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Alexander T, Tassy N, Domenech A, Kramer E, Jessop H, Kenyon M, Sharrack B, Saccardi R, Bolanos N, Snowden JA, Greco R. Patient-reported outcomes in HSCT for autoimmune diseases: Considerations on behalf of the EBMT ADWP, PAC, and Nurses Group. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100283. [PMID: 38952895 PMCID: PMC11215328 DOI: 10.1016/j.jacig.2024.100283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/03/2024] [Accepted: 04/05/2024] [Indexed: 07/03/2024]
Abstract
Background Over the last 3 decades, hematopoietic stem cell transplantation (HSCT) has been successfully used to treat severe and refractory autoimmune diseases (AIDs). A multidisciplinary appraisal of potential benefits and risks by disease and transplant specialists is essential to determine individual suitability for HSCT. Objective Our aim was to observe that patient-reported outcomes (PROs) and health-related quality of life instruments can capture the unique patient perspective on disease burden and impact of treatment. Methods Herein, we describe the basis and complexity of end points measuring patient-reported perceptions of efficacy and tolerability used in clinical practice and trials for patients with AIDs undergoing autologous HSCT. Results PRO measures and patient-reported experience measures are key tools to evaluate the impact and extent of disease burden for patients affected by AIDs. For formal scientific assessment, it is essential that validated general instruments are used, whereas adaptations have resulted in disease-specific instruments that may help guide tailored interventions. An additional approach relates to qualitative evaluations, from carefully structured qualitative research to informal narratives, as patient stories. The patients' subjectively reported responses to HSCT may be influenced by their preprocedure expectations and investment in the HSCT journey. Conclusions The complexity of AIDs advocates for individualized and multidisciplinary approach to positively affect the patient journey. PROs and health-related quality of life need to be collected using validated instruments in clinical practice and trials to enable robustness of data and to ensure the impact of the intervention is comprehensively assessed, addressing the main questions and needs of the involved stakeholders.
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Affiliation(s)
- Tobias Alexander
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and the Department of Rheumatology and Clinical Immunology, Berlin Institute of Health, Berlin, Germany
| | - Noëlle Tassy
- EBMT Patient Advocacy Committee (PAC), EBMT Executive Office, Barcelona, Spain
- Philosophy Department, University of Rouen, Rouen, France
| | - Ariadna Domenech
- Bone Marrow Transplant Unit, Department of Hematology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Ellen Kramer
- EBMT Patient Advocacy Committee (PAC), EBMT Executive Office, Barcelona, Spain
- Department of Hematology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Helen Jessop
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Michelle Kenyon
- Department of Haematology, King’s College Hospital, London, United Kingdom
| | - Basil Sharrack
- Department of Neuroscience and Sheffield NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust and University of Sheffield, Sheffield, United Kingdom
| | - Riccardo Saccardi
- Cellular Therapies and Transfusion Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Natacha Bolanos
- EBMT Patient Advocacy Committee (PAC), EBMT Executive Office, Barcelona, Spain
- Lymphoma Coalition, Mississauga, Ontario, Canada
| | - John A. Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Sheffield, United Kingdom
| | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Satirer Ö, Henes JC, Döring M, Lesk T, Benseler S, Kuemmerle-Deschner JB. Autologous haematopoiesis stem cell transplantation (AHSCT) for treatment-refractory autoimmune diseases in children. RMD Open 2024; 10:e004381. [PMID: 39004431 PMCID: PMC11253738 DOI: 10.1136/rmdopen-2024-004381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 06/27/2024] [Indexed: 07/16/2024] Open
Abstract
OBJECTIVES To evaluate the long-term effectiveness and safety of autologous haematopoiesis stem cell transplantation (AHSCT) for severe, refractory autoimmune diseases in paediatric patients. METHODS A single-centre study of consecutive children and adolescents with refractory autoimmune diseases undergoing AHSCT was performed. Demographics, clinical, laboratory features, pre-AHSCT medications, disease activity and functional status were captured. The primary outcome was progression-free survival, secondary outcomes included overall survival, disease-specific treatment responses, disease activity at the last follow-up and AHSCT safety. RESULTS The study included seven patients: two systemic sclerosis, one pansclerotic morphoea, one eosinophilic fasciitis, one juvenile dermatomyositis and two patients with systemic juvenile idiopathic arthritis; four women, three men median age at AHSCT of 10 years (7-19), median follow-up post-AHSCT of 17 years. Median progression-free survival and overall survival was 4.2 years (95% CI: 0.98 to 8.3) and 17 years (95% CI: 11.8 to 22.1), respectively. Progression-free survival rates at 1 and 2 years post-AHSCT were 100% and 77%, respectively. All children survived. All patients are in clinical remission, only four require ongoing immunotherapy. SAFETY Three experienced infections, including HHV6, Candida and Ralstonia sepsis; one developed a systemic inflammatory response syndrome; two new onset secondary autoimmune diseases including autoimmune haemolytic anaemia, Graves' disease and one was found to have a breast fibroadenoma. Treatment toxicity: one cyclophosphamide-associated transient renal failure and pericardial effusion, one patient with amenorrhoea/infertility. CONCLUSIONS AHSCT was an effective and safe approach for children and adolescents with treatment-refractory autoimmune diseases. The indication and timing of transplantation requires a careful consideration and a multidisciplinary approach.
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Affiliation(s)
- Özlem Satirer
- Department of Paediatrics and Autoinflammation reference Center Tuebingen (arcT), Universitatsklinikum Tubingen, Tubingen, Baden-Württemberg, Germany
| | - Joerg C Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Auto-inflammatory Diseases and Department of Internal Medicine II (Oncology, Haematology, Immunology and Rheumatology), Universitatsklinikum Tubingen, Tubingen, Baden-Württemberg, Germany
| | - Michaela Döring
- Pediatric Hematology &Oncology, University of Tübingen, Tubingen, Baden-Württemberg, Germany
| | - Till Lesk
- Universitatsklinikum Tubingen, Tubingen, Baden-Württemberg, Germany
| | - Susanne Benseler
- Rheumatology, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- Children's Health Ireland, Dublin, Dublin, Ireland
| | - Jasmin Beate Kuemmerle-Deschner
- Department of Paediatrics and Autoinflammation reference Center Tuebingen (arcT), Universitatsklinikum Tubingen, Tubingen, Baden-Württemberg, Germany
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Assmann G, Schmidt M, Sester M. Scattered pustular lesions 10 days after Shingrix vaccination in systemic sclerosis patient after successful autologous non-myeloablative haemopoietic stem-cell transplantation. BMJ Case Rep 2024; 17:e259620. [PMID: 38991572 DOI: 10.1136/bcr-2024-259620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024] Open
Affiliation(s)
- Gunter Assmann
- Johhanes Wesling University Hospital, OWL, Department of Rheumatology, Ruhr University Bochum, Minden, Nordrhein-Westfalen, Germany
- Universitaetsklinikum des Saarlandes Jose Carreras Institut fuer Immun- und Gentherapie, Homburg, Saarland, Germany
| | - Michael Schmidt
- Johhanes Wesling University Hospital, OWL, Department of Rheumatology, Ruhr University Bochum, Minden, Nordrhein-Westfalen, Germany
| | - Martina Sester
- Department of Transplantation and Immunology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
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Pyka V, Vangala DB, Mika T, Kreuter A, Susok L, Baraliakos X, Treiber H, Schroers R, Nilius-Eliliwi V. High-dose chemotherapy and autologous hematopoietic stem cell transplantation for progressive systemic sclerosis: a retrospective study of outcome and prognostic factors. J Cancer Res Clin Oncol 2024; 150:301. [PMID: 38850365 PMCID: PMC11162374 DOI: 10.1007/s00432-024-05815-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 05/22/2024] [Indexed: 06/10/2024]
Abstract
PURPOSE Systemic sclerosis (SSc) is a rare autoimmune disease associated with high morbidity and mortality. SSc treatment is still challenging, and evidence is scarce. In the last decades high-dose chemotherapy and autologous stem cell transplantation (HD-ASCT) has proven to be effective. However, treatment related morbidity and mortality (TRM) are high. We conducted a retrospective, single-center analysis of SSc patients following HD-ASCT focusing on TRM and risk factors. METHODS 32 patients who underwent HD-ASCT at our hospital between June 2000 and September 2020 were included. Clinical characteristics were evaluated based on chart review before and after HD-ASCT. Analyses focused on overall survival (OS), TRM, and response to HD-ASCT. RESULTS Median OS was 81 months (range 0-243). Within one year, 20 of 32 (76.9%) patients responded to HD-ASCT. Overall, 6 patients (18.8%) died in the context of HD-ASCT. Patients with subjective response to HD-ASCT (p = 0.024) and those with shorter time to platelet engraftment (p = 0.047) had significantly longer OS. Impaired renal function, age at HD-ASCT ≥ 55, disease duration < 12 months, high Hematopoietic cell transplantation-specific comorbidity index (HCT-CI) and Charlton Comorbidity Index (CCI) scores were associated with higher TRM. Patients receiving conditioning chemotherapy with thiotepa needed longer time for neutrophil (p = 0.035) and platelet engraftment (p = 0.021). CONCLUSION This study confirms the efficacy of HD-ASCT for patients with SSc in a single center real-world setting. High TRM is still a challenge. However, TRM could be reduced by exclusion of high-risk patients and attention to prognostic parameters and scores as suggested in this study.
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Affiliation(s)
- Vanessa Pyka
- Department of Hematology and Oncology, Ruhr-University Bochum, Knappschaftskrankenhaus, In der Schornau 23-25, 44892, Bochum, Germany
| | - Deepak B Vangala
- Department of Human Genetics, Ruhr-University Bochum, Bochum, Germany
| | - Thomas Mika
- Department of Hematology and Oncology, Ruhr-University Bochum, Knappschaftskrankenhaus, In der Schornau 23-25, 44892, Bochum, Germany
| | - Alexander Kreuter
- Department of Dermatology, Venerology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - Laura Susok
- Department of Dermatology, Venerology and Allergology, Klinikum Dortmund, University Witten-Herdecke, Dortmund, Germany
- Department of Dermatology, Venerology and Allergology, Ruhr-University Bochum, Bochum, Germany
| | | | - Hannes Treiber
- Department of Hematology and Oncology, Georg-August University, Göttingen, Germany
| | - Roland Schroers
- Department of Hematology and Oncology, Ruhr-University Bochum, Knappschaftskrankenhaus, In der Schornau 23-25, 44892, Bochum, Germany.
| | - Verena Nilius-Eliliwi
- Department of Hematology and Oncology, Ruhr-University Bochum, Knappschaftskrankenhaus, In der Schornau 23-25, 44892, Bochum, Germany.
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5
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Kang N, Ji Z, Li Y, Gao J, Wu X, Zhang X, Duan Q, Zhu C, Xu Y, Wen L, Shi X, Liu W. Metabolite-derived damage-associated molecular patterns in immunological diseases. FEBS J 2024; 291:2051-2067. [PMID: 37432883 DOI: 10.1111/febs.16902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 06/05/2023] [Accepted: 07/10/2023] [Indexed: 07/13/2023]
Abstract
Damage-associated molecular patterns (DAMPs) are typically derived from the endogenous elements of necrosis cells and can trigger inflammatory responses by activating DAMPs-sensing receptors on immune cells. Failure to clear DAMPs may lead to persistent inflammation, thereby contributing to the pathogenesis of immunological diseases. This review focuses on a newly recognized class of DAMPs derived from lipid, glucose, nucleotide, and amino acid metabolic pathways, which are then termed as metabolite-derived DAMPs. This review summarizes the reported molecular mechanisms of these metabolite-derived DAMPs in exacerbating inflammation responses, which may attribute to the pathology of certain types of immunological diseases. Additionally, this review also highlights both direct and indirect clinical interventions that have been explored to mitigate the pathological effects of these DAMPs. By summarizing our current understanding of metabolite-derived DAMPs, this review aims to inspire future thoughts and endeavors on targeted medicinal interventions and the development of therapies for immunological diseases.
