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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
| | - Daniela Aparecida de Moraes
- 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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2
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Ruiz MA, Junior RLK, Piron-Ruiz L, Saran PS, Castiglioni L, Quadros LGD, Pinho TS, Burt RK. Medical, ethical, and legal aspects of hematopoietic stem cell transplantation for Crohn’s disease in Brazil. World J Stem Cells 2020; 12:1113-1123. [PMID: 33178395 PMCID: PMC7596442 DOI: 10.4252/wjsc.v12.i10.1113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 07/08/2020] [Accepted: 08/26/2020] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease that can affect any part of the gastrointestinal tract. The etiology of CD is unknown; however, genetic, epigenetic, environmental, and lifestyle factors could play an essential role in the onset and establishment of the disease. CD results from immune dysregulation due to loss of the healthy symbiotic relationship between host and intestinal flora and or its antigens. It affects both sexes equally with a male to female ratio of 1.0, and its onset can occur at any age, but the diagnosis is most commonly observed in the range of 20 to 40 years of age. CD diminishes quality of life, interferes with social activities, traumatizes due to the stigma of incontinence, fistulae, strictures, and colostomies, and in severe cases, affects survival when compared to the general population. Symptoms fluctuate between periods of remission and activity in which complications such as fistulas, strictures, and the need for bowel resection, surgery, and colostomy implantation make up the most severe aspects of the disease. CD can be progressive and the complications recurrent despite treatment with anti-inflammatory drugs, corticosteroids, immunosuppressants, and biological agents. However, over time many patients become refractory without treatment alternatives, and in this scenario, hematopoietic stem cell transplantation (HSCT) has emerged as a potential treatment option. The rationale for the use of HSCT for CD is anchored in animal studies and human clinical trials where HSCT could reset a patient's immune system by eliminating disease-causing effector cells and upon immune recovery increase regulatory and suppressive immune cells. Autologous HSCT using a non-myeloablative regimen of cyclophosphamide and anti-thymocyte globulin without CD34+ selection has been to date the most common transplant conditioning regimen adopted. In this review we will address the current situation regarding CD treatment with HSCT and emphasize the medical, ethical, and legal aspects that permeate the procedure in Brazil.
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Affiliation(s)
- Milton Artur Ruiz
- Department of Bone Marrow Transplant, Beneficência Portuguesa Hospital, São José do Rio Preto 15090 470, Brazil
| | | | - Lilian Piron-Ruiz
- Department of Bone Marrow Transplantation, Beneficência Portuguesa Hospital, São José do Rio Preto 15090 470, Brazil
| | - Priscila Samara Saran
- Department of Bone Marrow Transplantation, Beneficência Portuguesa Hospital, São José do Rio Preto 15090 470, Brazil
| | - Lilian Castiglioni
- Genetics and Molecular Biology, FAMERP- Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto 15090 470 Brazil
| | - Luiz Gustavo de Quadros
- Department of Endoscopy, Beneficência Portuguesa Hospital, ABC Medical School, São Bernardo 15015 110, Brazil
| | - Tainara Souza Pinho
- Department of Bone Marrow Transplantation, Beneficência Portuguesa Hospital, São José do Rio Preto 15090 470, Brazil
| | - Richard K Burt
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States
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Comini-Frota ER, Marques BCC, Torres C, Cohen KMS, Miranda EC. Nine-year follow up after hematopoietic stem cell transplantation in five multiple sclerosis patients. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:531-535. [PMID: 31508677 DOI: 10.1590/0004-282x20190097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 05/14/2019] [Indexed: 11/22/2022]
Abstract
Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system. Its treatment has focused on inflammation control as early as possible to avoid disability. Autologous hematopoietic stem cell transplantation (AHSCT) has been used for treating MS since 1996, with recent decisive results regarding benefits in long-term efficacy. Five patients followed up at an MS center in Belo Horizonte, Brazil, who had relapsing-remitting MS with high disease activity, underwent AHSCT between 2009 and 2011. They were evaluated clinically, with magnetic resonance imaging, and by the EDSS every six months after transplantation, up to July 2018. The patients were four women and one man, with ages ranging from 25-50 years, and time since disease onset ranging from 4-17 years at the time of the procedure. Four patients improved, one patient was stabilized, and all patients were free of disease activity after 5-9 years. Through improving patient selection and decreasing the time from disease onset, AHSCT could stop epitope spreading and disease progression. Despite multiple other therapeutic choices being approved for relapsing-remitting MS, AHSCT continues to be a treatment to consider for aggressive MS disease.
