1
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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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2
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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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3
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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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4
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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: 3] [Impact Index Per Article: 1.5] [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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5
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Achini-Gutzwiller FR, Snowden JA, Corbacioglu S, Greco R. Haematopoietic stem cell transplantation for severe autoimmune diseases in children: A review of current literature, registry activity and future directions on behalf of the autoimmune diseases and paediatric diseases working parties of the European Society for Blood and Marrow Transplantation. Br J Haematol 2022; 198:24-45. [PMID: 37655707 DOI: 10.1111/bjh.18176] [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: 12/31/2021] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 11/27/2022]
Abstract
Although modern clinical management strategies have improved the outcome of paediatric patients with severe autoimmune and inflammatory diseases over recent decades, a proportion will experience ongoing or recurrent/relapsing disease activity despite multiple therapies often leading to irreversible organ damage, and compromised quality of life, growth/development and long-term survival. Autologous and allogeneic haematopoietic stem cell transplantation (HSCT) have been used successfully to induce disease control and often apparent cure of severe treatment-refractory autoimmune diseases (ADs) in children. However, transplant-related outcomes are disease-dependent and long-term outcome data are limited in respect to efficacy and safety. Moreover, balancing risks of HSCT against AD prognosis with continually evolving non-transplant options is challenging. This review appraises published literature on HSCT strategies and outcomes in individual paediatric ADs. We also provide a summary of the European Society for Blood and Marrow Transplantation (EBMT) Registry, where 343 HSCT procedures (176 autologous and 167 allogeneic) have been reported in 326 children (<18 years) for a range of AD indications. HSCT is a promising treatment modality, with potential long-term disease control or cure, but therapy-related morbidity and mortality need to be reduced. Further research is warranted to establish the position of HSCT in paediatric ADs via registries and prospective clinical studies to support evidence-based interspeciality guidelines and recommendations.
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Affiliation(s)
- Federica R Achini-Gutzwiller
- Division of Paediatric Stem Cell Transplantation and Haematology, Children's Research Centre (CRC), University Children's Hospital of Zurich, Zurich, Switzerland
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Selim Corbacioglu
- Department of Paediatric Oncology, Haematology and Stem Cell Transplantation, University Children's Hospital Regensburg, Regensburg, Germany
| | - Raffaella Greco
- Unit of Haematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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6
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Volkmann ER, Chai-Ho W. Allogeneic mesenchymal stromal cell transplantation for systemic sclerosis. THE LANCET. RHEUMATOLOGY 2022; 4:e74-e75. [PMID: 38288739 PMCID: PMC10954215 DOI: 10.1016/s2665-9913(21)00388-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/17/2021] [Indexed: 03/22/2024]
Affiliation(s)
- Elizabeth R Volkmann
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA.
| | - Wanxing Chai-Ho
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
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7
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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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8
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SFRP4 Expression Is Linked to Immune-Driven Fibrotic Conditions, Correlates with Skin and Lung Fibrosis in SSc and a Potential EMT Biomarker. J Clin Med 2021; 10:jcm10245820. [PMID: 34945116 PMCID: PMC8706846 DOI: 10.3390/jcm10245820] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/03/2021] [Accepted: 12/08/2021] [Indexed: 11/20/2022] Open
Abstract
Secreted Frizzled Receptor Protein 4 (SFRP4) has been shown to be increased in Scleroderma (SSc). To determine its role in immune-driven fibrosis, we analysed SSc and sclerotic Chronic Graft Versus Host Disease (sclGVHD) biosamples; skin biopsies (n = 24) from chronic GVHD patients (8 with and 5 without sclGVHD), 8 from SSc and 3 healthy controls (HC) were analysed by immunofluorescence (IF) and SSc patient sera (n = 77) assessed by ELISA. Epithelial cell lines used for in vitro Epithelial-Mesenchymal-Transition (EMT) assays and analysed by Western Blot, RT-PCR and immunofluorescence. SclGVHD skin biopsies resembled pathologic features of SSc. IF of fibrotic skin biopsies indicated the major source of SFRP4 expression were dermal fibroblasts, melanocytes and vimentin positive/caveolin-1 negative cells in the basal layer of the epidermis. In vitro studies showed increased vimentin and SFRP4 expression accompanied with decreased caveolin-1 expression during TGFβ-induced EMT. Additionally, SFRP4 serum concentration correlated with severity of lung and skin fibrosis in SSc. In conclusion, SFRP4 expression is increased during skin fibrosis in two different immune-driven conditions, and during an in vitro EMT model. Its serum levels correlate with skin and lung fibrosis in SSc and may function as biomarker of EMT. Further studies are warranted to elucidate the role of SFRP4 in EMT within the pathogenesis of tissue fibrosis.
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9
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Shifa I, Hazlewood GS, Durand C, Barr SG, Mydlarski PR, Beck PL, Burton JM, Khan FM, Jamani K, Osman M, Storek J. Efficacy of Allogeneic Hematopoietic Cell Transplantation for Autoimmune Diseases. Transplant Cell Ther 2021; 27:489.e1-489.e9. [PMID: 33775907 DOI: 10.1016/j.jtct.2021.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/06/2021] [Accepted: 03/21/2021] [Indexed: 12/29/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) may be efficacious for autoimmune diseases (AIDs), but its efficacy for individual AIDs is unknown. Factors influencing the likelihood of relapse for each AID are also unknown. This study aimed to determine the likelihood of relapse for each common AID and to generate hypotheses about factors influencing the likelihood of relapse. We reviewed charts of adult patients with nonhematologic AIDs who had undergone HCT in Alberta (n = 21) and patients described in the literature (n = 67). We used stringent inclusion criteria to minimize the inclusion of patients whose AID may have been cured before transplantation. We also used stringent definitions of AID relapse and remission. AID relapsed in 2 of 9 patients (22%) with lupus, in 4 of 12 (33%) with rheumatoid arthritis (RA), in 0 of 4 (0%) with systemic sclerosis (SSc), in 3 of 16 (19%) with psoriasis, in 1 of 12 (8%) with Behçet's disease (BD), in 1 of 15 (7%) with Crohn's disease (CD), in 0 of 5 (0%) with ulcerative colitis (UC), in 4 of 8 (50%) with multiple sclerosis (MS), and in 3 of 3 (100%) with type 1 diabetes mellitus (T1DM). Among highly informative patients (followed for >1 year after discontinuation of immunosuppressive therapy if no relapse, or donor AID status known if relapse), relapse occurred in 0 of 3 patients with lupus, in 2 of 7 with RA, in 0 of 2 with SSc, in 3 of 6 with psoriasis, in 0 of 3 with BD, in 0 of 10 with CD, in 0 of 3 with UC, in 2 of 3 with MS, and in 2 of 2 with T1DM. There appeared to be no associations between AID relapse and low intensity of pretransplantation chemoradiotherapy, multiple lines of AID therapy (surrogate for AID refractoriness) except perhaps for lupus, absence of serotherapy for graft-versus-host disease (GVHD) prophylaxis, lack of GVHD except perhaps for lupus, or incomplete donor chimerism. Even though remission commonly occurs after HCT in lupus, RA, SSc, psoriasis, BD, CD, and UC, HCT is efficacious for only a subset of patients. The efficacy appears to be unrelated to pretransplantation therapy, GVHD, or chimerism. Large studies are needed to determine the characteristics of patients likely to benefit from HCT for each AID.
