher were present in 48/69 patients treated with AHSCT and 0/75 treated with ALZ in the first 100 days after treatment initiation. The most common long-term adverse event was thyroid disease with Kaplan-Meier estimates at 3 years of 21% for AHSCT and 46% for ALZ, p=0.005. CONCLUSIONS In this observational cohort study, treatment with AHSCT was associated with a higher likelihood of maintaining 'no evidence of disease activity'. Adverse events were more frequent with AHSCT in the first 100 days, but thereafter more common in patients treated with ALZ.
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Affiliation(s)
| | - Sofia Sandgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Thomas Silfverberg
- Department of of Medical Sciences, Uppsala University, Uppsala, Sweden.,Center for Clinical Research Dalarna, Uppsala University, Uppsala, Sweden
| | - Sigrun Einarsdottir
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Tolf
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | | | - Lenka Novakova
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Markus Axelsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Clas Malmestrom
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Honar Cherif
- Department of of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Kristina Carlson
- Department of of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
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30
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Miller AE, Chitnis T, Cohen BA, Costello K, Sicotte NL, Stacom R. Autologous Hematopoietic Stem Cell Transplant in Multiple Sclerosis: Recommendations of the National Multiple Sclerosis Society. JAMA Neurol 2021; 78:241-246. [PMID: 33104165 DOI: 10.1001/jamaneurol.2020.4025] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Autologous hematopoietic stem cell transplant (AHSCT) for multiple sclerosis has gained increasing interest in recent years. Despite the availability of many US Food and Drug Administration-approved disease-modifying therapies, some patients do not respond adequately and others may have very early aggressive disease that prompts consideration of alternative, highly effective, long-lasting therapy. The National Medical Advisory Committee of the National Multiple Sclerosis Society has reviewed recent literature on AHSCT for the purpose of making recommendations about its use based on current knowledge, as well as pointing out areas of controversy and issues requiring further research. Observations Studies on AHSCT have repeatedly demonstrated high efficacy and a durable outcome in people with relapsing multiple sclerosis. Recent studies have shown considerable improvement in the safety of the procedure, with much lower mortality rates than were reported earlier. Consensus is emerging about the characteristics of the best candidates for the procedure. Questions remain about the ideal protocol, particularly about the best conditioning regimen to be used to kill immune cells. Larger randomized clinical trials are needed to address the question of whether AHSCT has advantages over the most efficacious disease-modifying agents currently available. One such trial (Best Available Therapy Versus Autologous Hematopoietic Stem Cell Transplant for Multiple Sclerosis [BEAT-MS) is currently in progress. Conclusions and Relevance The National Multiple Sclerosis Society believes that AHSCT may be a useful treatment option for people with relapsing multiple sclerosis who demonstrate substantial breakthrough disease activity (ie, new inflammatory central nervous system lesions and/or clinical relapses) despite treatment with high-efficacy disease-modifying therapy or have contraindications to high-efficacy disease-modifying therapies. The best candidates are likely people younger than 50 years with shorter durations of disease (<10 years). The procedure should only be performed at centers with substantial experience and expertise. Ideally, recipients of the procedure should be entered into a single database, and further research is needed to establish ideal cell mobilization and immune-conditioning regimens.
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Affiliation(s)
- Aaron E Miller
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tanuja Chitnis
- Partners Multiple Sclerosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bruce A Cohen
- Davee Department of Neurology and Clinical Neurosciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Nancy L Sicotte
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, California
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31
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Mariottini A, De Matteis E, Muraro PA. Haematopoietic Stem Cell Transplantation for Multiple Sclerosis: Current Status. BioDrugs 2021; 34:307-325. [PMID: 32166703 DOI: 10.1007/s40259-020-00414-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Autologous haematopoietic stem cell transplantation (AHSCT) is a treatment option for aggressive forms of multiple sclerosis (MS) that has been derived from haematological indications and repurposed for treatment of refractory autoimmune diseases. In the present review, a search for clinical studies on AHSCT was performed on the PubMed website and ClinicalTrials.gov databases. Papers were selected according to the following criteria: text written in English language, publication date between 2014 and August 2019, and reports including more than five patients. Prospective randomised and uncontrolled trials and retrospective case series were reviewed to examine the safety and efficacy of the procedure. Treatment protocols, pathological data and economic aspects of AHSCT were also succinctly covered. Growing evidence suggests that long-term suppression of inflammatory activity with stabilization or improvement of disability can be achieved in a high proportion of properly selected patients. More sophisticated outcome measures recently adopted, including effect on brain atrophy and disease biomarkers, are giving further insight into the effectiveness of transplant. The risks of the procedure have decreased to levels that can be considered acceptable for treatment of individuals with aggressive forms of MS. Careful selection of patients with an expected good benefit/risk profile, which is maximal when AHSCT is performed in early phases of the disease, and the expertise of transplant centres are critical to the success of treatment. Higher efficacy of AHSCT than with conventional treatments has recently been demonstrated by one randomised trial and further evidence is awaited from ongoing and planned trials comparing AHSCT with the most effective disease-modifying therapeutic agents.