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Affiliation(s)
| | | | - Caio Torres
- Universidade José do Rosário Vellano, Belo Horizonte, MG, Brasil
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Ruiz-Argüelles GJ, Olivares-Gazca JC, Olivares-Gazca M, Leon-Peña AA, Murrieta-Alvarez I, Cantero-Fortiz Y, Gomez-Cruz GB, Ruiz-Argüelles A, Priesca-Marin M, Ruiz-Delgado GJ. Self-reported changes in the expanded disability status scale score in patients with multiple sclerosis after autologous stem cell transplants: real-world data from a single center. Clin Exp Immunol 2019; 198:351-358. [PMID: 31394007 DOI: 10.1111/cei.13358] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2019] [Indexed: 11/29/2022] Open
Abstract
In order to reset the immune system to baseline function, autologous hematopoietic stem cell transplantation (HSCT) has been performed in patients with multiple sclerosis (MS). After June 2015, 617 new consecutive patients with MS were autografted in our center with non-frozen peripheral blood stem cells. The autografts were performed on an out-patient basis, after conditioning with cyclophosphamide and rituximab. The aim of the study was the assessment of both safety and efficacy of the method. The study's primary co-end-points were recovery of granulocyte and platelet counts and transplant-related mortality. Secondary end-points were overall survival and clinical response (improvement or stabilization of the self-reported expanded disability status scale score). The protocol was registered in ClinicalTrials.gov identifier NCT02674217.0. We included 401 females and 216 males, with a median age of 46 years. A total of 259 patients had relapsing-remitting MS (RRMS), 228 had secondary progressive (SPMS) and 130 had primary progressive (PPMS) multiple sclerosis. All procedures were initially performed on an out-patient basis and only 32 individuals (5%) required hospitalization. One to three aphereses (median 1) were required to harvest at least 1 × 106 /kg viable CD34+ cells. The total number of viable CD34+ infused cells ranged between 1 and 37·83 × 106 /kg (median 5·68). Patients recovered more than 0·5 × 109 /l absolute granulocytes by day 8 (median, range = 2-14), and platelet values were above 20 × 109 /l by day 4 (median, range = 0-11). Eleven individuals required red blood cells and six needed platelet transfusions. To date, there have been no deaths attributable to the transplant, yielding a 30-month overall survival of 100%. Patients have been followed for 3-42 months (median = 12). The overall response rate (decrease or stabilization of the self-reported EDSS score) at 12 months was 78% for all patients (83% in RRMS, 78% in PPMS and 73% in SPMS), while the disability progression-free survival was 82% for all patients (86% in RRMS, 78·5% in SPMS and 78% in SPMS). Changes in the self-reported EDSS score in parallel with neurological improvement were observed in people with all types of MS after HSCT, employing the 'Mexican method'.
