Detection and management of HLA sensitization in candidates for adult heart transplantation

Heart transplantation (HT) remains the preferred therapy for patients with advanced heart failure. However, for sensitized HT candidates who have antibodies to human leukocyte antigens , finding a suitable donor can be challenging and can lead to adverse waitlist outcomes. In recent years, the number of sensitized patients awaiting HT has increased likely due to the use of durable and mechanical circulatory support as well as increasing number of candidates with underlying congenital heart disease. This State-of-the-Art review discusses the assessment of human leukocyte antigens antibodies, potential desensitization strategies including mechanisms of action and specific protocols, the approach to a potential donor including the use of complement-dependent cytotoxicity, flow cytometry, and virtual crossmatches, and peritransplant induction management.

60 Years Young: The Evolving Role of Allogeneic Hematopoietic Stem Cell Transplantation in Cancer Immunotherapy

The year 2020 marked the 30th anniversary of the Nobel Prize in Medicine awarded to E. Donnall Thomas for the development of allogeneic hematopoietic stem cell transplantation (allo-HSCT) to treat hematologic malignancies and other blood disorders. Dr. Thomas, "father of bone marrow transplantation," first developed and reported this technique in 1957, and in the ensuing decades, this seminal study has impacted fundamental work in hematology and cancer research, including advances in hematopoiesis, stem cell biology, tumor immunology, and T-cell biology. As the first example of cancer immunotherapy, understanding the mechanisms of antitumor biology associated with allo-HSCT has given rise to many of the principles used today in the development and implementation of novel transformative immunotherapies. Here we review the historical basis underpinning the development of allo-HSCT as well as advances in knowledge obtained by defining mechanisms of allo-HSCT activity. We review how these principles have been translated to novel immunotherapies currently utilized in clinical practice and describe potential future applications for allo-HSCT in cancer research and development of novel therapeutic strategies.

[Research advances in immune tolerance of allogeneic cell transplantation in preterm infants]

Preterm infants are a special group, and related severe neurological, respiratory, and digestive disorders have high disability/fatality rates. Allogeneic cell transplantation may be an effective method for the prevention and treatment of these diseases. At present, animal studies have been conducted for allogeneic cell transplantation in the treatment of hypoxic-ischemic encephalopathy, bronchopulmonary dysplasia, and necrotizing enterocolitis. The main difficulty of this technique is graft-versus-host reaction (GVHR), and successful induction of immune tolerance needs to be achieved in order to solve this problem. This article reviews the research advances in immune tolerance of allogeneic cell transplantation in preterm infants.

[Non-infectious lung diseases after hematopoietic stem cell transplantation]

Non-infectious pulmonary complications following hematopoietic stem cell transplantation are entities occuring early or late, depending on whether they occur before or after 100 days post-transplantation. They have firstly to be differentiated from infectious complications, which is not always easy, as their clinical and radiological aspects can mimic a viral or bacterial pneumonia. Corticosteroids are the most given treatment but a significant subset of patients have a fatal outcome. This article will review the clinical, radiological, functionnal features and the therapeutic options of six entities (engraftment syndrome, diffuse alveolar hemorrage, idiopathic pneumonia syndrome, organizing pneumonia, bronchiolitis obliterans, post-transplantation lympho-proliferative disease).

Immunologically induced tubulo-interstitial nephritis: experimental models in rats

Experimental models of immunologically induced tubulo-interstitial nephritis (TIN) in rats are described. Antitubular basement membrane (anti-TBM) nephritis was demonstrated to be a TIN resulting from an antigen antibody reaction. Renal transplant rejection and the local graft-vs-host (GVH) reaction were cell-mediated immune reactions in which the antigen was possibly shared by kidney structures. A cellular immune reaction to locally applied antigens was shown to be the basis for another experimental model of TIN, possibly originating from activated mediator systems.

Possible cellular events in leukemia

An immunologically unresponsive state induced in experimental animals can be modulated by a number of procedures. Such modulation can result in the termination of the unresponsive state if there exists a normal complement of immunocompetent B cells in the presence of unresponsive T cells. It is possible to bypass the T cells and activate the B cells to respond to otherwise tolerated antigens. The bypass results from supplying a second (nonspecific) signal to the B cells, which, in the presence of antigen (specific signal), permits the B cell to differentiate. The role of the T and B cells and their activation and/or inactivation in the fate of both leukemic cells and oncogenic viruses is discussed.