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Affiliation(s)
- Iman Shifa
- Division of Hematology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Glen S Hazlewood
- Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Caylib Durand
- Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Susan G Barr
- Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P Régine Mydlarski
- Division of Dermatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul L Beck
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jodie M Burton
- Department of Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Faisal M Khan
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kareem Jamani
- Division of Hematology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mohamed Osman
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jan Storek
- Division of Hematology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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10
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Wais V, Bunjes D, Kuchenbauer F, Sorror ML. Comorbidities, age, and other patient-related predictors of allogeneic hematopoietic cell transplantation outcomes. Expert Rev Hematol 2018; 11:805-816. [PMID: 30092693 DOI: 10.1080/17474086.2018.1509703] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Allogeneic hematopoietic cell transplantation (HCT) provides potential cure to a large number of malignant and nonmalignant hematological disorders. With the development of non-myeloablative and reduced-intensity conditioning regimens, allogeneic HCT can nowadays be offered to a number of older or medically unfit patients. Up until the twenty-first century, chronological age was considered a hypothetical barrier. Recent reports, however, have shown that comorbidities, function, and other patient-related factors influence HCT outcomes at a higher magnitude than age alone. Areas covered: To define the eligibility of older or medically unfit patients for allogeneic HCT, a range of factors have to be considered. To solve this considerable issue, we need to further understand the mechanism and consequences of aging, such as chronic inflammation, sarcopenia, and especially the structure of frailty. Domains covering functional, physical, mental, social, nutritional, bone, and other health statuses should be evaluated and considered. Expert commentary: In this review we merge the current assessment tools with the potential approaches to objectify functional resources, as well as with possible methods to improve these resources in older or otherwise medically unfit patients prior to allogeneic HCT.
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Affiliation(s)
- Verena Wais
- a Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,b Department of Internal Medicine III , University Hospital of Ulm , Ulm , Germany
| | - Donald Bunjes
- b Department of Internal Medicine III , University Hospital of Ulm , Ulm , Germany
| | - Florian Kuchenbauer
- b Department of Internal Medicine III , University Hospital of Ulm , Ulm , Germany
| | - Mohamed L Sorror
- a Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,c Division of Medical Oncology, Department of Medicine , University of Washington School of Medicine , Seattle , WA , USA
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11
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Walker UA, Saketkoo LA, Distler O. Haematopoietic stem cell transplantation in systemic sclerosis. RMD Open 2018; 4:e000533. [PMID: 30018796 PMCID: PMC6045702 DOI: 10.1136/rmdopen-2017-000533] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/23/2018] [Accepted: 06/04/2018] [Indexed: 12/29/2022] Open
Abstract
Three randomised controlled trials of haematopoietic stem cell transplantation (HSCT) in systemic sclerosis (SSc) demonstrated long-term survival benefits, induction of clinically meaningful, sustained improvement of forced vital capacity with improvements in skin thickening, vasculopathy and health-related quality of life, in contrast to a clinical decline in standard of care control groups. These benefits, however, must be weighed against the increased risk of transplant-related mortality. Further, with disease progression, severe extensive internal organ involvement and damage ensues, constituting an exclusion criterion for safety reasons, leaving a limited window whereby patients with SSc are eligible for HSCT. Although autologous HSCT offers the possibility of drug-free remission, relapse can occur, requiring re-initiation of disease modifying antirheumatic drugs. HSCT is also associated with secondary autoimmune diseases and gonadal failure. HSCT should be proposed for carefully selected patients with early rapidly progressive diffuse SSc whose clinical picture portends a poor prognosis for survival, but yet lacks advanced organ involvement.
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Affiliation(s)
- Ulrich A Walker
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - Lesley Ann Saketkoo
- Tulane University School of Medicine Lung Center, New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, University Medical Center - Comprehensive Pulmonary Hypertension Center, New Orleans, Louisiana, USA
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
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12
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Zeher M, Papp G, Nakken B, Szodoray P. Hematopoietic stem cell transplantation in autoimmune disorders: From immune-regulatory processes to clinical implications. Autoimmun Rev 2017; 16:817-825. [PMID: 28572052 DOI: 10.1016/j.autrev.2017.05.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 04/28/2017] [Indexed: 12/29/2022]
Abstract
Autoimmune diseases are characterized by the development of autoreactive T- and B-cells targeting self-antigens, which eventually can result in chronic and persistent organ damage. The autologous hematopoietic stem cell transplantation (AHSCT) opened new avenues in the treatment of patients with severe, treatment-resistant autoimmune diseases. This paper reviews the immune-regulatory mechanisms behind AHSCT, and also summarizes the experiences of clinical practice related to the therapy in organ-specific and systemic autoimmune diseases. It seems that the intricate interplay of various immune competent cells with regulatory capacity control in a synergistic manner the repopulated immune system after AHSCT, which potentially leads to a significant clinical improvement in certain autoimmune diseases. However, the widespread use of AHSCT was intrinsically limited, due to the serious side-effects of conditioning treatment and relatively high treatment-related mortality; moreover, the development of new effective and safe therapeutic approaches and the dawn of biological agents further limited its indications in the last decade. Nevertheless, with an appropriate patient selection and increased experience of transplant centres, the risks can be minimized, and AHSCT remained still a reasonable choice in multiple sclerosis and systemic sclerosis when the conventional therapy failed and further progression of disease is inevitable.
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Affiliation(s)
- Margit Zeher
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
| | - Gábor Papp
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Britt Nakken
- Centre for Immune Regulation, Department of Immunology, University of Oslo, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Peter Szodoray
- Centre for Immune Regulation, Department of Immunology, University of Oslo, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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13
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Storek J, Daly A, LeClercq SA. Autologous hematopoietic cell transplantation for systemic sclerosis - a challenge for the Canadian health care system. CMAJ 2017; 189:E623-E624. [PMID: 28461373 DOI: 10.1503/cmaj.161346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Jan Storek
- Departments of Medicine (Storek, Daly, LeClercq) and Oncology (Storek, Daly), University of Calgary; Alberta Health Services (Storek, Daly, LeClercq), Calgary, Alta.
