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Kumar PA, Wazir A, Pu JJ. Resolution of Chronic Immune Thrombocytopenia Purpura after Autologous Hematopoietic Stem Cell Transplantation for Diffuse Large B-Cell Lymphoma. J Med Cases 2021; 12:37-40. [PMID: 33391580 PMCID: PMC7771832 DOI: 10.14740/jmc3607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) is a hematological disorder characterized by immune-mediated destruction of platelets that could be triggered by a number of causes. ITPs are usually treated with steroid, immunomodulators or immunosuppressors, and intravenous immunoglobulin therapy though refractory/relapsed status frequently occurs. It was suggested that autologous hematopoietic stem cell transplant (HSCT) after high-dose chemotherapy conditioning might improve ITP patients’ peripheral blood platelet counts via reorganizing disrupted immune balance in the hematopoietic and hematologic systems. In this case report, we describe how a patient, who suffered from both severe thrombocytopenia due to chronic ITP and refractory/relapsed diffuse large B-cell lymphoma (DLBCL), was managed to successfully receive autologous HSCT using carmustine, etoposide, cytarabine and melphalan (BEAM) conditioning regimens and how his chronic ITP was eventually cured after receiving autologous HSCT. This is the first clinical case in the world demonstrating that high-dose BEAM chemotherapy conditioned autologous HSCT could cure chronic ITP while successfully managing refractory/relapse DLBCL. The clinical hematology professionals and the patients will benefit from our experience in managing severe thrombocytopenia while conducting high-dose chemotherapy conditioning and autologous HSCT for DLBCL.
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Affiliation(s)
- Prashanth A Kumar
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA.,The authors equally contributed to this manuscript
| | - Ali Wazir
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA.,The authors equally contributed to this manuscript
| | - Jeffrey J Pu
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA
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2
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Evans' Syndrome: From Diagnosis to Treatment. J Clin Med 2020; 9:jcm9123851. [PMID: 33260979 PMCID: PMC7759819 DOI: 10.3390/jcm9123851] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 12/13/2022] Open
Abstract
Evans' syndrome (ES) is defined as the concomitant or sequential association of warm auto-immune haemolytic anaemia (AIHA) with immune thrombocytopenia (ITP), and less frequently autoimmune neutropenia. ES is a rare situation that represents up to 7% of AIHA and around 2% of ITP. When AIHA and ITP occurred concomitantly, the diagnosis procedure must rule out differential diagnoses such as thrombotic microangiopathies, anaemia due to bleedings complicating ITP, vitamin deficiencies, myelodysplastic syndromes, paroxysmal nocturnal haemoglobinuria, or specific conditions like HELLP when occurring during pregnancy. As for isolated auto-immune cytopenia (AIC), the determination of the primary or secondary nature of ES is important. Indeed, the association of ES with other diseases such as haematological malignancies, systemic lupus erythematosus, infections, or primary immune deficiencies can interfere with its management or alter its prognosis. Due to the rarity of the disease, the treatment of ES is mostly extrapolated from what is recommended for isolated AIC and mostly relies on corticosteroids, rituximab, splenectomy, and supportive therapies. The place for thrombopoietin receptor agonists, erythropoietin, immunosuppressants, haematopoietic cell transplantation, and thromboprophylaxis is also discussed in this review. Despite continuous progress in the management of AIC and a gradual increase in ES survival, the mortality due to ES remains higher than the ones of isolated AIC, supporting the need for an improvement in ES management.
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Hawsawi YM, Al-Zahrani F, Mavromatis CH, Baghdadi MA, Saggu S, Oyouni AAA. Stem Cell Applications for Treatment of Cancer and Autoimmune Diseases: Its Promises, Obstacles, and Future Perspectives. Technol Cancer Res Treat 2019; 17:1533033818806910. [PMID: 30343639 PMCID: PMC6198389 DOI: 10.1177/1533033818806910] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Since the original discovery of stem cells, a new era of promising results has emerged in the clinical application of stem cells for the treatment of several important diseases, including cancer and autoimmune diseases. The plentiful research on stem cells during the past decades has provided significant information on the developmental, morphological, and physiological processes that govern tissue and organ formation, maintenance, and regeneration; cellular differentiation; molecular processes; and tissue homeostasis. In this review, we present the history of the use of stem cells in different clinical applications. Furthermore, we discuss the various therapeutic options for stem cells in cancer, followed by the role of stem cells in the treatment of autoimmune disorders. Additionally, we highlight the risks of and obstacles to the application of stem cells in clinical practice. Ultimately, we show future perspectives in stem cell use, with an aim to improve the clinical usefulness of stem cells.
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Affiliation(s)
- Yousef M Hawsawi
- 1 Department of Genetics, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.,2 Department of Biological Sciences, Faculty of Science and Arts, King Abdulaziz University, Rabigh, Kingdom of Saudi Arabia.,3 Department of Epidemiology and Biostatistics, King Faisal Specialist Hospital and Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Faisal Al-Zahrani
- 2 Department of Biological Sciences, Faculty of Science and Arts, King Abdulaziz University, Rabigh, Kingdom of Saudi Arabia
| | - Charalampos Harris Mavromatis
- 2 Department of Biological Sciences, Faculty of Science and Arts, King Abdulaziz University, Rabigh, Kingdom of Saudi Arabia
| | - Mohammed A Baghdadi
- 1 Department of Genetics, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.,3 Department of Epidemiology and Biostatistics, King Faisal Specialist Hospital and Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Shalini Saggu
- 4 Department of Biology, Faculty of Sciences, University of Tabuk, Tabuk, Kingdom of Saudi Arabia
| | - Atif Abdulwahab A Oyouni
- 4 Department of Biology, Faculty of Sciences, University of Tabuk, Tabuk, Kingdom of Saudi Arabia
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4
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Jaime-Pérez JC, Aguilar-Calderón PE, Salazar-Cavazos L, Gómez-Almaguer D. Evans syndrome: clinical perspectives, biological insights and treatment modalities. J Blood Med 2018; 9:171-184. [PMID: 30349415 PMCID: PMC6190623 DOI: 10.2147/jbm.s176144] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Evans syndrome (ES) is a rare and chronic autoimmune disease characterized by autoimmune hemolytic anemia and immune thrombocytopenic purpura with a positive direct anti-human globulin test. It is classified as primary and secondary, with the frequency in patients with autoimmune hemolytic anemia being 37%–73%. It predominates in children, mainly due to primary immunodeficiencies or autoimmune lymphoproliferative syndrome. ES during pregnancy is associated with high fetal morbidity, including severe hemolysis and intracranial bleeding with neurological sequelae and death. The clinical presentation can include fatigue, pallor, jaundice and mucosal bleeding, with remissions and exacerbations during the person’s lifetime, and acute manifestations as catastrophic bleeding and massive hemolysis. Recent molecular theories explaining the physiopathology of ES include deficiencies of CTLA-4, LRBA, TPP2 and a decreased CD4/CD8 ratio. As in other autoimmune cytopenias, there is no established evidence-based treatment and steroids are the first-line therapy, with intravenous immunoglobulin administered as a life-saving resource in cases of severe immune thrombocytopenic purpura manifestations. Second-line treatment for refractory ES includes rituximab, mofetil mycophenolate, cyclosporine, vincristine, azathioprine, sirolimus and thrombopoietin receptor agonists. In cases unresponsive to immunosuppressive agents, hematopoietic stem cell transplantation has been successful, although it is necessary to consider its potential serious adverse effects. In conclusion, ES is a disease with a heterogeneous course that remains challenging to patients and physicians, with prospective clinical trials needed to explore potential targeted therapy to achieve an improved long-term response or even a cure.