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Affiliation(s)
- Alice Mariottini
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.,Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
| | - Eleonora De Matteis
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.,Department of Neurosciences, Mental Health and Sensory Organs, Faculty of Medicine and Psychology, Centre for Experimental Neurological Therapies, Sapienza University, Rome, Italy
| | - Paolo A Muraro
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.
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32
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Oliveira MC, Elias JB, Moraes DAD, Simões BP, Rodrigues M, Ribeiro AAF, Piron-Ruiz L, Ruiz MA, Hamerschlak N. A review of hematopoietic stem cell transplantation for autoimmune diseases: multiple sclerosis, systemic sclerosis and Crohn's disease. Position paper of the Brazilian Society of Bone Marrow Transplantation. Hematol Transfus Cell Ther 2021; 43:65-86. [PMID: 32418777 PMCID: PMC7910166 DOI: 10.1016/j.htct.2020.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 12/16/2022] Open
Abstract
Autoimmune diseases are an important field for the development of bone marrow transplantation, or hematopoietic stem cell transplantation. In Europe alone, almost 3000 procedures have been registered so far. The Brazilian Society for Bone Marrow Transplantation (Sociedade Brasileira de Transplantes de Medula Óssea) organized consensus meetings for the Autoimmune Diseases Group, to review the available literature on hematopoietic stem cell transplantation for autoimmune diseases, aiming to gather data that support the procedure for these patients. Three autoimmune diseases for which there are evidence-based indications for hematopoietic stem cell transplantation are multiple sclerosis, systemic sclerosis and Crohn's disease. The professional stem cell transplant societies in America, Europe and Brazil (Sociedade Brasileira de Transplantes de Medula Óssea) currently consider hematopoietic stem cell transplantation as a therapeutic modality for these three autoimmune diseases. This article reviews the evidence available.
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Affiliation(s)
- Maria Carolina Oliveira
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Juliana Bernardes Elias
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | | | - Belinda Pinto Simões
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | | | | | - Lilian Piron-Ruiz
- Associação Portuguesa de Beneficência de São José do Rio Preto, São José do Rio Preto, SP, Brazil
| | - Milton Arthur Ruiz
- Associação Portuguesa de Beneficência de São José do Rio Preto, São José do Rio Preto, SP, Brazil
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33
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Selective cognitive dysfunction and physical disability improvement after autologous hematopoietic stem cell transplantation in highly active multiple sclerosis. Sci Rep 2020; 10:21286. [PMID: 33277590 PMCID: PMC7718237 DOI: 10.1038/s41598-020-78160-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/18/2020] [Indexed: 12/29/2022] Open
Abstract
The aim was to assess the cognitive dysfunction and physical disability after autologous hematopoietic stem cell transplantation (AHSCT), to explore the potential factors influencing disability regression after AHSCT and to estimate the safety of low-dose immunosuppressive therapy in highly active Multiple Sclerosis (MS) patients. In single-center prospective study patients who failed to conventional therapies for highly active relapsing MS underwent the AHSCT. The disability was followed up with Expanded Disability Status Scale and cognition with Brief International Cognitive Assessment for Multiple Sclerosis. Twenty four patients [18 (72.0%) female] underwent AHSCT. Two patients of 13 had one relapse during the first year and three patients-during the second year after AHSCT. Disability regression was found in 84.6% of patients. The scores of information processing speed and verbal learning were significantly higher at month 12 after AHSCT. The clinical variable that explained the disability regression at months 6 and 12 after AHSCT was the disability progression over 6 months before AHSCT. No transplant related-deaths were observed. Selective cognitive improvement was found after AHSCT in MS patients. The disability may be temporarily reversible after AHSCT in a significant proportion of highly active RMS patients if AHSCT is well-timed performed.
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Abstract
The introduction of targeted biologic therapies has changed the treatment landscape for autoimmune diseases (ADs) substantially, but although these therapies provide more specificity, they require continuous administration, rarely restore organ function or reverse disability, and are not curative. Over the last 25 years, hematopoietic stem cell transplantation (HSCT) has been increasingly used to treat patients in whom the risk:benefit ratio of HSCT is acceptable. In contrast to chronic suppression of immune function, this intensive one-off procedure aims to provide treatment-free remissions by the reinduction of self-tolerance. The European Society for Blood and Marrow Transplantation (EBMT) Autoimmune Diseases Working Party (ADWP) has been central to development of this approach, with over 3,300 HSCT registrations for ADs. Recent data have improved the evidence base to support autologous HSCT in multiple sclerosis, systemic sclerosis, and Crohn's disease, along with a wide range of rarer disease indications, and autologous HSCT has become an integral part of treatment algorithms in various ADs.