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Affiliation(s)
- Na Kang
- State Key Laboratory of Membrane Biology, School of Life Sciences, Institute for Immunology, Beijing Advanced Innovation Center for Structural Biology, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing Key Lab for Immunological Research on Chronic Diseases, Tsinghua University, Beijing, China
- Tsinghua-Peking Center for Life Sciences, Beijing, China
| | - Zhenglin Ji
- State Key Laboratory of Membrane Biology, School of Life Sciences, Institute for Immunology, Beijing Advanced Innovation Center for Structural Biology, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing Key Lab for Immunological Research on Chronic Diseases, Tsinghua University, Beijing, China
| | - Yuxin Li
- State Key Laboratory of Membrane Biology, School of Life Sciences, Institute for Immunology, Beijing Advanced Innovation Center for Structural Biology, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing Key Lab for Immunological Research on Chronic Diseases, Tsinghua University, Beijing, China
| | - Ji Gao
- State Key Laboratory of Membrane Biology, School of Life Sciences, Institute for Immunology, Beijing Advanced Innovation Center for Structural Biology, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing Key Lab for Immunological Research on Chronic Diseases, Tsinghua University, Beijing, China
| | - Xinfeng Wu
- Department of Rheumatology and Immunology, the First Affiliated Hospital, and College of Clinical Medical of Henan University of Science and Technology, Luoyang, China
| | - Xiaoyang Zhang
- State Key Laboratory of Membrane Biology, School of Life Sciences, Institute for Immunology, Beijing Advanced Innovation Center for Structural Biology, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing Key Lab for Immunological Research on Chronic Diseases, Tsinghua University, Beijing, China
| | - Qinghui Duan
- State Key Laboratory of Membrane Biology, School of Life Sciences, Institute for Immunology, Beijing Advanced Innovation Center for Structural Biology, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing Key Lab for Immunological Research on Chronic Diseases, Tsinghua University, Beijing, China
- Tsinghua-Peking Center for Life Sciences, Beijing, China
| | - Can Zhu
- State Key Laboratory of Membrane Biology, School of Life Sciences, Institute for Immunology, Beijing Advanced Innovation Center for Structural Biology, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing Key Lab for Immunological Research on Chronic Diseases, Tsinghua University, Beijing, China
| | - Yue Xu
- State Key Laboratory of Membrane Biology, School of Life Sciences, Institute for Immunology, Beijing Advanced Innovation Center for Structural Biology, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing Key Lab for Immunological Research on Chronic Diseases, Tsinghua University, Beijing, China
| | - Luyao Wen
- Department of Rheumatology and Immunology, the First Affiliated Hospital, and College of Clinical Medical of Henan University of Science and Technology, Luoyang, China
| | - Xiaofei Shi
- Department of Rheumatology and Immunology, the First Affiliated Hospital, and College of Clinical Medical of Henan University of Science and Technology, Luoyang, China
| | - Wanli Liu
- State Key Laboratory of Membrane Biology, School of Life Sciences, Institute for Immunology, Beijing Advanced Innovation Center for Structural Biology, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing Key Lab for Immunological Research on Chronic Diseases, Tsinghua University, Beijing, China
- Tsinghua-Peking Center for Life Sciences, Beijing, China
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6
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Pecher AC, Klein R, Koetter I, Wagner M, Vogel W, Wirths S, Lengerke C, Henes JC. Patients with systemic sclerosis and low CD4 numbers after autologous stem cell transplantation have a favorable outcome. Arthritis Res Ther 2024; 26:75. [PMID: 38509633 PMCID: PMC10953154 DOI: 10.1186/s13075-024-03300-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/01/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Treatment with high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (aHSCT) is an intensive treatment option for patients with severe forms of systemic sclerosis (SSc). Even though associated with a high treatment related mortality, the results in this high-risk population are generally favourable. The knowledge on the potential mechanism of action of this therapy and how it can improve patients with SSc is crucial to better select the right patients for aHSCT. METHODS This is a monocentric retrospective study from Tübingen, Germany, including 32 patients who underwent aHSCT. Peripheral blood samples were analysed for different lymphocyte subsets at various timepoints before and after aHSCT. Patients were divided into responders and non-responders according to the modified Rodnan skin score and lung function test in the three years following aHSCT. RESULTS Responders showed significantly lower levels of cluster of differentiation (CD)4 positive T cells in the first months after aHSCT (month 1 and 3), B cells (month 3 and 6 after aHSCT) and natural killer cells (month 1). Mantel-cox test showed a significant deviation of the probability curves, i.e. patients with lower CD4 + T cells and natural killer cells one month and B cells after 3 months after stem cell transplantation had a higher probability to belong to the responder group. CONCLUSIONS Taken together, this study supports the theory that a profound CD4 + T cell and B cell lymphopenia is important for patients with SSc to achieve a sustained response after aHSCT.
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Affiliation(s)
- Ann-Christin Pecher
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tuebingen, Otfried-Mueller-Strasse 10, 72076, Tuebingen, Germany.
| | - Reinhild Klein
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tuebingen, Otfried-Mueller-Strasse 10, 72076, Tuebingen, Germany
| | - Ina Koetter
- Division of Rheumatology and Systemic Inflammatory Rheumatic Diseases, University Hospital Hamburg-Eppendorf and Clinic for Rheumatology and Immunology, Bad Bramstedt, Germany
| | - Marieke Wagner
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tuebingen, Otfried-Mueller-Strasse 10, 72076, Tuebingen, Germany
| | - Wichard Vogel
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tuebingen, Otfried-Mueller-Strasse 10, 72076, Tuebingen, Germany
| | - Stefan Wirths
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tuebingen, Otfried-Mueller-Strasse 10, 72076, Tuebingen, Germany
| | - Claudia Lengerke
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tuebingen, Otfried-Mueller-Strasse 10, 72076, Tuebingen, Germany
| | - Joerg Christoph Henes
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tuebingen, Otfried-Mueller-Strasse 10, 72076, Tuebingen, Germany
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7
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Farge D, Pugnet G, Allez M, Castilla-Llorente C, Chatelus E, Cintas P, Faucher-Barbey C, Labauge P, Labeyrie C, Lioure B, Maria A, Michonneau D, Puyade M, Talouarn M, Terriou L, Treton X, Wojtasik G, Zephir H, Marjanovic Z. French protocol for the diagnosis and management of hematopoietic stem cell transplantation in autoimmune diseases. Rev Med Interne 2024; 45:79-99. [PMID: 38220493 DOI: 10.1016/j.revmed.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/29/2023] [Indexed: 01/16/2024]
Abstract
Hematopoietic stem cell transplantation (HSCT) for severe ADs was developed over the past 25years and is now validated by national and international medical societies for severe early systemic sclerosis (SSc) and relapsing-remitting multiple sclerosis (MS) and available as part of routine care in accredited center. HSCT is also recommended, with varying levels of evidence, as an alternative treatment for several ADs, when refractory to conventional therapy, including specific cases of connective tissue diseases or vasculitis, inflammatory neurological diseases, and more rarely severe refractory Crohn's disease. The aim of this document was to provide guidelines for the current indications, procedures and follow-up of HSCT in ADs. Patient safety considerations are central to guidance on patient selection and conditioning, always validated at the national MATHEC multidisciplinary team meeting (MDTM) based on recent (less than 3months) thorough patient evaluation. HSCT procedural aspects and follow-up are then carried out within appropriately experienced and Joint Accreditation Committee of International Society for Cellular Therapy and SFGM-TC accredited centres in close collaboration with the ADs specialist. These French recommendations were performed according to HAS/FAI2R standard operating procedures and coordinated by the Île-de-France MATHEC Reference Centre for Rare Systemic Autoimmune Diseases (CRMR MATHEC) within the Filière FAI2R and in association with the Filière MaRIH. The task force consisted of 3 patients and 64 clinical experts from various specialties and French centres. These data-derived and consensus-derived recommendations will help clinicians to propose HSCT for their severe ADs patients in an evidence-based way. These recommendations also give directions for future clinical research in this area. These recommendations will be updated according to newly emerging data. Of note, other cell therapies that have not yet been approved for clinical practice or are the subject of ongoing clinical research will not be addressed in this document.
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Affiliation(s)
- D Farge
- AP-HP, hôpital St-Louis, centre de référence des maladies auto-immunes systémiques rares d'Île-de-France MATHEC (FAI2R), unité de Médecine Interne (UF 04) : CRMR MATHEC, maladies auto-immunes et thérapie cellulaire (UF 04), 1, avenue Claude-Vellefaux, 75010 Paris, France; Université de Paris, IRSL, Recherche clinique appliquée à l'hématologie, URP-3518, 75010 Paris, France; Department of Medicine, McGill University, H3A 1A1, Montreal, Canada.
| | - G Pugnet
- Service de médecine interne et immunologie clinique, pôle hospitalo-universitaire des maladies digestives, CHU Rangueil, 1, avenue du Pr-Jean-Poulhès, 31059 Toulouse cedex 9, France
| | - M Allez
- AP-HP, hôpital Saint-Louis, service d'hépato-gastro-entérologie, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - C Castilla-Llorente
- Gustave-Roussy cancer center, département d'hématologie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - E Chatelus
- Département de rhumatologie, hôpitaux universitaires de Strasbourg, Strasbourg, France; Centre de référence des maladies auto-immunes systémiques rares de l'Est et du Sud-Ouest, Strasbourg, France
| | - P Cintas
- CHU Toulouse Purpan, service de neurologie, place du Dr-Baylac, 31059 Toulouse cedex 9, France
| | - C Faucher-Barbey
- Direction prélèvements et greffes de CSH, Direction médicale et scientifique, Agence de la biomédecine, 93212 St-Denis/La Plaine, France
| | - P Labauge
- CRC SEP, service de neurologie, CHU de Montpellier, 34295 Montpellier cedex 5, France
| | - C Labeyrie
- AP-HP, CHU de Bicêtre, service de neurologie, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - B Lioure
- Département d'onco-hématologie, université de Strasbourg, ICANS, Strasbourg, France
| | - A Maria
- Médecine interne & immuno-oncologie (MedI2O), Institute for Regenerative Medicine & Biotherapy (IRMB), hôpital Saint-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, Montpellier, France; IRMB, Inserm U1183, hôpital Saint-Éloi, CHU de Montpellier, 34295 Montpellier, France
| | - D Michonneau
- Université de Paris, IRSL, Recherche clinique appliquée à l'hématologie, URP-3518, 75010 Paris, France; Service d'hématologie-greffe, AP-HP, hôpital Saint-Louis, institut de recherche Saint-Louis, Paris, France
| | - M Puyade
- CHU de Poitiers, service de médecine interne, 2, rue de La-Miletrie, 86021 Poitiers, France
| | - M Talouarn
- AP-HP, hôpital Saint-Antoine, service d'hématologie clinique et thérapie cellulaire, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - L Terriou
- CHU de Lille, département de médecine interne et immunologie clinique, 59000 Lille, France; Centre de référence des maladies auto-immunes et auto-inflammatoires rares (CERAINO), 59000 Lille, France
| | - X Treton
- Université de Paris, hôpital Beaujon, service de gastro-entérologie, MICI et assistance nutritive, DMU DIGEST, 100, boulevard Leclerc, 92110 Clichy, France
| | - G Wojtasik
- Université de Lille, Inserm, CHU de Lille, service de médecine interne et immunologie clinique, Centre de référence des maladies auto-immunes systémiques rares du Nord et Nord-Ouest de France (CeRAINO), U1286 - INFINITE - Institut de recherche translationnelle sur l'inflammation, Lille, France
| | - H Zephir
- CHU de Lille, université de Lille, pôle des neurosciences et de l'appareil locomoteur, Lille Inflammation Research International Center (LIRIC), UMR 995, rue Émile-Laine, 59000 Lille, France
| | - Z Marjanovic
- AP-HP, hôpital Saint-Antoine, service d'hématologie clinique et thérapie cellulaire, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
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8
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Pugnet G. [The arguments favoring autologous haematopoietic stem cell transplantation in systemic scleroderma]. Rev Med Interne 2024; 45:104-108. [PMID: 38267322 DOI: 10.1016/j.revmed.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Autologous haematopoietic stem cell transplantation for systemic scleroderma, developed over more than 25 years, has shown in three randomised controlled clinical trials a significant impact not only in event-free survival, overall survival, cutaneous and pulmonary involvement, but also in the quality of life of patients living with recent severe diffuse cutaneous systemic scleroderma, compared with IV cyclophosphamid despite a transplant-related mortality between 2.4 and 10%. No immunosuppressants or biologics have shown such an impact on mortality in this disease. The risk of relapse is estimated between 9 and 24%, two years after transplant. On the basis of these results, French and international guidelines now position autologous haematopoietic stem cell transplantation as a level 1A evidence-based therapeutic alternative in severe early and rapidly progressive systemic scleroderma.
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Affiliation(s)
- G Pugnet
- Service de médecine interne et immunologie clinique, CHU de Toulouse, 2, rue Viguerie, 31059 Toulouse, France.
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9
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Mouthon L. [Autologous peripheral stem cell transplantation in systemic sclerosis: An important step forward, but we must temper our enthusiasm!]. Rev Med Interne 2024; 45:100-103. [PMID: 38238136 DOI: 10.1016/j.revmed.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
Three prospective randomized studies have demonstrated the efficacy of autologous hematopoietic stem cell (HSC) transplantation in systemic sclerosis (SSc) on survival. These results encourage us to offer this therapy to patients who have a rapidly progressive disease and who have early symptoms but no advanced visceral involvement. HSC autograft can thus be discussed in patients with diffuse cutaneous SSc with a duration of the disease since the first visceral manifestations (cutaneous, cardiac, digestive, pulmonary, or renal) excluding Raynaud's phenomenon of less than 5 years. However, the indications for HSC autograft in SSc validated at European level and in the national diagnostic and care protocol (PNDS) are broader and some of these indications are debatable, in particular in patients with worsening diffuse interstitial lung disease. These indications are discussed in a reasoned way, taking into account the level of evidence and the toxicity of the HSC autograft.
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Affiliation(s)
- L Mouthon
- Service de médecine interne, centre de référence maladies autoimmunes et autoinflammatoires systémiques rares d'Ile de France, de l'Est et de l'Ouest, hôpital Cochin, Assistance Publique-hôpitaux de Paris (AP-HP), hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Cité, AP-HP-CUP, Hôpital Cochin, 75014 Paris, France.
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10
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Campochiaro C, Allanore Y, Braun-Moscovici Y, Matucci-Cerinic M, Balbir-Gurman A. Is cyclophosphamide still the gold standard in early severe rapidly progressive systemic sclerosis? Autoimmun Rev 2024; 23:103439. [PMID: 37690478 DOI: 10.1016/j.autrev.2023.103439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Abstract
Cyclophosphamide (CYC) has been a gold standard of treatment for severe progressive Systemic Sclerosis (SSc), especially in patients with concomitant interstitial lung disease (ILD). This approach was based on results of several interventional studies, including randomized control trials, which mainly addressed SSc-ILD as a primary end point and skin involvement as a second one. The use of CYC is time-limited due to significant adverse events. More recently, other immunosuppressive and biological agents showed efficacy but better safety profile in patients with SSc and SSc-ILD. With regards to other end-points, post-hoc analyses, systematic reviews and metalysis showed that CYC had limited influence on patients' quality of life, event-free survival and mortality. Comprehensive patient's stratification according to a molecular, cellular and phenotypic pattern may help in choosing of personalized medicine with more ambitious treatment effect and should be the future direction. According to the above available data and even if scientific evidence may be missing, experts' opinion has changed the attitude to CYC as an anchor drug in the management of severe SSc. Indeed, CYC has been pushed to the second and even third treatment option after mycophenolate mofetil, tocilizumab or rituximab. This position became obvious during debate on this topic at CORA meeting 2023.
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Affiliation(s)
- Corrado Campochiaro
- IRCCS San Raffaele Hospital, Unit of Immunology, Rheumatology, Allergy and Rare Diseases; Vita-Salute San Raffaele University, Milan, Italy
| | - Yannick Allanore
- Service de Rhumatologie, Hôpital Cochin, Université de Paris, Paris, France
| | - Yolanda Braun-Moscovici
- Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel; The Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Rheumatology, Univercity of Florence, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases; Vita-Salute San Raffaele Univercity, Milan, Italy
| | - Alexandra Balbir-Gurman
- Rheumatology Institute, Rambam Health Care Campus, Haifa, Israel; The Rappaport Faculty of Medicine, Technion, Haifa, Israel.
