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Lee WI, Chen CC, Chen SH, Lai WT, Jaing TH, Ou LS, Liang CJ, Kang CC, Huang JL. Clinical Features and Genetic Analysis of Taiwanese Primary Immunodeficiency Patients with Prolonged Diarrhea and Monogenetic Inflammatory Bowel Disease. J Clin Immunol 2023:10.1007/s10875-023-01503-w. [PMID: 37202577 DOI: 10.1007/s10875-023-01503-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/26/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE Diarrhea lasting longer than 14 days which fails to respond to conventional management is defined as severe and protracted diarrhea and might overlap with inflammatory bowel disease (IBD). METHODS The prevalence, associated pathogens, and prognosis of severe and protracted diarrhea without IBD (SD) and with monogenetic IBD (mono-IBD) in primary immunodeficiency patients (PID) were investigated in Taiwan. RESULTS A total of 301 patients were enrolled between 2003 and 2022, with predominantly pediatric-onset PID. Of these, 24 PID patients developed the SD phenotype before prophylactic treatment, including Btk (six), IL2RG (four), WASP, CD40L, gp91 (three each), gp47, RAG1 (one each), CVID (two), and SCID (one) without identified mutations. The most detectable pathogens were pseudomonas and salmonella (six each), and all patients improved after approximately 2 weeks of antibiotic and/or IVIG treatments. Six (25.0%) mortalities without HSCT implementation were due to respiratory failure from interstitial pneumonia (3 SCID and 1 CGD), intracranial hemorrhage (WAS), and lymphoma (HIGM). In the mono-IBD group, seventeen patients with mutant TTC7A (2), FOXP3 (2), NEMO (2), XIAP (2), LRBA (1), TTC37 (3), IL10RA (1), STAT1 (1), ZAP70 (1), PIK3CD (1), and PIK3R1 (1) genes failed to respond to aggressive treatments. Nine mono-IBD patients with TTC7A (2), FOXP3 (2), NEMO (2), XIAP (2), and LRBA (1) mutations were fatal in the absence of HSCT. The mono-IBD group had a significantly earlier age of diarrhea onset (1.7 vs 33.3 months, p = 0.0056), a longer TPN duration (34.2 vs 7.0 months, p < 0.0001), a shorter follow-up period (41.6 vs 132.6 months, p = 0.007), and a higher mortality rate (58.9 vs 25.0%, p = 0.012) compared with the SD group. CONCLUSION When compared to those with the SD phenotype, the mono-IBD patients had significant early-onset and poor responses to empiric antibiotics, IVIG, and steroids. Anti-inflammatory biologics and suitable HSCT still have the potential to control or even cure the mono-IBD phenotype.
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Affiliation(s)
- Wen-I Lee
- Primary Immunodeficiency Care and Research (PICAR) Institute, College of Medicine, Chang Gung Memorial University and Hospital, Kwei-Shan, #5 Fu-Shing St. (Pediatric Office 12 L), Taoyuan, Taiwan.
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Chien-Chang Chen
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shih-Hsiang Chen
- Division of Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wan-Tz Lai
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tang-Her Jaing
- Primary Immunodeficiency Care and Research (PICAR) Institute, College of Medicine, Chang Gung Memorial University and Hospital, Kwei-Shan, #5 Fu-Shing St. (Pediatric Office 12 L), Taoyuan, Taiwan
- Division of Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Liang-Shiou Ou
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chi-Jou Liang
- Primary Immunodeficiency Care and Research (PICAR) Institute, College of Medicine, Chang Gung Memorial University and Hospital, Kwei-Shan, #5 Fu-Shing St. (Pediatric Office 12 L), Taoyuan, Taiwan
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chen-Chen Kang
- Primary Immunodeficiency Care and Research (PICAR) Institute, College of Medicine, Chang Gung Memorial University and Hospital, Kwei-Shan, #5 Fu-Shing St. (Pediatric Office 12 L), Taoyuan, Taiwan
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jing-Long Huang
- Primary Immunodeficiency Care and Research (PICAR) Institute, College of Medicine, Chang Gung Memorial University and Hospital, Kwei-Shan, #5 Fu-Shing St. (Pediatric Office 12 L), Taoyuan, Taiwan.
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
- Department of Pediatrics, New Taipei Municipal TuChen Hospital, New Taipei, Taiwan.
