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Coppola E, Giardino G, Abate M, Tambaro FP, Bifano D, Toriello E, De Rosa A, Cillo F, Pignata C, Cirillo E. Rare solid tumors in a patient with Wiskott-Aldrich syndrome after hematopoietic stem cell transplantation: case report and review of literature. Front Immunol 2023; 14:1229674. [PMID: 37781361 PMCID: PMC10533990 DOI: 10.3389/fimmu.2023.1229674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/23/2023] [Indexed: 10/03/2023] Open
Abstract
Background and aims Wiskott-Aldrich syndrome (WAS) is an X-linked recessive primary immunodeficiency disorder characterized by severe eczema, recurrent infections, and micro-thrombocytopenia. Allogeneic hematopoietic stem cell transplantation (HSCT) is a potentially curative therapeutic option for patients with classic form. The risk of developing post-transplant tumors appears to be higher in patients with WAS than in other inborn errors of immunity (IEIs), but the actual incidence is not well defined, due to the scarcity of published data. Methods Herein, we describe a 10-year-old patient diagnosed with WAS, treated with HSCT in the first year of life, who subsequently developed two rare solid tumors, kaposiform hemangioendothelioma and desmoid tumor. A review of the literature on post-HSCT tumors in WAS patients has been performed. Results The patient received diagnosis of classic WAS at the age of 2 months (Zhu score = 3), confirmed by WAS gene sequencing, which detected the nonsense hemizygous c.37C>T (Arg13X) mutation. At 9 months, patient underwent HSCT from a matched unrelated donor with an adequate immune reconstitution, characterized by normal lymphocyte subpopulations and mitogen proliferation tests. Platelet count significantly increased, even though platelet count never reached reference values. A mixed chimerism was also detected, with a residual WASP- population on monocytes (27.3%). The patient developed a kaposiform hemangioendothelioma at the age of 5. A second abdominal tumor was identified, histologically classified as a desmoid tumor when he reached the age of 10 years. Both hematopoietic and solid tumors were identified in long-term WAS survivors after HSCT. Conclusion Here, we describe the case of a patient with WAS who developed two rare solid tumors after HSCT. An active surveillance program for the risk of tumors is necessary in the long-term follow-up of post-HSCT WAS patients.
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Affiliation(s)
- Emma Coppola
- Department of Translational Medical Sciences, Pediatrics Section, Federico II University of Naples, Naples, Italy
| | - Giuliana Giardino
- Department of Translational Medical Sciences, Pediatrics Section, Federico II University of Naples, Naples, Italy
| | - Massimo Abate
- Pediatric Oncology Department, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Francesco Paolo Tambaro
- Division of Stem Cell Transplantation and Cell Therapy, Pediatric Oncology Department, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Delfina Bifano
- Department of Pathology, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Elisabetta Toriello
- Department of Translational Medical Sciences, Pediatrics Section, Federico II University of Naples, Naples, Italy
| | - Antonio De Rosa
- Department of Translational Medical Sciences, Pediatrics Section, Federico II University of Naples, Naples, Italy
| | - Francesca Cillo
- Department of Translational Medical Sciences, Pediatrics Section, Federico II University of Naples, Naples, Italy
| | - Claudio Pignata
- Department of Translational Medical Sciences, Pediatrics Section, Federico II University of Naples, Naples, Italy
| | - Emilia Cirillo
- Department of Translational Medical Sciences, Pediatrics Section, Federico II University of Naples, Naples, Italy
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Fazlalipour M, Ghoreshi ZAS, Molaei HR, Arefinia N. The Role of DNA Viruses in Human Cancer. Cancer Inform 2023; 22:11769351231154186. [PMID: 37363356 PMCID: PMC10286548 DOI: 10.1177/11769351231154186] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/03/2023] [Indexed: 06/28/2023] Open
Abstract
This review discusses the possible involvement of infections-associated cancers in humans, with virus infections contributing 15% to 20% of total cancer cases in humans. DNA virus encoded proteins interact with host cellular signaling pathways and control proliferation, cell death and genomic integrity viral oncoproteins are known to bind cellular Deubiquitinates (DUBs) such as cyclindromatosis tumor suppressor, ubiquitin-specific proteases 7, 11, 15 and 20, and A-20 to improve their intracellular stability and cellular signaling pathways and finally transformation. Human papillomaviruses (cervical carcinoma, oral cancer and laryngeal cancer); human polyomaviruses (mesotheliomas, brain tumors); Epstein-Barr virus (B-cell lymphoproliferative diseases and nasopharyngeal carcinoma); Kaposi's Sarcoma Herpesvirus (Kaposi's Sarcoma and primary effusion lymphomas); hepatitis B (hepatocellular carcinoma (HCC)) cause up to 20% of malignancies around the world.