| | - Andrew Daly
- Departments of Medicine (Storek, Daly, LeClercq) and Oncology (Storek, Daly), University of Calgary; Alberta Health Services (Storek, Daly, LeClercq), Calgary, Alta
| | - Sharon A LeClercq
- Departments of Medicine (Storek, Daly, LeClercq) and Oncology (Storek, Daly), University of Calgary; Alberta Health Services (Storek, Daly, LeClercq), Calgary, Alta
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14
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Mina-Osorio P. Stem Cell Therapy in the Treatment of Rheumatic Diseases and Application in the Treatment of Systemic Lupus Erythematosus. NEXT-GENERATION THERAPIES AND TECHNOLOGIES FOR IMMUNE-MEDIATED INFLAMMATORY DISEASES 2017. [PMCID: PMC7123283 DOI: 10.1007/978-3-319-42252-7_9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Current systemic therapies help to improve the symptoms and quality of life for patients with severe life-threatening rheumatic diseases but provide no curative treatment. For the past two decades, preclinical and clinical studies of stem cell transplantation (SCT) have demonstrated tremendous therapeutic potential for patients with autoimmune rheumatic diseases. Herein, the current advances on stem cell therapies, both in animal models and clinical studies, are discussed, with particular attention on systemic lupus erythematosus (SLE). Despite extensive research and promising data, our knowledge on mechanisms of action for SCT, its administration route and timing, the optimal dose of cells, the cells’ fate and distribution in vivo, and the safety and efficacy of the treatments remains limited. Further research on stem cell biology is required to ensure that therapeutic safety and efficacy, as observed in animal models, can be successfully translated in clinical trials. Current understanding, limitations, and future directions for SCT with respect to rheumatic diseases are also discussed.
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Volkmann ER, Furst DE. Management of Systemic Sclerosis-Related Skin Disease: A Review of Existing and Experimental Therapeutic Approaches. Rheum Dis Clin North Am 2015. [PMID: 26210126 DOI: 10.1016/j.rdc.2015.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The skin is the most common organ system involved in patients with systemic sclerosis (SSc). Nearly all patients experience cutaneous symptoms, including sclerosis, Raynaud's phenomenon, digital ulcers, telangiectasias, and calcinosis. In addition to posing functional challenges, cutaneous symptoms are often a major cause of pain, psychological distress, and body image dissatisfaction. The present article reviews the main features of SSc-related cutaneous manifestations and highlights an evidence-based treatment approach for treating each manifestation. This article also describes novel treatment approaches and opportunities for further research in managing this important clinical dimension of SSc.
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Affiliation(s)
- Elizabeth R Volkmann
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 1000 Veteran Avenue, Suite 32-59, Los Angeles, CA 90095, USA.
| | - Daniel E Furst
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 1000 Veteran Avenue, Suite 32-59, Los Angeles, CA 90095, USA
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van Laar JM, Naraghi K, Tyndall A. Haematopoietic stem cell transplantation for poor-prognosis systemic sclerosis. Rheumatology (Oxford) 2015; 54:2126-33. [PMID: 25953700 DOI: 10.1093/rheumatology/kev117] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Indexed: 12/29/2022] Open
Abstract
Haematopoietic stem cell transplantation (HSCT) following intensive immune suppression has been used in >2000 patients with severe autoimmune diseases for 18 years, including 300 with SSc. The concept is to profoundly reduce the bulk of auto-aggressive immune competent cells and then rescue the patient's ablated haematopoiesis via an autologous HSCT. An early analysis of uncontrolled phase I/II data suggested that approximately one-third of these achieved a substantial improvement, with a relapse rate of 25% and a treatment-related mortality ranging from 6% to 23% across different studies. These early results led to three prospective randomized controlled trials, two of which are completed, confirming that HSCT shows clear advantages over conventional immunosuppression, but with significant toxicity. In some patients, sustained complete normalization of skin changes, reversal of positive autoantibody status and withdrawal of immunosuppressive medication were observed. These results attest to the profound effects of HSCT.
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Affiliation(s)
- Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands,
| | - Kamran Naraghi
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK and
| | - Alan Tyndall
- Department of Rheumatology, University Hospital, Basel, Switzerland
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Abstract
The presence of autoimmune diseases, including Systemic Sclerosis (SSc), suggest failure of the normal immune regulatory processes leading to activation and expansion of autoreactive effector immune cells. Recently, stem cell transplantation emerged as a novel rescue therapy for a variety of refractory autoimmune diseases. The therapeutic strategy involves the ablation of the aberrant self-reactive immune cells by chemotherapy and the regeneration of a new self-tolerant immune system formed by the transplanted stem cells. In the last few years, thousands of patients worldwide have received haematopoietic stem cell transplantation (HSCT), mostly autologous, as treatment for severe irreversible autoimmune diseases, with promising results. Here we review the results of published small series of SSc patients treated with allogeneic and autologous HSCT, as well as three randomized trials, exploring the safety and efficacy of autologous HSCT in SSc. Although the results are encouraging, nonetheless, the correct application of stem cell transplantation remains an area of active investigation. Results of larger randomized, double blind clinical trials, will certainly improve our knowledge of the appropriate clinical use of stem cell therapy in SSc patients.
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Affiliation(s)
- Paola Cipriani
- Clinical Immunology and Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, "San Salvatore" University Hospital, University of L'Aquila, L'Aquila, Italy
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Stem Cell Therapy in Autoimmune Rheumatic Diseases: a Comprehensive Review. Clin Rev Allergy Immunol 2014; 47:244-57. [DOI: 10.1007/s12016-014-8445-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Verrecchia F, Wang Y, Vija L, Farge D. Evidence of an antifibrotic effect of immunosuppressive drugs: applications in the treatment of systemic sclerosis. Expert Rev Clin Immunol 2014; 5:35-43. [DOI: 10.1586/1744666x.5.1.35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Emer J, George DD, Bernardo S, Sidhu H. Shiny white patches of the arms and forehead. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2013; 6:39-46. [PMID: 24003351 PMCID: PMC3760605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Jason Emer
- Dr. Emer and Mr. Bernardo are from Mount Sinai School of Medicine, Departments of Dermatology, New York, New York. Mr. Dr. George is from Saint George's University School of Medicine, Grenada. Dr. Sidhu is from Mount Sinai School of Medicine, Department of Pathology, New York, New York
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Rodrigues MCDO, Hamerschlak N, de Moraes DA, Simões BP, Rodrigues M, Ribeiro AAF, Voltarelli JC. Guidelines of the Brazilian society of bone Marrow transplantation on hematopoietic stem cell transplantation as a treatment for the autoimmune diseases systemic sclerosis and multiple sclerosis. Rev Bras Hematol Hemoter 2013; 35:134-43. [PMID: 23741192 PMCID: PMC3672124 DOI: 10.5581/1516-8484.20130035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 02/27/2013] [Indexed: 12/21/2022] Open
Affiliation(s)
| | | | | | - Belinda Pinto Simões
- Hospital das Clínicas de Ribeirão Preto, Universidade de
São Paulo - USP, Ribeirão Preto, SP, Brazil
| | | | | | - Júlio César Voltarelli
- Hospital das Clínicas de Ribeirão Preto, Universidade de
São Paulo - USP, Ribeirão Preto, SP, Brazil
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Induction of antigen-specific tolerance through hematopoietic stem cell-mediated gene therapy: the future for therapy of autoimmune disease? Autoimmun Rev 2012; 12:195-203. [PMID: 23047179 DOI: 10.1016/j.autrev.2011.08.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 08/28/2011] [Indexed: 12/29/2022]
Abstract
Based on the principle that immune ablation followed by HSC-mediated recovery purges disease-causing leukocytes to interrupt autoimmune disease progression, hematopoietic stem cell transplantation (HSCT) has been increasingly used as a treatment for severe autoimmune diseases. Despite clinically-relevant outcomes, HSCT is associated with serious iatrogenic risks and is suitable only for the most serious and intractable diseases. A further limitation of autologous HSCT is that relapse rates can be high, suggesting disease-causing leukocytes are incompletely purged or the environmental and genetic determinants that drive disease remain active. Incorporation of antigen-specific tolerance approaches that synergise with autologous HSCT could reduce or prevent relapse. Further, by reducing the requirement for highly toxic immune-ablation and instead relying on antigen-specific tolerance, the clinical utility of HSCT could be significantly diversified. Substantial progress has been made exploring HSCT-mediated induction of antigen-specific tolerance in animal models but studies have focussed on primarily on prevention of autoimmune diseases. However, as diagnosis of autoimmune disease is often not made until autoimmune disease is well developed and populations of autoantigen-specific pathogenic effector and memory T cells have become well established, immunotherapies must be developed to address effector and memory T-cell responses which have traditionally been considered the key impediment to immunotherapy. Here, focusing on T-cell mediated autoimmune diseases we review progress made in antigen-specific immunotherapy using HSCT-mediated approaches, induction of tolerance in effector and memory T cells and the challenges for progression and clinical application of antigen-specific 'tolerogenic' HSCT therapy.