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Morris EC. Allogeneic hematopoietic stem cell transplantation in adults with primary immunodeficiency. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:649-660. [PMID: 33275750 PMCID: PMC7727582 DOI: 10.1182/hematology.2020000152] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
With recent advances in genetic sequencing and its widespread adoption for clinical diagnostics, the identification of a primary immunodeficiency (PID) as the underlying cause of diseases presenting to hematologists including refractory autoimmunity, cytopenias, immune dysregulation, and hematologic malignancy, is increasing, particularly in the adult population. Where the pathogenic genetic variants are restricted to the hematopoietic system, selected patients may benefit from allogeneic hematopoietic stem cell transplantation (allo-HSCT). Although it is generally accepted that early allo-HSCT (ie, in infancy or childhood) for PID is preferable, this is not always possible. The clinical phenotype of non-severe combined immune deficiency forms of PID can be very heterogeneous, in part because of the high number of genetic and functional defects affecting T, B, and natural killer cells, neutrophils, and/or antigen presentation. As a result, some patients have less severe disease manifestations in childhood and/or a later de novo presentation. For others, a delayed diagnosis, lack of a genetic diagnosis, or a previous lack of a suitable donor has precluded prior allo-HSCT. Specific issues which make transplantation for adult PID patients particularly challenging are discussed, including understanding the natural history of rare diseases and predicting outcome with conservative management alone; indications for and optimal timing of transplant; donor selection; conditioning regimens; and PID-specific transplant management. The role of gene therapy approaches as an alternative to allo-HSCT in high-risk monogenic PID is also discussed.
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Affiliation(s)
- Emma C Morris
- Institute of Immunity and Transplantation, University College London, London, United Kingdom
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Lum SH, Slatter MA. Malignancy post-hematopoietic stem cell transplant in patients with primary immunodeficiency. Expert Rev Clin Immunol 2020; 16:493-511. [PMID: 32441164 DOI: 10.1080/1744666x.2020.1763792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Hematopoietic cell transplantation (HCT) is a curative treatment for an expanding number of primary immunodeficiencies (PIDs). Malignancies are more common in patients with PID than in the general population, and this review will discuss whether a successful HCT is expected to abolish or alter this risk. Second malignancy post HCT for a malignant disease is well known to occur, but generally less expected in patients transplanted for PID. AREAS COVERED This article reviews recently published literature focusing on the pattern of malignancy in children with PID, incidence, and risk factors for developing malignancy post-HCT for PID and possible strategies to reduce the risks. EXPERT OPINION Survival post HCT for PID has improved dramatically in the last 20 years and the genomic revolution has led to an expanding number of indications. To improve long-term quality of life attention needs to focus on late effects, including the possibility of malignancy occurring more frequently than expected in the general population, understand the risks and improve the process of transplantation in order to minimize them. Further studies are needed.
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Affiliation(s)
- Su Han Lum
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust , Newcastle upon Tyne, UK.,Department of Paediatrics, Leiden University Medical Centre , Leiden, The Netherlands
| | - Mary A Slatter
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust , Newcastle upon Tyne, UK.,Translational & Clinical Research Institute, Newcastle University , Newcastle upon Tyne, UK
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Lum SH, Hoenig M, Gennery AR, Slatter MA. Conditioning Regimens for Hematopoietic Cell Transplantation in Primary Immunodeficiency. Curr Allergy Asthma Rep 2019; 19:52. [PMID: 31741098 PMCID: PMC6861349 DOI: 10.1007/s11882-019-0883-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Hematopoietic cell transplantation (HCT) is an established curative treatment for children with primary immunodeficiencies. This article reviews the latest developments in conditioning regimens for primary immunodeficiency (PID). It focuses on data regarding transplant outcomes according to newer reduced toxicity conditioning regimens used in HCT for PID. RECENT FINDINGS Conventional myeloablative conditioning regimens are associated with significant acute toxicities, transplant-related mortality, and late effects such as infertility. Reduced toxicity conditioning regimens have had significant positive impacts on HCT outcome, and there are now well-established strategies in children with PID. Treosulfan has emerged as a promising preparative agent. Use of a peripheral stem cell source has been shown to be associated with better donor chimerism in patients receiving reduced toxicity conditioning. Minimal conditioning regimens using monoclonal antibodies are in clinical trials with promising results thus far. Reduced toxicity conditioning has emerged as standard of care for PID and has resulted in improved transplant survival for patients with significant comorbidities.
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Affiliation(s)
- S H Lum
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, UK
| | - M Hoenig
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - A R Gennery
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - M A Slatter
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, UK.