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Affiliation(s)
- Tobias Alexander
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Rheumatology and Clinical Immunology, 10117 Berlin, Germany; .,Deutsches Rheuma-Forschungszentrum (DRFZ), an Institute of the Leibniz Association, 10117 Berlin, Germany
| | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan 20132, Italy
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, United Kingdom
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35
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Burt RK, Tappenden P, Han X, Quigley K, Arnautovic I, Sharrack B, Snowden JA, Hartung D. Health economics and patient outcomes of hematopoietic stem cell transplantation versus disease-modifying therapies for relapsing remitting multiple sclerosis in the United States of America. Mult Scler Relat Disord 2020; 45:102404. [DOI: 10.1016/j.msard.2020.102404] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/23/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
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36
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Das J, Sharrack B, Snowden JA. Autologous hematopoietic stem-cell transplantation in neurological disorders: current approach and future directions. Expert Rev Neurother 2020; 20:1299-1313. [PMID: 32893698 DOI: 10.1080/14737175.2020.1820325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Autologous hematopoietic stem-cell transplantation (AHSCT) has become increasingly popular in recent years as an effective treatment of immune-mediated neurological diseases. Treatment-related mortality has significantly reduced primarily through better patient selection, optimization of transplant technique, and increased center experience. AREA COVERED Multiple sclerosis is the main indication, but people with neuromyelitis optica spectrum disorder, stiff-person spectrum disorder, chronic inflammatory demyelinating polyneuropathy, myasthenia gravis, and other immune-mediated neurological disorders also have been treated. The review herein discusses the use of AHSCT in these neurological disorders, the importance of patient selection and transplant technique optimization and future directions. EXPERT OPINION Phase II and III clinical trials have confirmed the safety and efficacy of AHSCT in multiple sclerosis and recent phase II clinical trials have also suggested its safety and efficacy in chronic inflammatory demyelinating polyneuropathy and neuromyelitis optica spectrum disorder, with the evidence in other neurological disorders limited to individual case reports, small case series, and registry data. Therefore, further randomized controlled clinical trials are required to assess its safety and efficacy in other neurological conditions. However, in rare neurological conditions, pragmatic treatment trials or registry-based studies may be more realistic options for gathering efficacy and safety data.
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Affiliation(s)
- Joyutpal Das
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust , Salford, UK.,Cardiovascular medicine, University of Manchester , Manchester, UK.,Department of Neuroscience, NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield , Sheffield, UK
| | - Basil Sharrack
- Department of Neuroscience, NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield , Sheffield, UK
| | - John A Snowden
- Department of Hematology, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK
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37
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Abstract
PURPOSE OF REVIEW Autologous hematopoietic stem cell transplantation (HSCT) is a promising therapeutic modality for severe autoimmune diseases. In this review, we will outline the immunological mechanisms and the clinical evidence and experiences for therapeutic HSCT in autoimmune diseases, with particular focus on systemic sclerosis and multiple sclerosis. RECENT FINDINGS Approximately 3000 patients with autoimmune diseases worldwide have been treated with HSCT. HSCT in systemic sclerosis has been shown in three randomized controlled trials to be associated with significant long-term event-free survival despite some transplant-related mortality in the first year. A recent controlled trial in multiple sclerosis has also show benefit with transplant. SUMMARY The aim of HSCT is to 'reset' one's immune system into a naïve and self-tolerant state through immune depletion and regulation. HSCT requires careful patient selection, close collaboration between physicians and expertise of transplant team to ensure optimal outcome.
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Sorensen PS, Sellebjerg F, Hartung HP, Montalban X, Comi G, Tintoré M. The apparently milder course of multiple sclerosis: changes in the diagnostic criteria, therapy and natural history. Brain 2020; 143:2637-2652. [DOI: 10.1093/brain/awaa145] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/28/2020] [Accepted: 03/14/2020] [Indexed: 02/06/2023] Open
Abstract
Abstract
In the past decade, changes have occurred in the spectrum of multiple sclerosis courses. The natural history of multiple sclerosis appears milder from the first sign of demyelinating disease to the progressive course, probably as a result of an interplay between several factors including changes in the diagnostic criteria, changes in the epidemiology of multiple sclerosis, impact of early and appropriate disease-modifying treatment and improvement of the general state of health in the population. It has been suggested to regard incidental findings of demyelinating lesions in MRI in individuals without any history of clinical symptoms consistent with neurological dysfunction, so-called radiological isolated syndrome, as the initial course of multiple sclerosis. New diagnostic criteria have enabled the multiple sclerosis diagnosis in many patients at the first clinical demyelinating event, clinically isolated syndrome. The remaining patients with clinically isolated syndrome have a more benign prognosis, and for relapsing-remitting multiple sclerosis, the prognosis has become more favourable. Reduced disease activity in patients with relapsing-remitting multiple sclerosis can partly be ascribed to more efficacious new disease-modifying therapies but decrease in disease activity has also be seen in placebo-treated patients in clinical trials. This may be explained by several factors: change in the diagnostic criteria, more explicit inclusion criteria, exclusion of high-risk patients e.g. patients with co-morbidities, and more rigorous definitions of relapses and disease worsening. However, these factors also make the disease course in patients treated with disease-modifying therapies seem more favourable. In addition, change in the therapeutic target to stable disease (no evidence of disease activity = no relapses, no disease worsening and no MRI activity) could by itself change the course in relapsing-remitting multiple sclerosis. The effectiveness of disease-modifying drugs has reduced the transition from relapsing-remitting to secondary progressive multiple sclerosis. The concept of progressive multiple sclerosis has also evolved from two very distinct categories (primary progressive and secondary progressive multiple sclerosis) to a unified category of progressive multiple sclerosis, which can then be split into the categories of active or inactive. Also, an increasing tendency to treat progressive multiple sclerosis with disease-modifying therapies may have contributed to change the course in progressive multiple sclerosis. In conclusion, during the past decade the entire course of multiple sclerosis from the first sign of a demyelinating disorder through the progressive course appears to be milder due to a complex interplay of several factors.