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11
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Mouthon L. [Autologous peripheral stem cell transplantation in systemic sclerosis: An important step forward, but we must temper our enthusiasm!]. Rev Med Interne 2023:S0248-8663(23)01297-3. [PMID: 38057166 DOI: 10.1016/j.revmed.2023.11.010] [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: 12/08/2023]
Abstract
Three prospective randomized studies have demonstrated the efficacy of autologous hematopoietic stem cell (HSC) transplantation in systemic sclerosis (SSc) on survival. These results encourage us to offer this therapy to patients who have a rapidly progressive disease and who have early symptoms but no advanced visceral involvement. HSC autograft can thus be discussed in patients with diffuse cutaneous SSc with a duration of the disease since the first visceral manifestations (cutaneous, cardiac, digestive, pulmonary, or renal) excluding Raynaud's phenomenon of less than 5 years. However, the indications for HSC autograft in SSc validated at European level and in the national diagnostic and care protocol (PNDS) are broader and some of these indications are debatable, in particular in patients with worsening diffuse interstitial lung disease. These indications are discussed in a reasoned way, taking into account the level of evidence and the toxicity of the HSC autograft.
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Affiliation(s)
- L Mouthon
- Service de médecine interne, centre de référence maladies auto-immunes systémiques rares d'Île-de-France, hôpital Cochin, Assistance publique-Hôpitaux de Paris (AP-HP), 27, rue du Faubourg Saint-Jacques, 75014 Paris, France; Hôpital Cochin, université Paris Cité, AP-HP - CUP, 75014 Paris, France.
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12
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Strunz PP, Labinsky H, Nagler LK, Portegys J, Froehlich M, Gernert M, Schmalzing M. Case Report: Effectiveness of secukinumab in systemic sclerosis with early skin progress after autologous hematopoietic stem cell transplantation and end-stage kidney disease. Front Immunol 2023; 14:1294496. [PMID: 38045701 PMCID: PMC10693324 DOI: 10.3389/fimmu.2023.1294496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/03/2023] [Indexed: 12/05/2023] Open
Abstract
Autologous hematopoietic stem cell transplantation (aHSCT) represents an effective treatment option in patients with severe forms of systemic sclerosis (SSc) by resetting the immune system. Nevertheless, secondary autoimmune disorders and progressive disease after aHSCT might necessitate renewed immunosuppressive treatments. This is particularly challenging when organ dysfunction, i.e., end-stage kidney failure, is present. In this case report, we present the unique case of a 43-year-old female patient with rapidly progressive diffuse systemic sclerosis who underwent aHSCT despite end-stage renal failure as consequence of SSc-renal crisis. Therefore, conditioning chemotherapy was performed with melphalan instead of cyclophosphamide with no occurrence of severe adverse events during the aplastic period and thereafter. After aHSCT, early disease progression of the skin occurred and was successfully treated with secukinumab. Thereby, to the best of our knowledge, we report the first case of successful aHSCT in a SSc-patient with end-stage kidney failure and also the first successful use of an IL-17 inhibitor to treat early disease progression after aHSCT.
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Affiliation(s)
- Patrick-Pascal Strunz
- Department of Internal Medicine 2, Rheumatology/Clinical Immunology, University Hospital Würzburg, Würzburg, Germany
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13
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Chiu YH, Drijver A, Admiraal R, van Rhenen A, Nierkens S, van Laar JM, Spierings J. Anti-thymocyte globulin exposure in patients with diffuse cutaneous systemic sclerosis undergoing autologous haematopoietic stem cell transplantation. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2023; 8:241-246. [PMID: 37744043 PMCID: PMC10515999 DOI: 10.1177/23971983231188232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/28/2023] [Indexed: 09/26/2023]
Abstract
Introduction Autologous haematopoietic stem cell transplantation improves event-free survival and lung function and reduces skin thickening in patients with progressive diffuse cutaneous systemic sclerosis. Anti-thymocyte globulin is a key lymphoablative constituent of conditioning protocols and is administered in a weight-based dosage. However, whether anti-thymocyte globulin exposure contributes to response to autologous haematopoietic stem cell transplantation and lymphocyte reconstitution in diffuse cutaneous systemic sclerosis patients is unknown. We aimed to explore the relationship between anti-thymocyte globulin exposure, lymphocyte reconstitution and treatment response in diffuse cutaneous systemic sclerosis patients undergoing autologous haematopoietic stem cell transplantation. Methods A retrospective cohort of 15 diffuse cutaneous systemic sclerosis patients undergoing autologous haematopoietic stem cell transplantation was performed. Clinical characteristics and routine laboratory results were retrieved from electronic medical records. Anti-thymocyte globulin concentrations were measured in cryopreserved plasma samples at four time points (day 1 and week 1, 2 and 4) after stem cell reinfusion. Anti-thymocyte globulin exposure was estimated using a validated population pharmacokinetic model. Results During a median follow-up of 45 months (interquartile range 19-66), 11 (73%) patients had a treatment response, and 4 (27%) were non-responders. Although all patients received the same weight-based anti-thymocyte globulin dosage, 7.5 mg/kg divided over 3 days, anti-thymocyte globulin exposure varied. Anti-thymocyte globulin exposure was higher in responders than in non-responders (163 AU*day/mL (interquartile range 153-183) and 137 AU*day/mL (interquartile range 101-149), respectively, p = .026). Anti-thymocyte globulin exposure was not correlated with lymphocyte reconstitution or infection rate. Conclusion Weight-based dosing of anti-thymocyte globulin results in variable anti-thymocyte globulin exposure and treatment response across individuals.
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Affiliation(s)
- Yu-Hsiang Chiu
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Division of Rheumatology/Immunology/Allergy, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Anouk Drijver
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rick Admiraal
- Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
| | - Anna van Rhenen
- Department of Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stefan Nierkens
- Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
- Centre for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Julia Spierings
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
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14
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Higuero Sevilla JP, Memon A, Hinchcliff M. Learnings from clinical trials in patients with connective tissue disease-associated interstitial lung disease. Arthritis Res Ther 2023; 25:118. [PMID: 37422652 PMCID: PMC10329300 DOI: 10.1186/s13075-023-03090-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/10/2023] [Indexed: 07/10/2023] Open
Abstract
Many clinical trial results are available to inform best practices in the treatment of patients with connective tissue disease-associated interstitial lung disease (CTD-ILD).Herein, we summarize the results of clinical trials, including patient-reported outcome instruments, for the treatment of patients with ILD associated with systemic sclerosis (SSc/scleroderma), rheumatoid arthritis, and idiopathic inflammatory myositis, the diseases with the most available data. For SSc-ILD, the US Food and Drug Administration approved nintedanib (a tyrosine kinase inhibitor) in 2020 and subcutaneous tocilizumab (an IL-6 receptor monoclonal antibody) in 2021. Rituximab was recently shown to have similar efficacy but better tolerability than intravenous cyclophosphamide (CYC) for CTD-ILD therapy. Scleroderma Lung Study II, conducted in patients with SSc-ILD, showed that oral CYC and mycophenolate mofetil (MMF) were comparable in their effects on lung function, but MMF was better tolerated. The increasing treatment armamentarium for patients with CTD-ILD offers physicians new opportunities to improve patient outcomes.
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Affiliation(s)
- Jean Paul Higuero Sevilla
- Department of Internal Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, CT, 06520, USA
| | - Areeka Memon
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, 06032, USA
| | - Monique Hinchcliff
- Department of Internal Medicine, Section of Rheumatology, Allergy & Immunology, Yale School of Medicine, 300 Cedar Street, The Anlyan Center PO BOX 208031, New Haven, CT, 06520, USA.
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15
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Akbarzadeh R, Müller A, Humrich JY, Riemekasten G. When natural antibodies become pathogenic: autoantibodies targeted against G protein-coupled receptors in the pathogenesis of systemic sclerosis. Front Immunol 2023; 14:1213804. [PMID: 37359516 PMCID: PMC10285309 DOI: 10.3389/fimmu.2023.1213804] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/30/2023] [Indexed: 06/28/2023] Open
Abstract
Systemic sclerosis (SSc) is a chronic, multisystem connective tissue, and autoimmune disease with the highest case-specific mortality and complications among rheumatic diseases. It is characterized by complex and variable features such as autoimmunity and inflammation, vasculopathy, and fibrosis, which pose challenges in understanding the pathogenesis of the disease. Among the large variety of autoantibodies (Abs) present in the sera of patients suffering from SSc, functionally active Abs against G protein-coupled receptors (GPCRs), the most abundant integral membrane proteins, have drawn much attention over the last decades. These Abs play an essential role in regulating the immune system, and their functions are dysregulated in diverse pathological conditions. Emerging evidence indicates that functional Abs targeting GPCRs, such as angiotensin II type 1 receptor (AT1R) and the endothelin-1 type A receptor (ETAR), are altered in SSc. These Abs are part of a network with several GPCR Abs, such as those directed to the chemokine receptors or coagulative thrombin receptors. In this review, we summarize the effects of Abs against GPCRs in SSc pathologies. Extending the knowledge on pathophysiological roles of Abs against GPCRs could provide insights into a better understanding of GPCR contribution to SSc pathogenesis and therefore help in developing potential therapeutic strategies that intervene with pathological functions of these receptors.
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16
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Penglase R, Girgis L, Englert H, Brennan X, Jabbour A, Kotlyar E, Ma D, Moore J. Cardiotoxicity in autologous haematopoietic stem cell transplantation for systemic sclerosis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2023; 8:87-100. [PMID: 37287946 PMCID: PMC10242691 DOI: 10.1177/23971983221145639] [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: 08/23/2022] [Accepted: 11/15/2022] [Indexed: 09/20/2023]
Abstract
Autologous haematopoietic stem cell transplantation is now well-established as an effective treatment for severe systemic sclerosis with clear demonstration of favourable end-organ and survival outcomes. Treatment-related cardiotoxicity remains the predominant safety concern and contraindicates autologous haematopoietic stem cell transplantation in patients with severe cardiopulmonary disease. In this review, we describe the cardiovascular outcomes of autologous haematopoietic stem cell transplantation recipients, discuss the potential mechanisms of cardiotoxicity and propose future mitigating strategies.
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Affiliation(s)
- Ross Penglase
- Department of Rheumatology, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- St. Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - Laila Girgis
- Department of Rheumatology, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- St. Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - Helen Englert
- Department of Haematology and BM Transplantation, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
| | - Xavier Brennan
- Department of Cardiology and Heart and Lung Transplantation, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
| | - Andrew Jabbour
- University of New South Wales, Sydney, NSW, Australia
- Department of Cardiology and Heart and Lung Transplantation, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
| | - Eugene Kotlyar
- University of New South Wales, Sydney, NSW, Australia
- Department of Cardiology and Heart and Lung Transplantation, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
| | - David Ma
- University of New South Wales, Sydney, NSW, Australia
- St. Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
- Department of Haematology and BM Transplantation, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
| | - John Moore
- University of New South Wales, Sydney, NSW, Australia
- St. Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia
- Department of Haematology and BM Transplantation, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
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17
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Khanna D, Krieger N, Sullivan KM. Improving outcomes in scleroderma: recent progress of cell-based therapies. Rheumatology (Oxford) 2023; 62:2060-2069. [PMID: 36355455 PMCID: PMC10234204 DOI: 10.1093/rheumatology/keac628] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/23/2022] [Indexed: 08/27/2023] Open
Abstract
Scleroderma is a rare, potentially fatal, clinically heterogeneous, systemic autoimmune connective tissue disorder that is characterized by progressive fibrosis of the skin and visceral organs, vasculopathy and immune dysregulation. The more severe form of the disease, diffuse cutaneous scleroderma (dcSSc), has no cure and limited treatment options. Haematopoietic stem cell transplantation has emerged as a potentially disease-modifying treatment but faces challenges such as toxicity associated with fully myeloablative conditioning and recurrence of autoimmunity. Novel cell therapies-such as mesenchymal stem cells, chimeric antigen receptor-based therapy, tolerogenic dendritic cells and facilitating cells-that may restore self-tolerance with more favourable safety and tolerability profiles are being explored for the treatment of dcSSc and other autoimmune diseases. This narrative review examines these evolving cell therapies.
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Affiliation(s)
- Dinesh Khanna
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Nancy Krieger
- Talaris Therapeutics, Boston, MA and Louisville, KY, USA
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18
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Pope JE, Denton CP, Johnson SR, Fernandez-Codina A, Hudson M, Nevskaya T. State-of-the-art evidence in the treatment of systemic sclerosis. Nat Rev Rheumatol 2023; 19:212-226. [PMID: 36849541 PMCID: PMC9970138 DOI: 10.1038/s41584-023-00909-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 03/01/2023]
Abstract
Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease with multi-organ involvement, fibrosis and vasculopathy. Treatment in SSc, including early diffuse cutaneous SSc (dcSSc) and the use of organ-specific therapies, has improved, as evident from randomized clinical trials. Treatments for early dcSSc include immunosuppressive agents such as mycophenolate mofetil, methotrexate, cyclophosphamide, rituximab and tocilizumab. Patients with rapidly progressive early dcSSc might be eligible for autologous haematopoietic stem cell transplantation, which can improve survival. Morbidity from interstitial lung disease and pulmonary arterial hypertension is improving with the use of proven therapies. Mycophenolate mofetil has surpassed cyclophosphamide as the initial treatment for SSc-interstitial lung disease. Nintedanib and possibly perfinidone can be considered in SSc pulmonary fibrosis. Pulmonary arterial hypertension is frequently treated with initial combination therapy (for example, with phosphodiesterase 5 inhibitors and endothelin receptor antagonists) and, if necessary, the addition of a prostacyclin analogue. Raynaud phenomenon and digital ulcers are treated with dihydropyridine calcium channel blockers (especially nifedipine), then phosphodiesterase 5 inhibitors or intravenous iloprost. Bosentan can reduce the development of new digital ulcers. Trial data for other manifestations are mostly lacking. Research is needed to develop targeted and highly effective treatments, best practices for organ-specific screening and early intervention, and sensitive outcome measurements.
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Affiliation(s)
- Janet E Pope
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada.
- Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada.
| | | | - Sindhu R Johnson
- Toronto Scleroderma Program, Toronto Western Hospital, Mount Sinai Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Andreu Fernandez-Codina
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada
- General Internal Medicine, Windsor Regional Hospital, Windsor, ON, Canada
- Critical Care, Emergency and Systemic Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Marie Hudson
- Department of Medicine, McGill University, Montreal, QC, Canada
- Division of Rheumatology and Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
| | - Tatiana Nevskaya
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada
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19
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Henes JC, Martac I, Vogel W, Lengerke C, Klein R, Hensen L, Pecher AC. COVID-19 infection after autologous stem cell transplantation for systemic sclerosis. Ann Rheum Dis 2023:ard-2023-223915. [PMID: 36889905 DOI: 10.1136/ard-2023-223915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/28/2023] [Indexed: 03/10/2023]
Affiliation(s)
- Joerg Christoph Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Auto-inflammatory Diseases and Department of Internal Medicine II (Hematology, Oncology, Rheumatology and Clinical Immunology), University Hospital Tubingen, Tuebingen, Germany
| | - Ioana Martac
- Department of Internal Medicine II (Hematology, Oncology, Rheumatology and Clinical Immunology), University Hospital Tubingen, Tuebingen, Germany
| | - Wichard Vogel
- Department of Internal Medicine II (Hematology, Oncology, Rheumatology and Clinical Immunology), University Hospital Tubingen, Tuebingen, Germany
| | - Claudia Lengerke
- Department of Internal Medicine II (Hematology, Oncology, Rheumatology and Clinical Immunology), University Hospital Tubingen, Tuebingen, Germany
| | - Reinhild Klein
- Department of Internal Medicine II (Hematology, Oncology, Rheumatology and Clinical Immunology), University Hospital Tubingen, Tuebingen, Germany
| | - Luca Hensen
- Department of Internal Medicine II (Hematology, Oncology, Rheumatology and Clinical Immunology), University Hospital Tubingen, Tuebingen, Germany
| | - Ann-Christin Pecher
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Auto-inflammatory Diseases and Department of Internal Medicine II (Hematology, Oncology, Rheumatology and Clinical Immunology), University Hospital Tubingen, Tuebingen, Germany
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20
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Higashitani K, Takase-Minegishi K, Yoshimi R, Kirino Y, Hamada N, Nagai H, Hagihara M, Matsumoto K, Namkoong H, Horita N, Nakajima H. Benefits and risks of haematopoietic stem cell transplantation for systemic sclerosis: A systematic review and meta-analysis. Mod Rheumatol 2023; 33:330-337. [PMID: 35285885 DOI: 10.1093/mr/roac026] [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: 02/15/2022] [Revised: 03/07/2022] [Accepted: 03/09/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVES We aimed to evaluate the efficacy and safety of haematopoietic stem cell transplantation (HSCT) in patients with systemic sclerosis. METHODS A systematic literature review and meta-analysis were carried out. We compared survival outcomes using the Kaplan-Meier method with patient-level data between HSCT and intravenous pulse cyclophosphamide. Additionally, the incidence rate of treatment-related deaths with HSCT was pooled using a random-effect model. RESULTS Of the 2091 articles screened, 22 were included: 3 randomized controlled trials and 19 observational studies. HSCT studies showed significant improvement in the skin thickness score and lung function. Despite treatment-related deaths being higher in HSCT than in intravenous pulse cyclophosphamide, the Kaplan-Meier analysis showed a high survival rate of 2 years post-transplant (log-rank, P = 0.004). The pooled frequency of transplant-related death from 700 systemic sclerosis patients was 6.30% (95% confidence interval 4.21-8.38). However, the estimated frequency of treatment-related deaths has been reducing over the last decade. CONCLUSIONS HSCT is an effective treatment for systemic sclerosis, but the optimal indications must be carefully determined by balancing the risks.
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Affiliation(s)
- Kana Higashitani
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kaoru Takase-Minegishi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Naoki Hamada
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hideto Nagai
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Maki Hagihara
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kenji Matsumoto
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ho Namkoong
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
| | - Nobuyuki Horita
- Chemotherapy Center, Yokohama City University Hospital, Yokohama, Japan
| | - Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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21
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Pecher AC, Ach KR, Vogel W, Henes JC. Mobilization with reduced cyclophosphamide for autologous stem cell transplantation is feasible in patients with systemic sclerosis. Rheumatology (Oxford) 2023; 62:SI107-SI113. [PMID: 35951758 DOI: 10.1093/rheumatology/keac455] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/25/2022] [Accepted: 07/25/2022] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To assess the feasibility of reduced cyclophosphamide dosing in the setting of mobilization chemotherapy prior to high dose chemotherapy and autologous stem cell transplantation in patients with SSc. The primary end point was the occurrence of 'poor mobilization' when using different cyclophosphamide dosing. The second end point was to analyse potential risk factors for difficult stem cell mobilization in this cohort of patients with SSc. METHODS This single-centre study retrospectively reviewed 32 patients with SSc who underwent autologous stem cell transplantation. We analysed the occurrence of 'poor mobilization' (defined as CD34+ progenitor cell count <2 × 106/kg body weight, the use of increasing G-CSF dose, the use of plerixafor, or leukapheresis on >2 consecutive days) in different cyclophosphamide mobilization regimens: We herein compared low dose (2 × 1-1.5 g/m2) cyclophosphamide vs high dose (2 × 2 g/m2) for mobilization. RESULTS Higher dosing of cyclophosphamide seems not to be beneficial regarding stem cell collection as there was no significant difference in stem cell yield between high dose and reduced dose cyclophosphamide (6.2 vs 5.2 × 106/kg bodyweight after CD34+ enrichment). Furthermore, higher doses of cyclophosphamide might be associated with more side effects; this difference was, however, not statistically significant. Lower bodyweight and BMI (P < 0.001) as well as rituximab pre-therapy (P < 0.05) and cardiac involvement (P < 0.01) might negatively impact stem cell collection independently from the chosen regimen. CONCLUSION Our data demonstrate that a reduced cyclophosphamide mobilization regimen seems to be feasible. Risk factors for poor mobilization might be low bodyweight, prior rituximab therapy and cardiac involvement.
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Affiliation(s)
- Ann-Christin Pecher
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Autoinflammatory Diseases, University Hospital Tuebingen
| | | | - Wichard Vogel
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Joerg Christoph Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Autoinflammatory Diseases, University Hospital Tuebingen
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22
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Gadioli LP, Costa-Pereira K, Dias JBE, Moraes DA, Crescêncio JC, Schwartzmann PV, Gallo-Júnior L, Schmidt A, Oliveira MC. Autologous stem cell transplantation improves cardiopulmonary exercise testing outcomes in systemic sclerosis patients. Rheumatology (Oxford) 2023; 62:SI101-SI106. [PMID: 35861395 DOI: 10.1093/rheumatology/keac413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/29/2022] [Accepted: 07/11/2022] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Autologous haematopoietic stem cell transplantation (AHSCT) is a disease-modifying treatment for patients with severe SSc. Here, we aimed at assessing cardiopulmonary function outcomes of SSc patients after AHSCT. METHODS Twenty-seven SSc adult patients treated with AHSCT were included in this retrospective study. Most had the diffuse cutaneous subset (93%) and pulmonary involvement (85%). Before and 12 months after AHSCT, patients underwent cardiopulmonary exercise testing, transthoracic echocardiography, pulmonary function test with diffusing capacity for carbon monoxide (DLCO), 6-min walk test (6MWT) and quality of life evaluations. RESULTS After AHSCT, the peak VO2 increased from 954 to 1029 ml/min (P = 0.02), the percentage of predicted peak VO2 increased from 48.9 to 53.5 m (P = 0.01), and the distance measured by the 6MWT increased from 445 to 502 m (P = 0.01), compared with baseline. Improvements in peak VO2 correlated positively with improvements in 6MWT distance, and negatively with a decrease in resting heart rate. At baseline, patients with DLCO >70% had higher peak VO2 values than those with DLCO <70% (P = 0.04), but after AHSCT all patients showed improved VO2 values, regardless of baseline DLCO levels. Increases in VO2 levels after AHSCT positively correlated with increases in the physical component scores of the Short Form-36 quality of life questionnaire (r = 0.70; P = 0.0003). CONCLUSION AHSCT improves the aerobic capacity of SSc patients probably reflecting combined increments in lungs, skeletal muscle and cardiac function.
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Affiliation(s)
| | - Karla Costa-Pereira
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo
| | - Juliana B E Dias
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo
| | - Daniela A Moraes
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo
| | - Júlio C Crescêncio
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School
| | | | - Lourenço Gallo-Júnior
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School
| | - André Schmidt
- Division of Cardiology, Department of Internal Medicine, Ribeirão Preto Medical School
| | - Maria Carolina Oliveira
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo.,Center for Cell-based Therapy, Regional Hemotherapy Center of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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23
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Behr J, Bonella F, Frye BC, Günther A, Hagmeyer L, Henes J, Klemm P, Koschel D, Kreuter M, Leuschner G, Nowak D, Prasse A, Quadder B, Sitter H, Costabel U. [Pharmacological treatment of idiopathic pulmonary fibrosis (update) and progressive pulmonary fibrosis - S2k Guideline of the German Respiratory Society]. Pneumologie 2023; 77:94-119. [PMID: 36791790 DOI: 10.1055/a-1983-6796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Jürgen Behr
- Medizinische Klinik und Polklinik V, LMU Klinikum der Universität München, Mitglied des Deutschen Zentrums für Lungenforschung; Delegierte/r der DGP
| | - Francesco Bonella
- Zentrum für interstitielle und seltene Lungenerkrankungen, Klinik für Pneumologie, Ruhrlandklinik, Universitätsmedizin Essen; Delegierter der DGP
| | - Björn C Frye
- Klinik für Pneumologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Deutschland; Delegierter der DGP
| | - Andreas Günther
- Center for Interstitial and Rare Lung Diseases, University Hospital Giessen Marburg, Giessen, Agaplesion Evangelisches Krankenhaus Mittelhessen, Giessen, Germany; Delegierter der DGP
| | - Lars Hagmeyer
- Krankenhaus Bethanien Solingen, Klinik für Pneumologie und Allergologie, Zentrum für Schlaf- und Beatmungsmedizin, Institut für Pneumologie an der Universität zu Köln; Delegierter der DGP
| | - Jörg Henes
- Zentrum für interdisziplinäre Rheumatologie, Immunologie und Autoimmunerkrankungen (INDIRA) und Innere Medizin II; Delegierter DGRh
| | - Philipp Klemm
- Abt. Rheumatologie und klinische Immunologie, Kerckhoff Klinik und Campus Kerckhoff der Justus-Liebig-Universität Gießen, Bad Nauheim; Delegierter der DGRh
| | - Dirk Koschel
- Fachkrankenhaus Coswig, Lungenzentrum und Medizinische Klinik 1, Universitätsklinik Carl Gustav Carus der TU Dresden; Delegierter der DGP
| | - Michael Kreuter
- Zentrum für interstitielle und seltene Lungenerkrankungen & interdisziplinäres Sarkoidosezentrum, Thoraxklinik, Universitätsklinikum Heidelberg, Deutsches Zentrum für Lungenforschung Heidelberg und Klinik für Pneumologie, Interdisziplinäres Lungenzentrum Ludwigsburg, RKH Klinik Ludwigsburg; Delegierter der DGIM
| | - Gabriela Leuschner
- Medizinische Klinik und Polklinik V, LMU Klinikum der Universität München, Mitglied des Deutschen Zentrums für Lungenforschung; Delegierte/r der DGP
| | - Dennis Nowak
- Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU Klinikum der Universität München, Comprehensive Pneumology Center (CPC) München, Mitglied des Deutsches Zentrums für Lungenforschung; Delegierter der DGAUM
| | - Antje Prasse
- Klinik für Pneumologie und Infektiologie, Medizinische Hochschule Hannover, DZL BREATH und Abteilung für Fibroseforschung, Fraunhofer ITEM, Hannover, Delegierte der DGP
| | | | - Helmut Sitter
- Institut für Theoretische Chirurgie, Philipps-Universität Marburg, Moderator
| | - Ulrich Costabel
- Zentrum für interstitielle und seltene Lungenerkrankungen, Klinik für Pneumologie, Ruhrlandklinik, Universitätsmedizin Essen; Delegierter der DGP
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24
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Schmalzing M, Henes J, van Laar JM, Sullivan KM. Editorial: Stem cell transplantation in autoimmune diseases (AID). Front Immunol 2023; 14:1150664. [PMID: 36936937 PMCID: PMC10014887 DOI: 10.3389/fimmu.2023.1150664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/06/2023] [Indexed: 03/06/2023] Open
Affiliation(s)
- Marc Schmalzing
- Rheumatology/Clinical Immunology, Department of Internal Medicine II, University of Würzburg, Wuerzburg, Germany
- *Correspondence: Marc Schmalzing,
| | - Joerg Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Auto-inflammatory Diseases and Department of Internal Medicine II, University Hospital Tuebingen, Tuebingen, Germany
| | - Jacob M. van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Keith M. Sullivan
- Department of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC, United States
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25
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Hematopoietic Cell Transplantation for Systemic Sclerosis-A Review. Cells 2022; 11:cells11233912. [PMID: 36497169 PMCID: PMC9739132 DOI: 10.3390/cells11233912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune, multi-organ, connective tissue disease associated with significant morbidity and mortality. Conventional immunosuppressive therapies demonstrate limited efficacy. Autologous hematopoietic stem cell transplantation (HCT) is more efficacious but carries associated risks, including treatment-related mortality. Here, we review HCT as a treatment for SSc, its efficacy and toxicity in comparison to conventional therapies, and the proposed mechanisms of action. Furthermore, we discuss the importance of and recent developments in patient selection. Finally, we highlight the knowledge gaps and future work required to further improve patient outcomes.