Acute host reaction after anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) rupture is a common condition often treated with an allograft reconstruction. In this case, a patient presented 2 months post-ACL allograft reconstruction with acute knee synovitis. Initially, it was assumed to be septic arthritis; however, based on magnetic resonance imaging, pathology, serology, and cultures, his acute synovitis was believed to be due to a host mediated immune response.

Tuna cornea as biomaterial for cardiac applications

Among available biomaterials, cornea is almost completely devoid of cells and is composed only of collagen fibers oriented in an orderly pattern, which contributes to low antigenicity. Thunnus thynnus, the Atlantic bluefin tuna, is a fish with large eyes that can withstand pressures of approximately 10 MPa. We evaluated the potential of this tuna cornea in cardiac bioimplantation. Eyes from freshly caught Atlantic bluefin tuna were harvested and preserved in a fixative solution. Sterilized samples of corneal stroma were embedded in paraffin and stained with hematoxylin and eosin, and the histologic features were studied. Physical and mechanical resistance tests were performed in comparison with bovine pericardial strips and porcine mitral valves. Corneal material was implanted subcutaneously in 7 rats, to evaluate in vivo calcification rates. Mitral valves made from tuna corneal leaflets were implanted in 9 sheep. We found that the corneal tissue consisted only of parallel collagen fibers without evidence of vascular or neural structures. In tensile strength, the tuna corneal specimens were substantially similar to bovine pericardium. After 23 days, the rat-implanted samples showed no calcium or calcium salt deposition. Hydrodynamic and fatigue testing of valve prototypes yielded acceptable functional and long-term behavioral results. In the sheep, valvular performance was stable during the 180-day follow-up period, with no instrumental sign of calcification at the end of observation. We conclude that low antigenicity and favorable physical properties qualify tuna cornea as a potential material for durable bioimplantation. Further study is warranted.

[Pancreas-preserving duodenectomy in acute situations. Surgical treatment of an iatrogenic hemorrhage in the duodenal wall]

We report the case of a 24-year-old patient who underwent a duodenal biopsy due to the suspicion of graft-versus-host disease following allogeneic stem cell transplantation 3 months previously. The patient developed severe upper abdominal pain after the biopsy. A computed tomography scan revealed diffuse hemorrhaging in the duodenal wall and mesenteric root. Following supraselective angioembolization to stop the bleeding a control computed tomography scan was carried out the following day and revealed increasing destruction of the duodenal wall due to a dissecting aneurysm. A pancreas-preserving duodectomy was carried out.

[Results of hematopoietic cell transplantation in the first complete remission in children with acute myeloid leukemia from an intermediate risk group]

AIM

To analyze the results of allogeneic and autologous hemopoietic cell transplantations (allo- and auto-HCT) in children with acute myeloid leukemia (AML) from an intermediate risk group, most of which were performed using lower-intensity conditioning modes. SUBJECTS AND METHODS. The study enrolled 36 children from an intermediate risk group, who had undergone auto-HCT (n = 22) or allo-HCT (n = 14) in December 1994 to December 2008. The patients' age was 0.7 to 16.6 years (median 12.8 years). Chemotherapeutic conditioning regimens were applied to all the patients. Melphalan was a basic myeloablative agent in 83.3% of cases.

RESULTS

With a median follow-up of 4.6 years (1.1-13.8 years), three-year relapse-free survival (RFS) was 80.4%; overall survival (OS) was 65.6%. Recurrences were documented only in 6 (16.6%) patients from the auto-HCT. Transplantation-associated mortality (TAM) was 13.8% (five patients died). After allo-HCT versus auto-HCT, RFS, OS, and TAM were 100 and 68.7% (p = 0.03), 93.2 and 55.5% (p = 0.02), and 7.1 and 18.2%, respectively. Acute and chronic graft-versus-host reactions developed in 57.1 and 23.1%, respectively.

CONCLUSION

Transplantation of allogeneic hemopoietic cells from a compatible related donor in the intermediate risk group children with AML, by using melphalan-based conditioning regimen, demonstrates a high survival rate with the minimum toxicity.

Interaction of the B locus and the GVHR-selected lines in the graft-versus-host reaction in chickens

Genetic differences affecting the degree of splenomegaly in the graft-versus-host reaction (GVHR) of chickens were studied. Two B genotypes, B9 B9 and B11 B11, and two GVHR-selected lines, H and L, were examined. The degree of splenomegaly of B9 B9 leads to B11 B11 was significantly higher than that of B11 B11 leads to B9 B9 for all line combinations. In contrast, the inoculation of H into L gave consistently higher splenomegaly than that of L into H. This suggested that the effects of B locus were higher in hosts than in donors, while those of the GVHR-selected lines were higher in donors than in hosts. The analysis of variance revealed that both the differences between the reciprocal combination of B genotypes and between the GVHR line combinations were statistically highly significant. Furthermore, the interaction of B genotypes and GVHR lines was also highly significant.