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Vitiello M, Abuchar A, Santana N, Dehesa L, Kerdel FA. An Update on the Treatment of the Cutaneous Manifestations of Systemic Sclerosis: The Dermatologist's Point of View. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2012; 5:33-43. [PMID: 22798974 PMCID: PMC3396456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Systemic sclerosis is a connective tissue disorder that affects multiple organs. Although the initial symptoms of the disease are vascular, skin involvement is almost universally present in patients with systemic sclerosis. The presence of Raynaud's phenomenon, progressive thickening of the skin, digital ulcers, and calcinosis all correlate proportionally with disease severity. Since no treatment is available to completely prevent the natural course of the disease, emphasis is often placed on managing symptoms and complications. In this review, the authors focus on the management of each one of the skin manifestations seen in systemic sclerosis, as the dermatologist may facilitate the early recognition and treatment of these complications.
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Affiliation(s)
- Magalys Vitiello
- University of Miami Hospital/Florida Academic Dermatology Center, Miami, Florida
| | - Adriana Abuchar
- University of Miami Hospital/Florida Academic Dermatology Center, Miami, Florida
| | - Néstor Santana
- Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Luis Dehesa
- University of Miami Hospital/Florida Academic Dermatology Center, Miami, Florida
| | - Francisco A. Kerdel
- University of Miami Hospital/Florida Academic Dermatology Center, Miami, Florida
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Pasquini MC, Voltarelli J, Atkins HL, Hamerschlak N, Zhong X, Ahn KW, Sullivan KM, Carrum G, Andrey J, Bredeson CN, Cairo M, Gale RP, Hahn T, Storek J, Horowitz MM, McSweeney PA, Griffith LM, Muraro PA, Pavletic SZ, Nash RA. Transplantation for autoimmune diseases in north and South America: a report of the Center for International Blood and Marrow Transplant Research. Biol Blood Marrow Transplant 2012; 18:1471-8. [PMID: 22705497 DOI: 10.1016/j.bbmt.2012.06.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 06/05/2012] [Indexed: 12/29/2022]
Abstract
Hematopoietic cell transplantation (HCT) is an emerging therapy for patients with severe autoimmune diseases (AID). We report data on 368 patients with AID who underwent HCT in 64 North and South American transplantation centers reported to the Center for International Blood and Marrow Transplant Research between 1996 and 2009. Most of the HCTs involved autologous grafts (n = 339); allogeneic HCT (n = 29) was done mostly in children. The most common indications for HCT were multiple sclerosis, systemic sclerosis, and systemic lupus erythematosus. The median age at transplantation was 38 years for autologous HCT and 25 years for allogeneic HCT. The corresponding times from diagnosis to HCT were 35 months and 24 months. Three-year overall survival after autologous HCT was 86% (95% confidence interval [CI], 81%-91%). Median follow-up of survivors was 31 months (range, 1-144 months). The most common causes of death were AID progression, infections, and organ failure. On multivariate analysis, the risk of death was higher in patients at centers that performed fewer than 5 autologous HCTs (relative risk, 3.5; 95% CI, 1.1-11.1; P = .03) and those that performed 5 to 15 autologous HCTs for AID during the study period (relative risk, 4.2; 95% CI, 1.5-11.7; P = .006) compared with patients at centers that performed more than 15 autologous HCTs for AID during the study period. AID is an emerging indication for HCT in the region. Collaboration of hematologists and other disease specialists with an outcomes database is important to promote optimal patient selection, analysis of the impact of prognostic variables and long-term outcomes, and development of clinical trials.
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Affiliation(s)
- Marcelo C Pasquini
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI, USA.
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Snowden JA, Saccardi R, Allez M, Ardizzone S, Arnold R, Cervera R, Denton C, Hawkey C, Labopin M, Mancardi G, Martin R, Moore JJ, Passweg J, Peters C, Rabusin M, Rovira M, van Laar JM, Farge D. Haematopoietic SCT in severe autoimmune diseases: updated guidelines of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 2012; 47:770-90. [PMID: 22002489 PMCID: PMC3371413 DOI: 10.1038/bmt.2011.185] [Citation(s) in RCA: 210] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 07/04/2011] [Accepted: 07/04/2011] [Indexed: 12/13/2022]
Abstract
In 1997, the first consensus guidelines for haematopoietic SCT (HSCT) in autoimmune diseases (ADs) were published, while an international coordinated clinical programme was launched. These guidelines provided broad principles for the field over the following decade and were accompanied by comprehensive data collection in the European Group for Blood and Marrow Transplantation (EBMT) AD Registry. Subsequently, retrospective analyses and prospective phase I/II studies generated evidence to support the feasibility, safety and efficacy of HSCT in several types of severe, treatment-resistant ADs, which became the basis for larger-scale phase II and III studies. In parallel, there has also been an era of immense progress in biological therapy in ADs. The aim of this document is to provide revised and updated guidelines for both the current application and future development of HSCT in ADs in relation to the benefits, risks and health economic considerations of other modern treatments. Patient safety considerations are central to guidance on patient selection and HSCT procedural aspects within appropriately experienced and Joint Accreditation Committee of International Society for Cellular Therapy and EBMT accredited centres. A need for prospective interventional and non-interventional studies, where feasible, along with systematic data reporting, in accordance with EBMT policies and procedures, is emphasized.