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Affiliation(s)
- Mehdi Fazlalipour
- WHO Collaborating Center for Reference and Research on Rabies, Pasteur Institute of Iran (IPI), Tehran, Iran
- Research Center for Emerging and Reemerging Infectious diseases, Pasteur Institute of Iran (IPI), Tehran, Iran
| | | | - Hamid Reza Molaei
- Department of Medical Bacteriology and Virology, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Nasir Arefinia
- Student Research Committee, Jiroft University of Medical Sciences, Jiroft, Iran
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Castiello MC, Ferrari S, Villa A. Correcting inborn errors of immunity: From viral mediated gene addition to gene editing. Semin Immunol 2023; 66:101731. [PMID: 36863140 PMCID: PMC10109147 DOI: 10.1016/j.smim.2023.101731] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/25/2023] [Accepted: 02/14/2023] [Indexed: 03/04/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation is an effective treatment to cure inborn errors of immunity. Remarkable progress has been achieved thanks to the development and optimization of effective combination of advanced conditioning regimens and use of immunoablative/suppressive agents preventing rejection as well as graft versus host disease. Despite these tremendous advances, autologous hematopoietic stem/progenitor cell therapy based on ex vivo gene addition exploiting integrating γ-retro- or lenti-viral vectors, has demonstrated to be an innovative and safe therapeutic strategy providing proof of correction without the complications of the allogeneic approach. The recent advent of targeted gene editing able to precisely correct genomic variants in an intended locus of the genome, by introducing deletions, insertions, nucleotide substitutions or introducing a corrective cassette, is emerging in the clinical setting, further extending the therapeutic armamentarium and offering a cure to inherited immune defects not approachable by conventional gene addition. In this review, we will analyze the current state-of-the art of conventional gene therapy and innovative protocols of genome editing in various primary immunodeficiencies, describing preclinical models and clinical data obtained from different trials, highlighting potential advantages and limits of gene correction.
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Affiliation(s)
- Maria Carmina Castiello
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy; Istituto di Ricerca Genetica e Biomedica, Consiglio Nazionale delle Ricerche (IRGB-CNR), Milan, Italy
| | - Samuele Ferrari
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy; Vita-Salute San Raffaele University, Milan 20132, Italy
| | - Anna Villa
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy; Istituto di Ricerca Genetica e Biomedica, Consiglio Nazionale delle Ricerche (IRGB-CNR), Milan, Italy.
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Liu S, Yao X, Xia K, Zhang J, Liu Y, Xia X, Li G. Frontier and hotspot evolution in Wiskott-Aldrich syndrome: A bibliometric analysis from 2001 to 2021. Medicine (Baltimore) 2022; 101:e32347. [PMID: 36550896 PMCID: PMC9771241 DOI: 10.1097/md.0000000000032347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Wiskott-Aldrich syndrome (WAS) is a rare X-linked primary immunodeficiency disorder. Despite our enormous progress in the strategies used to diagnose, treat, and cure WAS, no bibliometric studies have been performed in this research field. This study explored the trends in WAS research through a bibliometric analysis evaluating relevant literature quantitatively and qualitatively. METHODS The literature concerning WAS from 2001 to 2021 was retrieved from the Science Citation Index Expanded (SCI-expanded) of the Web of Science Core Collection database. Acquired data were then visually analyzed using CiteSpace and VOSviewer. RESULTS 2036 papers were included in the final analysis. The annual publication outputs reached its peak in 2013 but declined in recent years. The dominant position of the United States in WAS research was quite obvious. Harvard University (USA), University College London (UK), and Inserm (France) were the three most prolific institutions. Adrian J. Thrasher exerted significant publication impact and made the most notable contributions in the field of WAS. Blood was the most influential journal with the highest publication outputs, and nearly all the top 10 journals and co-cited journals belonged to Q1. Immune dysregulation, thrombocytopenia, syndrome protein deficiency, stem cell, mutation, and diagnosis were the keywords with the strongest citation burst. CONCLUSION From 2001 to 2021, the United States was a global leader in the WAS research. Collaboration between countries and institutions is expected to deepen and strengthen in the future. Research hotspots included pathogenesis, clinical manifestations, diagnosis, and therapy. Our results suggest a greater understanding of the mechanistic underpinnings of immune dysfunction in WAS patients, the application of targeted therapies for individual complications, and the development of curative approaches, which will remain research hotspots in the future.