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Affiliation(s)
- G J Ruiz-Argüelles
- Centro de HematologÃa y Medicina Interna de Puebla, Puebla, México.,Laboratorios ClÃnicos de Puebla, Puebla, México.,Universidad Popular Autónoma del Estado de Puebla, Puebla, México
| | - J C Olivares-Gazca
- Centro de HematologÃa y Medicina Interna de Puebla, Puebla, México.,Universidad Popular Autónoma del Estado de Puebla, Puebla, México
| | - M Olivares-Gazca
- Centro de HematologÃa y Medicina Interna de Puebla, Puebla, México.,Universidad Popular Autónoma del Estado de Puebla, Puebla, México
| | - A A Leon-Peña
- Centro de HematologÃa y Medicina Interna de Puebla, Puebla, México.,Benemérita Universidad Autónoma de Puebla, Puebla, México
| | - I Murrieta-Alvarez
- Centro de HematologÃa y Medicina Interna de Puebla, Puebla, México.,Universidad Popular Autónoma del Estado de Puebla, Puebla, México
| | - Y Cantero-Fortiz
- Centro de HematologÃa y Medicina Interna de Puebla, Puebla, México.,Universidad de las Américas Puebla, Puebla, México
| | - G B Gomez-Cruz
- Centro de HematologÃa y Medicina Interna de Puebla, Puebla, México.,Benemérita Universidad Autónoma de Puebla, Puebla, México
| | - A Ruiz-Argüelles
- Laboratorios ClÃnicos de Puebla, Puebla, México.,Universidad Popular Autónoma del Estado de Puebla, Puebla, México
| | - M Priesca-Marin
- Centro de HematologÃa y Medicina Interna de Puebla, Puebla, México
| | - G J Ruiz-Delgado
- Centro de HematologÃa y Medicina Interna de Puebla, Puebla, México.,Laboratorios ClÃnicos de Puebla, Puebla, México.,Universidad Popular Autónoma del Estado de Puebla, Puebla, México
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Smith V, Scirè CA, Talarico R, Airo P, Alexander T, Allanore Y, Bruni C, Codullo V, Dalm V, De Vries-Bouwstra J, Della Rossa A, Distler O, Galetti I, Launay D, Lepri G, Mathian A, Mouthon L, Ruaro B, Sulli A, Tincani A, Vandecasteele E, Vanhaecke A, Vanthuyne M, Van den Hoogen F, Van Vollenhoven R, Voskuyl AE, Zanatta E, Bombardieri S, Burmester G, Eurico FJ, Frank C, Hachulla E, Houssiau F, Mueller-Ladner U, Schneider M, van Laar JM, Vieira A, Cutolo M, Mosca M, Matucci-Cerinic M. Systemic sclerosis: state of the art on clinical practice guidelines. RMD Open 2018; 4:e000782. [PMID: 30402270 PMCID: PMC6203100 DOI: 10.1136/rmdopen-2018-000782] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/21/2018] [Accepted: 09/22/2018] [Indexed: 12/29/2022] Open
Abstract
Systemic sclerosis (SSc) is an orphan disease characterised by autoimmunity, fibrosis of the skin and internal organs, and vasculopathy. SSc may be associated with high morbidity and mortality. In this narrative review we summarise the results of a systematic literature research, which was performed as part of the European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases project, aimed at evaluating existing clinical practice guidelines or recommendations. Only in the domains ‘Vascular & Ulcers’ (ie, non-pharmacological approach to digital ulcer), ‘PAH’ (ie, screening and treatment), ‘Treatment’ and ‘Juveniles’ (ie, evaluation of juveniles with Raynaud’s phenomenon) evidence-based and consensus-based guidelines could be included. Hence there is a preponderance of unmet needs in SSc referring to the diagnosis and (non-)pharmacological treatment of several SSc-specific complications. Patients with SSc experience significant uncertainty concerning SSc-related taxonomy, management (both pharmacological and non-pharmacological) and education. Day-to-day impact of the disease (loss of self-esteem, fatigue, sexual dysfunction, and occupational, nutritional and relational problems) is underestimated and needs evaluation.