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Affiliation(s)
- J A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
- Department of Oncology, University of Sheffield, Sheffield, UK
| | - R Saccardi
- Department of Haematology, Careggi University Hospital, Firenze, Italy
| | - M Allez
- Service de Gastroentérologie, INSERM U 662, Hôpital St Louis, Paris, France
| | - S Ardizzone
- Department of Gastroenterology, Sacco University Hospital, Milan, Italy
| | - R Arnold
- Charite Hospital Berlin, Berlin, Germany
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - C Denton
- Centre for Rheumatology, Royal Free and University College Medical School, Hampstead, London, UK
| | - C Hawkey
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - M Labopin
- Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, AP-HP, UPMC Univ Paris 06, Paris, France
| | - G Mancardi
- Department of Neuroscience, Ophthalmology and Genetics, University of Genova, Genova, Italy
| | - R Martin
- Institute for Neuroimmunology and Clinical MS Research, Hamburg, Germany
| | - J J Moore
- St Vincent's Hospital, Sydney, NSW, Australia
| | - J Passweg
- Universitaetsspital Basel, Basel, Switzerland
| | - C Peters
- BMT Unit, St Anna Children's Hospital, Vienna, Austria
| | - M Rabusin
- BMT Unit, Department of Pediatrics, Institute of Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - M Rovira
- SCT Unit, Hematology Department, Hospital Clinic, Barcelona, Spain
| | | | - D Farge
- Department of Internal Medicine, INSERM U 796, Hôpital St Louis, Paris, France
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Zeher M, Papp G, Szodoray P. Autologous haemopoietic stem cell transplantation for autoimmune diseases. Expert Opin Biol Ther 2011; 11:1193-201. [PMID: 21609185 DOI: 10.1517/14712598.2011.580272] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
Systemic scleroderma may serve as a paradigm for orphan diseases where the rarity, different subsets and fluctuating disease activity constitute major obstacles of research into mechanisms and therapeutic development. Recently, significant advances in the detailed understanding of the functioning of growth factors, their receptors and of the physiology of the connective tissue have been achieved. In particular, an improved concept was developed for the pathophysiology of scleroderma, highlighting the role of hypoxia, cellular stress and a concert of interacting cytokines. Tyrosine kinases have been shown to regulate the activity of a number of cytokines and growth factors, e.g. transforming growth factor-beta and platelet-derived growth factor, which play a central role in the pathophysiology of SSc. Novel pharmacological compounds interacting with signalling cascades induced by hypoxia and intracellular signal transduction pathways of mesenchymal cells, e.g. tyrosine kinase inhibitors, are currently being investigated for the treatment of this life-threatening disease.
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García-Bosch O, Ricart E, Panés J. Review article: stem cell therapies for inflammatory bowel disease - efficacy and safety. Aliment Pharmacol Ther 2010; 32:939-52. [PMID: 20804451 DOI: 10.1111/j.1365-2036.2010.04439.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Drugs available for the treatment of inflammatory bowel disease fail to induce and maintain remission in a significant number of patients. AIM To assess the value of stem cell therapies for treatment of inflammatory bowel disease based on published studies. METHODS Publications were identified through a MEDLINE search using the Medical Subject Heading terms: inflammatory bowel diseases, or Crohn's disease, or ulcerative colitis, and stem cell, or stromal cell or transplant. RESULTS Haematopoietic stem cell therapy as a primary treatment for inflammatory bowel disease was originally supported by animal experiments, and by remissions in patients undergoing transplant for haematological disorders. Later, transplantation specifically performed for patients with refractory Crohn's disease showed long-lasting clinical remission and healing of inflammatory intestinal lesions. Use of autologous nonmyeloablative regimens and concentration of the procedures in centres with large experience are key in reducing treatment-related mortality. Initial trials of mesenchymal stem cell therapy with local injection in Crohn's perianal fistulas had positive results. CONCLUSIONS Autologous haematopoietic stem cell transplant changes the natural course of Crohn's disease, and may be a therapeutic option in patients with refractory disease if surgery is not feasible due to disease location or extension.
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Affiliation(s)
- O García-Bosch
- Department of Gastroenterology, Hospital Clínic de Barcelona, CiBERehd, Spain
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Craciunescu OI, Steffey BA, Kelsey CR, Larrier NA, Paarz-Largay CJ, Prosnitz RG, Chao N, Chute J, Gasparetto C, Horwitz M, Long G, Rizzieri D, Sullivan KM. Renal shielding and dosimetry for patients with severe systemic sclerosis receiving immunoablation with total body irradiation in the scleroderma: cyclophosphamide or transplantation trial. Int J Radiat Oncol Biol Phys 2010; 79:1248-55. [PMID: 20800376 DOI: 10.1016/j.ijrobp.2010.05.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 05/19/2010] [Accepted: 05/21/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE To describe renal shielding techniques and dosimetry in delivering total body irradiation (TBI) to patients with severe systemic sclerosis (SSc) enrolled in a hematopoietic stem cell transplant protocol. METHODS AND MATERIALS The Scleroderma: Cyclophosphamide or Transplantation (SCOT) protocol uses a lymphoablative preparative regimen including 800 cGy TBI delivered in two 200-cGy fractions twice a day before CD34(+) selected autologous hematopoietic stem cell transplantation. Lung and kidney doses are limited to 200 cGy to protect organs damaged by SSc. Kidney block proximity to the spinal cord was investigated, and guidelines were developed for acceptable lumbar area TBI dosing. Information about kidney size and the organ shifts from supine to standing positions were recorded using diagnostic ultrasound (US). Minimum distance between the kidney blocks (dkB) and the lumbar spine region dose was recorded, and in vivo dosimetry was performed at several locations to determine the radiation doses delivered. RESULTS Eleven patients were treated at our center with an anteroposterior (AP)/posteroanterior (PA) TBI technique. A 10% to 20% dose inhomogeneity in the lumbar spine region was achieved with a minimum kidney block separation of 4 to 5 cm. The average lumbar spine dose was 179.6 ± 18.1 cGy, with an average dkB of 5.0 ± 1.0 cm. Kidney block shield design was accomplished using a combination of US and noncontrast computerized tomography (CT) or CT imaging alone. The renal US revealed a wide range of kidney displacement from upright to supine positions. Overall, the average in vivo dose for the kidney prescription point was 193.4 ± 5.1 cGy. CONCLUSIONS The dose to the kidneys can be attenuated while maintaining a 10% to 20% dose inhomogeneity in the lumbar spine area. Kidneys were localized more accurately using both US and CT imaging. With this technique, renal function has been preserved, and the study continues to enroll patients.
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Affiliation(s)
- Oana I Craciunescu
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA.