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Affiliation(s)
- José Carlos Jaime-Pérez
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - Patrizia Elva Aguilar-Calderón
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - Lorena Salazar-Cavazos
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - David Gómez-Almaguer
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
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5
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Ozelo MC, Colella MP, de Paula EV, do Nascimento ACKV, Villaça PR, Bernardo WM. Guideline on immune thrombocytopenia in adults: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. Project guidelines: Associação Médica Brasileira - 2018. Hematol Transfus Cell Ther 2018; 40:50-74. [PMID: 30057974 PMCID: PMC6001928 DOI: 10.1016/j.htct.2017.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 11/29/2017] [Indexed: 02/07/2023] Open
Affiliation(s)
| | | | | | | | - Paula Ribeiro Villaça
- Universidade de São Paulo, Faculdade de Medicina Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Wanderley Marques Bernardo
- Universidade de São Paulo, Faculdade de Medicina Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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6
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Thompson RW, Gungor A. Immune thrombocytopenia of childhood responsive to tonsillectomy in the setting of chronic tonsillitis: A case report and literature review. Am J Otolaryngol 2017. [PMID: 28648251 DOI: 10.1016/j.amjoto.2016.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Immune thrombocytopenia of childhood (platelet count <100,000/μL) is the most common cause of thrombocytopenia in children. Patients typically present with bruising and bleeding in the setting of thrombocytopenia. Although it is usually short-lived, some cases persist and are unresponsive to treatment. This can lead to exposure to a variety of treatment regimens including immunosuppressants and splenectomy. The goal of this report is to present a case of chronic ITP of childhood that responded to tonsillectomy addressing the tonsils as a source of chronic infection and inflammation triggering ITP. METHODS A 4-year-old male with ITP of childhood presented with enlarged tonsils and obstructive sleep apnea. History and physical were consistent with chronic tonsillitis/adenoiditis including malaise, poor oral intake, congestion, rhinorrhea, tonsil hypertrophy, and lymphadenopathy persisting despite antibiotic therapy. Tonsillectomy and adenoidectomy were performed. RESULTS One, six, and eighteen weeks post-operatively the platelet count was 371, 215, and 205 respectively. Although at 12months two relapses had occurred, during the observed period, he had decreased incidence and severity of disease. CONCLUSION In around 60% of ITP there is a history of prior infection within the last month but no systemic symptoms at time of diagnosis. Additionally, chronic ITP is characterized by relapses coinciding with infection. This case is unique because the patient had chronic ITP and a clinical history and physical exam concerning for a subclinical, indolent inflammatory process that responded to surgical intervention. Given that chronic ITP exacerbation has been associated with recurrent acute infections it seems probable that chronic tonsillitis could serve as a trigger for relapse or contribute to a prolonged and/or more severe disease course. Therefore, tonsillectomy may result in earlier treatment and/or an altered disease course with avoidance of the expense and morbidity associated with frequent exacerbations and multiple treatment regimens.
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Affiliation(s)
- Richard William Thompson
- Lousiana State University Health-Shreveport, Department of Otolaryngology/Head and Neck Surgery-Pediatric ENT, Shreveport, LA, USA.
| | - Anil Gungor
- Lousiana State University Health-Shreveport, Department of Otolaryngology/Head and Neck Surgery-Pediatric ENT, Shreveport, LA, USA
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7
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Hill QA, Stamps R, Massey E, Grainger JD, Provan D, Hill A. Guidelines on the management of drug-induced immune and secondary autoimmune, haemolytic anaemia. Br J Haematol 2017; 177:208-220. [PMID: 28369704 DOI: 10.1111/bjh.14654] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | | | - John D Grainger
- Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Drew Provan
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
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8
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Moukhadder HM, Chaya BF, Bazarbachi AHA, Taher AT. Immune thrombocytopenia: a comprehensive review from pathophysiology to promising treatment modalities. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1247691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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9
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How I treat refractory immune thrombocytopenia. Blood 2016; 128:1547-54. [DOI: 10.1182/blood-2016-03-603365] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 04/04/2016] [Indexed: 01/19/2023] Open
Abstract
Abstract
This article summarizes our approach to the management of children and adults with primary immune thrombocytopenia (ITP) who do not respond to, cannot tolerate, or are unwilling to undergo splenectomy. We begin with a critical reassessment of the diagnosis and a deliberate attempt to exclude nonautoimmune causes of thrombocytopenia and secondary ITP. For patients in whom the diagnosis is affirmed, we consider observation without treatment. Observation is appropriate for most asymptomatic patients with a platelet count of 20 to 30 × 109/L or higher. We use a tiered approach to treat patients who require therapy to increase the platelet count. Tier 1 options (rituximab, thrombopoietin receptor agonists, low-dose corticosteroids) have a relatively favorable therapeutic index. We exhaust all Tier 1 options before proceeding to Tier 2, which comprises a host of immunosuppressive agents with relatively lower response rates and/or greater toxicity. We often prescribe Tier 2 drugs not alone but in combination with a Tier 1 or a second Tier 2 drug with a different mechanism of action. We reserve Tier 3 strategies, which are of uncertain benefit and/or high toxicity with little supporting evidence, for the rare patient with serious bleeding who does not respond to Tier 1 and Tier 2 therapies.
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10
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Vaughn JE, Anwer F, Deeg HJ. Treatment of refractory ITP and Evans syndrome by haematopoietic cell transplantation: is it indicated, and for whom? Vox Sang 2015; 110:5-11. [PMID: 26178735 DOI: 10.1111/vox.12314] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 05/27/2015] [Accepted: 05/28/2015] [Indexed: 12/13/2022]
Abstract
Several lines of therapy have been established for patients with immune thrombocytopenia (ITP) and Evans syndrome. However, these therapies generally require prolonged administration, lead to profound immunosuppression and increased infectious risk, and are often poorly tolerated. While most patients with these disorders will respond to first-line steroid therapy, others will prove refractory or intolerant to multiple treatments. In these patients (and possibly even selected patients who are not considered refractory), autologous or allogeneic haematopoietic stem cell transplantation (HCT) may provide definitive therapy. We review the literature on the treatment of ITP and Evans syndrome with HCT and discuss its use in the management of these disorders. We also pose, for the purpose of discussion, research questions that will be important to address if HCT is to be considered a viable option for more patients with these diseases.