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
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Morris EC, Albert MH. Allogeneic HSCT in Adolescents and Young Adults With Primary Immunodeficiencies. Front Pediatr 2019; 7:437. [PMID: 31709207 PMCID: PMC6821713 DOI: 10.3389/fped.2019.00437] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 10/07/2019] [Indexed: 01/20/2023] Open
Abstract
Significant advances in hematopoietic transplantation over the past 20 years, have facilitated the safe transplantation of older adults with higher co-morbidities. In pediatric practice these advances have simultaneously improved outcomes for sicker children with complex, rare diseases including the primary immunodeficiencies, PID. With more widespread adoption of genetic sequencing, older patients with disease-causing mutations restricted to the hematopoietic system can be identified who may benefit from allogeneic hematopoietic stem cell transplantation (Allo-HSCT). Here we discuss the evidence for Allo-HSCT in adolescent and younger adults (AYAs) with PID.
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Affiliation(s)
- Emma C Morris
- Institute of Immunity and Transplantation, University College London, London, United Kingdom.,University College London Hospital and Royal Free London Hospitals, London, United Kingdom
| | - Michael H Albert
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
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Fox TA, Chakraverty R, Burns S, Carpenter B, Thomson K, Lowe D, Fielding A, Peggs K, Kottaridis P, Uttenthal B, Bigley V, Buckland M, Grandage V, Denovan S, Grace S, Dahlstrom J, Workman S, Symes A, Mackinnon S, Hough R, Morris E. Successful outcome following allogeneic hematopoietic stem cell transplantation in adults with primary immunodeficiency. Blood 2018; 131:917-931. [PMID: 29279357 PMCID: PMC6225386 DOI: 10.1182/blood-2017-09-807487] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 12/14/2017] [Indexed: 12/14/2022] Open
Abstract
The primary immunodeficiencies (PIDs), rare inherited diseases characterized by severe dysfunction of immunity, have been successfully treated by allogeneic hematopoietic stem cell transplantation (Allo-HSCT) in childhood. Controversy exists regarding optimal timing and use of Allo-HSCT in adults, due to lack of experience and previous poor outcomes. Twenty-nine consecutive adult patients, with a mean age at transplant of 24 years (range, 17-50 years), underwent Allo-HSCT. Reduced-intensity conditioning (RIC) included fludarabine (Flu)/melphalan/alemtuzumab (n = 20), Flu/busulfan (Bu)/alemtuzumab (n = 8), and Flu/Bu/antithymocyte globulin (n = 1). Stem cell donors were matched unrelated donors or mismatched unrelated donors (n = 18) and matched related donors (n = 11). Overall survival (OS), event-free survival, transplant-related mortality (TRM), acute and chronic graft-versus-host disease incidence and severity, time to engraftment, lineage-specific chimerism, immune reconstitution, and discontinuation of immunoglobulin replacement therapy were recorded. OS at 3 years for the whole cohort was 85.2%. The rarer PID patients without chronic granulomatous disease (CGD) achieved an OS at 3 years of 88.9% (n = 18), compared with 81.8% for CGD patients (n = 11). TRM was low with only 4 deaths observed at a median follow-up of 3.5 years. There were no cases of early or late rejection. In all surviving patients, either stable mixed chimerism or full donor chimerism were observed. At last follow-up, 87% of the surviving patients had no evidence of persistent or recurrent infections. Allo-HSCT is safe and effective in young adult patients with severe PID and should be considered the treatment of choice where an appropriate donor is available.
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Affiliation(s)
- Thomas A Fox
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
| | - Ronjon Chakraverty
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - Siobhan Burns
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
| | - Benjamin Carpenter
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Kirsty Thomson
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - David Lowe
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
| | - Adele Fielding
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - Karl Peggs
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - Panagiotis Kottaridis
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
| | - Benjamin Uttenthal
- Department of Haematology, Addenbrookes' Hospital, Cambridge, United Kingdom; and
| | - Venetia Bigley
- Institute of Cellular Medicine, Newcastle University, Newcastle, United Kingdom
| | - Matthew Buckland
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
| | - Victoria Grandage
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Shari Denovan
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Sarah Grace
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Julia Dahlstrom
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Sarita Workman
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
| | - Andrew Symes
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
| | - Stephen Mackinnon
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - Rachael Hough
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Emma Morris
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
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Slatter MA, Gennery AR. Hematopoietic cell transplantation in primary immunodeficiency - conventional and emerging indications. Expert Rev Clin Immunol 2018; 14:103-114. [PMID: 29300535 DOI: 10.1080/1744666x.2018.1424627] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Hematopoietic stem cell transplantation (HSCT) is an established curative treatment for many primary immunodeficiencies. Advances in donor selection, graft manipulation, conditioning and treatment of complications, mean that survival for many conditions is now around 90%. Next generation sequencing is identifying new immunodeficiencies, many of which are treatable with HSCT. Challenges remain however with short and long-term sequalae. This article reviews latest developments in HSCT for conventional primary immunodeficiencies and presents data on outcome for emerging diseases, Areas covered: This article reviews recently published literature detailing advances, particularly in conditioning regimens and new methods of T-lymphocyte depletion, as well as new information regarding approach and out come of transplanting patients with conventional primary immunodeficiencies. The article reviews data regarding transplant outcomes for newly described primary immunodeficiencies, particularly those associated with gain-of-function mutations. Expert commentary: New methods of graft manipulation have had significant impact on HSCT outcomes, with the range of PIDs treated using T-lymphocyte depletion significantly expanded. Outcomes for newly described diseases with variable phenotypes and clinical features, transplanted when the diagnosis was unknown are beginning to be described, and will improve as patients are identified earlier, and targeted therapies such as JAK inhibitors are used as a bridge to transplantation.