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Affiliation(s)
- Per Soelberg Sorensen
- Danish Multiple Sclerosis Center, Department of Neurology, University of Copenhagen and Rigshospitalet, Copenhagen, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, University of Copenhagen and Rigshospitalet, Copenhagen, Denmark
| | - Hans-Peter Hartung
- Department of Neurology, University Hospital, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Xavier Montalban
- Department of Neurology, Hospital General Universitari Vall D’Hebron, Cemcat, Barcelona, Spain
- Division of Neurology, University of Toronto, St. Michael’s Hospital, Toronto, Canada
| | - Giancarlo Comi
- Department of Neurology and Institute of Experimental Neurology, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Mar Tintoré
- Department of Neurology, Hospital General Universitari Vall D’Hebron, Cemcat, Barcelona, Spain
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39
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Autologous Haematopoietic Stem Cell Transplantation in Multiple Sclerosis: a Review of Current Literature and Future Directions for Transplant Haematologists and Oncologists. Curr Hematol Malig Rep 2020; 14:127-135. [PMID: 30828772 PMCID: PMC6510794 DOI: 10.1007/s11899-019-00505-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of Review We summarise the current development of autologous haematopoietic stem cell transplantation (AHSCT) in treating multiple sclerosis (MS) and discuss future directions for the general neurologist, transplant haematologist and oncologist. Recent Findings AHSCT was initially performed to treat MS over 20 years ago. Over recent years, the evidence base has grown, especially in relapsing-remitting MS (RRMS), with significant improvements in safety and efficacy through better patient selection, choice of transplant technique and increase in centre experience. Summary AHSCT is now a treatment option in very carefully selected patients with severe, treatment-resistant RRMS. However, it is important for transplant haematologists and oncologists to work closely with specialist MS neurologists in patient selection, during transplant and in long-term follow-up of patients. Data should be registered into international transplant registries and, ideally, patients should be enrolled on prospective clinical trials in order to build the evidence base and refine transplant techniques.
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40
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Lycke J, Lenhoff S. Intensive immunosuppression followed by autologous hematopoietic stem cell transplantation for the treatment of multiple sclerosis. Ther Adv Neurol Disord 2020; 13:1756286420929467. [PMID: 32636931 PMCID: PMC7315665 DOI: 10.1177/1756286420929467] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/22/2020] [Indexed: 12/20/2022] Open
Abstract
Autologous hematopoietic stem cell transplantation (AHSCT) to treat multiple sclerosis (MS) has mostly been used in devastating cases as the last option to stop further neurological deterioration. However, evidence from several retrospective clinical trials indicates that young, less disabled patients with highly inflammatory active MS are the most likely to benefit from AHSCT, and after moving from high-intensity to nonmyeloablative procedures the tolerability of AHSCT has increased and its associated risk and mortality have declined considerably. Recent meta-analyses and randomized clinical trials show that AHSCT is more effective than currently approved disease-modifying therapies (DMTs), with suppression of disease activity in 70-90% of patients and long-term cessation of disease activity in two-thirds of treated patients. The rationale for AHSCT is to eliminate autoimmunity and achieve immune resetting by intense immunosuppression followed by infusion of autologous hematopoietic stem cells. Similar effects on the immune system have been suggested for cladribine and alemtuzumab treatment and, together with AHSCT, they constitute the induction or immune-reconstitution therapies for MS. Although, further randomized controlled trials of AHSCT for MS are needed, it has become clear that improved patient selection and lower intensity conditioning regimens have reduced AHSCT associated risks and mortality and strengthened the position of AHSCT among other DMTs. Do we have enough experience and scientific support for AHSCT in MS to move from an exclusive treatment for aggressive, treatment-resistant MS and acquire broader indications, similar to other effective DMTs?