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Affiliation(s)
- J E Vaughn
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - F Anwer
- University of Arizona Cancer Center, Tucson, AZ, USA
| | - H J Deeg
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
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11
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Severe Refractory Immune Thrombocytopenia Successfully Treated with High-Dose Pulse Cyclophosphamide and Eltrombopag. Case Rep Hematol 2015; 2015:583451. [PMID: 26180646 PMCID: PMC4477130 DOI: 10.1155/2015/583451] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/03/2015] [Indexed: 12/29/2022] Open
Abstract
Severe refractory ITP is clinically challenging and a variety of single or combination chemotherapies have been tried with limited outcome. We report a case of ITP that was unresponsive to multiple agents including high-dose steroid, IVIG, Rho(D) immune globulin, rituximab, cyclosporine, azathioprine, vincristine, mycophenolate mofetil, romiplostim, and eltrombopag; however, it achieved complete remission with combination treatment of cyclophosphamide and eltrombopag.
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12
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Affiliation(s)
- Adam J Mead
- Department of Haematology, St Bartholomew's and the Royal London School of Medicine and Dentistry, London, UK.
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13
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Rabusin M, Snowden J, Veys P, Quartier P, Dalle JH, Dhooge C, Di Bartolomeo P, Gonzalez-Vicent M, Gibson B, Iriondo A, Juergens H, Lisukov I, Messina C, Mialou V, Steward CG, Urban C, Renard M, Giurici N, Peters C, Badoglio M, Ronfani L, Dini G, Farge D, Saccardi R. Long-Term Outcomes of Hematopoietic Stem Cell Transplantation for Severe Treatment-Resistant Autoimmune Cytopenia in Children. Biol Blood Marrow Transplant 2013; 19:666-9. [DOI: 10.1016/j.bbmt.2012.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 12/11/2012] [Indexed: 12/29/2022]
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14
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Snowden JA, Saccardi R, Allez M, Ardizzone S, Arnold R, Cervera R, Denton C, Hawkey C, Labopin M, Mancardi G, Martin R, Moore JJ, Passweg J, Peters C, Rabusin M, Rovira M, van Laar JM, Farge D. Haematopoietic SCT in severe autoimmune diseases: updated guidelines of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 2012; 47:770-90. [PMID: 22002489 PMCID: PMC3371413 DOI: 10.1038/bmt.2011.185] [Citation(s) in RCA: 212] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 07/04/2011] [Accepted: 07/04/2011] [Indexed: 12/13/2022]
Abstract
In 1997, the first consensus guidelines for haematopoietic SCT (HSCT) in autoimmune diseases (ADs) were published, while an international coordinated clinical programme was launched. These guidelines provided broad principles for the field over the following decade and were accompanied by comprehensive data collection in the European Group for Blood and Marrow Transplantation (EBMT) AD Registry. Subsequently, retrospective analyses and prospective phase I/II studies generated evidence to support the feasibility, safety and efficacy of HSCT in several types of severe, treatment-resistant ADs, which became the basis for larger-scale phase II and III studies. In parallel, there has also been an era of immense progress in biological therapy in ADs. The aim of this document is to provide revised and updated guidelines for both the current application and future development of HSCT in ADs in relation to the benefits, risks and health economic considerations of other modern treatments. Patient safety considerations are central to guidance on patient selection and HSCT procedural aspects within appropriately experienced and Joint Accreditation Committee of International Society for Cellular Therapy and EBMT accredited centres. A need for prospective interventional and non-interventional studies, where feasible, along with systematic data reporting, in accordance with EBMT policies and procedures, is emphasized.
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Affiliation(s)
- J A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
- Department of Oncology, University of Sheffield, Sheffield, UK
| | - R Saccardi
- Department of Haematology, Careggi University Hospital, Firenze, Italy
| | - M Allez
- Service de Gastroentérologie, INSERM U 662, Hôpital St Louis, Paris, France
| | - S Ardizzone
- Department of Gastroenterology, Sacco University Hospital, Milan, Italy
| | - R Arnold
- Charite Hospital Berlin, Berlin, Germany
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - C Denton
- Centre for Rheumatology, Royal Free and University College Medical School, Hampstead, London, UK
| | - C Hawkey
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - M Labopin
- Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, AP-HP, UPMC Univ Paris 06, Paris, France
| | - G Mancardi
- Department of Neuroscience, Ophthalmology and Genetics, University of Genova, Genova, Italy
| | - R Martin
- Institute for Neuroimmunology and Clinical MS Research, Hamburg, Germany
| | - J J Moore
- St Vincent's Hospital, Sydney, NSW, Australia
| | - J Passweg
- Universitaetsspital Basel, Basel, Switzerland
| | - C Peters
- BMT Unit, St Anna Children's Hospital, Vienna, Austria
| | - M Rabusin
- BMT Unit, Department of Pediatrics, Institute of Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - M Rovira
- SCT Unit, Hematology Department, Hospital Clinic, Barcelona, Spain
| | | | - D Farge
- Department of Internal Medicine, INSERM U 796, Hôpital St Louis, Paris, France
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15
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Diagnosis and Management of Immune Thrombocytopenia in the Era of Thrombopoietin Mimetics. Hematology 2011; 2011:384-90. [DOI: 10.1182/asheducation-2011.1.384] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Abstract
The recognition of that patients with Immune Thrombocytopenia (ITP) have functional thrombopoietin deficiency and decreased platelet production due to immune-mediated megakaryocytic injury has challenged the traditional view of this disease as predominantly a disorder of antibody-mediated platelet destruction. The therapy of chronic refractory ITP has been transformed by the approval of the thrombopoietin minetics, romiplostim and eltrombopag, which have shown remarkable efficacy in randomized trials. The use of these agents earlier in the disease course after failure of corticosteroid therapy remains controversial. In this article, we review the current data on the efficacy and safety of thrombopoietin receptor agonists and discuss other therapies as well as diagnostic work up of ITP.
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16
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Fang B, Mai L, Li N, Song Y. Favorable response of chronic refractory immune thrombocytopenic purpura to mesenchymal stem cells. Stem Cells Dev 2011; 21:497-502. [PMID: 21711157 DOI: 10.1089/scd.2011.0231] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Seven patients with chronic refractory immune thrombocytopenic purpura (ITP) received adipose tissue-derived mesenchymal stem cells (AMSC) from haplo-identical family donors. The AMSC dose was 2.0×10(6)/kg. No side effects were noted after the AMSC infusions. Overall responses were reached in all patients and sustained response rate was 57.1% (4/7). The serum levels of transforming growth factor β1 (TGF-β1), interleukin (IL)-4, and IL-10 were significantly elevated, whereas those of interferon-γ (IFN-γ) and IL-2 were significantly decreased after AMSC administration, compared with those in the patients with active ITP. During follow-up, the cytokine profiles in patients maintaining sustained response remained stable compared with the post-treatment level, but IFN-γ and IL-2 levels were significantly increased, and those of TGF-β1, IL-4, and IL-10 were significantly reduced again in relapsed patients. AMSC therapy seems to represent reasonable salvage treatment in severe, chronic refractory ITP by causing a shift in the Th1/Th2 cytokine balance to the same levels as normal controls.