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Affiliation(s)
- Shixu Liu
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaoyan Yao
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Kun Xia
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jinzhi Zhang
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yanyi Liu
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School of Beijing University of Chinese Medicine, Beijing, China
| | - Xiao Xia
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Guangxi Li
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- * Correspondence: Guangxi Li, Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China (e-mail: )
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Pan C, Zhao A, Li M. Atopic Dermatitis-like Genodermatosis: Disease Diagnosis and Management. Diagnostics (Basel) 2022; 12:diagnostics12092177. [PMID: 36140582 PMCID: PMC9498295 DOI: 10.3390/diagnostics12092177] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/23/2022] [Accepted: 08/15/2022] [Indexed: 11/29/2022] Open
Abstract
Eczema is a classical characteristic not only in atopic dermatitis but also in various genodermatosis. Patients suffering from primary immunodeficiency diseases such as hyper-immunoglobulin E syndromes, Wiskott-Aldrich syndrome, immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome, STAT5B deficiency, Omenn syndrome, atypical complete DiGeorge syndrome; metabolic disorders such as acrodermatitis enteropathy, multiple carboxylase deficiency, prolidase deficiency; and other rare syndromes like severe dermatitis, multiple allergies and metabolic wasting syndrome, Netherton syndrome, and peeling skin syndrome frequently perform with eczema-like lesions. These genodermatosis may be misguided in the context of eczematous phenotype. Misdiagnosis of severe disorders unavoidably affects appropriate treatment and leads to irreversible outcomes for patients, which underlines the importance of molecular diagnosis and genetic analysis. Here we conclude clinical manifestations, molecular mechanism, diagnosis and management of several eczema-related genodermatosis and provide accessible advice to physicians.
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Affiliation(s)
- Chaolan Pan
- Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Anqi Zhao
- Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Ming Li
- Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
- Department of Dermatology, The Children’s Hospital of Fudan University, Shanghai 200092, China
- Correspondence: ; Tel.: +86-2125078571
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Naseem A, Steinberg Z, Cavazza A. Genome editing for primary immunodeficiencies: A therapeutic perspective on Wiskott-Aldrich syndrome. Front Immunol 2022; 13:966084. [PMID: 36059471 PMCID: PMC9433875 DOI: 10.3389/fimmu.2022.966084] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022] Open
Abstract
Primary immunodeficiency diseases (PIDs) are a group of rare inherited disorders affecting the immune system that can be conventionally treated with allogeneic hematopoietic stem cell transplantation and with experimental autologous gene therapy. With both approaches still facing important challenges, gene editing has recently emerged as a potential valuable alternative for the treatment of genetic disorders and within a relatively short period from its initial development, has already entered some landmark clinical trials aimed at tackling several life-threatening diseases. In this review, we discuss the progress made towards the development of gene editing-based therapeutic strategies for PIDs with a special focus on Wiskott - Aldrich syndrome and outline their main challenges as well as future directions with respect to already established treatments.