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Affiliation(s)
- Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gröna stråket 11, 3 tr, Sahlgrenska University Hospital, Gothenburg, 415 45, Sweden
| | - Stig Lenhoff
- Department of Hematology, Oncology and Radiophysics, Skane University Hospital, Lund, Sweden
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Iacobaeus E, Arrambide G, Amato MP, Derfuss T, Vukusic S, Hemmer B, Tintore M, Brundin L. Aggressive multiple sclerosis (1): Towards a definition of the phenotype. Mult Scler 2020; 26:1352458520925369. [PMID: 32530385 PMCID: PMC7412876 DOI: 10.1177/1352458520925369] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 04/06/2020] [Accepted: 04/16/2020] [Indexed: 02/06/2023]
Abstract
While the major phenotypes of multiple sclerosis (MS) and relapsing-remitting, primary and secondary progressive MS have been well characterized, a subgroup of patients with an active, aggressive disease course and rapid disability accumulation remains difficult to define and there is no consensus about their management and treatment. The current lack of an accepted definition and treatment guidelines for aggressive MS triggered a 2018 focused workshop of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) on aggressive MS. The aim of the workshop was to discuss approaches on how to describe and define the disease phenotype and its treatments. Unfortunately, it was not possible to come to consensus on a definition because of unavailable data correlating severe disease with imaging and molecular biomarkers. However, the workshop highlighted the need for future research needed to define this disease subtype while also focusing on its treatment and management. Here, we review previous attempts to define aggressive MS and present characteristics that might, with additional research, eventually help characterize it. A companion paper summarizes data regarding treatment and management.
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Affiliation(s)
- Ellen Iacobaeus
- Department of Clinical Neuroscience, Division of Neurology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Georgina Arrambide
- Servei de Neurologia-Neuroimmunologia. Centre d’Esclerosi Múltiple de Catalunya, (Cemcat), Vall d’Hebron Institut de Recerca, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Pia Amato
- Department NeuroFarBa, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Tobias Derfuss
- Departments of Neurology and Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Sandra Vukusic
- Service de neurologie, Sclérose en plaques, Pathologies de la myéline et neuro-inflammation, and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon/Bron, France; Centre des Neurosciences de Lyon, Observatoire Français de la Sclérose en Plaques, INSERM 1028 et CNRS UMR5292, Lyon, France; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, Lyon, France
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Mar Tintore
- Servei de Neurologia-Neuroimmunologia. Centre d’Esclerosi Múltiple de Catalunya, (Cemcat), Vall d’Hebron Institut de Recerca, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lou Brundin
- Department of Clinical Neuroscience, Division of Neurology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
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Bose G, Thebault S, Rush CA, Atkins HL, Freedman MS. Autologous hematopoietic stem cell transplantation for multiple sclerosis: A current perspective. Mult Scler 2020; 27:167-173. [PMID: 32364422 DOI: 10.1177/1352458520917936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The most effective treatment at halting inflammation in patients with highly active multiple sclerosis (MS) is immune ablation followed by autologous hematopoietic stem cell transplantation (AHSCT). Better patient selection and supportive management, as well as advances in conditioning regimens have resulted in improved safety with AHSCT. However, which comorbidities or prior therapies increase the risks associated with AHSCT still need to be determined. In addition, there is still debate as to which AHSCT conditioning regimen offers the best balance of long-term efficacy and safety. New studies comparing AHSCT with highly effective disease-modifying therapies will help to inform on the ideal placement of AHSCT in the treatment algorithm. Currently, many centers are experienced and use AHSCT to treat select patients with MS, contributing to ongoing registries and clinical trials which will help answer these questions.
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Affiliation(s)
- Gauruv Bose
- Department of Medicine, Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Simon Thebault
- Department of Medicine, Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Carolina A Rush
- Department of Medicine, Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Harold L Atkins
- Department of Medicine, Division of Hematology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Mark S Freedman
- Department of Medicine, Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Therapeutic potential of stem cells for treatment of neurodegenerative diseases. Biotechnol Lett 2020; 42:1073-1101. [DOI: 10.1007/s10529-020-02886-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 04/05/2020] [Indexed: 12/13/2022]
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Jaime-Pérez JC, Gómez-Galaviz AC, Turrubiates-Hernández GA, Picón-Galindo E, Salazar-Riojas R, Méndez-Ramírez N, Gómez-Almaguer D. Mobilization kinetics of CD34+ hematopoietic stem cells stimulated by G-CSF and cyclophosphamide in patients with multiple sclerosis who receive an autotransplant. Cytotherapy 2020; 22:144-148. [PMID: 32057615 DOI: 10.1016/j.jcyt.2020.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/29/2019] [Accepted: 01/06/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND AIMS Autologous hematopoietic stem cell transplantation (AHSCT) is an alternative for multiple sclerosis (MS) patients who do not respond to conventional treatment. Mobilization kinetics of CD34+ cells in MS patients has not been studied. METHODS Patients with MS mobilized with granulocyte colony-stimulating factor (G-CSF) and cyclophosphamide (Cy) were prospectively studied. Three counts of CD34+ cells were done in peripheral blood: at baseline before mobilization, at the start, and immediately at the end of apheresis. Complete blood counts were performed at the times of CD34+ cell counting. Standard statistical descriptive analysis of MS patients' salient features was performed, and after log 10 transformation of the data, Pearson test was performed to assess correlation between variables and CD34+ cell count. In addition, multiple linear regression of relevant data was carried out for multivariate analysis. RESULTS Data of 51 consecutive MS patients with median age of 48 (31-64) years were analyzed. The CD34+ cell count increased 26-fold after mobilization. During large volume leukapheresis (LVL), the number of CD34+ cells in peripheral blood increased from 51.29 CD34+/μL at the start to 62.3 CD34+/μL at the end. A negative correlation between CD34+ cell count after leukapheresis and age (r = -0.32, P = 0.02) was observed. Neither the CD34+ baseline count nor sex correlated with the CD34+ count in peripheral blood immediately at the end of apheresis. CONCLUSIONS Mobilization with G-CSF and Cy in MS patients resulted in effective CD34+ hematoprogenitors release from the bone marrow and in intra-apheresis recruitment.