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Affiliation(s)
- Baijun Fang
- Henan Key Laboratory of Experimental Haematology, Henan Institute of Haematology, Henan Tumor Hospital, Zhengzhou University, Zhengzhou, China
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17
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Lodi D, Iannitti T, Palmieri B. Stem cells in clinical practice: applications and warnings. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2011; 30:9. [PMID: 21241480 PMCID: PMC3033847 DOI: 10.1186/1756-9966-30-9] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 01/17/2011] [Indexed: 12/11/2022]
Abstract
Stem cells are a relevant source of information about cellular differentiation, molecular processes and tissue homeostasis, but also one of the most putative biological tools to treat degenerative diseases. This review focuses on human stem cells clinical and experimental applications. Our aim is to take a correct view of the available stem cell subtypes and their rational use in the medical area, with a specific focus on their therapeutic benefits and side effects. We have reviewed the main clinical trials dividing them basing on their clinical applications, and taking into account the ethical issue associated with the stem cell therapy.
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Affiliation(s)
- Daniele Lodi
- Department of Nephrology, Dialysis and Transplantation, University of Modena and Reggio Emilia Medical School, Modena, Italy
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18
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Toltl LJ, Arnold DM. Pathophysiology and management of chronic immune thrombocytopenia: focusing on what matters. Br J Haematol 2010; 152:52-60. [PMID: 21083652 DOI: 10.1111/j.1365-2141.2010.08412.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is a common autoimmune disease characterized by low platelet counts and an increased risk of bleeding. Antibody-mediated platelet destruction has been the prevailing hypothesis to explain ITP pathogenesis, supported by the efficacy of B-cell depletion therapy; however, the recent success of thrombopoietin receptor agonists lends support to the notion that platelet production is also insufficient. Best practice for the management of chronic ITP has not yet been established because data from comparative trials are lacking. Despite renewed interest in novel drugs capable of increasing platelet counts, ultimate treatment goals for ITP patients must be kept in mind: to improve patients' health and well-being. In this article, the pathophysiology of ITP is reviewed and key remaining questions about mechanism are explored. A rational approach to the management of ITP in adults is outlined, acknowledging evidence and evidence gaps, and highlighting the need for clinically important endpoints in future clinical trials.
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Affiliation(s)
- Lisa J Toltl
- Department of Medicine, Michael DeGroote School of Medicine, McMaster University Canadian Blood Services, 1200 Main Street West, Hamilton, Ontario, Canada
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19
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Palau J, Jarque I, Sanz MA. Long-term management of chronic immune thrombocytopenic purpura in adults. Int J Gen Med 2010; 3:305-11. [PMID: 21042569 PMCID: PMC2962326 DOI: 10.2147/ijgm.s4722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Chronic immune thrombocytopenic purpura (ITP) is generally a more benign disease than previously thought. Currently it is recommended that only those patients with severe and/or symptomatic thrombocytopenia definitely require treatment. Additional factors, such as age, lifestyle, and uremia can also influence the hemorrhagic risk and should be carefully assessed before decision-making on the appropriate management of patients with less severe forms of ITP. The recent introduction of new classes of therapeutic agents such as rituximab and the thrombopoietic growth factors has had a major impact on the management of ITP. Updated treatment guidelines have recently been made available but they are based largely on expert opinion rather than on high-quality clinical trial evidence. This structured review is focused on the management of adults with chronic ITP, including the use of new classes of agents.
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Affiliation(s)
- Javier Palau
- Department of Hematology, Hospital, Universitario La Fe, Valencia, Spain.
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Benesch M, Urban C, Platzbecker U, Passweg J. Stem cell transplantation for patients with Evans syndrome. Expert Rev Clin Immunol 2010; 5:341-8. [PMID: 20477011 DOI: 10.1586/eci.09.9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Evans syndrome (ES) is a chronic hematological disorder characterized by autoimmune hemolytic anemia and immune-mediated thrombocytopenia that often requires profound and long-term immunosuppression. Only a few small case series or single case studies of autologous and allogeneic hematopoietic stem cell transplantation (HSCT) in patients with ES have been reported in the literature, with long-term remissions being observed after both autologous and allogeneic HSCT. Patients with ES suffering from refractory disease, multiple relapses and serious disease-related complications should be offered allogeneic HSCT, which is the only treatment with curative potential. Autologous HSCT might be preferable in patients with serious pre-existing comorbidities lacking an HLA-identical donor. Owing to the rarity of this disease and the small number of patients receiving HSCT for ES, prospective controlled studies on this approach are not available. A prospective registration of patients transplanted for ES would allow the development of optimal transplant strategies.
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Affiliation(s)
- Martin Benesch
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 30, A-8036 Graz, Austria.
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Bussel JB. Traditional and new approaches to the management of immune thrombocytopenia: issues of when and who to treat. Hematol Oncol Clin North Am 2010; 23:1329-41. [PMID: 19932437 DOI: 10.1016/j.hoc.2009.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Diagnosis and management of chronic ITP requires experience and the appropriate use of the laboratory despite the absence of a diagnostic test for ITP. Consideration of secondary ITP is important because identification of immunodeficiency infections or of lymphoproliferative disorders would change the management approach to a given patient. The development of newer therapies such as rituximab and the thrombopoietic agents has had a major impact on the management of ITP. In the future, combinations of agents may be a critical approach although the schedule and dosing remains difficult to establish. Finally, current studies to augment therapy in newly diagnosed ITP patients to prevent chronic disease may lessen the number of patients in chronic disease category.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, Weill Medical College of Cornell University, 525 E 68th Street, P695, New York, NY 10065, USA.
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Chihara D, Sakamoto T, Arimoto-Miyamoto K, Kishimoto W, Takeoka T, Tsuji M, Ohno T. Refractory Evans syndrome after autologous stem cell transplantation for multiple myeloma: management with a second transplantation. Intern Med 2010; 49:683-7. [PMID: 20371959 DOI: 10.2169/internalmedicine.49.2922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The development of autoimmune disease after autologous stem cell transplantation (ASCT) is very rare in multiple myeloma (MM). We describe the first case of Evans syndrome after ASCT for MM. A 60-year-old man with MM received ASCT and subsequently developed Evans syndrome following two febrile episodes. The syndrome was refractory to conventional therapies but it was managed with a second ASCT. This unique complication was thought to have been triggered by an infection during the recovery of the immune system. We assumed that reconstructing the immune system via ASCT might eliminate infection-induced autoantibodies to platelets and erythrocytes.