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Affiliation(s)
- Mary A Slatter
- a Institute of Cellular Medicine , Newcastle University , Newcastle Upon Tyne , UK.,b Paediatric Immunology and HSCT , Great North Children's Hospital , Newcastle Upon Tyne , UK
| | - Andrew R Gennery
- a Institute of Cellular Medicine , Newcastle University , Newcastle Upon Tyne , UK.,b Paediatric Immunology and HSCT , Great North Children's Hospital , Newcastle Upon Tyne , UK
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A Nationwide Study of Severe and Protracted Diarrhoea in Patients with Primary Immunodeficiency Diseases. Sci Rep 2017. [PMID: 28623282 PMCID: PMC5473906 DOI: 10.1038/s41598-017-03967-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Diarrhoea lasting longer than 14 days and failing to respond to conventional management is defined as severe and protracted diarrhoea (SD). In this study, we investigated the prevalence, pathogens and prognosis of SD in primary immunodeficiency diseases (PIDs). Among 246 patients with predominantly paediatric-onset PIDs from 2003–2015, 21 [Btk (six), IL2RG (four), WASP, CD40L, gp91 (three each), gp47, RAG2 (one each)] and five [CVID (four), SCID (one)] without identified mutations had SD before prophylactic treatment. Detectable pathogens included pseudomonas, salmonella (six each), E. coli, cytomegalovirus, coxsackie virus and cryptosporidium (one each), all of whom improved after a mean 17 days of antibiotics and/or IVIG treatment. Seven (7/26; 27.0%) patients died [respiratory failure (four), lymphoma, sepsis and intracranial haemorrhage (one each)]. The patients with WAS, CGD and CD40L and SD had a higher mortality rate than those without. Another five males with mutant XIAP, STAT1, FOXP3 (one each) and STAT3 (two) had undetectable-pathogenic refractory diarrhoea (RD) that persisted >21 days despite aggressive antibiotic/steroid treatment and directly resulted in mortality. For the patients with RD without anti-inflammatory optimization, those with mutant XIAP and FOXP3 died of Crohn’s-like colitis and electrolyte exhaustion in awaiting transplantation, while transplantation cured the STAT1 patient.
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Salzer E, Santos-Valente E, Keller B, Warnatz K, Boztug K. Protein Kinase C δ: a Gatekeeper of Immune Homeostasis. J Clin Immunol 2016; 36:631-40. [PMID: 27541826 PMCID: PMC5018258 DOI: 10.1007/s10875-016-0323-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 07/21/2016] [Indexed: 01/20/2023]
Abstract
Human autoimmune disorders present in various forms and are associated with a life-long burden of high morbidity and mortality. Many different circumstances lead to the loss of immune tolerance and often the origin is suspected to be multifactorial. Recently, patients with autosomal recessive mutations in PRKCD encoding protein kinase c delta (PKCδ) have been identified, representing a monogenic prototype for one of the most prominent forms of humoral systemic autoimmune diseases, systemic lupus erythematosus (SLE). PKCδ is a signaling kinase with multiple downstream target proteins and with functions in various signaling pathways. Interestingly, mouse models have indicated a special role of the ubiquitously expressed protein in the control of B-cell tolerance revealed by the severe autoimmunity in Prkcd (-/-) knockout mice as the major phenotype. As such, the study of PKCδ deficiency in humans has tremendous potential in enhancing our knowledge on the mechanisms of B-cell tolerance.