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26
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High Throughput Fabrication of Flexible Top-Driven Sensing Probe. Polymers (Basel) 2022; 14:polym14235124. [PMID: 36501518 PMCID: PMC9738077 DOI: 10.3390/polym14235124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022] Open
Abstract
In this work, considering the current status of conservative and complicated traditional thrombosis treatment methods, a kind of flexible intelligent probe (FIP) with a top-driven sensing strategy is proposed to realize the expected function of thrombosis accurate localization in a liquid flow environment. After throughput fabrication, we find that the FIP has excellent electrical conductivity and mechanical properties. Notable, our FIP with the principle of piezo-resistive sensing has a quasi-linear sensitivity (approx. 0.325 L per minute) to flow sensing in the low flow velocity range (0-1 L per minute). Via the well-designed magnetically driven method, our FIP has a maximum deflection output force of 443.264 mN, a maximum deflection angle of 43°, and a maximum axial force of 54.176 mN. We demonstrate that the FIP is capable of completing the specified command actions relatively accurately and has a good response to real-time sensing feedback performance, which has broad application prospects in thrombus localization detection.
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27
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Xue E, Minniti A, Alexander T, Del Papa N, Greco R. Cellular-Based Therapies in Systemic Sclerosis: From Hematopoietic Stem Cell Transplant to Innovative Approaches. Cells 2022; 11:3346. [PMID: 36359742 PMCID: PMC9658618 DOI: 10.3390/cells11213346] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 08/28/2023] Open
Abstract
Systemic sclerosis (SSc) is a systemic disease characterized by autoimmune responses, vasculopathy and tissue fibrosis. The pathogenic mechanisms involve a wide range of cells and soluble factors. The complexity of interactions leads to heterogeneous clinical features in terms of the extent, severity, and rate of progression of skin fibrosis and internal organ involvement. Available disease-modifying drugs have only modest effects on halting disease progression and may be associated with significant side effects. Therefore, cellular therapies have been developed aiming at the restoration of immunologic self-tolerance in order to provide durable remissions or to foster tissue regeneration. Currently, SSc is recommended as the 'standard indication' for autologous hematopoietic stem cell transplantation by the European Society for Blood and Marrow Transplantation. This review provides an overview on cellular therapies in SSc, from pre-clinical models to clinical applications, opening towards more advanced cellular therapies, such as mesenchymal stem cells, regulatory T cells and potentially CAR-T-cell therapies.
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Affiliation(s)
- Elisabetta Xue
- Hematopoietic and Bone Marrow Transplant Unit, San Raffaele Hospital, 20132 Milan, Italy
| | - Antonina Minniti
- Department of Rheumatology, ASST G. Pini-CTO, 20122 Milan, Italy
| | - Tobias Alexander
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Rheumatology and Clinical Immunology, 10117 Berlin, Germany
- Deutsches Rheuma-Forschungszentrum (DRFZ), an Institute of the Leibniz Association, 10117 Berlin, Germany
| | | | - Raffaella Greco
- Hematopoietic and Bone Marrow Transplant Unit, San Raffaele Hospital, 20132 Milan, Italy
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28
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Graßhoff H, Fourlakis K, Comdühr S, Riemekasten G. Autoantibodies as Biomarker and Therapeutic Target in Systemic Sclerosis. Biomedicines 2022; 10:biomedicines10092150. [PMID: 36140251 PMCID: PMC9496142 DOI: 10.3390/biomedicines10092150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 12/03/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare connective tissue disorder characterized by immune dysregulation evoking the pathophysiological triad of inflammation, fibrosis and vasculopathy. In SSc, several alterations in the B-cell compartment have been described, leading to polyclonal B-cell hyperreactivity, hypergammaglobulinemia and autoantibody production. Autoreactive B cells and autoantibodies promote and maintain pathologic mechanisms. In addition, autoantibodies in SSc are important biomarkers for predicting clinical phenotype and disease progression. Autoreactive B cells and autoantibodies represent potentially promising targets for therapeutic approaches including B-cell-targeting therapies, as well as strategies for unselective and selective removal of autoantibodies. In this review, we present mechanisms of the innate immune system leading to the generation of autoantibodies, alterations of the B-cell compartment in SSc, autoantibodies as biomarkers and autoantibody-mediated pathologies in SSc as well as potential therapeutic approaches to target these.
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29
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Broens B, van der Laken CJ, Zwezerijnen GJ, Nossent EJ, Meijboom LJ, Spierings J, de Vries-Bouwstra JK, van Laar JM, Voskuyl AE. Positron Emission Tomography to Improve Assessment of Interstitial Lung Disease in Patients With Systemic Sclerosis Eligible for Autologous Stem Cell Transplantation. Front Immunol 2022; 13:923869. [PMID: 35865521 PMCID: PMC9294594 DOI: 10.3389/fimmu.2022.923869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Positron emission tomography (PET) is a promising technique to improve the assessment of systemic sclerosis associated interstitial lung disease (SSc-ILD). This technique could be of particular value in patients with severe diffuse cutaneous SSc (dcSSc) that are possibly eligible for autologous hematopoietic stem cell transplantation (aHSCT). aHSCT is a potentially effective therapy for patients with severe dcSSc and ILD, leading to stabilization or improvement of lung function. However, there is a high need to improve patient selection, which includes (1) the selection of patients with rapidly progressive ILD for early rather than last-resort aHSCT (2) the prediction of treatment response on ILD and (3) the understanding of the mechanism(s) of action of aHSCT in the lungs. As previous studies with 18F-FDG PET in SSc-ILD and other forms of ILD have demonstrated its potential value in predicting disease progression and reactivity to anti-inflammatory treatment, we discuss the potential benefit of using this technique in patients with early severe dcSSc and ILD in the context of aHSCT. In addition, we discuss the potential value of other PET tracers in the assessment of ILD and understanding the mechanisms of action of aHSCT in the lung. Finally, we provide several suggestions for future research.
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Affiliation(s)
- Bo Broens
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, Amsterdam, Netherlands
| | - Conny J. van der Laken
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, Amsterdam, Netherlands
| | | | - Esther J. Nossent
- Department of Pulmonary Medicine, Amsterdam UMC, Amsterdam, Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, Netherlands
| | - Lilian J. Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Amsterdam, Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, Netherlands
| | - Julia Spierings
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Jacob M. van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Alexandre E. Voskuyl
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, Amsterdam, Netherlands
- *Correspondence: Alexandre E. Voskuyl,
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30
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Pugnet G, Petermann A, Collot S, Otal P, Lansiaux P, Ait Abdallah N, Lorillon G, Resche-Rigon M, Borel C, Marjanovic Z, Farge D. Changes on chest HRCT in systemic sclerosis-related interstitial lung disease after autologous haematopoietic stem cell transplantation. Rheumatology (Oxford) 2022; 62:SI32-SI42. [PMID: 35686921 PMCID: PMC9910571 DOI: 10.1093/rheumatology/keac319] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/20/2022] [Accepted: 04/29/2022] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To evaluate extent of interstitial lung disease (ILD) and oesophageal involvement using high-resolution computed tomography (HRCT) in early diffuse SSc patients after autologous haematopoietic stem cell transplantation (aHSCT). METHODS Overall chest HRCT, lung function and skin score changes were evaluated in 33 consecutive diffuse SSc patients before and after aHSCT during yearly routine follow-up visits between January 2000 and September 2016. Two independent radiologists blindly assessed the ILD extent using semi-quantitative Goh and Wells method, the widest oesophageal diameter (WOD) and the oesophageal volume (OV) on HRCT. Patients were retrospectively classified as radiological responders or non-responders, based on achieved stability or a decrease of 5% or more of HRCT-ILD at 24 months post-aHSCT. RESULTS Using a linear mixed model, the regressions of the extent of ILD and of ground glass opacities were significant at 12 months (ILD P = 0.001; ground glass opacities P = 0.0001) and at 24 months (ILD P = 0.007; ground glass opacities P = 0.0008) after aHSCT, with 18 patients classified as radiological responders (probability of response 0.78 [95% CI 0.58, 0.90]). Meanwhile the WOD and the OV increased significantly at 12 months (WOD P = 0.03; OV P = 0.34) and at 24 months (WOD P = 0.002; OV P = 0.007). Kaplan-Meier analyses showed a trend towards better 5-year survival rates (100% vs 60%; hazard ratio 0.23 [95% CI 0.03, 1.62], P = 0.11) among radiological responders vs non-responders at 24 month follow-up after aHSCT. CONCLUSION Real-world data analysis confirmed significant improvement in extent of HRCT SSc-ILD 24 months after aHSCT, although oesophageal dilatation worsened requiring specific attention.
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Affiliation(s)
- Grégory Pugnet
- Correspondence to: Grégory Pugnet, Service de Médecine Interne et Immunologie Clinique, CHU Toulouse Rangueil, 2 rue Viguerie 31059 Toulouse, France. E-mail:
| | | | - Samia Collot
- Service de Radiologie Centrale, CHU Toulouse, Toulouse
| | - Philippe Otal
- Service de Radiologie Centrale, CHU Toulouse, Toulouse
| | - Pauline Lansiaux
- Unité de Médecine Interne (UF 04): CRMR MATHEC, Maladies auto-immunes et thérapie cellulaire; Centre de Référence des Maladies auto-immunes systémiques Rares d’Ile-de-France MATHEC, AP-HP, Hôpital St-Louis,Université de Paris, IRSL, Recherche clinique appliquée à l'hématologie, EA3518 (Equipe 3 MATHEC-EUROCORD), Paris
| | - Nassim Ait Abdallah
- Unité de Médecine Interne (UF 04): CRMR MATHEC, Maladies auto-immunes et thérapie cellulaire; Centre de Référence des Maladies auto-immunes systémiques Rares d’Ile-de-France MATHEC, AP-HP, Hôpital St-Louis,Université de Paris, IRSL, Recherche clinique appliquée à l'hématologie, EA3518 (Equipe 3 MATHEC-EUROCORD), Paris
| | | | | | - Cécile Borel
- Service Hématologie clinique CHU Toulouse, Toulouse
| | - Zora Marjanovic
- Hématologie clinique et thérapie cellulaire-hôpital Saint-Antoine, AP-HP, Paris, France
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Indications for haematopoietic cell transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe, 2022. Bone Marrow Transplant 2022; 57:1217-1239. [PMID: 35589997 PMCID: PMC9119216 DOI: 10.1038/s41409-022-01691-w] [Citation(s) in RCA: 117] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 12/17/2022]
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Alexander T, Greco R. Hematopoietic stem cell transplantation and cellular therapies for autoimmune diseases: overview and future considerations from the Autoimmune Diseases Working Party (ADWP) of the European Society for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2022; 57:1055-1062. [PMID: 35578014 PMCID: PMC9109750 DOI: 10.1038/s41409-022-01702-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/26/2022] [Accepted: 04/29/2022] [Indexed: 02/06/2023]
Abstract
Autoimmune diseases (ADs) represent a heterogenous group of complex diseases with increasing incidence in Western countries and are a major cause of morbidity. Hematopoietic stem cell transplantation (HSCT) has evolved over the last 25 years as a specific treatment for patients with severe ADs, through eradication of the pathogenic immunologic memory and profound immune renewal. HSCT for ADs is recently facing a unique developmental phase across transplant centers. This review provides a comprehensive overview of the recent evidence and developments in the area, including fundamentals of preclinical research, clinical studies in neurologic, rheumatologic and gastroenterologic diseases, which represent major indications at present, along with evidence of HSCT for rarer indications. Moreover, we describe the interwoven challenges of delivering more advanced cellular therapies, exploiting mesenchymal stem cells, regulatory T cells and potentially CAR-T cell therapies, in patients affected by ADs. Overall, we discuss past and current indications, efficacy, associated risks and benefits, and future directions of HSCT and advanced cellular therapies in the treatment of severe/refractory ADs, integrating the available literature with European Society for Blood and Marrow Transplantation (EBMT) registry data.
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Affiliation(s)
- Tobias Alexander
- Department of Rheumatology and Clinical Immunology, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
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Ahmed S, Handa R. Management of Connective Tissue Disease-related Interstitial Lung Disease. CURRENT PULMONOLOGY REPORTS 2022; 11:86-98. [PMID: 35530438 PMCID: PMC9062859 DOI: 10.1007/s13665-022-00290-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 01/16/2023]
Abstract
Purpose of Review This review aims to collate current evidence on the screening, diagnosis, and treatment of various connective tissue disease (CTD)–associated interstitial lung diseases (CTD-ILD) and present a contemporary framework for the management of such patients. It also seeks to summarize treatment outcomes including efficacy and safety of immunosuppressants, anti-fibrotics, and stem cell transplantation in CTD-ILD. Recent Findings Screening for ILD has been augmented by the use of artificial intelligence, ultra-low dose computerized tomography (CT) of the chest, and the use of chest ultrasound. Serum biomarkers have not found their way into clinical practice as yet. Identifying patients who need treatment and choosing the appropriate therapy is important to minimize the risk of therapy-related toxicity. The first-line drugs for systemic sclerosis (SSc) ILD include mycophenolate and cyclophosphamide. Nintedanib, an anti-fibrotic tyrosine kinase inhibitor, is approved for use in SSc-ILD. The US Food and Drug Administration (FDA) has recently approved tocilizumab subcutaneous injection for slowing the rate of decline in pulmonary function in adult patients with SSc-ILD. Autologous stem cell transplantation may have a role in select cases of SSc-ILD. Summary CTD-ILD is a challenging area with diverse entities and variable outcomes. High-resolution CT is the investigative modality of choice. Treatment decisions need to be individualized and are based on patient symptoms, lung function, radiologic abnormalities, and the risk of disease progression. Precision medicine may play an important role in determining the optimal therapy for an individual patient in the future.