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Cavannaugh C, Ochs HD, Buchbinder D. Diagnosis and clinical management of Wiskott-Aldrich syndrome: current and emerging techniques. Expert Rev Clin Immunol 2022; 18:609-623. [PMID: 35533396 DOI: 10.1080/1744666x.2022.2074400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Wiskott-Aldrich syndrome (WAS) serves as the prototype of how variants in a gene which encodes a protein central to actin cytoskeletal homeostasis can manifest clinically in a variety of ways including infection, atopy, autoimmunity, inflammation, bleeding, neutropenia, non-malignant lymphoproliferation, and malignancy. Despite the discovery of the WAS gene almost 30 years ago, our understanding of the pathophysiological mechanisms underlying WAS continues to unfold. AREAS COVERED This review will provide an overview of the approach to the diagnosis of WAS as well as the management of its associated complications. Advances in the use of allogeneic hematopoietic stem cell transplantation (HSCT) and gene therapy as well as the associated challenges unique to WAS will be discussed. EXPERT OPINION Basic research, combined with clinical research focusing on longitudinal analysis of WAS patients, will help clarify determinants that influence WAS pathogenesis as well as clinical complications and outcomes. Advances in curative approaches including the use of alternative donor HSCT for WAS continue to evolve. Gene therapy employing safer and more effective protocols ensuring full correction of WAS will provide life-saving benefit to WAS patients that are unable to undergo HSCT.
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Affiliation(s)
- Corey Cavannaugh
- Department of Pediatrics University of California at Irvine 333 The City Blvd. West Suite 800 Orange, CA 92868
| | - Hans D Ochs
- Department of Pediatrics University of Washington and Seattle Children's Research Institute Seattle, WA 98105
| | - David Buchbinder
- Division of Hematology Children's Hospital of Orange County 1201 La Veta Avenue Orange, CA 92868
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Durkee-Shock J, Zhang A, Liang H, Wright H, Magnusson J, Garabedian E, Marsh RA, Sullivan KE, Keller MD. Morbidity, Mortality, and Therapeutics in Combined Immunodeficiency: Data From the USIDNET Registry. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1334-1341.e6. [PMID: 35172220 DOI: 10.1016/j.jaip.2022.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/05/2022] [Accepted: 01/13/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Optimal management of patients with combined immunodeficiency, especially pertaining to hematopoietic stem cell transplantation (HSCT), remains unclear. OBJECTIVE To identify factors influencing HSCT and mortality in the population with combined immunodeficiency in North America. METHODS We identified 337 participants in the United States Immunodeficiency Network database with diverse forms of combined immunodeficiency and their characteristics, including demographic characteristics, laboratory values, infectious history, comorbidities, and treatment strategies. Univariate analysis was performed using logistic regression, whereas multivariate analysis was performed using multiple Cox proportional hazards. RESULTS On univariate analysis, disseminated invasive viral infections and variants in STAT3, GATA2, and, DOCK8 were associated with increased odds of HSCT. Mucocutaneous fungal infections and variants in STAT3 were associated with increased odds of survival, whereas disseminated/invasive fungal infections, disseminated/invasive viral infections, and parasitic infections were associated with decreased odds of survival. On multiple variable Cox proportional hazards analysis, variants in ZAP70, nonspecific bacterial, and disseminated/invasive viral infections were associated with increased hazards of transplantation, whereas variants in multiple genes (RMRP, NEMO, DOCK8, CD40L, and CARD9), disseminated/invasive viral infections, autoimmune disease, and higher absolute lymphocyte count were associated with increased hazards of death. Importantly, demographic characteristics, basic lymphocyte subset counts, and absence of genetic diagnosis were not associated with HSCT or mortality. CONCLUSIONS We determined that specific genetic diagnoses and infection burden impacts the decision to undergo HSCT in this cohort. In addition, certain genetic diagnoses and invasive viral infections carry an increased risk of mortality.
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Affiliation(s)
- Jessica Durkee-Shock
- National Institute of Allergy and Infectious Diseases, Bethesda, Md; Children's National Medical Center, Washington, DC
| | - Anqing Zhang
- George Washington University Department of Biostatistics, Washington, DC
| | - Hua Liang
- George Washington University Department of Biostatistics, Washington, DC
| | | | | | | | - Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kathleen E Sullivan
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Michael D Keller
- Division of Allergy and Immunology, Children's National Hospital, Washington, DC; Department of Pediatrics, George Washington University, Washington, DC.