[Allogeneic hematopoietic stem cell transplantation]

Allogeneic hematopoietic stem cell transplantation is a curative option in different hematologic malignancies. This benefit is traditionally based on the immune anti-tumour effect mediated by the allogeneic immune effectors derived from the graft, usually called "graft versus leukemia". Several categories of donors and sources of stem cells are currently used. In addition, different types of preparative regimens are available, and can be distinguished based on their myeloablative and immunosuppressive properties. Despite significant progress in terms of short term toxicity and morbidity, and despite effective prophylactic strategies, graft versus host disease remains a major complication, with its corollary of prolonged immunosuppression and opportunistic infections. However, allogeneic stem cell transplantation is rapidly expanding because the immunological anti-tumour effect has been demonstrated both in myeloid and lymphoid malignancies with a relatively acceptable risk of toxicity.

Use of natural killer cells as immunotherapy for leukaemia

Natural killer (NK) cells potentially play a significant role in eradicating residual disease following allogeneic haematopoietic cell transplantation, and have been explored as tools for adoptive immunotherapy for chemotherapy-refractory patients. NK cell cytotoxicity is modulated by multiple activating and inhibitory receptors that maintain a balance between self-tolerance and providing surveillance against pathogens and malignant transformation. The functional characteristics of NK cells are dictated by the strength of inhibitory receptor signalling. Major histocompatibility complex (MHC)-specific inhibitory receptor acquisition occurs sequentially during NK cell development, and is determined by the nature of immunological reconstitution after allogeneic haematopoietic cell transplantation. Polymorphisms of inhibitory receptors [killer immunoglobulin-like receptors (KIRs)] and their ligands (MHC) contribute to interindividual variability. As a result, the functional NK cell repertoire of individual donors has variable potential for graft-vs-leukaemia reactions. Models predicting NK cell alloreactivity, including KIR ligand mismatch and missing KIR ligand strategies, are discussed as algorithms for optimal NK cell donor selection. Future modifications to improve NK cell adoptive immunotherapy by means of increasing target recognition and reducing inhibitory signalling are being explored.

Allogeneic bone marrow transplantation for severe aplastic anaemia--the London experience

Using the Seattle protocol with minor modifications, 23 patients with severe aplastic anaemia received allogeneic bone marrow transplants from HLA/mixed leucocyte culture matched sibs in three London centres between 1973 and 1977. Ten patients (43.5%) are alive 6 months to 5 years after transplantation, and are well with full haemopoietic reconstitution, two with autologous bone marrow recovery following the graft procedure. A failure of the marrow graft to take, or take followed by rejection occurred in 12 patients (52%). Failure of marrow recovery was associated with a high early mortality from bacterial or fungal infection. The only survivors amongst those who rejected the first graft were four patients in whom a subsequent graft from the same donor was successful, and two in whom autologous recovery occurred. Graft versus host disease (GVHD) occurred in seven patients, and was fatal in one case. The most frequent complication after successful engraftment was varicella-zoster infection which occurred in five patients and was fatal in one patient. The overall results compare favourably with those from other transplant centres, but the high rate of graft rejection and low incidence of GVHD differ from other series. The results should encourage further referral of patients with severe AA for bone marrow transplantation.

Anti-parental lymphocyte reactions in neonatal F1 hybrid rats

The subpopulation of parental-strain lymphocytes responsible for the recognition of a particular F1 hybrid strain as foreign has been shown to be subject to specific, reversible inactivation after its injection into neonatal rats of that F1 hybrid strain. Neonates born to mothers that were syngeneic with the parental-strain lymphocytes under test acquired the capacity to inactivate these lymphocytes at an earlier age than did the genotypically identical reciprocal F1 hybrids. Neonates had little capacity to inactivate completely allogeneic lymphocytes. It is inferred from the difference in behavior between reciprocal F1 hybrids that the augmented ability to inactivate anti-F1 hybrid maternal-strain lymphocytes follows exposure to such cells in utero and to antibodies with anti-F1 hybrid activity in colostrum. Specific inactivation of those marauding maternal lymphocytes with anti-fetal activity is envisaged as an important means of protection of the fetus from immunological attack by the mother. On the basis of the results presented in this and the preceding paper, it has been proposed that many of the sequelae of the transfer of immunocompetent parental-strain cells to F1 hybrid animals result not from graft anti-host activity but from an F1 hybrid anti-parental lymphocyte response that has eluded normal regulatory mechanisms. These experiments also raise the possibility that regulation of auto-immune responses may be achieved by the inactivation of lymphocytes with anti-self reactivity by other lymphocytes that respond to the recognition structure required for such reactivity.