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Affiliation(s)
- Dai Chihara
- Division of Hematology and Immunology, Department of Internal Medicine, Ohtsu Red Cross Hospital, Ohtsu
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International consensus report on the investigation and management of primary immune thrombocytopenia. Blood 2009; 115:168-86. [PMID: 19846889 DOI: 10.1182/blood-2009-06-225565] [Citation(s) in RCA: 1219] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Previously published guidelines for the diagnosis and management of primary immune thrombocytopenia (ITP) require updating largely due to the introduction of new classes of therapeutic agents, and a greater understanding of the disease pathophysiology. However, treatment-related decisions still remain principally dependent on clinical expertise or patient preference rather than high-quality clinical trial evidence. This consensus document aims to report on new data and provide consensus-based recommendations relating to diagnosis and treatment of ITP in adults, in children, and during pregnancy. The inclusion of summary tables within this document, supported by information tables in the online appendices, is intended to aid in clinical decision making.
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Passweg JR, Rabusin M. Hematopoetic stem cell transplantation for immune thrombocytopenia and other refractory autoimmune cytopenias. Autoimmunity 2009; 41:660-5. [DOI: 10.1080/08916930802198436] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Resolution of Refractory Chronic Autoimmune Thrombocytopenic Purpura Following Mesenchymal Stem Cell Transplantation: A Case Report. Transplant Proc 2009; 41:1827-30. [DOI: 10.1016/j.transproceed.2008.12.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2008] [Accepted: 12/02/2008] [Indexed: 01/14/2023]
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Abstract
PURPOSE OF REVIEW To summarize recent evidence and current trends in the use of haematopoietic stem cell transplantation (HSCT) for autoimmune diseases. RECENT FINDINGS Updates of published trials and data from the registries indicate a long-lasting, immunosuppression-free condition in about 50% of the patients who underwent an HSCT for a severe, progressive autoimmune disease. For all diseases, autologous HSCT is largely preferred for safety reasons, whereas allogeneic HSCT is to be considered only for carefully selected cases. Transplant-related mortality (TRM) has decreased in the past 5 years, due to both better selection of patients and the use of less intensive conditioning regimens. The most employed conditioning regimens in Europe are BCNU (carmustine), etoposide, ARA-C (cytosine arabinoside), M (melphalan) (BEAM)/anti-thymocyte globulin in multiple sclerosis and high-dose cyclophosphamide/anti-thymocyte globulin for all other diseases, with a trend for more intense regimens in North America. Multiple sclerosis and systemic sclerosis are currently the most frequent diagnoses. Prospective comparative trials are currently ongoing both in Europe and North America. SUMMARY Recent reports confirm the evidence that HSCT is able to induce a high rate of sustained remissions in most severe autoimmune diseases, unresponsive to conventional treatments. Valuable information is expected by the finalization of the ongoing prospective, comparative trials.
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Burzynski J. New options after first-line therapy for chronic immune thrombocytopenic purpura. Am J Health Syst Pharm 2009; 66:S11-21. [DOI: 10.2146/ajhp080493] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Julianna Burzynski
- Hematology/Oncology, Mayo Clinic, 200 First Southwest, Rochester, MN 55905
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Godeau B, Bierling P. [Treatment of idiopathic thrombocytopenic purpura in adults]. Presse Med 2008; 37:1292-8. [PMID: 18644317 DOI: 10.1016/j.lpm.2008.01.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Accepted: 01/07/2008] [Indexed: 11/30/2022] Open
Abstract
The lack of controlled studies of the treatment of idiopathic thrombocytopenic purpura (ITP), also known as immune thrombocytopenic purpura, means that no evidence-based recommendations are available. ITP is a benign disease and severe hemorrhages are rare. Oral prednisone remains the first-line treatment. In patients with very low platelet counts and significant bleeding, intravenous immunoglobulins and high-dose oral dexamethasone may be an alternative. A validated bleeding score would help physicians use these treatments more effectively. Splenectomy remains the best curative treatment for adults with chronic ITP and platelet counts <30 x 10(9)/L after failure of the first-line treatments. Rituximab is probably the single most effective agent, as well as the least toxic, when splenectomy fails: the short-term response rate is 50% and the sustained-response rate more than 30%. Cytotoxic or other immunosuppressive agents should be reserved for patients with severe disease refractory to both splenectomy and rituximab. Thrombopoietin receptor agonists are a class of new investigational drugs for which promising results have been reported, but more data regarding long-term safety are needed.
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Affiliation(s)
- Bertrand Godeau
- Centre de référence labellisé pour la prise en charge des cytopénies auto-immunes de l'adulte, Service de médecine interne, Assistance-Publique Hôpitaux de Paris APHP, Université Paris 12, Hôpital Henri Mondor, Créteil, France.
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Deane S, Meyers FJ, Gershwin ME. On reversing the persistence of memory: Hematopoietic stem cell transplant for autoimmune disease in the first ten years. J Autoimmun 2008; 30:180-96. [DOI: 10.1016/j.jaut.2007.12.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
Immune thrombocytopenic purpura (ITP) can be classified as primary (known also as idiopathic thrombocytopenic purpura) or as secondary to an underlying condition such as a malignant or nonmalignant disorder. Commonly occurring conditions associated with secondary ITP include lymphoproliferative disorders (chronic lymphocytic leukemia [CLL], Hodgkin's disease and non-Hodgkin's lymphomas), autoimmune collagen vascular diseases (systemic lupus erythematosus [SLE], thyroid disease, antiphospholipid syndrome [APS]), and chronic infections (human immunodeficiency virus [HIV], Helicobacter pylori, hepatitis C virus [HCV]). The mechanism of platelet destruction in thrombocytopenias associated with lymphoproliferative disorders and collagen vascular diseases is identical to the autoimmune mechanism seen in primary ITP. Drug-induced thrombocytopenias are uncommon and generally resolve quickly upon drug discontinuation, but are often attributed to other causes. Platelet destruction in infection-associated ITP occurs via various mechanisms including accelerated platelet clearance due to immune complex disease as seen in HIV infection or cross-reactivity of anti-platelet glycoprotein antibodies and viral antigens in HIV, HCV, and H pylori infections (antigenic mimicry). In patients with HCV-related cirrhotic liver disease, splenic sequestration secondary to portal hypertension and decreased production of thrombopoietin may further contribute to development of thrombocytopenia. The current treatment paradigm for secondary ITP varies according to the underlying condition. Standard treatments for primary ITP (corticosteroids, IVIG, anti-D, splenectomy) are often successful in secondary ITP. In cases of ITP with H pylori and HCV infection, treatment should focus on the underlying disorder.
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Affiliation(s)
- Howard Liebman
- Hematology Section, Department of Medicine, University of Southern California-Keck School of Medicine, Division of Cancer Medicine and Blood Diseases, Los Angeles, CA.