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Affiliation(s)
- Elisabeth Salzer
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Lazarettgasse 14 AKH BT 25.3, Vienna, Austria
| | - Elisangela Santos-Valente
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Lazarettgasse 14 AKH BT 25.3, Vienna, Austria
| | - Bärbel Keller
- Center for Chronic Immunodeficiency, University Medical Center Freiburg and University of Freiburg, Freiburg, Germany
| | - Klaus Warnatz
- Center for Chronic Immunodeficiency, University Medical Center Freiburg and University of Freiburg, Freiburg, Germany
| | - Kaan Boztug
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Lazarettgasse 14 AKH BT 25.3, Vienna, Austria.
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Lazarettgasse 14 AKH BT 25.3, Vienna, Austria.
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases and CeRUD Vienna Center for Rare and Undiagnosed Diseases, Vienna, Austria.
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Lee WI, Huang JL, Yeh KW, Cheng PJ, Jaing TH, Lin SJ, Chen LC, Ou LS, Yao TC. The effects of prenatal genetic analysis on fetuses born to carrier mothers with primary immunodeficiency diseases. Ann Med 2016; 48:103-10. [PMID: 26856578 DOI: 10.3109/07853890.2016.1140224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Prenatal genetic analysis in primary immunodeficiency diseases (PIDs) can decrease morbidity and mortality. METHODS We compared the postnatal prognoses of index cases and their subsequent sibling-fetuses using prenatal genetic analysis. RESULTS From 2007 to 2014, 14 sibling-fetuses receiving a prenatal diagnosis born to four mothers with WAS, three with X-CGD, and one each with IPEX, XLA and severe combined immunodeficiency [RAG2-SCID] were recruited. There were six affected, two carriers, and six wild types. Among the six affected, four [3X-CGD and 1RAG2-SCID] were terminated and two [1WAS and 1X-CGD] with early prophylactics underwent successful hematopoietic stem cell transplantation (HSCT) without infection. In the 12 index cases with a postnatal diagnosis, eight died (five due to infections and one each due to refractory bleeding, severe diarrhea, and post-transplant pneumothorax), two X-CGD underwent reconstituted HSCT after recurrent life-threatening infections, one WAS developed malignancy, and another WAS developed autoimmune disorders despite the administration of prophylactics and regular immunoglobulin infusion. CONCLUSION Instead of recurrent life-threatening infections leading to mortality in the postnatal diagnosis group, the severe PIDs who received early prophylactics were cured by HSCT, and all of mortality were terminations in the prenatal diagnosis group. Further large-scale studies are needed to validate this beneficial effect. Key message Prenatal genetic analysis in fetuses born to PIDs carrier mothers allows for the affected fetuses to receive optimal management including prophylactics against infections and HSCT if indicated. Patients with PIDs diagnosed postnatally who are prone to severe infections have higher rates of morbidity and mortality than their subsequent siblings who have a prenatal genetic diagnosis.
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Affiliation(s)
- Wen-I Lee
- a Department of Pediatrics, Division of Allergy , Asthma, Immunology and Rheumatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine , Taoyuan , Taiwan ;,b Primary Immunodeficiency Care and Research (PICAR) Institute, Chang Gung University College of Medicine and Chang Gung Memorial Hospital , Taoyuan , Taiwan
| | - Jing-Long Huang
- a Department of Pediatrics, Division of Allergy , Asthma, Immunology and Rheumatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine , Taoyuan , Taiwan ;,b Primary Immunodeficiency Care and Research (PICAR) Institute, Chang Gung University College of Medicine and Chang Gung Memorial Hospital , Taoyuan , Taiwan
| | - Kuo-Wei Yeh
- a Department of Pediatrics, Division of Allergy , Asthma, Immunology and Rheumatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine , Taoyuan , Taiwan
| | - Po-Jen Cheng
- c Department of Obstetrics/Gynecology , Chang Gung Memorial Hospital , Taoyuan , Taiwan
| | - Tang-Her Jaing
- b Primary Immunodeficiency Care and Research (PICAR) Institute, Chang Gung University College of Medicine and Chang Gung Memorial Hospital , Taoyuan , Taiwan ;,d Department of Pediatrics, Division of Hematology and Oncology , Chang Gung Memorial Hospital , Taoyuan , Taiwan
| | - Syh-Jae Lin
- a Department of Pediatrics, Division of Allergy , Asthma, Immunology and Rheumatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine , Taoyuan , Taiwan