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Affiliation(s)
- José C Jaime-Pérez
- Department of Hematology, Internal Medicine Division, Facultad de Medicina y Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico.
| | - Ana Cristina Gómez-Galaviz
- Department of Hematology, Internal Medicine Division, Facultad de Medicina y Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Grecia A Turrubiates-Hernández
- Department of Hematology, Internal Medicine Division, Facultad de Medicina y Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Ernesto Picón-Galindo
- Department of Hematology, Internal Medicine Division, Facultad de Medicina y Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Rosario Salazar-Riojas
- Department of Hematology, Internal Medicine Division, Facultad de Medicina y Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Nereida Méndez-Ramírez
- Department of Hematology, Internal Medicine Division, Facultad de Medicina y Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - David Gómez-Almaguer
- Department of Hematology, Internal Medicine Division, Facultad de Medicina y Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
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Andrejew R, Glaser T, Oliveira-Giacomelli Á, Ribeiro D, Godoy M, Granato A, Ulrich H. Targeting Purinergic Signaling and Cell Therapy in Cardiovascular and Neurodegenerative Diseases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1201:275-353. [PMID: 31898792 DOI: 10.1007/978-3-030-31206-0_14] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Extracellular purines exert several functions in physiological and pathophysiological mechanisms. ATP acts through P2 receptors as a neurotransmitter and neuromodulator and modulates heart contractility, while adenosine participates in neurotransmission, blood pressure, and many other mechanisms. Because of their capability to differentiate into mature cell types, they provide a unique therapeutic strategy for regenerating damaged tissue, such as in cardiovascular and neurodegenerative diseases. Purinergic signaling is pivotal for controlling stem cell differentiation and phenotype determination. Proliferation, differentiation, and apoptosis of stem cells of various origins are regulated by purinergic receptors. In this chapter, we selected neurodegenerative and cardiovascular diseases with clinical trials using cell therapy and purinergic receptor targeting. We discuss these approaches as therapeutic alternatives to neurodegenerative and cardiovascular diseases. For instance, promising results were demonstrated in the utilization of mesenchymal stem cells and bone marrow mononuclear cells in vascular regeneration. Regarding neurodegenerative diseases, in general, P2X7 and A2A receptors mostly worsen the degenerative state. Stem cell-based therapy, mainly through mesenchymal and hematopoietic stem cells, showed promising results in improving symptoms caused by neurodegeneration. We propose that purinergic receptor activity regulation combined with stem cells could enhance proliferative and differentiation rates as well as cell engraftment.
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Affiliation(s)
- Roberta Andrejew
- Neuroscience Laboratory, Institute of Chemistry, Department of Biochemistry, University of São Paulo, São Paulo, Brazil
| | - Talita Glaser
- Neuroscience Laboratory, Institute of Chemistry, Department of Biochemistry, University of São Paulo, São Paulo, Brazil
| | - Ágatha Oliveira-Giacomelli
- Neuroscience Laboratory, Institute of Chemistry, Department of Biochemistry, University of São Paulo, São Paulo, Brazil
| | - Deidiane Ribeiro
- Neuroscience Laboratory, Institute of Chemistry, Department of Biochemistry, University of São Paulo, São Paulo, Brazil
| | - Mariana Godoy
- Neuroscience Laboratory, Institute of Chemistry, Department of Biochemistry, University of São Paulo, São Paulo, Brazil.,Laboratory of Neurodegenerative Diseases, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alessandro Granato
- Neuroscience Laboratory, Institute of Chemistry, Department of Biochemistry, University of São Paulo, São Paulo, Brazil
| | - Henning Ulrich
- Neuroscience Laboratory, Institute of Chemistry, Department of Biochemistry, University of São Paulo, São Paulo, Brazil.