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Abstract
PURPOSE OF REVIEW Refractory immune thrombocytopenic purpura is infrequent in children, but carries substantial morbidity and even mortality. Management of these children is controversial despite the availability of several treatment options as these strategies have not been directly compared and there are many definitions for refractory immune thrombocytopenic purpura. This review will provide an update on the pathogenesis, diagnosis and treatment options for children with severe, acute and chronic refractory immune thrombocytopenic purpura. RECENT FINDINGS Recent studies have demonstrated a number of immunologic alterations (dominant proinflammatory state, inadequate thrombopoiesis, and various B and T lymphocyte disturbances) in the pathogenesis of chronic immune thrombocytopenic purpura. New agents that target certain of these mechanisms (e.g. anti-CD20 monoclonal antibody, thrombopoietic agents) have shown promising results in recent clinical trials, primarily but not solely in adults. SUMMARY Management of refractory immune thrombocytopenic purpura often requires multiple agents that may provide only short-term benefit. Lack of clear views about the use of these medications, their unwanted side effects and an inability to specifically target a particular patient's disease all lead to frustration among patients, family and the physicians. Better understanding of pathogenesis with the availability of newer therapies with different mechanisms of effect should, however, allow improved management of these patients.
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Immunohematologic disorders. Clin Immunol 2008. [DOI: 10.1016/b978-0-323-04404-2.10062-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Rosa SB, Voltarelli JC, Chies JAB, Pranke P. The use of stem cells for the treatment of autoimmune diseases. Braz J Med Biol Res 2007; 40:1579-97. [PMID: 17713674 DOI: 10.1590/s0100-879x2006005000166] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Accepted: 07/02/2007] [Indexed: 12/13/2022] Open
Abstract
Autoimmune diseases constitute a heterogeneous group of conditions commonly treated with anti-inflammatory, immunosuppressant and immunomodulating drugs, with satisfactory results in most cases. Nevertheless, some patients become resistant to conventional therapy. The use of high doses of drugs in such cases results in the need for bone marrow reconstitution, a situation which has stimulated research into the use of hematopoietic stem cells in autoimmune disease therapy. Stem cell transplantation in such diseases aims to destroy the self-reacting immune cells and produce a new functional immune system, as well as substitute cells for tissue damaged in the course of the disease. Significant results, such as the reestablishment of tolerance and a decrease in the recurrence of autoimmune disease, have been reported following stem cell transplantation in patients with autoimmune disease in Brazil and throughout the world. These results suggest that stem cell transplantation has the potential to become an important therapeutic approach to the treatment of various autoimmune diseases including rheumatoid arthritis, juvenile idiopathic arthritis, systemic lupus erythematosus, multiple sclerosis, systemic sclerosis, Crohn's disease, autoimmune blood cytopenias, and type I diabetes mellitus.
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Affiliation(s)
- S B Rosa
- Laboratório de Hematologia, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
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35
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Arnold DM, Kelton JG. Current Options for the Treatment of Idiopathic Thrombocytopenic Purpura. Semin Hematol 2007; 44:S12-23. [DOI: 10.1053/j.seminhematol.2007.11.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Kapoor S, Wilson AG, Sharrack B, Lobo A, Akil M, Sun L, Dalley CD, Snowden JA. Haemopoietic stem cell transplantation--an evolving treatment for severe autoimmune and inflammatory diseases in rheumatology, neurology and gastroenterology. ACTA ACUST UNITED AC 2007; 12:179-91. [PMID: 17558693 DOI: 10.1080/10245330701255106] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The concept of haemopoietic stem cell transplantation (HSCT) to treat severe autoimmune diseases has been around for several decades. Advances in the safety of HSCT have made it a clinical reality since 1995. Databases have registered around a thousand patients treated specifically for a wide range of diseases, predominantly multiple sclerosis (MS), systemic sclerosis (SSc), rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Phase I/II prospective and retrospective studies have supported the potential of autologous HSCT as a treatment option in severely affected patients, with profound and prolonged clinical responses in some diseases, although procedures are generally not curative. Allogeneic HSCT appears to offer curative potential, but the potential of high toxicity has limited its use in this context. The exact role of HSCT remains to be defined, particularly in the context of other advances in the treatment of autoimmune disease. Along with other groups, the European Group for Blood and Marrow Transplantation (EBMT) are overseeing several phase III trials in autologous transplantation. Given the risks of the HSCT, eligibility is restricted to patients who have severe, treatment resistant disease, in whom the prognosis is otherwise poor. This review aims to summarise the current published data in this evolving treatment for relatively rare patients with resistant or rapidly progressive disease where treatment options are otherwise limited. This cross-fertilization of knowledge between many specialties may provide increasing therapeutic opportunities in otherwise untreatable diseases. Moreover, destroying and rebuilding immune systems may provide insights into autoimmune diseases.
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Affiliation(s)
- Sabrina Kapoor
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
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38
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Marmont AM, Gualandi F, Occhini D, Morandi F, Ferretti E, Pezzolo A, Strada P, Ravetti JL, Pistoia V, Falanga A, Bacigalupo A. Catastrophic relapse of Evans syndrome five years after allogeneic BMT notwithstanding full donor chimerism. Terminal hemolytic-uremic syndrome. Autoimmunity 2007; 39:505-11. [PMID: 17060030 DOI: 10.1080/08916930600847598] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A patient with severe Evans syndrome received an allo-BMT from his HLA-identical sister on November, 2000. Full marrow and blood donor chimerism were achieved only after 5 donor lymphocyte infusions (DLI), and coincided with complete clinical remission and disappearence of auto-antibodies. Five years later, hemolytic anemia recurred with rapid increase of serum bilirubin to over 50 mg%: he responded to combined therapy, but died on day +17 from admission of an acute hemolytic uremic syndrome (HUS). All circulating blood cells, including erythrocytes, were 100% donor. Ex vivo cultured and expanded T and B cells from the peripheral blood were also 100% donor. The supernatants from B cell cultures, containing either IgM or IgG, did not react with a panel of erythrocytes. Thus in this typical autoimmune disease with a predominant B cell pathogenesis the donor immune system resulted "innocent of autoimmunity". The persistence of long-lived recipient autoreactive plasma-cell lines in survival niches, still producing autoantibodies, may be hypothesized for this and similar cases. The postulated graft-versus-autoimmunity (GVA) effect was apparently not sufficient to eradicate autoimmunity in this patient.
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Affiliation(s)
- A M Marmont
- Division of Hematology and Stem Cell Transplantation Center, Istituto G. Gaslini, Genova, Italy.