| | - Li-Chen Chen
- a Department of Pediatrics, Division of Allergy , Asthma, Immunology and Rheumatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine , Taoyuan , Taiwan
| | - Liang-Shiou Ou
- a Department of Pediatrics, Division of Allergy , Asthma, Immunology and Rheumatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine , Taoyuan , Taiwan
| | - Tsung-Chieh Yao
- a Department of Pediatrics, Division of Allergy , Asthma, Immunology and Rheumatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine , Taoyuan , Taiwan
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Du H, Chen J, Qin M, Fang J, Li Z, Zhu Y, Sun X, Huang D, Yu J, Tang Y, Hu S, Li J, Zhang Z, Luan Z. Pediatric hematopoietic stem cell transplantation in China: Data and trends during 1998-2012. Pediatr Transplant 2015; 19:563-70. [PMID: 26058853 DOI: 10.1111/petr.12525] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/26/2022]
Abstract
The success of treating a wide variety of pediatric diseases with HSCT, hematologic malignancies in particular, has resulted in an increased number of long-term survivors. This study is the first large-scale, multicentre report that describes the evolution of pediatric HSCTs in China during the period of 1998-2012. Of all 1052 patients, 266 cases were treated with autologous HSCs and 786 used allogeneic HSCs. The disease indications for HSCTs mainly included leukemias, lymphoma, solid tumors, and non-malignant disorders. The total number of HSCTs, especially unrelated donor transplants, appeared to be increasing year by year. For patients with neuroblastoma, the therapeutic efficacy seemed to be poor, with a five-yr OS and DFS rate of 34.5 ± 14.3% and 20.7 ± 9.6%, respectively. In contrast, the survival of patients with SAA was prominently improved, and their five-yr OS and DFS rates were 82.8 ± 4% and 80.7 ± 4.1%, respectively. Patients who received cord blood transplants had a lower incidence of acute GVHD than that of PB and/or BM transplants from unrelated donors. This report offers us a valuable resource for evaluating the changes in HSCTs in China over the past 14 yr.
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Affiliation(s)
- Hong Du
- Navy General Hospital, Beijing, China
| | - Jing Chen
- Shanghai Children's Medical Center, Shanghai, China
| | | | - Jianpei Fang
- Second Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | | | - Yiping Zhu
- West China Second University Hospital of Sichuan University, Chengdu, China
| | - Xin Sun
- Guangzhou Women and Children Medical Center, Guangzhou, China
| | | | - Jie Yu
- Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yongmin Tang
- Zhe Jiang University School of Medicine Children Hospital, Hangzhou, China
| | - Shaoyan Hu
- Soochow University Affiliated Children's Hospital, Suzhou, China
| | - Junhui Li
- Capital Institute of Pediatics, Beijing, China
| | | | - Zuo Luan
- Navy General Hospital, Beijing, China
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Hematopoietic Stem Cell Transplantations for Primary Immune Deficiencies: 3 Decades of Experience From a Tertiary Medical Center. J Pediatr Hematol Oncol 2015; 37:e295-300. [PMID: 25985240 DOI: 10.1097/mph.0000000000000352] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) remains the leading treatment for the majority of severe primary immune deficiency (PID). This study aims to analyze changes in outcome over time. We conducted a retrospective analysis of HSCT in children with PID in a tertiary medical center over the period of 1983 to 2012. We identified 93 children with PID with a median follow-up of 3.6 years (range, 29 d to 21.2 y) after HSCT. The 2-year survival rates after HSCT for children with severe combined immune deficiency, hemophagocytic lymphohistiocytosis/lymphoproliferative disease, Wiskott-Aldrich syndrome, granulocyte defect, and undefined PID were 65.7%±6.8%, 80%±10.3%, 83.3%±15.2%, 75%±12.5%, and 25%±21.7%, respectively. Survival was associated with year of HSCT and matching. The hazard ratio (HR) (95% CI) for HSCT done in 1983 to 1999 compared with 2000 to 2012 and for matched (related and unrelated) compared with mismatched donor were 2.14 (0.99 to 4.653) and 3.07 (1.46 to 6.4), respectively. Survival was not associated with age, sex of the recipient, underlying PID, conditioning regimen, and presence of acute graft-versus-host disease. After adjustment to the underlying PID, donor and use of fludarabine-based conditioning, the HR (95% CI) for HSCT from the year 2000 was 4.69 (range, 1.4 to 15.45). Advances in HSCT over time have improved the survival of children with PID.