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Hosing C, Nash R, McSweeney P, Mineishi S, Seibold J, Griffith LM, Shulman H, Goldmuntz E, Mayes M, Parikh CR, Crofford L, Keyes-Elstein L, Furst D, Steen V, Sullivan KM. Acute kidney injury in patients with systemic sclerosis participating in hematopoietic cell transplantation trials in the United States. Biol Blood Marrow Transplant 2010; 17:674-81. [PMID: 20708086 DOI: 10.1016/j.bbmt.2010.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 08/03/2010] [Indexed: 01/21/2023]
Abstract
Recipients of hematopoietic cell transplantation may be at risk for developing acute kidney injury (AKI), and this risk may be increased in patients who undergo transplantation for severe systemic sclerosis (SSc) due to underlying scleroderma renal disease. AKI after transplantation can increase treatment-related mortality. To better define these risks, we analyzed 91 patients with SSc who were enrolled in 3 clinical trials in the United States of autologous or allogeneic hematopoietic cell transplantation (HCT). Eleven (12%) of the 91 patients with SSc in these studies (8 undergoing autologous HCT, 1 undergoing allogeneic HCT, 1 pretransplantation, 1 given i.v. cyclophosphamide on a transplantation trial) experienced AKI, of whom 8 required dialysis and/or therapeutic plasma exchange. AKI injury in the 9 HCT recipients developed a median of 35 days (range, 0-90 days) after transplantation. Ten of 11 patients with AKI received angiotensin-converting enzyme inhibitor (ACE-I) therapy. The etiology of AKI was attributed to scleroderma renal crisis in 6 patients (including 2 with normotensive renal crisis), to AKI of uncertain etiology in 2 patients, and to AKI superimposed on scleroderma kidney disease in 3 patients. Eight of the 11 patients died, one each because of progression of SSc, multiorgan failure, gastrointestinal and pulmonary bleeding, pericardial tamponade and pulmonary complications, diffuse alveolar hemorrhage, pulmonary embolism, graft-versus-host disease, and malignancy. Limiting nephrotoxins, cautious use of corticosteroids, renal shielding during total body irradiation, strict control of blood pressure, and aggressive use of ACE-Is may be of importance in preventing renal complications after HCT for SSc.
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Affiliation(s)
- Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Abstract
Fibrosis is a pathological process that includes scar formation and overproduction of extracellular matrix by the connective tissue as a response to tissue damage. The fibrotic process involves multiple organs and results in progressive life-threatening diseases. Today, we know more about the molecular mechanism that leads to fibrosis involving different type of cells, cytokines, chemokines, and tissue enzymes. Fibrosis was considered an irreversible process, at least clinically, and is still usually treated by anti-inflammatory and immunosuppressive agents. No proven antifibrotic therapy has shown efficacy in ameliorating the clinical course of fibrotic diseases, but our current understanding led to the development of different drugs with promising results, like: mycophenolate mofetil, interferon, relaxin, and intravenous immunoglobulin. This review will provide a glance to this heavily investigated subject.
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Affiliation(s)
- Ziv Paz
- Department of Medicine B, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
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Hügle T, van Laar JM. Allogeneic stem cell transplantation for rheumatic autoimmune diseases. F1000 MEDICINE REPORTS 2010; 2. [PMID: 20948863 PMCID: PMC2948403 DOI: 10.3410/m2-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Haematopoietic stem cell transplantation (HSCT) has evolved from an experimental concept to an effective treatment option for severe autoimmune diseases and has a unique ability to restore immune regulation. It is a complex multistep procedure involving the administration of high doses of immunosuppressive medication and transplantation of stem cells. Most HSCT procedures in autoimmune disease have involved autologous stem cells. In the case of allogeneic transplantation, stem cells are derived from peripheral blood or bone marrow of a healthy HLA-matched donor. Allogeneic HSCT has curative potential based on studies in experimental models of autoimmune disease, case reports, and a registry analysis but carries significant risks of rejection and graft-versus-host disease. Unless these risks become manageable, allogeneic HSCT should be offered only if all alternative treatment options have failed, if a patient has a suitable donor, and if a patient still has a chance to benefit significantly from the procedure.
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Affiliation(s)
- Thomas Hügle
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University 4th Floor, Catherine Cookson Building, The Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
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Abstract
Systemic sclerosis (SSc) is a generalised autoimmune disease, of yet unknown origin, with two major clinical subsets: the limited (lcSSc) and the diffuse cutaneous (dcSSc) forms, which can be distinguished by the extent of skin involvement, the autoantibody profile and the pattern of organ involvement. With an incidence of 1/10(5), SSc affects around 250,000 people in Europe and is responsible for significant morbidity with a 5-year mortality rate of at least 30% of all patients. In patients with rapidly progressive dcSSc, the 5-year mortality is estimated to be 40-50%. Hematopoietic stem cell transplantation (HSCT), mostly autologous but also allogeneic in some specific cases, has been employed worldwide since 1996 as a new therapeutic strategy in patients with a poor prognosis. In 2007, 150 HSCT procedures have been reported in the EBMT data base. We review herein both the short and the long-term reports from the various European and North American phase I-II studies, which have shown that autologous HSCT in selected patients with severe dcSSc results in sustained improvement of skin thickening and stabilisation of organ function up to seven years after transplantation. Based on these promising results, ongoing phase III trials have been designed in parallel, both in Europe (ASTIS) and in North America (SCOTT) aiming to analyse the respective benefits from autologous HSCT respectively without or with high dose irradiation. This review reports the current data concerning the effects of HSCT on survival, skin, and major organ function in patients with severe dcSSc.
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Affiliation(s)
- Dominique Farge
- Service de Médecine Interne, Hopital Saint Louis, Paris, France.
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Xiong W, Derk CT. Treatment of systemic sclerosis: potential role for stem cell transplantation. Stem Cells Cloning 2009; 2:1-9. [PMID: 24198505 PMCID: PMC3781687 DOI: 10.2147/sccaa.s5282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Indexed: 12/29/2022] Open
Abstract
Hematopoietic stem cell transplantation may "reset" the immune reconstitution and induce self tolerance of autoreactive lymphocytes, and has been explored in the treatments for systemic sclerosis. Phase I/II trials have shown a satisfactory risk benefit ratio. The true benefit will be identified by two ongoing prospective, randomized phase III trials. Multipotent mesenchymal stromal cells (MSCs) possess antiproliferative, anti-inflammatory, and immunosuppressive properties. The use of MSCs has showed successful responses in patients with severe steroid-resistant acute graft versus host disease in phase II trials, and may be a potentially promising option for patients with systemic sclerosis.