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Successful Allogeneic Peripheral Blood Stem Cell Transplantation in 4 Wiskott-Aldrich Syndrome Patients. J Pediatr Hematol Oncol 2022; 44:e324-e328. [PMID: 33828030 DOI: 10.1097/mph.0000000000002154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/24/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation is a potential curative treatment in Wiskott-Aldrich syndrome (WAS). Here, we analyzed the outcomes in 4 WAS patients who underwent this procedure with peripheral blood stem cell (PBSC) in our center. PATIENTS AND METHODS Four patients with severe WAS phenotype have received allogeneic hematopoietic stem cell transplantation between January 2014 and December 2019 from matched sibling donors with PBSC. Two different preparative conditioning regimens were provided: the first associated busulfan-cyclophosphamide (2 patients) and the second with busulfan-fludarabine administered to the others. Cyclosporine gave as preferred graft-versus-host disease prophylaxis with a short course of methotrexate. RESULTS All patients achieved engraftment after PBSC with a median CD34+ cell count: 13.6×106/kg (8 to 24.9×106/kg). Chronic graft-versus-host disease developed in 2 patients treated by cyclosporine-steroids with complete resolution. Chimerism for all the patients was fully donor (>95% donor). After a median follow-up of 41 months (8 to 74 mo), all patients (100%) are alive, healthy, with complete clinical, immunologic, and hematologic recovery, without signs of WAS. CONCLUSION This limited study with high-dose PBSC transplantation approach for WAS, demonstrated a safe and effective treatment option, with rapid engraftment, without complications, excellent long-term outcomes, independent of conditioning regimen.
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Hematopoietic stem cell transplantation for Wiskott-Aldrich syndrome: an EBMT inborn errors working party analysis. Blood 2022; 139:2066-2079. [PMID: 35100336 DOI: 10.1182/blood.2021014687] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/17/2022] [Indexed: 11/20/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is a potentially curative treatment for patients affected by Wiskott-Aldrich syndrome (WAS). Reported HSCT outcomes have improved over time with respect to overall survival, but some studies have identified older age and HSCT from alternative donors as risk factors predicting poorer outcome. We analyzed 197 patients transplanted at EBMT centers between 2006 and 2017, who received conditioning as recommended by the inborn errors working party (IEWP): either busulfan (n=103) or treosulfan (n=94) combined with fludarabine ± thiotepa. After a median follow-up after HSCT of 44.9 months, 176 patients were alive, resulting in a 3-year overall survival of 88.7%, and chronic GVHD-free survival (CRFS; events: death, graft failure, severe chronic GVHD) of 81.7%. Overall survival and CRFS were not significantly impacted by conditioning regimen (busulfan- versus treosulfan-based), donor type (MSD/MFD vs MUD/MMUD vs. MMFD), and period of HSCT (2006-2013 vs. 2014-2017). Patients younger than 5 years at HSCT had a significantly better overall survival. The overall cumulative incidences of grade III-IV acute GVHD and extensive/moderate/severe chronic GVHD were 6.6% and 2.1%, respectively. Patients receiving treosulfan-based conditioning had a higher incidence of graft failure, mixed donor chimerism and more frequently received secondary procedures (2nd HSCT, unconditioned stem cell boost, donor lymphocyte infusion, or splenectomy). In summary, HSCT for WAS with conditioning regimens currently recommended by IEWP results in excellent survival and low rates of GVHD, regardless of donor or stem cell source, but age ≥5 years remains a risk factor for overall survival.
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Long-term safety and efficacy of lentiviral hematopoietic stem/progenitor cell gene therapy for Wiskott-Aldrich syndrome. Nat Med 2022; 28:71-80. [PMID: 35075289 PMCID: PMC8799465 DOI: 10.1038/s41591-021-01641-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 11/24/2021] [Indexed: 12/14/2022]
Abstract
Patients with Wiskott–Aldrich syndrome (WAS) lacking a human leukocyte antigen-matched donor may benefit from gene therapy through the provision of gene-corrected, autologous hematopoietic stem/progenitor cells. Here, we present comprehensive, long-term follow-up results (median follow-up, 7.6 years) (phase I/II trial no. NCT02333760) for eight patients with WAS having undergone phase I/II lentiviral vector-based gene therapy trials (nos. NCT01347346 and NCT01347242), with a focus on thrombocytopenia and autoimmunity. Primary outcomes of the long-term study were to establish clinical and biological safety, efficacy and tolerability by evaluating the incidence and type of serious adverse events and clinical status and biological parameters including lentiviral genomic integration sites in different cell subpopulations from 3 years to 15 years after gene therapy. Secondary outcomes included monitoring the need for additional treatment and T cell repertoire diversity. An interim analysis shows that the study meets the primary outcome criteria tested given that the gene-corrected cells engrafted stably, and no serious treatment-associated adverse events occurred. Overall, severe infections and eczema resolved. Autoimmune disorders and bleeding episodes were significantly less frequent, despite only partial correction of the platelet compartment. The results suggest that lentiviral gene therapy provides sustained clinical benefits for patients with WAS. Long-term monitoring of patients with Wiskott–Aldrich syndrome following lentiviral gene therapy shows a safe profile and a reduction in the frequency of autoimmune manifestations and bleeding events, despite incomplete platelet reconstitution.