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The role of donor-derived veto cells in nonmyeloablative haploidentical HSCT. Bone Marrow Transplant 2015; 50 Suppl 2:S14-20. [DOI: 10.1038/bmt.2015.89] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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14
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Hladun R, Badell I, González M, Martínez A, Sánchez de Toledo J, Olivé M, González M, Elorza I, Díaz de Heredia C. Survival analysis of hematopoietic stem cell transplantation in children with primary immunodeficiency in Spain. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.anpede.2014.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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15
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Bilateral lung transplantation in a patient with humoral immune deficiency: a case report with review of the literature. Case Reports Immunol 2014; 2014:910215. [PMID: 25379312 PMCID: PMC4213409 DOI: 10.1155/2014/910215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 09/15/2014] [Accepted: 09/20/2014] [Indexed: 11/18/2022] Open
Abstract
Humoral immune deficiencies have been associated with noninfectious disease complications including autoimmune cytopenias and pulmonary disease. Herein we present a patient who underwent splenectomy for autoimmune cytopenias and subsequently was diagnosed with humoral immune deficiency in the context of recurrent infections. Immunoglobulin analysis prior to initiation of intravenous immunoglobulin (IVIG) therapy was notable for low age-matched serum levels of IgA (11 mg/dL), IgG2 (14 mg/L), and IgG4 (5 mg/L) with a preserved total level of IgG. Flow cytometry was remarkable for B cell maturation arrest at the IgM+/IgD+ stage. Selective screening for known primary immune deficiency-causing genetic defects was negative. The disease course was uniquely complicated by the development of pulmonary arteriovenous malformations (AVMs), ultimately requiring bilateral lung transplantation in 2012. This is a patient with humoral immune deficiency that became apparent only after splenectomy, which argues for routine immunologic evaluation prior to vaccination and splenectomy. Lung transplantation is a rare therapeutic endpoint and to our knowledge has never before been described in a patient with humoral immune deficiency for the indication of pulmonary AVMs.
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Touzot F, Neven B, Dal-Cortivo L, Gabrion A, Moshous D, Cros G, Chomton M, Luby JM, Terniaux B, Magalon J, Picard C, Blanche S, Fischer A, Cavazzana M. CD45RA depletion in HLA-mismatched allogeneic hematopoietic stem cell transplantation for primary combined immunodeficiency: A preliminary study. J Allergy Clin Immunol 2014; 135:1303-9.e1-3. [PMID: 25282016 DOI: 10.1016/j.jaci.2014.08.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 07/21/2014] [Accepted: 08/12/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Combined immunodeficiencies (CIDs) form a heterogeneous group of inherited conditions that affect the development, function, or both of T cells. The treatment of CIDs with allogeneic hematopoietic stem cell transplantation (HSCT) is complicated by a high incidence of life-threatening infections and an increased risk of graft-versus-host disease (GVHD). OBJECTIVE In view of the growing evidence that alloreactivity is mainly derived from human naive T cells, the selective depletion of naive T cells from allografts might constitute a way of reducing alloreactivity while maintaining memory T-cell responsiveness to pathogens. METHODS Five consecutive patients with CIDs and chronic viral infections underwent an allogeneic, HLA-mismatched HSCT. Given the patients' infection status and the potential risk of severe GVHD in the mismatched setting, the CD34(-) fraction of the allograft was depleted of naive T cells by using magnetic CD45RA beads. RESULTS Engraftment occurred in 4 of the 5 patients. No severe GVHD occurred. In the 4 engrafted patients viral infections were cleared within 2 months of the HSCT, and both cellular and humoral immunity were re-established within a year of the HSCT. An early T-cell response against viral pathogens was documented in 2 patients. CONCLUSION The present pilot study shows that clinical-grade depletion of naive T cells from an allograft through the use of magnetic CD45RA beads seems to be a feasible and efficacious option for the treatment of patients with CIDs at high risk of GVHD, infection, or both in an HLA-mismatched setting.
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Affiliation(s)
- Fabien Touzot
- Département de Biothérapie, Centre d'Investigation Clinique intégré en Biothérapies, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine, Paris, France; INSERM UMR1163, Paris, France.