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Effect of autologous hematopoietic stem cell transplantation on multiple sclerosis and neuromyelitis optica spectrum disorder: a PRISMA-compliant meta-analysis. Bone Marrow Transplant 2020; 55:1928-1934. [PMID: 32020080 DOI: 10.1038/s41409-020-0810-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 12/29/2022]
Abstract
We should consider both the treatment effects and adverse effects of autologous hematopoietic stem cell transplantation (AHSCT) on multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). Articles exploring the effect and safety of AHSCT in the treatment of MS and NMOSD and published before December 2019 were identified from the following databases (PubMed, Web of Science, Medline, EMBASE, Cochrane and Google Scholar). The study used STATA 13.0 software to compute the efficacy outcomes. Finally, the meta-analysis included 27 studies (including 1626 MS and 31 NMOSD patients). Regarding the effect of AHSCT on MS, the computed PFS was 74%. Subgroup analyses showed that intermediate-intensity regimen caused PFS 73%. Low-intensity regimen resulted in PFS 85%. High-intensity regimen resulted in PFS 58%. Subgroup analyses indicated that relapsing remitting MS (RRMS), primary progressive MS (PPMS) and secondary progressive MS (SPMS) patients showed PFS 81%, 78% and 60%, respectively. Computed transplant-related mortality (TRM) in MS was 1%. Regarding effect of AHSCT on NMOSD, the computed PFS and TRM was 76% and 0%, respectively. In conclusion, the study supported that AHSCT showed long-term effect on MS and NMOSD patients with a high safety. Low- and intermediate-intensity regimens and RRMS patients showed optimal benefit from AHSCT.
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Sharrack B, Saccardi R, Alexander T, Badoglio M, Burman J, Farge D, Greco R, Jessop H, Kazmi M, Kirgizov K, Labopin M, Mancardi G, Martin R, Moore J, Muraro PA, Rovira M, Sormani MP, Snowden JA. Autologous haematopoietic stem cell transplantation and other cellular therapy in multiple sclerosis and immune-mediated neurological diseases: updated guidelines and recommendations from the EBMT Autoimmune Diseases Working Party (ADWP) and the Joint Accreditation Committee of EBMT and ISCT (JACIE). Bone Marrow Transplant 2020; 55:283-306. [PMID: 31558790 PMCID: PMC6995781 DOI: 10.1038/s41409-019-0684-0] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 08/17/2019] [Indexed: 12/18/2022]
Abstract
These updated EBMT guidelines review the clinical evidence, registry activity and mechanisms of action of haematopoietic stem cell transplantation (HSCT) in multiple sclerosis (MS) and other immune-mediated neurological diseases and provide recommendations for patient selection, transplant technique, follow-up and future development. The major focus is on autologous HSCT (aHSCT), used in MS for over two decades and currently the fastest growing indication for this treatment in Europe, with increasing evidence to support its use in highly active relapsing remitting MS failing to respond to disease modifying therapies. aHSCT may have a potential role in the treatment of the progressive forms of MS with a significant inflammatory component and other immune-mediated neurological diseases, including chronic inflammatory demyelinating polyneuropathy, neuromyelitis optica, myasthenia gravis and stiff person syndrome. Allogeneic HSCT should only be considered where potential risks are justified. Compared with other immunomodulatory treatments, HSCT is associated with greater short-term risks and requires close interspeciality collaboration between transplant physicians and neurologists with a special interest in these neurological conditions before, during and after treatment in accredited HSCT centres. Other experimental cell therapies are developmental for these diseases and patients should only be treated on clinical trials.
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Affiliation(s)
- Basil Sharrack
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- NIHR Neurosciences Biomedical Research Centre, University of Sheffield, Sheffield, UK
| | - Riccardo Saccardi
- Cell Therapy and Transfusion Medicine Unit, Careggi University Hospital, Firenze, Italy
| | - Tobias Alexander
- Klinik fur Rheumatologie und Klinische Immunologie, Charite-Universitatsmedizin, Berlin, Germany
| | - Manuela Badoglio
- EBMT Paris study office, Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Dominique Farge
- Unité de Médecine Interne, Maladies Auto-immunes et Pathologie Vasculaire (UF 04), Hôpital St-Louis, AP-HP, Paris, France
- Centre de Référence des Maladies Auto-Immunes Systémiques Rares d'Ile-de-France, Filière, FAI2R, Paris, France
- EA 3518, Université Denis Diderot, Paris, France
- Department of Internal Medicine, McGill University, Montreal, QC, Canada
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico, San Raffaele Scientific Institute, Milan, Italy
| | - Helen Jessop
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Majid Kazmi
- Kings Health Partners, Department of Haematology, Guys Hospital, London, UK
| | - Kirill Kirgizov
- N.N. Blokhin National Medical Center of Oncology, Institute of Pediatric Oncology and Hematology, Moscow, Russia
| | - Myriam Labopin
- EBMT Paris study office, Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
| | - Gianluigi Mancardi
- Department of Neuroscience, University of Genova and Clinical Scientific Institutes Maugeri, Genoa, Italy
| | - Roland Martin
- Neuroimmunology and MS Research, Neurology Clinic, University Hospital, Zurich, Switzerland
| | - John Moore
- Haematology Department, St. Vincent's Health Network, Darlinghurst, NSW, Australia
| | - Paolo A Muraro
- Department of Brain Sciences, Imperial College London, London, UK
| | - Montserrat Rovira
- BMT Unit, Department of Hematology, IDIBAPS, Hospital Clinic, Institut Josep Carreras, Barcelona, Spain
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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Huang H, Chen L, Mao G, Sharma HS. Clinical neurorestorative cell therapies: Developmental process, current state and future prospective. JOURNAL OF NEURORESTORATOLOGY 2020. [DOI: 10.26599/jnr.2020.9040009] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Clinical cell therapies (CTs) for neurological diseases and cellular damage have been explored for more than 2 decades. According to the United States Food and Drug Administration, there are 2 types of cell categories for therapy, namely stem cell-derived CT products and mature/functionally differentiated cell-derived CT products. However, regardless of the type of CT used, the majority of reports of clinical CTs from either small sample sizes based on single-center phase 1 or 2 unblinded trials or retrospective clinical studies showed effects on neurological improvement and the ability to either partially or temporarily thwart the deteriorating cellular processes of the neurodegenerative diseases. There have been only a few prospective, multicenter, randomized, double- blind placebo-control clinical trials of CTs so far in this developing novel area that have shown negative results, and more clinical trials are needed. This will expand our knowledge in exploring the type of cells that yield promising results and restore damaged neurological structure and functions of the central nervous system based on higher level evidence-based medical data. In this review, we briefly introduce the developmental process, current state, and future prospective for clinical neurorestorative CT.