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Hosahalli Vasanna S, Pereda MA, Dalal J. Clinical Features, Cancer Biology, Transplant Approach and Other Integrated Management Strategies for Wiskott-Aldrich Syndrome. J Multidiscip Healthc 2022; 14:3497-3512. [PMID: 34992377 PMCID: PMC8711845 DOI: 10.2147/jmdh.s295386] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/24/2021] [Indexed: 11/23/2022] Open
Abstract
Wiskott–Aldrich syndrome (WAS) is a rare X-linked recessive inborn error of immunity (IEI) first described in 1937. Classic WAS is characterized by the triad of thrombocytopenia with small platelets, recurrent infections due to combined immunodeficiency, and eczema. Hematopoietic stem cell transplantation (HSCT) was the only curative option available for five decades, with excellent outcomes reported for matched sibling donors (MSD) and matched unrelated donors (MUD). More recently, alternative donor transplants such as umbilical cord blood (UCB) and haploidentical transplant have emerged as viable options due to improvements in better graft selection, cell dosing, and effective allograft manipulation measures. Gene therapy is another potential curative option with promising results, yet currently is offered only as part of a clinical trial.
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Affiliation(s)
- Smitha Hosahalli Vasanna
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Rainbow Babies and Children's Hospital, University Hospitals, Cleveland, OH, USA
| | - Maria A Pereda
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Rainbow Babies and Children's Hospital, University Hospitals, Cleveland, OH, USA
| | - Jignesh Dalal
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Rainbow Babies and Children's Hospital, University Hospitals, Cleveland, OH, USA
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Sudhakar M, Rikhi R, Loganathan SK, Suri D, Singh S. Autoimmunity in Wiskott-Aldrich Syndrome: Updated Perspectives. APPLICATION OF CLINICAL GENETICS 2021; 14:363-388. [PMID: 34447261 PMCID: PMC8384432 DOI: 10.2147/tacg.s213920] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/18/2021] [Indexed: 11/23/2022]
Abstract
Wiskott–Aldrich syndrome (WAS) is an uncommon X-linked combined-immunodeficiency disorder characterized by a triad of thrombocytopenia, eczema, and immunodeficiency. Patients with WAS are also predisposed to autoimmunity and malignancy. Autoimmune manifestations have been reported in 26%–72% of patients with WAS. Autoimmunity is an independent predictor of poor prognosis and predisposes to malignancy. Development of autoimmunity is also an early pointer of the need for hematopoietic stem–cell transplantation. In this manuscript, we have collated the published data and present a narrative review on autoimmune manifestations in WAS. A summary of currently proposed immunopathogenic mechanisms and genetic variants associated with development of autoimmunity in WAS is also included.