The effect of Rhodiola quadrifida extracts on cellular immunity in mice and rats

Rhodiola quadrifida (Rq) roots and rhizomes are traditionally used in Asia as a tonic, adaptogen, antidepressant and anti-inflammatory drug. The aim of this work was to study the in vivo effect of aqueous and 50% hydro-alcoholic extracts of Rq rhizomes on some parameters of cellular immunity in mice and rats. The metabolic activity of blood phagocyting cells was determined based on the measurement of intracellular respiratory burst after stimulation by PMA in RBA test. Potential bactericidal activity of phagocyting cells was determined in isolated blood leukocytes stimulated with killed microorganisms, according to the PKA test. Proliferative response of lymphocytes stimulated by mitogen concanavaline A (ConA) or lipopolysaccharide (LPS) were determined by MTT assay. Both extracts stimulated granulocytes activity in vitro and increased lymphocyte response to mitogens. The ability of parental strain mice lymphocytes to induce local cutaneous graft-versus-host reaction (GVH) in F1 hybrids was stimulated by 50% hydro-alcoholic extract only.

DC homeostasis in hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation is an important experimental tool and therapeutic modality. Its efficacy and toxicity are both linked to a GvH reaction that is initiated by donor T cells recognizing recipient APC, of which DC are the most potent. In most tissues recipient DC are replaced after transplantation because they turnover rapidly from BM-derived precursors. However, in a number of sites, notably the skin, recipient DC may persist and even self-renew for many months after transplantation. Understanding the homeostasis of different APC populations and how they are related to the induction of alloreactivity may help to improve the therapeutic benefit of transplantation.

Psychiatric disorders in bone marrow transplant patients

OBJECTIVE

To identify the psychiatric illnesses in patients with hematological/oncological disorders encountered during blood and bone marrow transplantation.

DESIGN

Cross-sectional study.

PLACE AND DURATION OF STUDY

Bismillah Taqee Institute of Health Sciences and Blood Diseases Centre, Karachi from December 2002 to December 2005.

PATIENTS AND METHODS

All consecutive patients, aged 15 years and above, who fulfilled inclusion and exclusion criteria and underwent blood and bone marrow transplantation, were enrolled in this study. Psychiatric assessment comprised of a semi-structured interview based on Present Status Examination (PSE). The psychiatric diagnosis was made on the basis of International Classification of Diseases (ICD-10) system of classification devised by W.H.O.

RESULTS

Eighty patients, who fulfilled the inclusion criteria, were inducted in this study. Thirty (37.5%) cases were found to have psychiatric disorders. Out of the total, 60 (75%) were males and 20 (25%) females. Adjustment disorder was the most frequent diagnosis (n=12), followed by major depression (n=7). Rest of the diagnoses made were generalized anxiety disorder, acute psychotic disorder, delirium and depressive psychosis.

CONCLUSION

High psychiatric morbidity associated with blood and bone marrow transplantation was observed. It indicates the importance of psychiatric intervention during the isolation period of BMT as well as pre-transplant psychiatric assessment and counseling regarding procedure.

Hematopoietic cell transplantation: progress and obstacles

The use of hematopoietic cell transplantation has expanded and evolved substantially in the last decade. New stem cell sources and stem cell mobilizing agents have been introduced in clinical practice. The incidence of life-threatening complications following autologous stem cell transplant procedures has decreased dramatically. Understanding the immune mediated effect of allogeneic stem cell transplantation has resulted in the development of reduced intensity and non-myeloablative conditioning regimens, allowing transplantation of elderly patients. Long-term complications are starting to emerge, and will gain in importance in the near future.

Therapy of relapsed Hodgkin lymphoma

The majority of patients who are diagnosed with Hodgkin lymphoma (HL) will be cured with primary chemotherapy. For those who relapse, autologous stem cell transplantation (ASCT) has become the standard of care. Randomized clinical trials have demonstrated that approximately 50% of patients with chemosensitive relapsed HL can achieve long term disease free survival with ASCT. However, optimal therapy of those who have chemorefractory disease or who relapse after an ASCT has not been established. Reduced intensity allogeneic stem cell transplantation may benefit these patients, although a definite graft versus HL effect has not been demonstrated and treatment-related mortality remains relatively high. New salvage regimens that incorporate gemcitabine, vinorelbine, rituximab, and/or monoclonal antibodies against CD30 are being investigated.