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Kvistad SAS, Lehmann AK, Trovik LH, Kristoffersen EK, Bø L, Myhr KM, Torkildsen Ø. Safety and efficacy of autologous hematopoietic stem cell transplantation for multiple sclerosis in Norway. Mult Scler 2019; 26:1889-1897. [DOI: 10.1177/1352458519893926] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Hematopoietic stem cell treatment (HSCT) is a promising treatment option for multiple sclerosis (MS), but detailed safety and efficacy measures are still scarce. Objective: To evaluate the efficacy and safety of HSCT in MS. Methods: Retrospective single-center observational study of all MS patients that underwent HSCT in Norway during January 2015 to January 2018. The primary outcome was no evidence of disease activity (NEDA-3) status. Results: A total of 30 patients with a median follow-up time of 26 months (range: 11–48) were evaluated. In total, 25 (83%) achieved NEDA-3 status, and none received disease-modifying treatment after HSCT. For 13 (43%) of the patients, there were sustained improvement in Expanded Disability Status Scale (EDSS) score, and 10 (33%) were working full time after the treatment, compared to only 1 (3%) before treatment. There were no serious treatment-related complications and was no mortality. Five patients (17%) were diagnosed with an autoimmune thyroid disease after the procedure, and 10 (43%) of the women had amenorrhea lasting >12 months and symptoms of ovarian failure. Conclusion: HSCT in MS is an effective and relatively safe treatment option, with few serious complications and no mortality in Norway, so far. However, long-term adverse event with amenorrhea is a common problem.
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Affiliation(s)
- Silje Agnethe Stokke Kvistad
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway/Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | | | | | - Lars Bø
- Norwegian Multiple Sclerosis Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway/Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway/Norwegian Multiple Sclerosis Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway/Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
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50
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Tolf A, Fagius J, Carlson K, Åkerfeldt T, Granberg T, Larsson E, Burman J. Sustained remission in multiple sclerosis after hematopoietic stem cell transplantation. Acta Neurol Scand 2019; 140:320-327. [PMID: 31297793 DOI: 10.1111/ane.13147] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/24/2019] [Accepted: 07/03/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To determine whether treatment with autologous hematopoietic stem cell transplantation (HSCT) can induce sustained complete remission in patients with multiple sclerosis (MS). MATERIAL AND METHODS Case series of patients with relapsing-remitting MS (n = 10) treated at a single center between 2004 and 2007 and followed up for 10 years. The patients were treated with a BEAM/ATG conditioning regimen (n = 9) or a cyclophosphamide/ATG conditioning regimen (n = 1) followed by infusion of unmanipulated autologous hematopoietic stem cells. The primary endpoint was sustained complete remission. Sustained complete remission was defined as "no evidence of disease activity-4," sustained for a period of at least 5 years without any ongoing disease-modifying treatment. Furthermore, MS was considered as "resolved" if intrathecal IgG production and cerebrospinal fluid neurofilament light levels were normalized as well. RESULTS Five out of 10 patients were in sustained complete remission at the end of the study. In three of them, MS was resolved. CONCLUSIONS Our data demonstrate that sustained complete remission after autologous HSCT for MS is possible.
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Affiliation(s)
- Andreas Tolf
- Department of Neuroscience Uppsala University Uppsala Sweden
| | - Jan Fagius
- Department of Neuroscience Uppsala University Uppsala Sweden
| | - Kristina Carlson
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Torbjörn Åkerfeldt
- Section of Clinical Chemistry and Pharmacology Uppsala University Hospital Uppsala Sweden
| | - Tobias Granberg
- Department of Clinical Neuroscience Karolinska Institutet Stockholm Sweden
- Division of Neuroradiology, Department of Radiology Karolinska University Hospital Stockholm Sweden
| | - Elna‐Marie Larsson
- Department of Surgical Sciences/Radiology Uppsala University Uppsala Sweden
| | - Joachim Burman
- Department of Neuroscience Uppsala University Uppsala Sweden
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