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Affiliation(s)
- Vanessa Smith
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium.,Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Carlo Alberto Scirè
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Epidemiology Unit, Italian Society for Rheumatology (SIR), Milan, Italy
| | - Rosaria Talarico
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Paolo Airo
- Rheumatology and Clinical Immunology Unit, Azienda Ospedaliera Spedali Civili di Brescia, Brescia, Italy
| | - Tobias Alexander
- Department of Rheumatology and Clinical Immunology Unit, Charité University Hospital Berlin, Berlin, Germany
| | - Yannick Allanore
- Service de Médicine Interne, Université Paris Descartes, Paris, France.,Centre de Référence Maladies systémiques Autoimmunes Rares d'Ile de France, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Cochin, Paris, France
| | - Cosimo Bruni
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy.,Division of Rheumatology and Scleroderma Unit, AOU Careggi, Florence, Italy
| | - Veronica Codullo
- Department of Rheumatology, University of Pavia, Pavia, Italy.,Department of Rheumatology, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Virgil Dalm
- Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Alessandra Della Rossa
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Ilaria Galetti
- Federation of European Scleroderma Associations (FESCA), Brussels, Belgium
| | - David Launay
- Département de Médecine Interne et Immunologie Clinique, Université de Lille, Lille, France.,Centre de Référence des Maladies Systémiques et Auto-Immunes Rares du Nord-Ouest (CERAINO), LIRIC, INSERM, CHU Lille, Lille, France
| | - Gemma Lepri
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy.,Division of Rheumatology and Scleroderma Unit, AOU Careggi, Florence, Italy
| | - Alexis Mathian
- Department of Internal Medicine, Hospital Pitié-Salpêtrière, Paris, France
| | - Luc Mouthon
- Service de Médicine Interne, Université Paris Descartes, Paris, France.,Centre de Référence Maladies systémiques Autoimmunes Rares d'Ile de France, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Cochin, Paris, France
| | - Barbara Ruaro
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS San Martino Polyclinic Hospital, University of Genoa, Genoa, Italy
| | - Alberto Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS San Martino Polyclinic Hospital, University of Genoa, Genoa, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, Azienda Ospedaliera Spedali Civili di Brescia, Brescia, Italy
| | - Els Vandecasteele
- Department of Internal Medicine, Ghent University, Ghent, Belgium.,Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Amber Vanhaecke
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium.,Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Marie Vanthuyne
- Department of Rheumatology, Université Catholique de Louvain, Louvain-la-Neuve, Belgium.,Department of Rheumatology, Cliniques Universitaires Saint-Luc, Louvain-la-Neuve, Belgium
| | - Frank Van den Hoogen
- Department of Rheumatology, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands.,Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Ronald Van Vollenhoven
- Clinical Immunology & Rheumatology, Amsterdam Rheumatology & Immunology Center, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
| | - Alexandre E Voskuyl
- Department of Rheumatology, Amsterdam UMC, Amsterdam, The Netherlands.,Amsterdam Infection & Immunity Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Elisabetta Zanatta
- Division of Rheumatology, Department of Medicine, University of Padova, Padova, Italy
| | - Stefano Bombardieri
- Rheumatology Unit, Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité University Hospital Berlin, Berlin, Germany
| | - Fonseca João Eurico
- Department of Rheumatology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal.,Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Charissa Frank
- Flemish Patient Organization of Hereditary Collagen Disorders in Belgium, Koersel, Belgium
| | - Eric Hachulla
- Département de Médecine Interne et Immunologie Clinique, Université de Lille, Lille, France.,Centre de Référence des Maladies Systémiques et Auto-Immunes Rares du Nord-Ouest (CERAINO), LIRIC, INSERM, CHU Lille, Lille, France
| | - Frederic Houssiau
- Department of Rheumatology, Université Catholique de Louvain, Louvain-la-Neuve, Belgium.,Department of Rheumatology, Cliniques Universitaires Saint-Luc, Louvain-la-Neuve, Belgium
| | - Ulf Mueller-Ladner
- Department of Rheumatology and Clinical Immunology, Kerckhoff Klinik, Justus-Liebig University of Giessen, Giessen, Germany
| | - Matthias Schneider
- Institute for Rheumatology, Hiller Research Unit for Rheumatology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ana Vieira
- Núcleo SÃndrome de Sjögren of Liga Portuguesa Contra as Doenças Reumáticas (LPCDR, Portuguese League Against Rheumatic Diseases), Lisbon, Portugal
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS San Martino Polyclinic Hospital, University of Genoa, Genoa, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - Marco Matucci-Cerinic
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy.,Division of Rheumatology and Scleroderma Unit, AOU Careggi, Florence, Italy
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