Expression of allograft inflammatory factor-1 in inflammatory skin disorders

Allograft inflammatory factor-1 (AIF-1) is an evolutionarily conserved, inflammatory protein produced by activated macrophages during chronic transplant rejection and in inflammatory brain lesions. Since T-cell-mediated inflammation is common to various dermatoses and nothing is known about AIF-1 in skin, we studied its protein expression at the tissue level and regulation in monocytic cell lines by various agents. Using immunohistochemistry, we found that AIF-1 is expressed at low levels in normal skin, but is highly upregulated in various inflammatory skin disorders, such as psoriasis, lichen planus, graft-versus-host disease and mycosis fungoides. The main cell types expressing AIF-1 in affected skin are macrophages and Langerhans' cells. We also show by real-time PCR that AIF-1 mRNA levels in monocytic THP-1 and U937 cell lines are significantly upregulated by retinoic acid as well as a number of cytokines. We conclude that AIF-1 may mediate survival and pro-inflammatory properties of macrophages in skin diseases.

Factors governing the activation of adoptively transferred donor T cells infused after allogeneic bone marrow transplantation in the mouse

Murine models of bone marrow transplantation were used to study the mechanisms governing the activation of donor lymphocyte infusions (DLIs) manifesting as lymphohematopoietic graft-versus-host (LH-GVH) and graft-versus-leukemia (GVL) reactivities. We demonstrate here that established mixed chimerism influences the potency of DLI-mediated alloreactivity only in the MHC-mismatched but not MHC-matched setting. In the MHC-matched setting, high levels (>or= 40%) of residual host chimerism correlated negatively with DLI-mediated alloreactivity irrespective of the timing of their administration, the donor's previous sensitization to host antigens, or the level of residual host APCs. In vivo administration of Toll-like receptor (TLR) ligands was required to maximize DLI-mediated LH-GVH and GVL reactivities in chimeras with low levels (<or= 15%) of residual host chimerism. In contrast, coadministration of DLI with antigen-presenting cell (APC) activators was insufficient to augment their LH-GVH response in the presence of high levels of host chimerism unless the host's T cells were transiently depleted. Together, these results show the cardinal influence of donor-host incompatibility on DLI-mediated GVH responses and suggest that in MHC-matched chimeras, the induction of optimal alloreactivity requires not only donor T cells and host APCs but also TLR ligands and in the presence of high levels of host chimerism depletion of host T cells.

[The experience in non-relative allogenic transplantation of stem hemopoietic cells in the Clinic of Bone Marrow Transplantation at I.P. Pavlov St-Petersburg Medical Academy]

AIM

To evaluate efficacy of allogenic transplantation of hemopoietic stem cells (allo-THSC) from non-relative donor in patients with hematological diseases in the Clinic of Bone Marrow Transplantation at L.P. Pavlov St-Petersburg Medical Academy for the period 2000-2006.

MATERIAL AND METHODS

A total of 84 allo-THSC from non-relative donor to patients aged from 10 months to 65 years (median 18 months, 44 years) was carried out.

RESULTS

Six-year overall survival (OS) in all the patients was 51.4%, in remission of AML--66.7%, ALL--33%, depending on the presence or absence of acute reaction graft versus host reaction (GVHR)--54 and 50.9%, chronic FVHR--75.6 and 58.2%, blood group compatibility or incompatibility in donor/recipient pairs--58.4 and 47.9%, by gender--61.4 and 40.6%, in use of HSC of the bone marrow--58.3%, peripheral blood--26.7%. OS in the dose of transplanted CD 34+ cells per 1 kg body mass < 5.0 x 10(6)/kg--173%, in the dose 5.0--8.0 x 10(6)/kg--38.8%, > 8.0 x 10(6)/kg--35.5%. Acute GVHR developed in 56% patients, chronic--in 20%, hemorrhagic cystitis--in 27.7%, bacterial, cytomegalovirus and fungal infection--in 10, 70 and 30%, respectively. The causes of death were acute GVHR (20%), infection 99%), polyorganic failure (4%), transplant rejection (5.3%), recurrence (18.7%).

CONCLUSION

Bone marrow transplantation clinics in the Russian Federation must develop all kinds of allo-THSC--relative, non-relative and haploidentical using bone marrow, peripheral blood, umbilical blood as the source of HSC. It is necessary to create a national register of non-relative donors.