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Affiliation(s)
- Sakir Ahmed
- Department of Clinical Immunology & Rheumatology, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
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Zanin-Silva DC, Santana-Gonçalves M, Kawashima-Vasconcelos MY, Lima-Júnior JR, Dias JBE, Moraes DA, Covas DT, Malmegrim KCR, Ramalho L, Oliveira MC. Autologous hematopoietic stem cell transplantation promotes connective tissue remodeling in systemic sclerosis patients. Arthritis Res Ther 2022; 24:95. [PMID: 35488348 PMCID: PMC9052524 DOI: 10.1186/s13075-022-02779-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Autologous hematopoietic stem cell transplantation (AHSCT) treats patients with severe and progressive systemic sclerosis (SSc). However, basic mechanisms associated with the therapeutic efficacy of the procedure are not entirely understood. We aimed to evaluate how AHSCT affects skin fibrosis in SSc patients. METHODS Clinical data, serum, and skin samples from 39 SSc patients who underwent AHSCT were retrospectively evaluated. Skin biopsies were analyzed by immunohistochemistry with anti-MMP-1, -MMP-2, -MMP-3, -MMP-9, -TIMP-1, -α-SMA, -TGF-β, and -NF-κB p65 antibodies, and stained with hematoxylin and eosin and picrosirius red to assess skin thickness and collagen density, respectively. Serum samples were evaluated by Multiplex Assay for COL1A1, COL4A1, FGF-1, MMP-1, MMP-3, MMP-12, MMP-13, PDGF-AA, PDGF-BB, S100A9, and TIMP-1 levels and compared to healthy controls. RESULTS After AHSCT, SSc patients showed clinical improvement in skin involvement, assessed by modified Rodnan's skin score (mRSS). Histologically, collagen density and skin thickness decreased after AHSCT. Immunohistochemical analyses showed increased expression of MMP-2, MMP-3, MMP-9, and TIMP-1 after AHSCT, whereas expression of NF-κB p65 decreased. At baseline, serum levels of COL4A1 and S100A9 were higher than in healthy controls. Serum levels of S100A9 normalized after AHCST in SSc patients compared to controls. Serum levels of PDGF-AA, PDGF-BB, TIMP-1, and MMP-1 decreased, while COL1A1 increased after AHSCT in SSc patients. No changes were detected in MMP-3, MMP-12, MMP-13, and FGF-1 serum levels after AHSCT. CONCLUSIONS Our results suggest that the therapeutic effects of AHSCT on skin fibrosis are related to changes in molecules associated with connective tissue maintenance and inflammation in SSc.
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Affiliation(s)
- Djúlio C Zanin-Silva
- Center for Cell-based Therapy, Regional Hemotherapy Center of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Basic and Applied Immunology Graduate Program, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Maynara Santana-Gonçalves
- Center for Cell-based Therapy, Regional Hemotherapy Center of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Oncology, Stem cell and Cell-Therapy Graduate Program, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marianna Y Kawashima-Vasconcelos
- Center for Cell-based Therapy, Regional Hemotherapy Center of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Internal Medicine Graduate Program, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - João R Lima-Júnior
- Center for Cell-based Therapy, Regional Hemotherapy Center of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Department of Immuno-Oncology, Beckman Research Institute City of Hope, Duarte, CA, USA
| | - Juliana B E Dias
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes 3900, Ribeirão Preto, SP, 14048-900, Brazil
| | - Daniela A Moraes
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes 3900, Ribeirão Preto, SP, 14048-900, Brazil
| | - Dimas T Covas
- Center for Cell-based Therapy, Regional Hemotherapy Center of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Kelen C R Malmegrim
- Center for Cell-based Therapy, Regional Hemotherapy Center of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Oncology, Stem cell and Cell-Therapy Graduate Program, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Department of Clinical, Toxicological and Bromatological Analysis, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Leandra Ramalho
- Department of Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Maria Carolina Oliveira
- Center for Cell-based Therapy, Regional Hemotherapy Center of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil. .,Oncology, Stem cell and Cell-Therapy Graduate Program, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil. .,Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes 3900, Ribeirão Preto, SP, 14048-900, Brazil.
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35
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Herrick AL, Assassi S, Denton CP. Skin involvement in early diffuse cutaneous systemic sclerosis: an unmet clinical need. Nat Rev Rheumatol 2022; 18:276-285. [PMID: 35292731 PMCID: PMC8922394 DOI: 10.1038/s41584-022-00765-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 12/23/2022]
Abstract
Diffuse cutaneous systemic sclerosis (dcSSc) is associated with high mortality resulting from early internal-organ involvement. Clinicians therefore tend to focus on early diagnosis and treatment of potentially life-threatening cardiorespiratory and renal disease. However, the rapidly progressive painful, itchy skin tightening that characterizes dcSSc is the symptom that has the greatest effect on patients' quality of life, and there is currently no effective disease-modifying treatment for it. Considerable advances have been made in predicting the extent and rate of skin-disease progression (which vary between patients), including the development of techniques such as molecular analysis of skin biopsy samples. Risk stratification for progressive skin disease is especially relevant now that haematopoietic stem-cell transplantation is a treatment option, because stratification will inform the balance of risk versus benefit for each patient. Measurement of skin disease is a major challenge. Results from clinical trials have highlighted limitations of the modified Rodnan skin score (the current gold standard). Alternative patient-reported and other potential outcome measures have been and are being developed. Patients with early dcSSc should be referred to specialist centres to ensure best-practice management, including the management of their skin disease, and to maximize opportunities for inclusion in clinical trials.
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Affiliation(s)
- Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Shervin Assassi
- McGovern Medical School, The University of Texas, Houston, TX, USA
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36
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Autologous Haematopoietic Stem Cell Transplantation and Systemic Sclerosis: Focus on Interstitial Lung Disease. Cells 2022; 11:cells11050843. [PMID: 35269465 PMCID: PMC8909673 DOI: 10.3390/cells11050843] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 11/16/2022] Open
Abstract
Autologous hematopoietic stem cells transplantation (AHSCT) has been employed as treatment for severe systemic sclerosis (SSc) with high risk of organ failure. In the last 25 years overall survival and treatment-related mortality have improved, in accordance with a better patient selection and mobilization and conditioning protocols. This review analyzes the evidence from the last 5 years for AHSCT-treated SSc patients, considering in particular the outcomes related to interstitial lung disease. There are increasing data supporting the use of AHSCT in selected patients with rapidly progressive SSc. However, some unmet needs remain, such as an accurate patient selection, pre-transplantation analysis to identify subclinical conditions precluding the transplantation, and the alternatives for post-transplant ILD recurrence.
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37
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Gilkeson GS. Safety and Efficacy of Mesenchymal Stromal Cells and Other Cellular Therapeutics in Rheumatic Diseases in 2022: A review of what we know so far. Arthritis Rheumatol 2022; 74:752-765. [PMID: 35128813 DOI: 10.1002/art.42081] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 12/13/2021] [Accepted: 02/01/2022] [Indexed: 11/06/2022]
Abstract
Although there are a number of new immunosuppressives and biologics approved for treating various autoimmune/inflammatory rheumatic diseases, there remain a substantial number of patients who have no clinical response or limited clinical response to these available treatments. Use of cellular therapies is a novel approach for the treatment of autoimmune/inflammatory rheumatic diseases with perhaps enhanced efficacy and less toxicity than current therapies. Autologous hematopoietic stem cell transplants were the first foray into cellular therapies with proven efficacy in scleroderma and multiple sclerosis. Newer yet unproven cellular therapies include allogenic mesenchymal stromal cells, shown effective in graft vs host disease and in healing of Crohn's fistulas. CAR-T cells are effective in various malignancies with possible usage in rheumatic diseases, as shown in preclinical studies in murine lupus and recently in human lupus. T regulatory cells are one of the master controllers of the immune response and are decreased in number and/or effectiveness in specific autoimmune diseases. Expansion of autologous T regulatory cells is an attractive approach to controlling autoimmunity. There are a number of other regulatory cells in the immune system including regulatory B cells, dendritic cells, macrophages, and other T cell types that are early in development. In this review, the current evidence for efficacy and mechanisms of actions of cellular therapies already in use or in clinical trials in human autoimmune diseases will be discussed including limitations of these therapies and potential side effects.
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Affiliation(s)
- Gary S Gilkeson
- Department of Medicine, Medical University of South Carolina, Charleston, SC.,Medical Research Service, Ralph H. Johnson VAMC, Charleston, SC
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38
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Yoshimi R, Nakajima H. Current State and Issues of Regenerative Medicine for Rheumatic Diseases. Front Med (Lausanne) 2022; 9:813952. [PMID: 35155499 PMCID: PMC8831787 DOI: 10.3389/fmed.2022.813952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/05/2022] [Indexed: 12/15/2022] Open
Abstract
The prognosis of rheumatic diseases is generally better than that of malignant diseases. However, some cases with poor prognoses resist conventional therapies and cause irreversible functional and organ damage. In recent years, there has been much research on regenerative medicine, which uses stem cells to restore the function of missing or dysfunctional tissues and organs. The development of regenerative medicine is also being attempted in rheumatic diseases. In diseases such as systemic sclerosis (SSc), systemic lupus erythematosus (SLE), and rheumatoid arthritis, hematopoietic stem cell transplantation has been attempted to correct and reconstruct abnormalities in the immune system. Mesenchymal stem cells (MSCs) have also been tried for the treatment of refractory skin ulcers in SSc using the ability of MSCs to differentiate into vascular endothelial cells and for the treatment of systemic lupus erythematosus SLE using the immunosuppressive effect of MSCs. CD34-positive endothelial progenitor cells (EPCs), which are found in the mononuclear cell fraction of bone marrow and peripheral blood, can differentiate into vascular endothelial cells at the site of ischemia. Therefore, EPCs have been used in research on vascular regeneration therapy for patients with severe lower limb ischemia caused by rheumatic diseases such as SSc. Since the first report of induced pluripotent stem cells (iPSCs) in 2007, research on regenerative medicine using iPSCs has been actively conducted, and their application to rheumatic diseases is expected. However, there are many safety issues and bioethical issues involved in regenerative medicine research, and it is essential to resolve these issues for practical application and spread of regenerative medicine in the future. The environment surrounding regenerative medicine research is changing drastically, and the required expertise is becoming higher. This paper outlines the current status and challenges of regenerative medicine in rheumatic diseases.
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39
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Blank N, Schmalzing M, Moinzadeh P, Oberste M, Siegert E, Müller-Ladner U, Riemekasten G, Günther C, Kötter I, Zeidler G, Pfeiffer C, Juche A, Jandova I, Ehrchen J, Susok L, Schmeiser T, Sunderkötter C, Distler JHW, Worm M, Kreuter A, Keyßer G, Lorenz HM, Krieg T, Hunzelmann N, Henes J. Autologous hematopoietic stem cell transplantation improves long-term survival-data from a national registry. Arthritis Res Ther 2022; 24:258. [PMID: 36424638 PMCID: PMC9685870 DOI: 10.1186/s13075-022-02948-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 11/03/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Current recommendations on the management of systemic sclerosis (SSc) suggest that autologous hematopoietic stem cell therapy (HSCT) can be a rescue therapy for patients with rapidly progressive SSc. OBJECTIVES To assess the safety and efficacy of HSCT for patients with SSc and to compare these with non-HSCT patients in a control cohort with adjusted risk factors. METHODS A retrospective analysis of data from the multicentric German network for systemic scleroderma (DNSS) with 5000 patients with SSc. Control groups consisted of all patients with diffuse cutaneous (dc)-SSc (group A) and an adjusted high-risk cohort of male patients with Scl70-positive dc-SSc (group B). RESULTS Eighty SSc patients received an HSCT 4.1 ± 4.8 years after SSc diagnosis. Among them, 86.3% had dc-SSc, 43.5% were males, and 71.3% were positive for Scl70 antibodies. The control group A (n=1513) showed a significant underrepresentation of these risk factors for mortality. When the survival of the control group B (n=240) was compared with the HSCT group, a lower mortality of the latter was observed instead. Within 5 years after HSCT, we observed an improvement of the mRSS from 17.6 ± 11.5 to 11.0 ± 8.5 (p=0.001) and a stabilization of the DLCO. We did not see differences in transplant-related mortality between patients who received HSCT within 3 years after SSc diagnosis or later. CONCLUSION Our analysis of real-life data show that the distribution of risk factors for mortality is critical when HSCT cohorts are compared with non-HSCT control groups.
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Affiliation(s)
- Norbert Blank
- grid.5253.10000 0001 0328 4908Internal Medicine 5, Division of Hematology, Oncology and Rheumatology, Department of Rheumatology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Marc Schmalzing
- grid.411760.50000 0001 1378 7891Department of Rheumatology/Clinical Immunology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Pia Moinzadeh
- grid.411097.a0000 0000 8852 305XDepartment of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Max Oberste
- grid.6190.e0000 0000 8580 3777Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Elise Siegert
- grid.6363.00000 0001 2218 4662Department of Rheumatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ulf Müller-Ladner
- grid.8664.c0000 0001 2165 8627Campus Kerckhoff, Department of Rheumatology and Clinical Immunology, Justus Liebig University Giessen, Bad Nauheim, Germany
| | | | - Claudia Günther
- grid.412282.f0000 0001 1091 2917Department of Dermatology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Ina Kötter
- Department of Rheumatology and Immunology, University Hospital, Hamburg-Eppendorf and Rheumatology Hospital Bad Bramstedt, Bad Bramstedt, Germany
| | - Gabriele Zeidler
- Department of Rheumatology, Johanniter-Krankenhaus im Flaeming Treuenbrietzen, Treuenbrietzen, Germany
| | - Christiane Pfeiffer
- grid.411095.80000 0004 0477 2585Department of Dermatology, University Hospital Munich, Munich, Germany
| | - Aaron Juche
- grid.473656.50000 0004 0415 8446Department of Rheumatology, Immanuel Krankenhaus Berlin-Buch, Berlin, Germany
| | - Ilona Jandova
- grid.7708.80000 0000 9428 7911Department of Rheumatology, University Hospital Freiburg, Freiburg im Breisgau, Germany
| | - Jan Ehrchen
- grid.16149.3b0000 0004 0551 4246Department of Dermatology and Venerology, University Hospital Muenster, Muenster, Germany
| | - Laura Susok
- grid.5570.70000 0004 0490 981XDepartment of Dermatology and Venereology, Ruhr-University-Bochum, Bochum, Germany
| | - Tim Schmeiser
- grid.416438.cDepartment of Dermatology, St. Josef Hospital Wuppertal, Wuppertal, Germany
| | - Cord Sunderkötter
- grid.461820.90000 0004 0390 1701Dermatology, University Hospital Halle, Halle, Germany
| | - Jörg H. W. Distler
- grid.411668.c0000 0000 9935 6525Department of Rheumatology, University Hospital Erlangen, Erlangen, Germany
| | - Margitta Worm
- grid.6363.00000 0001 2218 4662Department of Dermatology and Allergology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Kreuter
- grid.412581.b0000 0000 9024 6397Allergology, HELIOS St. Elisabeth Hospital Oberhausen, University Witten-Herdecke, Witten, Germany
| | - Gernot Keyßer
- grid.461820.90000 0004 0390 1701Rheumatology, University Hospital Halle, Halle, Germany
| | - Hanns-Martin Lorenz
- grid.5253.10000 0001 0328 4908Internal Medicine 5, Division of Hematology, Oncology and Rheumatology, Department of Rheumatology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Thomas Krieg
- grid.411097.a0000 0000 8852 305XDepartment of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Nicolas Hunzelmann
- grid.411097.a0000 0000 8852 305XDepartment of Dermatology and Venereology, University Hospital Cologne, Cologne, Germany
| | - Jörg Henes
- grid.411544.10000 0001 0196 8249Centre for Interdisciplinary Clinical Immunology, Rheumatology and Auto-inflammatory Diseases and Department of Internal Medicine II (Oncology, Hematology, Immunology, Rheumatology), University Hospital Tuebingen, Tuebingen, Germany
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40
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Velier M, Daumas A, Simoncini S, Arcani R, Magalon J, Benyamine A, Granel B, Dignat George F, Chabannon C, Sabatier F. Combining systemic and locally applied cellular therapies for the treatment of systemic sclerosis. Bone Marrow Transplant 2022; 57:17-22. [PMID: 34663928 DOI: 10.1038/s41409-021-01492-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/03/2021] [Accepted: 09/29/2021] [Indexed: 02/08/2023]
Abstract
Systemic sclerosis (SSc) is a complex autoimmune disease characterized by a functional and structural alteration of the microvascular network associated with cutaneous and visceral fibrosis lesions. Conventional therapies are based on the use of immunomodulatory molecules and symptomatic management but often prove to be insufficient, particularly for patients suffering from severe and rapidly progressive forms of the disease. In this context, cellular therapy approaches could represent a credible solution with the goal to act on the different components of the disease: the immune system, the vascular system and the extracellular matrix. The purpose of this review is to provide an overview of the cellular therapies available for the management of SSc. The first part will focus on systemically injected therapies, whose primary effect is based on immunomodulatory properties and immune system resetting, including autologous hematopoietic stem cell transplantation and intravenous injection of mesenchymal stem cells. The second part will discuss locally administered regenerative cell therapies, mainly derived from adipose tissue, developed for the management of local complications as hand and face disabilities.