| | - Bénédicte Neven
- Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine, Paris, France; Unité d'Immunologie-Hématologie et Rhumatologie Pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, Paris, France; INSERM UMR1163, Paris, France
| | - Liliane Dal-Cortivo
- Département de Biothérapie, Centre d'Investigation Clinique intégré en Biothérapies, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Aurélie Gabrion
- Département de Biothérapie, Centre d'Investigation Clinique intégré en Biothérapies, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Despina Moshous
- Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine, Paris, France; Unité d'Immunologie-Hématologie et Rhumatologie Pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, Paris, France; INSERM UMR1163, Paris, France
| | - Guilhem Cros
- Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine, Paris, France; Unité d'Immunologie-Hématologie et Rhumatologie Pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Maryline Chomton
- Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine, Paris, France; Unité d'Immunologie-Hématologie et Rhumatologie Pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Jean-Marc Luby
- Département de Biothérapie, Centre d'Investigation Clinique intégré en Biothérapies, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Brigitte Terniaux
- Département de Biothérapie, Centre d'Investigation Clinique intégré en Biothérapies, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jérémy Magalon
- Département de Biothérapie, Centre d'Investigation Clinique intégré en Biothérapies, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine, Paris, France
| | - Capucine Picard
- Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine, Paris, France; Centre d'étude des déficits immunitaires (CEDI), Hôpital Necker-Enfants Malades, AP-HP, Paris, France; INSERM UMR1163, Paris, France
| | - Stéphane Blanche
- Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine, Paris, France; Unité d'Immunologie-Hématologie et Rhumatologie Pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Alain Fischer
- Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine, Paris, France; Unité d'Immunologie-Hématologie et Rhumatologie Pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, Paris, France; INSERM UMR1163, Paris, France; College de France, Paris, France
| | - Marina Cavazzana
- Département de Biothérapie, Centre d'Investigation Clinique intégré en Biothérapies, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine, Paris, France; INSERM UMR1163, Paris, France
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17
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Hladun R, Badell I, González M, Martínez AM, Sánchez de Toledo J, Olivé MT, González ME, Elorza I, Díaz de Heredia C. [Survival analysis of hematopoietic stem cell transplantation in children with primary immunodeficiency in Spain]. An Pediatr (Barc) 2014; 82:62-7. [PMID: 24857430 DOI: 10.1016/j.anpedi.2014.04.014] [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: 02/23/2014] [Revised: 04/06/2014] [Accepted: 04/09/2014] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Children with primary immunodeficiency have severe life-threatening infections and a higher prevalence of autoimmune problems, allergy and lymphoproliferative disorders. Allogenic hematopoietic stem cell transplantation has been the only potentially curative option. PATIENTS AND METHODS Patients with primary immunodeficiency underwent allogenic stem cell transplantation in the period 1985-2011, and registered in the Spanish Working Party for Bone Marrow Transplantation in Children. RESULTS One hundred and fifty nine patients underwent 173 allogenic stem cell transplantations, of whom 97 had severe combined immunodeficiency, 30 with immune dysregulation disorders, 25 Wiskott-Aldrich syndrome, and 21 phagocyte disorders. The median patient age at diagnosis was 6 months (range: 17 days - 168 months) and the median patient age at transplant was 12 months (range: 1 month - 189 months). The donors were 30 (19%) identical siblings, 40 (25%) alternative family donors, and 89 (56%) unrelated donors. The source of stem cells was bone marrow in 68 (43%), cord blood in 52 (33%), and peripheral blood in 39 (24%). Ninety eight (61.6%) are alive, 57 (35.9%) died. Event-free survival at 10 years was 63%, with 90% for children transplanted from identical siblings, 36% for those transplanted from alternative family donors, and 66% for those transplanted from unrelated donors. CONCLUSIONS The best results have been obtained with identical siblings, but other options may be considered.
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Affiliation(s)
- R Hladun
- Servicio de Oncología, Hematología y Trasplante de Progenitores Hematopoyéticos Pediátrica, Hospital Vall d'Hebron, Barcelona, España.
| | - I Badell
- Servicio de Oncología y Hematología Pediátrica, Hospital Sant Pau i Santa Creu, Barcelona, España
| | - M González
- Servicio de Oncología y Hematología Pediátrica, Hospital del Niño Jesús, Madrid, España
| | - A M Martínez
- Servicio de Oncología y Hematología Pediátrica, Hospital La Paz, Madrid, España
| | - J Sánchez de Toledo
- Servicio de Oncología, Hematología y Trasplante de Progenitores Hematopoyéticos Pediátrica, Hospital Vall d'Hebron, Barcelona, España
| | - M T Olivé
- Servicio de Oncología, Hematología y Trasplante de Progenitores Hematopoyéticos Pediátrica, Hospital Vall d'Hebron, Barcelona, España
| | - M E González
- Servicio de Oncología y Hematología Pediátrica, Hospital Regional Universitario Carlos Haya, Málaga, España
| | - I Elorza
- Servicio de Oncología, Hematología y Trasplante de Progenitores Hematopoyéticos Pediátrica, Hospital Vall d'Hebron, Barcelona, España
| | - C Díaz de Heredia
- Servicio de Oncología, Hematología y Trasplante de Progenitores Hematopoyéticos Pediátrica, Hospital Vall d'Hebron, Barcelona, España
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Touzot F, Hacein-Bey-Abina S, Fischer A, Cavazzana M. Gene therapy for inherited immunodeficiency. Expert Opin Biol Ther 2014; 14:789-98. [DOI: 10.1517/14712598.2014.895811] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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