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41
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Abstract
Idiopathic thrombocytopenic purpura (ITP) is a hematologic disorder characterized by the destruction of antibody-coated platelets in the reticuloendothelial system. Whereas 70% to 80% of children experience the acute form of the disease and recover within a few weeks or months after diagnosis, most adults have persistent disease and will require therapy. Principles of management are largely predicated on the extent of thrombocytopenia and symptoms of disease. Minimizing the toxicity associated with treatment while achieving hemostatic platelet counts are essential goals of treatment. Although there are numerous therapeutic options, neither consensus among experts nor clear algorithms to treat this complex disease exist. This article will review appropriate treatment options available for adult patients with ITP prior to splenectomy, at splenectomy, and following splenectomy. In addition to conventional agents such as corticosteroids and intravenous immune globulin (IVIg), the role of newer therapies with diverse mechanisms of action, such as rituximab, anti-D, and thrombopoietin (TPO)-like agents, will be highlighted. When used as either monotherapy or in combination with conventional therapeutics, these treatments may offer a more tolerable side effect profile and improved clinical benefit compared to existing drugs.
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Affiliation(s)
- James Bussel
- Department of Pediatrics, Division of Hematology and Oncology, and Department of Pediatrics in Medicine and in Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY 10021, USA.
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Abstract
In immune thrombocytopenic purpura (ITP), thrombocytopenia is a result of both increased platelet destruction and insufficient platelet production. In adults, the course is commonly chronic, but most patients never experience serious bleeding even with severe thrombocytopenia. In case series of consecutive adult patients identified at the time of diagnosis, the frequency of death from bleeding is low, < 1%. The goal of treatment is only to prevent bleeding, not to correct the platelet count to normal. All current treatments are designed to diminish the increased platelet destruction, either by immunosuppression or splenectomy. The frequency of death from complications of treatment is similar to the frequency of death from bleeding. Perhaps because of increasing recognition of both the infrequent occurrence of serious bleeding and the risks of immunosuppressive treatment and splenectomy, data from case series across the past 30 years suggest a trend toward less therapy and fewer splenectomies among patients with ITP. However treatment is necessary for patients with severe and symptomatic thrombocytopenia. Splenectomy remains the most effective treatment for ITP, with two-thirds of patients achieving durable complete remissions. Immunosuppressive agents, including rituximab and combinations of agents, may be less effective than splenectomy in achieving complete remissions and the remissions may also be less durable. New agents for patients with ITP are currently in development that enhance platelet production, rather than diminish platelet destruction. In preliminary reports, these agents have been effective in maintaining safe platelet counts in patients with chronic ITP that was refractory to splenectomy and other treatments.
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Affiliation(s)
- J N George
- Hematology-Oncology Section, Department of Biostatistics and Epidemiology, Colleges of Medicine and Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73190, USA.
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Lechner K, Weltermann A, Pabinger I. Autoimmunthrombozytopenie (AITP) des Erwachsenen: Klinik, Diagnose und Therapie. Wien Klin Wochenschr 2006; 118:255-64. [PMID: 16810482 DOI: 10.1007/s00508-006-0602-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The incidence of AITP is 20-30/million/year. The diagnosis is based on the finding of an isolated thrombocytopenia without other blood abnormalities and absence of a palpable spleen. Additional tests such as bone marrow examination, determination of platelet antibodies and of thrombopoetin are required only in special cases. The usual first line therapy in patients with bleeding tendency and a low platelet count is prednisolone at a dose of 1 mg/kg/day. Patients who have platelet counts of less than 20,000/microl 3-6 months after steroid therapy are candidates for splenectomy, in particular if more than 0.1 mg/kg/day prednisolone is required to keep the patient free of bleedings. Laparoscopic splenectomy has a low mortality (0.2%) and morbidity (10%). The risk of post-splenectomy overwhelming pneumococcal septicaemia can be minimized by preoperative vaccination. Older patients, who have low platelet counts after splenectomy, have a high bleeding risk. The most effective treatment options for these patients are cyclophosphamide, azathioprine and rituximab, but the choice of treatment should be carefully considered, since the risk of adverse effects may be greater than the risk of fatal bleeding.
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Affiliation(s)
- Klaus Lechner
- Abteilung Hämatologie/Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Austria.
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Urban C, Lackner H, Sovinz P, Benesch M, Schwinger W, Dornbusch HJ, Moser A. Successful unrelated cord blood transplantation in a 7-year-old boy with Evans syndrome refractory to immunosuppression and double autologous stem cell transplantation. Eur J Haematol 2006; 76:526-30. [PMID: 16529601 DOI: 10.1111/j.0902-4441.2006.t01-1-ejh2549.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Evans syndrome is an autoimmunopathy characterized by thrombocytopenia and autoimmune hemolytic anemia with poor response to immunosuppression. A 2-yr-old boy with Evans syndrome showed only short-lasting responses to immunosuppressive treatment including double autologous peripheral stem cell transplantation (SCT). Intracranial bleeding required emergency splenectomy and external ventricular drainage. Unrelated umbilical cord blood was given following conditioning with busulfan, thiotepa, etoposide and antithymocyte globulin. One year after SCT the patient shows stable blood counts without immunosuppression. This is the first child reported with Evans syndrome successfully treated by means of unrelated cord blood transplantation.
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MESH Headings
- Adrenal Cortex Hormones/adverse effects
- Adrenal Cortex Hormones/therapeutic use
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/surgery
- Cerebral Hemorrhage/etiology
- Cerebral Hemorrhage/pathology
- Child, Preschool
- Cord Blood Stem Cell Transplantation
- Danazol/therapeutic use
- Drug Resistance
- Female
- Humans
- Immunoglobulins, Intravenous/therapeutic use
- Immunosuppressive Agents/therapeutic use
- Magnetic Resonance Imaging
- Male
- Peripheral Blood Stem Cell Transplantation
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/surgery
- Remission Induction
- Splenectomy
- Transplantation Conditioning
- Transplantation, Autologous
- Transplantation, Homologous
- Vincristine/therapeutic use
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Affiliation(s)
- Christian Urban
- Division of Pediatric Hematology/Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Stasi R, Amadori S, Osborn J, Newland AC, Provan D. Long-term outcome of otherwise healthy individuals with incidentally discovered borderline thrombocytopenia. PLoS Med 2006; 3:e24. [PMID: 16401142 PMCID: PMC1326262 DOI: 10.1371/journal.pmed.0030024] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2005] [Accepted: 10/24/2005] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The long-term outcome of individuals with mild degrees of thrombocytopenia is unknown. METHODS AND FINDINGS In a prospective study conducted between August 1992 and December 2002, 260 apparently healthy individuals with incidentally discovered platelet counts between 100 x 10(9)/l and 150 x 10(9)/l were monitored for 6 mo to determine whether their condition persisted. The monitoring period was completed in 217 cases, of whom 191 (88%) maintained stable platelet counts. These 191 individuals were included in a long-term follow-up study to gain knowledge of their natural history. With a median time of observation of 64 mo, the thrombocytopenia resolved spontaneously or persisted with no other disorders becoming apparent in 64% of cases. The most frequent event during the study period was the subsequent development of an autoimmune disease. The 10-y probability of developing idiopathic thrombocytopenic purpura (ITP), as defined by platelet counts persistently below 100 x 10(9)/l, was 6.9% (95% confidence interval [CI]: 4.0%-12.0%). The 10-y probability of developing autoimmune disorders other than ITP was 12.0% (95% CI: 6.9%-20.8%). Most of the cases (85%) of autoimmune disease occurred in women. CONCLUSIONS Healthy individuals with a sustained platelet count between 100 x 10(9)/l and 150 x 10(9)/l have a 10-y probability of developing autoimmune disorders of 12%. Further investigation is required to establish whether this risk is higher than in the general population and whether an intensive follow-up results in an improvement of prognosis.