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Affiliation(s)
- Wen Xiong
- Division of Rheumatology, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Chris T Derk
- Division of Rheumatology, Thomas Jefferson University, Philadelphia, PA, 19107, USA
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Snowden JA, Martin-Rendon E, Watt SM. Clinical stem cell therapies for severe autoimmune diseases. Transfus Med 2009; 19:223-34. [DOI: 10.1111/j.1365-3148.2009.00927.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Fleming JN, Shulman HM, Nash RA, Johnson PY, Wight TN, Gown A, Schwartz SM. Cutaneous chronic graft-versus-host disease does not have the abnormal endothelial phenotype or vascular rarefaction characteristic of systemic sclerosis. PLoS One 2009; 4:e6203. [PMID: 19587802 PMCID: PMC2705674 DOI: 10.1371/journal.pone.0006203] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 06/04/2009] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The clinical and histologic appearance of fibrosis in cutaneous lesions in chronic graft-versus -host disease (c-GVHD) resembles the appearance of fibrosis in scleroderma (SSc). Recent studies identified distinctive structural changes in the superficial dermal microvasculature and matrix of SSc skin. We compared the dermal microvasculature in human c-GVHD to SSc to determine if c-GVHD is a suitable model for SSc. METHODOLOGY/PRINCIPAL FINDINGS We analyzed skin biopsies of normal controls (n = 24), patients with SSc (n = 30) and c-GVHD with dermal fibrosis (n = 133)). Immunostaining was employed to identify vessels, vascular smooth muscle, dermal matrix, and cell proliferation. C-GVHD and SSc had similar dermal matrix composition and vascular smooth muscle pathology, including intimal hyperplasia. SSc, however, differed significantly from c-GVHD in three ways. First, there were significantly fewer (p = 0.00001) average vessels in SSc biopsies (9.8) when compared with c-GVHD (16.5). Second, in SSc, endothelial markers were decreased significantly (19/19 and 12/14 for VE cadherin and vWF (p = <0.0001 and <0.05), respectively). In contrast, 0/13 c-GVHD biopsies showed loss of staining with canonical endothelial markers. Third, c-GVHD contained areas of microvascular endothelial proliferation not present in the SSc biopsies. CONCLUSIONS/SIGNIFICANCE The sclerosis associated with c-GVHD appears to resemble wound healing. Focal capillary proliferation occurs in early c-GVHD. In contrast, loss of canonical endothelial markers and dermal capillaries is seen in SSc, but not in c-GVHD. The loss of VE cadherin in SSc, in particular, may be related to microvascular rarefaction because VE cadherin is necessary for angiogenesis. C-GVHD is a suitable model for studying dermal fibrosis but may not be applicable for studying the microvascular alterations characteristic of SSc.
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Affiliation(s)
- Jo Nadine Fleming
- Department of Pathology, University of Washington, Seattle, Washington, USA.
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Gratwohl A. Allogeneic hematopoietic stem cell transplantation for severe autoimmune diseases. Autoimmunity 2009; 41:673-8. [DOI: 10.1080/08916930802197677] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Kötter I, Schmalzing M, Henes J, Vogel W, Kanz L. [Current value of stem-cell transplantation in autoimmune diseases]. Z Rheumatol 2009; 67:716-22. [PMID: 19011875 DOI: 10.1007/s00393-008-0386-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Transplantations of autologous or allogeneic stem cells from bone marrow or peripheral blood are preformed for the treatment of resistant autoimmune diseases. Data have been systematically collected since 1996. We describe the historical development of this procedure for autoimmune diseases, the possible mechanisms of action, the options for stem cell collection, purging and conditioning (high-dose chemotherapy, combination with monoclonal anti-T- or B-cell antibodies, total body irradiation), as well as the reported outcomes in the literature.
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Affiliation(s)
- I Kötter
- Abteilung Innere Medizin II, Medizinische Universitätsklinik Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland.
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Abstract
PURPOSE OF REVIEW To summarize recent evidence and current trends in the use of haematopoietic stem cell transplantation (HSCT) for autoimmune diseases. RECENT FINDINGS Updates of published trials and data from the registries indicate a long-lasting, immunosuppression-free condition in about 50% of the patients who underwent an HSCT for a severe, progressive autoimmune disease. For all diseases, autologous HSCT is largely preferred for safety reasons, whereas allogeneic HSCT is to be considered only for carefully selected cases. Transplant-related mortality (TRM) has decreased in the past 5 years, due to both better selection of patients and the use of less intensive conditioning regimens. The most employed conditioning regimens in Europe are BCNU (carmustine), etoposide, ARA-C (cytosine arabinoside), M (melphalan) (BEAM)/anti-thymocyte globulin in multiple sclerosis and high-dose cyclophosphamide/anti-thymocyte globulin for all other diseases, with a trend for more intense regimens in North America. Multiple sclerosis and systemic sclerosis are currently the most frequent diagnoses. Prospective comparative trials are currently ongoing both in Europe and North America. SUMMARY Recent reports confirm the evidence that HSCT is able to induce a high rate of sustained remissions in most severe autoimmune diseases, unresponsive to conventional treatments. Valuable information is expected by the finalization of the ongoing prospective, comparative trials.
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Imanguli MM, Alevizos I, Brown R, Pavletic SZ, Atkinson JC. Oral graft-versus-host disease. Oral Dis 2008; 14:396-412. [PMID: 18593456 DOI: 10.1111/j.1601-0825.2008.01448.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Graft-versus-host disease (GVHD) is a leading cause of morbidity and mortality in patients receiving hematopoietic cell transplant. It is estimated that 40-70% of engrafted patients surviving the initial transplant eventually develop chronic GVHD (cGVHD), which can persist for months to years and require long-term management from multiple disciplines. This review describes the oral component of this transplant complication. DESIGN The search related to GVHD patho-biology, salivary gland disease after hematopoietic cell transplant and treatments for oral GVHD encompassed literature from 1966 through 2008. Searches were limited to the MEDLINE/PubMed database and English language literature in peer-reviewed journals. RESULTS Our understanding of the patho-biology of oral cGVHD is based on studies of other affected tissues. It is difficult to determine the prevalence and incidence of salivary gland disease after transplant because there is no universally accepted case definition. In general, clinical trials for treatment of oral cGVHD have been too small to make strong recommendations for use in clinical practice. CONCLUSIONS Larger well-designed clinical studies are needed to understand the patho-biology of oral cGVHD and determine best treatments for this disease.
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Affiliation(s)
- M M Imanguli
- Experimental Transplantation and Immunology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
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Abstract
Immunoablative therapy and hematopoietic stem cell transplantation (HSCT) is an intensive treatment modality aimed at 'resetting' the dysregulated immune system of a patient with immunoablative therapy and allow outgrowth of a nonautogressive immune system from reinfused hematopoietic stem cells, either from the patient (autologous HSCT) or a healthy donor (allogeneic HSCT). HSCT has been shown to induce profound alterations of the immune system affecting B and T cells, monocytes, and natural killer and dendritic cells, resulting in elimination of autoantibody-producing plasma cells and in induction of regulatory T cells. Most of the available data have been collected through retrospective cohort analyses of autologous HSCT, case series, and translational studies in patients with refractory autoimmune diseases. Long-term and marked improvements of disease activity have been observed, notably in systemic sclerosis, systemic lupus erythematosus, and juvenile idiopathic arthritis, and treatment-related morbidity and mortality have improved due to better patient selection and modifications of transplant regimens. Treatment-related mortality has decreased to approximately 7%. Prospective, randomised, controlled clinical trials are ongoing or planned in systemic sclerosis, systemic lupus erythematosus, and several nonrheumatological conditions.