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Affiliation(s)
- Mélanie Velier
- C2VN, Aix Marseille Univ, INSERM, INRA, Marseille, France. .,Laboratoire de Culture et Thérapie Cellulaire, Hôpital de la Conception, AP-HM, INSERM CIC BT 1409, Marseille, France.
| | - Aurélie Daumas
- C2VN, Aix Marseille Univ, INSERM, INRA, Marseille, France.,Service de Médecine Interne, Gériatrie et Thérapeutique, Hôpital La Timone, AP-HM, Marseille, France
| | | | - Robin Arcani
- C2VN, Aix Marseille Univ, INSERM, INRA, Marseille, France.,Service de Médecine Interne, Gériatrie et Thérapeutique, Hôpital La Timone, AP-HM, Marseille, France
| | - Jérémy Magalon
- C2VN, Aix Marseille Univ, INSERM, INRA, Marseille, France.,Laboratoire de Culture et Thérapie Cellulaire, Hôpital de la Conception, AP-HM, INSERM CIC BT 1409, Marseille, France
| | - Audrey Benyamine
- C2VN, Aix Marseille Univ, INSERM, INRA, Marseille, France.,Service de Médecine Interne, Hôpital Nord, pôle MICA, AP-HM, Marseille, France
| | - Brigitte Granel
- C2VN, Aix Marseille Univ, INSERM, INRA, Marseille, France.,Service de Médecine Interne, Hôpital Nord, pôle MICA, AP-HM, Marseille, France
| | | | - Christian Chabannon
- Centre de Thérapie Cellulaire et INSERM CIC BT-1409, Institut Paoli-Calmettes Comprehensive Cancer Center, Marseille, France
| | - Florence Sabatier
- C2VN, Aix Marseille Univ, INSERM, INRA, Marseille, France.,Laboratoire de Culture et Thérapie Cellulaire, Hôpital de la Conception, AP-HM, INSERM CIC BT 1409, Marseille, France
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41
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Moraes DA, Oliveira MC. Life after Autologous Hematopoietic Stem Cell Transplantation for Systemic Sclerosis. J Blood Med 2021; 12:951-964. [PMID: 34785969 PMCID: PMC8590726 DOI: 10.2147/jbm.s338077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/26/2021] [Indexed: 12/29/2022] Open
Abstract
Stem cell transplantation has been investigated as treatment for severe and progressive systemic sclerosis (SSc) for the past 25 years. To date, more than 1000 SSc patients have been transplanted worldwide. Overall and event-free survival have increased over the years, reflecting stricter patient selection criteria and better clinical management strategies. This review addresses long-term outcomes of transplanted SSc patients, considering phase I/II and randomized clinical trials, as well as observational studies and those assessing specific aspects of the disease. Clinical outcomes are discussed comparatively between studies, highlighting advances, drawbacks and controversies in the field. Areas for future development are also discussed.
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Affiliation(s)
- Daniela A Moraes
- Division of Clinical Immunology, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Maria Carolina Oliveira
- Center for Cell-Based Therapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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42
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Strunz PP, Froehlich M, Gernert M, Schwaneck EC, Fleischer A, Pecher AC, Tony HP, Henes JC, Schmalzing M. Immunological Adverse Events After Autologous Hematopoietic Stem Cell Transplantation in Systemic Sclerosis Patients. Front Immunol 2021; 12:723349. [PMID: 34539659 PMCID: PMC8447845 DOI: 10.3389/fimmu.2021.723349] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/13/2021] [Indexed: 12/29/2022] Open
Abstract
Autologous hematopoietic stem cell transplantation (aHSCT) represents an effective treatment for systemic sclerosis (SSc), but it also can cause immunological adverse events (iAEs). Therefore, we aimed to determine the frequency of iAEs [engraftment syndrome (ES) and secondary autoimmune disorder (sAD)] and to identify potential risk factors for their development in a retrospective analysis on 22 patients similarly transplanted due to SSc. While nine patients (41%) suffered from ESs, seven sADs occurred in six patients (27%). Patients who developed ES were older in our cohort (52.45 vs. 42.58 years, p = .0433, Cohen’s d = 0.86), and cardiac involvement by SSc was associated with development of ES (OR = 40.11, p = .0017). Patients with manifestation of sAD had a higher modified Rodnan skin score (mRSS) reduction after aHSCT (90.50% vs. 60.00%, p = .0064, r = .65). Thus, IAEs are common after aHSCT for SSc and can occur in different stages during and after aHSCT with characteristic clinical manifestations. Good cutaneous response after aHSCT might be considered as a risk factor for sAD, and higher age at aHSCT and cardiac involvement might be considered as risk factors for the development of ES.
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Affiliation(s)
- Patrick-Pascal Strunz
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Matthias Froehlich
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Michael Gernert
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | | | - Anna Fleischer
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Ann-Christin Pecher
- Department of Internal Medicine II, University Hospital of Tuebingen, Tuebingen, Germany
| | - Hans-Peter Tony
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Joerg Christoph Henes
- Department of Internal Medicine II, University Hospital of Tuebingen, Tuebingen, Germany
| | - Marc Schmalzing
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
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43
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Spierings J, Chiu YH, Voortman M, van Laar JM. Autologous stem-cell transplantation in systemic sclerosis-associated interstitial lung disease: early action in selected patients rather than escalation therapy for all. Ther Adv Musculoskelet Dis 2021; 13:1759720X211035196. [PMID: 34394749 PMCID: PMC8361525 DOI: 10.1177/1759720x211035196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/07/2021] [Indexed: 12/29/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare rheumatic disease characterised by inflammation, vasculopathy and fibrosis of skin and internal organs. A common complication and a leading cause of death in SSc is interstitial lung disease (ILD). The current armamentarium of treatments in SSc-ILD mainly includes immunosuppressive therapies and has recently been expanded with anti-fibrotic agent nintedanib. Autologous stem cell transplantation (SCT) is increasingly used in progressive diffuse cutaneous SSc. This intensive treatment has been studied in three randomised trials and demonstrated to improve survival and quality of life. In the subsets of patients with SSc-ILD, SCT resulted in stabilisation and modest improvement of lung volumes and disease extent on high resolution computed tomography, but less impact was seen on diffusion capacity. Comparison of SCT outcomes with results from SSc-ILD trials is difficult though, as lung involvement per se was not an inclusion criterion in all SCT trials. Also, baseline characteristics differed between studies. The risk of severe treatment-related complications from SCT is still considerable and patients with extensive lung disease are particularly at risk of complications during transplantation. Therefore SCT should only be provided by experienced multidisciplinary teams in carefully selected patients. Future research needs to include comprehensive pulmonary evaluation and establish whether SCT early in the disease might prevent irreversible pulmonary damage and reduce treatment-related complications. Also, more insight in mechanisms of action of SCT in the lung and predictors for response will improve the use of this treatment in SSc-ILD. In this review the role of SCT in the treatment of SSc-ILD is summarised.
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Affiliation(s)
- J. Spierings
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, the Netherlands
- Division of Medicine, Department of Inflammation, Centre for Rheumatology and Connective Tissue Diseases, Royal Free and University College Medical School, University College London, London, UK
| | - Y-H. Chiu
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, the Netherlands
- Division of Rheumatology/Immunology/Allergy, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - M. Voortman
- Department of Pulmonology, Division of Heart and Lungs, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J. M. van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, the Netherlands
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44
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Gressenberger P, Jud P, Kovacs G, Kreuzer S, Brezinsek HP, Guetl K, Muster V, Kolesnik E, Schmidt A, Odler B, Adelsmayr G, Neumeister P, Brcic L, Zenz S, Weber K, Gary T, Brodmann M, Graninger WB, Moazedi-Fürst FC. Rituximab as a Treatment Option after Autologous Hematopoietic Stem Cell Transplantation in a Patient with Systemic Sclerosis. J Pers Med 2021; 11:600. [PMID: 34201939 PMCID: PMC8305780 DOI: 10.3390/jpm11070600] [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] [Received: 05/03/2021] [Revised: 06/17/2021] [Accepted: 06/22/2021] [Indexed: 11/23/2022] Open
Abstract
Systemic sclerosis (SSc) is an intractable autoimmune disease characterized by vasculopathy and organ fibrosis. Autologous hematopoietic stem cell transplantation (AHSCT) should be considered for the treatment of selected patients with rapid progressive SSc at high risk of organ failure. It, however, remains elusive whether immunosuppressive therapies such as rituximab (RTX) are still necessary for such patients after AHSCT, especially in those with bad outcomes. In the present report, a 43-year-old man with diffuse cutaneous SSc received AHSCT. Despite AHSCT, SSc further progressed with progressive symptomatic heart failure with newly developed concomitant mitral and tricuspid valve insufficiency, thus the patient started on RTX 8 months after AHSCT. Shortly after initiation of RTX, clinical symptoms and organ functions ameliorated subsequently. Heart valve regurgitations were reversible after initiation of RTX treatment. Currently, the patient remains in a stable condition with significant improvement of clinical symptoms and organ functions. Reporting about therapies after AHSCT in SSc is a very important issue, as randomized controlled trials are lacking, and therefore this report adds to evidence that RTX can be considered as a treatment option in patients with SSc that do not respond to AHSCT.
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Affiliation(s)
- Paul Gressenberger
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (P.J.); (K.G.); (V.M.); (T.G.); (M.B.)
| | - Philipp Jud
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (P.J.); (K.G.); (V.M.); (T.G.); (M.B.)
| | - Gabor Kovacs
- Division of Pneumology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria;
- Ludwig Boltzmann Institute for Lung Vascular Research, 8010 Graz, Austria
| | - Sonja Kreuzer
- Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (S.K.); (H.-P.B.); (S.Z.); (K.W.); (W.B.G.); (F.C.M.-F.)
| | - Hans-Peter Brezinsek
- Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (S.K.); (H.-P.B.); (S.Z.); (K.W.); (W.B.G.); (F.C.M.-F.)
| | - Katharina Guetl
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (P.J.); (K.G.); (V.M.); (T.G.); (M.B.)
| | - Viktoria Muster
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (P.J.); (K.G.); (V.M.); (T.G.); (M.B.)
| | - Ewald Kolesnik
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (E.K.); (A.S.)
| | - Albrecht Schmidt
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (E.K.); (A.S.)
| | - Balazs Odler
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria;
| | - Gabriel Adelsmayr
- Division of General Radiology, Department of Radiology, Medical University of Graz, 8036 Graz, Austria;
| | - Peter Neumeister
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria;
| | - Luka Brcic
- Diagnostic and Research Institute of Pathology, Medical University of Graz, 8036 Graz, Austria;
| | - Sabine Zenz
- Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (S.K.); (H.-P.B.); (S.Z.); (K.W.); (W.B.G.); (F.C.M.-F.)
| | - Kurt Weber
- Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (S.K.); (H.-P.B.); (S.Z.); (K.W.); (W.B.G.); (F.C.M.-F.)
| | - Thomas Gary
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (P.J.); (K.G.); (V.M.); (T.G.); (M.B.)
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (P.J.); (K.G.); (V.M.); (T.G.); (M.B.)
| | - Winfried B. Graninger
- Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (S.K.); (H.-P.B.); (S.Z.); (K.W.); (W.B.G.); (F.C.M.-F.)
| | - Florentine C. Moazedi-Fürst
- Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (S.K.); (H.-P.B.); (S.Z.); (K.W.); (W.B.G.); (F.C.M.-F.)