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Affiliation(s)
- Roberto Stasi
- Department of Medical Sciences, Ospedale "Regina Apostolorum," Albano Laziale, Rome, Italy.
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47
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Abstract
Evans syndrome is an uncommon condition defined by the combination (either simultaneously or sequentially) of immune thrombocytopenia (ITP) and autoimmune haemolytic anaemia (AIHA) with a positive direct antiglobulin test (DAT) in the absence of known underlying aetiology. This condition generally runs a chronic course and is characterised by frequent exacerbations and remissions. First-line therapy is usually corticosteroids and/or intravenous immunoglobulin, to which most patients respond; however, relapse is frequent. Options for second-line therapy include immunosuppressive drugs, especially ciclosporin or mycophenolate mofetil; vincristine; danazol or a combination of these agents. More recently a small number of patients have been treated with rituximab, which induces remission in the majority although such responses are often sustained for <12 months and the long-term effects in children are unclear. Splenectomy may also be considered although long-term remissions are less frequent than in uncomplicated ITP. For very severe and refractory cases stem cell transplantation (SCT) offers the only chance of long-term cure. The limited data available suggest that allogeneic SCT may be superior to autologous SCT but both carry risks of severe morbidity and of transplant-related mortality. Cure following reduced-intensity conditioning has now been reported and should be considered for younger patients in the context of controlled clinical trials.
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Affiliation(s)
- Alice Norton
- Paediatric Haematology, Department of Paediatrics, St Mary's Hospital, Paddington, London, UK
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48
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Gratwohl A, Passweg J, Bocelli-Tyndall C, Fassas A, van Laar JM, Farge D, Andolina M, Arnold R, Carreras E, Finke J, Kötter I, Kozak T, Lisukov I, Löwenberg B, Marmont A, Moore J, Saccardi R, Snowden JA, van den Hoogen F, Wulffraat NM, Zhao XW, Tyndall A. Autologous hematopoietic stem cell transplantation for autoimmune diseases. Bone Marrow Transplant 2005; 35:869-79. [PMID: 15765114 DOI: 10.1038/sj.bmt.1704892] [Citation(s) in RCA: 141] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Experimental data and early phase I/II studies suggest that high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (HSCT) can arrest progression of severe autoimmune diseases. We have evaluated the toxicity and disease response in 473 patients with severe autoimmune disease treated with autologous HSCT between 1995 and 2003, from 110 centers participating in the European Group for Blood and Marrow Transplantation (EBMT) autoimmune disease working party database. Survival, transplant-related mortality, treatment response and disease progression were assessed. In all, 420 patients (89%; 86+/-4% at 3 years, median follow-up 20 months) were alive, 53 (11%) had died from transplant-related mortality (N=31; 7+/-3% at 3 years) or disease progression (N=22; 9+/-4% at 3 years). Of 370 patients, 299 evaluable for response (81%) showed a treatment response, which was sustained in 213 (71% of responders). Response was associated with disease (P<0.001), was better in patients who received cyclophosphamide during mobilization (relative risk (RR)3.28 (1.57-6.83)) and was worse with increasing age (>40 years, RR0.29 (0.11-0.82)). Disease progression was associated with disease (P<0.001) and conditioning intensity (high intensity, RR1; intermediate intensity, RR1.81 (0.96-3.42)); low intensity, RR2.34 (1.074-5.11)). These data from the collective EBMT experience support the hypothesis that autologous HSCT can alter disease progression in severe autoimmune disease.
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49
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Abstract
Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder in which platelets coated with mainly antibodies against platelet GPIIb/IIIa and GPIb/IX are destroyed in the spleen. Recent evidence suggests that platelets are also destroyed by cytotoxic T cells. The diagnosis is made by exclusion for other causes of thrombocytopenia. As routine blood counts are becoming more available, many mild cases of ITP (platelets >30 x 10(9) L(-1)) are being diagnosed and they usually do not require treatment. In patients with platelet counts persistently <30 x 10(9) L(-1), treatment with corticosteroids, and/or intravenous immunoglobulin (IVIG) or anti-D may be required. The primary goal of treatment is to maintain the platelet count at a safe level with minimal side effects. After 3-6 months, if spontaneous remission has not occurred and if the side effects are significant, splenectomy is recommended. This is the single most effective treatment of ITP. The refractory patients who fails splenectomy and subsequently first- and second-line therapies, is a management dilemma. Therapeutic options are limited, available treatments potentially toxic and the chances of sustained response low. Observation with no active treatment is a reasonable option. With the increased availability of the thrombopoietic agents in the future, there may be a good prospect of keeping the platelet counts of these refractory patients at a safe long-term level with one of these drugs.
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Affiliation(s)
- B H Chong
- Department of Medicine, Centre of Vascular Research, St George Clinical School, University of New South Wales, NSW, Australia.
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50
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Tyndall A, Saccardi R. Haematopoietic stem cell transplantation in the treatment of severe autoimmune disease: results from phase I/II studies, prospective randomized trials and future directions. Clin Exp Immunol 2005; 141:1-9. [PMID: 15958063 PMCID: PMC1809422 DOI: 10.1111/j.1365-2249.2005.02806.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Around 700 patients have received an autologous haematopoietic stem cell transplant (HSCT) as treatment for a severe autoimmune disease (AD). The majority of these have been within the context of phase I/II clinical trials and following international guidelines proposed 7 years ago. In general, a positive benefit/risk ratio has led to phase III prospective randomized controlled trials in multiple sclerosis (MS), systemic sclerosis (SSc) and rheumatoid arthritis (RA) in Europe. In the US, similar trials are being planned for SSc, MS and systemic lupus erythematosus (SLE). Transplant related mortality (TRM) has fallen in all disease subgroups since the inception due to more appropriate patient selection, and so far a clear advantage of the more intense myeloablative regimens in terms of remission induction and relapse rate has not emerged. Although each AD has a different profile, over a third of patients have sustained a durable remission, often with no further need for immunosuppressive drugs. In those who relapsed, many responded to agents which pre transplant had been ineffective. The study of immune reconstitution and gene expression pre and post HSCT is being undertaken to further understand the mechanism of autoimmunity.
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Affiliation(s)
- A Tyndall
- Department of Rheumatology, University Hospital Basle, Basle, Switzerland.
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