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Affiliation(s)
- Thomas Hügle
- Department of Rheumatology, University of Basel, Felix Platter Spital, Burgfelderstrasse 101, 4012 Basel, Switzerland
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Braiteh F, Hymes SR, Giralt SA, Jones R. Complete remission of psoriasis after autologous hematopoietic stem-cell transplantation for multiple myeloma. J Clin Oncol 2008; 26:4511-3. [PMID: 18802165 DOI: 10.1200/jco.2008.17.6560] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Fadi Braiteh
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Graduate School of Biomedical Sciences, University of Texas, Houston, TX, USA
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Shiratsuchi M, Motomura S, Abe Y, Shiokawa S, Nishimura J. Long-term follow-up after nonmyeloablative allogeneic hematopoietic stem cell transplantation for systemic sclerosis. Clin Rheumatol 2008; 27:1207-9. [PMID: 18483758 DOI: 10.1007/s10067-008-0927-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 04/23/2008] [Accepted: 04/28/2008] [Indexed: 10/22/2022]
Abstract
Systemic sclerosis (SSc) characteristically consists of fibrotic changes in various organs, and immunological abnormality is the main cause of the disease. Although high-dose immunosuppressive therapies with autologous or allogeneic hematopoietic stem cell support can reverse the disease course, they have a high treatment-related mortality. We report the successful use of nonmyeloablative allogeneic hematopoietic stem cell transplantation (HSCT) for SSc. A 40-year-old woman with diffuse scleroderma and interstitial pneumonia underwent allogeneic peripheral blood stem cell transplantation from an HLA-identical sibling after conditioning with low-dose total-body irradiation and fludarabine. Prophylaxis for graft-versus-host disease (GVHD) consisted of cyclosporine and mycophenolate mofetil. No infection or acute GVHD developed. One year after transplantation, the patient developed membranous glomerulopathy caused by chronic GVHD that was successfully treated with prednisolone. The patient's skin score decreased dramatically, and her pulmonary function is stable 4 years after transplantation. Nonmyeloablative allogeneic HSCT may be more effective than conventional therapies for SSc.
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Affiliation(s)
- Motoaki Shiratsuchi
- Department of Immunobiology and Neuroscience, Medical Institute of Bioregulation, Kyushu University, Beppu, Oita, Japan
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Hematopoietic stem cell transplantation for autoimmune diseases: What have we learned? J Autoimmun 2008; 30:116-20. [DOI: 10.1016/j.jaut.2007.12.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Deane S, Meyers FJ, Gershwin ME. On reversing the persistence of memory: Hematopoietic stem cell transplant for autoimmune disease in the first ten years. J Autoimmun 2008; 30:180-96. [DOI: 10.1016/j.jaut.2007.12.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Taïeb A, Constans J, Mahon FX. Une nouvelle piste thérapeutique pour les sclérodermies graves: le mésylate d’imatinib. Rev Med Interne 2008; 29:173-5. [PMID: 17597261 DOI: 10.1016/j.revmed.2007.05.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2007] [Accepted: 05/21/2007] [Indexed: 12/26/2022]
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Abstract
PURPOSE OF REVIEW Provides an update of hematopoietic stem cell transplantation for systemic sclerosis from phase I/II studies and prospective randomized phase III trials, and introduces the concept of mesenchymal stem cells as potential therapy for autoimmune disease. RECENT FINDINGS Around 170 transplanted systemic sclerosis patients are registered in Europe. Most received autologous, peripheral blood derived hematopoietic stem cell transplantation. Treatment-related mortality has fallen to 2.5% in the controlled trials compared with 12.5% in the first report in 2002. Over one-third of patients have experienced sustained remission. Two prospective randomized phase III studies are active: the Autologous Stem cell Transplantation International Scleroderma (ASTIS) trial in Europe and the Scleroderma Cyclophosphamide Or Transplant (SCOT) trial in the USA. Both have similar selection criteria, endpoint and control arms, but the SCOT trial uses radiation and less cyclophosphamide. So far, no unexpected toxicity has occurred. Reports produced in the past 12 months show reduction of skin collagen and reversal of microvascular remodelling, years after transplant. Bone marrow-derived mesenchymal stem cells from systemic sclerosis patients show in-vitro immunomodulatory properties equal to healthy controls. SUMMARY Hematopoietic stem cell transplantation is currently being tested in prospective randomized controlled trials and appears to 'reset' autoimmunity in systemic sclerosis. Mesenchymal stem cells may have an immunomodulatory role in autoimmune disease.
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Affiliation(s)
- Alan Tyndall
- Department of Rheumatology, University of Basel, Switzerland.
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Capillary regeneration in scleroderma: stem cell therapy reverses phenotype? PLoS One 2008; 3:e1452. [PMID: 18197262 PMCID: PMC2175530 DOI: 10.1371/journal.pone.0001452] [Citation(s) in RCA: 151] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Accepted: 12/21/2007] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Scleroderma is an autoimmune disease with a characteristic vascular pathology. The vasculopathy associated with scleroderma is one of the major contributors to the clinical manifestations of the disease. METHODOLOGY/PRINCIPAL FINDINGS We used immunohistochemical and mRNA in situ hybridization techniques to characterize this vasculopathy and showed with morphometry that scleroderma has true capillary rarefaction. We compared skin biopsies from 23 scleroderma patients and 24 normal controls and 7 scleroderma patients who had undergone high dose immunosuppressive therapy followed by autologous hematopoietic cell transplant. Along with the loss of capillaries there was a dramatic change in endothelial phenotype in the residual vessels. The molecules defining this phenotype are: vascular endothelial cadherin, a supposedly universal endothelial marker required for tube formation (lost in the scleroderma tissue), antiangiogenic interferon alpha (overexpressed in the scleroderma dermis) and RGS5, a signaling molecule whose expression coincides with the end of branching morphogenesis during development and tumor angiogenesis (also overexpressed in scleroderma skin. Following high dose immunosuppressive therapy, patients experienced clinical improvement and 5 of the 7 patients with scleroderma had increased capillary counts. It was also observed in the same 5 patients, that the interferon alpha and vascular endothelial cadherin had returned to normal as other clinical signs in the skin regressed, and in all 7 patients, RGS5 had returned to normal. CONCLUSION/SIGNIFICANCE These data provide the first objective evidence for loss of vessels in scleroderma and show that this phenomenon is reversible. Coordinate changes in expression of three molecules already implicated in angiogenesis or anti-angiogenesis suggest that control of expression of these three molecules may be the underlying mechanism for at least the vascular component of this disease. Since rarefaction has been little studied, these data may have implications for other diseases characterized by loss of capillaries including hypertension, congestive heart failure and scar formation.
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