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45
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Connolly MK. Systemic sclerosis (scleroderma): remaining challenges. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:438. [PMID: 33842659 PMCID: PMC8033370 DOI: 10.21037/atm-20-5449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Despite progress in treating internal organ involvement in systemic sclerosis (scleroderma) (SSc), such as pulmonary disease, effective treatments for the hallmark of the disease, cutaneous fibrosis, remain elusive. None of the disease-modifying antirheumatic drugs (DMARDS) have shown proven efficacy for SSc skin fibrosis, and there remain no FDA-approved medications, all of which are off-label, for cutaneous fibrosis in SSc. This review article will briefly summarize conventional therapies, biologics and hematopoietic stem cell transplants and select ongoing clinical trials in SSc. The gold standard for measuring skin fibrosis in SSc is the modified Rodnan skin score (MRSSS). This is a validated test that measures skin thickness (0 to 3) at 17 locations for a total score of 51. Improvements in skin score over time are used in clinical trials to quantitate skin fibrosis. Although recording the Rodnan skin score is technically straightforward, requiring no special equipment, and noninvasive, the fluctuating natural history of the disease includes improvement over time without interventions, rendering meaningful trials difficult to assess. Understanding of the basic molecular mechanisms driving pathologic fibrosis in SSc remains lacking, and underpins the often empiric nature and likely the lack of efficacy of many therapeutics that have been tried. Although repeated skin biopsies might be a more precise way to follow disease progression and regression, this is necessarily invasive and requires special tools. Here, this review will look at conventional therapies, biologics, autologous hematopoietic stem cell transplantation, and catalog some of the ongoing clinical trials in SSc with a focus on cutaneous fibrosis.
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Affiliation(s)
- Mary Karin Connolly
- Department of Dermatology, University of California, San Francisco, San Francisco, CA 94115, USA
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46
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Henrique-Neto Á, Vasconcelos MYK, Dias JBE, de Moraes DA, Gonçalves MS, Zanin-Silva DC, Zucoloto TG, de Oliveira MDFC, Dotoli GM, Weffort LF, Leopoldo VC, Oliveira MC. Hematopoietic stem cell transplantation for systemic sclerosis: Brazilian experience. Adv Rheumatol 2021; 61:9. [PMID: 33549135 DOI: 10.1186/s42358-021-00166-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/26/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In the past 20 years, hematopoietic stem cell transplantation (HSCT) has been investigated as treatment for systemic sclerosis (SSc). The goal of HSCT is to eradicate the autoreactive immune system, which is replaced by a new immune repertoire with long-lasting regulation and tolerance to autoantigens. Here, we describe the clinical outcomes of severe and refractory SSc patients that underwent HSCT at a single Brazilian center. PATIENTS AND METHODS This is a longitudinal and retrospective study, including 70 adult SSc patients, with an established diagnosis of SSc, and who underwent autologous HSCT from 2009 to 2016. The procedure included harvesting and cryopreservation of autologous hematopoietic progenitor cells, followed by administration of an immunoablative regimen and subsequent infusion of the previously collected cells. Patients were evaluated immediately before transplantation, at 6 months and then yearly until at least 5-years of post-transplantation follow-up. At each evaluation time point, patients underwent clinical examination, including modified Rodnan's skin score (mRSS) assessment, echocardiography, high-resolution computed tomography of the lungs and pulmonary function. RESULTS Median (range) age was 35.9 (19-59), with 57 (81.4%) female and median (range) non-Raynaud's disease duration of 2 (1-7) years. Before transplantation, 96% of the patients had diffuse skin involvement, 84.2%, interstitial lung disease and 67%, positive anti-topoisomerase I antibodies. Skin involvement significantly improved, with a decline in mRSS at all post-transplantation time points until at least 5-years of follow-up. When patients with pre-HSCT interstitial lung disease were analyzed, there was an improvement in pulmonary function (forced vital capacity and diffusing capacity of lung for carbon monoxide) over the 5-year follow-up. Overall survival was 81% and progression-free survival was 70.5% at 8-years after HSCT. Three patients died due to transplant-related toxicity, 9 patients died over follow-up due to disease reactivation and one patient died due to thrombotic thrombocytopenic purpura. CONCLUSIONS Autologous hematopoietic progenitor cell transplantation improves skin and interstitial lung involvement. These results are in line with the international experience and support HSCT as a viable therapeutic alternative for patients with severe and progressive systemic sclerosis.
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Affiliation(s)
- Álvaro Henrique-Neto
- Graduate Program in Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marianna Yumi Kawashima Vasconcelos
- Graduate Program in Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Center for Cell-Based Therapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Juliana Bernardes Elias Dias
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Daniela Aparecida de Moraes
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Maynara Santana Gonçalves
- Center for Cell-Based Therapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Graduate Program in Oncology, Stem Cells and Cell Therapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Djúlio César Zanin-Silva
- Center for Cell-Based Therapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Graduate Program in Basic and Applied Immunology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Talita Graminha Zucoloto
- Graduate Program in Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Center for Cell-Based Therapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marília de Fátima Cirioli de Oliveira
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Ribeirão Preto School of Nursing, University of São Paulo, Ribeirão Preto, Brazil
| | - Giuliana Martinelli Dotoli
- Graduate Program in Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Center for Cell-Based Therapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Luiz Fernando Weffort
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Vanessa Cristina Leopoldo
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.,Ribeirão Preto School of Nursing, University of São Paulo, Ribeirão Preto, Brazil
| | - Maria Carolina Oliveira
- Center for Cell-Based Therapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil. .,Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes 3900, Ribeirão Preto, SP, 14048-900, Brazil.
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AlOdhaibi KA, Varga J, Furst DE. Hematopoietic stem cell transplantation in systemic sclerosis: Yes!! BUT. . JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2021; 6:44-49. [PMID: 35382253 PMCID: PMC8922628 DOI: 10.1177/2397198320971967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/18/2020] [Indexed: 12/12/2023]
Abstract
Systemic sclerosis is a chronic multisystem, autoimmune disease with high mortality, and to date, has no effective approved therapy. For patients with the most severe forms of systemic sclerosis, autologous hematopoietic stem cell therapy has been proven to be effective, as demonstrated by three randomized controlled clinical trials and at least two registry studies. In the controlled studies, autologous hematopoietic stem cell therapy was shown to improve mortality, skin involvement, quality-of-life, and function compared with patients treated with intravenous cyclophosphamide. There is significant transplant-related mortality associated with autologous hematopoietic stem cell therapy, as well as infectious and noninfectious serious adverse events, including cardiac and renal compromise. Although the results of autologous hematopoietic stem cell therapy clinical trials to date are highly encouraging, a number of important unanswered questions remain. These include the following: What is the optimal transplant regimen; can the spectrum of systemic sclerosis patients who respond to autologous hematopoietic stem cell therapy be expanded; how can disease relapse following autologous hematopoietic stem cell therapy be predicted and managed; can treatment-related toxicity and mortality be mitigated; can response or toxicity be predicted; and finally, is there a place for allogeneic stem cell transplants in systemic sclerosis? Systemic sclerosis is an autoimmune disease with multiple immunological, vascular, and fibrotic abnormalities. Immunosuppressive therapy is frequently used, but to date its efficacy has been generally modest. Stem cell transplantation is the most potent immunosuppressive therapy currently available, and as discussed below, may have an important role in the management of systemic sclerosis.
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Affiliation(s)
| | - John Varga
- University of Michigan, Ann Arbor, MI, USA
| | - Daniel E Furst
- University of California-Los Angeles, Los Angeles, CA, USA
- University of Washington, Seattle, WA, USA
- University of Florence, Florence, Italy
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48
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Oliveira MC, Elias JB, Moraes DAD, Simões BP, Rodrigues M, Ribeiro AAF, Piron-Ruiz L, Ruiz MA, Hamerschlak N. A review of hematopoietic stem cell transplantation for autoimmune diseases: multiple sclerosis, systemic sclerosis and Crohn's disease. Position paper of the Brazilian Society of Bone Marrow Transplantation. Hematol Transfus Cell Ther 2021; 43:65-86. [PMID: 32418777 PMCID: PMC7910166 DOI: 10.1016/j.htct.2020.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 12/16/2022] Open
Abstract
Autoimmune diseases are an important field for the development of bone marrow transplantation, or hematopoietic stem cell transplantation. In Europe alone, almost 3000 procedures have been registered so far. The Brazilian Society for Bone Marrow Transplantation (Sociedade Brasileira de Transplantes de Medula Óssea) organized consensus meetings for the Autoimmune Diseases Group, to review the available literature on hematopoietic stem cell transplantation for autoimmune diseases, aiming to gather data that support the procedure for these patients. Three autoimmune diseases for which there are evidence-based indications for hematopoietic stem cell transplantation are multiple sclerosis, systemic sclerosis and Crohn's disease. The professional stem cell transplant societies in America, Europe and Brazil (Sociedade Brasileira de Transplantes de Medula Óssea) currently consider hematopoietic stem cell transplantation as a therapeutic modality for these three autoimmune diseases. This article reviews the evidence available.
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Affiliation(s)
- Maria Carolina Oliveira
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Juliana Bernardes Elias
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | | | - Belinda Pinto Simões
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | | | | | - Lilian Piron-Ruiz
- Associação Portuguesa de Beneficência de São José do Rio Preto, São José do Rio Preto, SP, Brazil
| | - Milton Arthur Ruiz
- Associação Portuguesa de Beneficência de São José do Rio Preto, São José do Rio Preto, SP, Brazil
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49
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Gernert M, Tony HP, Schwaneck EC, Fröhlich M, Schmalzing M. Low B cell counts as risk factor for infectious complications in systemic sclerosis after autologous hematopoietic stem cell transplantation. Arthritis Res Ther 2020; 22:183. [PMID: 32771029 PMCID: PMC7414656 DOI: 10.1186/s13075-020-02255-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/18/2020] [Indexed: 09/24/2023] Open
Abstract
Background Autologous hematopoietic stem cell transplantation (aHSCT) is a treatment option for a selected group of systemic sclerosis (SSc) patients with good available evidence but can be associated with considerable morbidity and mortality. The aim of this study was to describe infectious complications and distinct immune reconstitution patterns after aHSCT and to detect risk factors in lymphocyte subsets, which are associated with an elevated rate of infections after aHSCT. Methods Seventeen patients with SSc were included in this single-center retrospective cohort study. Clinical and laboratory data was collected before and for 12 months after aHSCT, including immunophenotyping of peripheral whole blood by fluorescence-activated cell sorting. Results Cytomegalovirus (CMV) reactivations were common in CMV-IgG-positive patients (50%) and needed treatment. Mycotic infections occurred in 17.6%. One patient died (resulting in a mortality of 5.9%) due to pneumonia with consecutive sepsis. All patients showed decreased T helper cells (CD3+/CD4+) and within the B cell compartment decreased post-switched memory B cells (CD19+/CD27+/IgD−) and elevated naïve B cells (CD19+/CD27−/IgD+) until 12 months after aHSCT. Patients who developed infections had significantly lower B cells before aHSCT than patients who did not develop infections. Conclusion After aHSCT, monitoring for infectious complications, especially for CMV reactivations, is crucial as the reconstitution of the immune system takes longer than 12 months. Low peripheral B cells might be a risk factor for an elevated infection rate.
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Affiliation(s)
- Michael Gernert
- Department of Medicine II, Rheumatology and Clinical Immunology, University Hospital of Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
| | - Hans-Peter Tony
- Department of Medicine II, Rheumatology and Clinical Immunology, University Hospital of Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Eva Christina Schwaneck
- Department of Medicine II, Rheumatology and Clinical Immunology, University Hospital of Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Matthias Fröhlich
- Department of Medicine II, Rheumatology and Clinical Immunology, University Hospital of Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Marc Schmalzing
- Department of Medicine II, Rheumatology and Clinical Immunology, University Hospital of Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
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50
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Erre GL, Sebastiani M, Fenu MA, Zinellu A, Floris A, Cavagna L, Renzoni E, Manfredi A, Passiu G, Woodman RJ, Mangoni AA. Efficacy, Safety, and Tolerability of Treatments for Systemic Sclerosis-Related Interstitial Lung Disease: A Systematic Review and Network Meta-Analysis. J Clin Med 2020; 9:E2560. [PMID: 32784580 PMCID: PMC7465266 DOI: 10.3390/jcm9082560] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/24/2020] [Accepted: 08/05/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There is a paucity of head-to-head comparisons of the efficacy and harms of pharmacological treatments for systemic sclerosis-related interstitial lung disease (SSc-ILD). METHODS We conducted a network meta-analysis (NMA) in order to compare the effects of different treatments with the placebo on change in forced vital capacity (FVC), change in diffusion lung capacity for CO (DLCO), serious adverse events (SAEs), discontinuation for adverse events and mortality in SSc-ILD. Standardized mean difference (SMD) and log odds ratio were estimated using NMA with fixed effects. RESULTS Nine randomized clinical trials (926 participants) comparing eight interventions and the placebo for an average follow-up of one year were included. Compared to the placebo, only rituximab significantly reduced FVC decline (SMD (95% CI) = 1.00 (0.39 to 1.61)). Suitable data on FVC outcome for nintedanib were not available for the analysis. No treatments influenced DLCO. Safety and mortality were also not different across treatments and the placebo, although there were few reported events. Cyclophosphamide and pomalidomide were less tolerated than the placebo, mycophenolate, and nintedanib. CONCLUSION Only rituximab significantly reduced lung function decline compared to the placebo. However, direct head-to-head comparison studies are required to confirm these findings and to better determine the safety profile of various treatments.
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Affiliation(s)
- Gian Luca Erre
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, Università degli Studi di Sassari, 07100 Sassari, Italy;
- Dipartimento di Specialità Mediche, Azienda Ospedaliero-Universitaria di Sassari, 07100 Sassari, Italy;
| | - Marco Sebastiani
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy; (M.S.); (A.M.)
| | - Maria Antonietta Fenu
- Dipartimento di Specialità Mediche, Azienda Ospedaliero-Universitaria di Sassari, 07100 Sassari, Italy;
| | - Angelo Zinellu
- Dipartimento di Scienze Biomediche, Università degli Studi di Sassari, 07100 Sassari, Italy;
| | - Alberto Floris
- Azienda Ospedaliero-Universitaria di Cagliari, 09042 Monserrato, Italy;
| | - Lorenzo Cavagna
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, 27100 Pavia, Italy;
| | - Elisabetta Renzoni
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London SW3 6NP, UK;
| | - Andreina Manfredi
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy; (M.S.); (A.M.)
| | - Giuseppe Passiu
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, Università degli Studi di Sassari, 07100 Sassari, Italy;
- Dipartimento di Specialità Mediche, Azienda Ospedaliero-Universitaria di Sassari, 07100 Sassari, Italy;
| | - Richard John Woodman
- Flinders Centre for Epidemiology and Biostatistics, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide 5001, Australia;
| | - Arduino Aleksander Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide 5001, Australia;
- Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
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