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Affiliation(s)
- Murugan Sudhakar
- Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rashmi Rikhi
- Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sathish Kumar Loganathan
- Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepti Suri
- Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Mallhi KK, Petrovic A, Ochs HD. Hematopoietic Stem Cell Therapy for Wiskott-Aldrich Syndrome: Improved Outcome and Quality of Life. J Blood Med 2021; 12:435-447. [PMID: 34149291 PMCID: PMC8206065 DOI: 10.2147/jbm.s232650] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/13/2021] [Indexed: 12/21/2022] Open
Abstract
The Wiskott-Aldrich syndrome (WAS) is an X-linked disorder caused by mutations in the WAS gene resulting in congenital thrombocytopenia, eczema, recurrent infections and an increased incidence of autoimmune diseases and malignancies. Without curative therapies, affected patients have diminished life expectancy and reduced quality of life. Since WAS protein (WASP) is constitutively expressed only in hematopoietic stem cell-derived lineages, hematopoietic stem cell transplantation (HSCT) and gene therapy (GT) are well suited to correct the hematologic and immunologic defects. Advances in high-resolution HLA typing, new techniques to prevent GvHD allowing the use of haploidentical donors, and the introduction of reduced intensity conditioning regimens with myeloablative features have increased overall survival (OS) to over 90%. The development of GT for WAS has provided basic knowledge into vector selection and random integration of various viral vectors into the genome, with the possibility of inducing leukemogenesis. After trials and errors, inactivating lentiviral vectors carrying the WAS gene were successfully evaluated in clinical trials, demonstrating cure of the disease except for insufficient resolution of the platelet defect. Thus, 50 years of clinical evaluation, genetic exploration and extensive clinical trials, a lethal syndrome has turned into a curable disorder.
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Affiliation(s)
- Kanwaldeep K Mallhi
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Division of Hematology and Oncology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Aleksandra Petrovic
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Division of Immunology and Division of Hematology and Oncology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Hans D Ochs
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Seattle Children’s Research Institute, Seattle, WA, USA
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15
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Bildik HN, Cagdas D, Ozturk Kura A, Oskay Halacli S, Sanal O, Tezcan I. Clinical, Laboratory Features and Clinical Courses of Patients with Wiskott Aldrich Syndrome and X-linked Thrombocytopenia-A single center study. Immunol Invest 2021; 51:1272-1283. [PMID: 34098853 DOI: 10.1080/08820139.2021.1933516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: Wiskott Aldrich Syndrome is an X-linked primary immunodeficiency disorder characterized by microthrombocytopenia, severe immunodeficiency, and eczema. To define clinical-laboratory features, genetic defects (known/novel) of 23 patients of Wiskott Aldrich Syndrome/X-linked Thrombocytopenia (WAS/XLT) cohort, establish relationships between molecular defects and clinical features if present, evaluate patients who underwent hematopoietic stem cell transplantation (HSCT) and did not.Methods: Qualitative analysis from patients' hospital files and Sanger sequencing for molecular diagnosis was performed. Twenty-two WAS patients and one XLT patient were included in the study.Results: The median age of diagnosis was 15 months (2.5-172 months). The most common symptom was otitis media and all patients had microthrombocytopenia. Autoimmune findings were detected in 34.7% (8 patients) of the patients; three patients (13%) had positive anti-nuclear antibody (ANA), three patients (13%) hemolytic anemia, one patient autoimmune neutropenia, two patients vasculitis, and one patient demyelinating polyneuropathy. Nine of the 23 (39,1%) patients had HSCT with nearly 90% success. We identified 13 different mutations in our cohort; seven were novel.Conclusions: HSCT is the only curative treatment for WAS. The study confirms that early diagnosis is very important for the success of therapy, so we must increase awareness in society and physicians to keep an eye out for clues. Our study cohort and follow-up period are not sufficient to establish phenotype-genotype correlation, so a larger cohort from various centers with longer follow-up will be more decisive.
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Affiliation(s)
- Hacer Neslihan Bildik
- Institute of Child Health, Division of Immunology, Hacettepe University Medical School, Ankara, Turkey.,Child Health and Diseases Department, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey
| | - Deniz Cagdas
- Institute of Child Health, Division of Immunology, Hacettepe University Medical School, Ankara, Turkey.,Child Health and Diseases Department, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey
| | - Aysenur Ozturk Kura
- Child Health and Diseases Department, Division of Genetic, Ankara University Medical School, Ankara, Turkey
| | - Sevil Oskay Halacli
- Institute of Child Health, Division of Immunology, Hacettepe University Medical School, Ankara, Turkey
| | - Ozden Sanal
- Institute of Child Health, Division of Immunology, Hacettepe University Medical School, Ankara, Turkey.,Child Health and Diseases Department, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey
| | - Ilhan Tezcan
- Institute of Child Health, Division of Immunology, Hacettepe University Medical School, Ankara, Turkey.,Child Health and Diseases Department, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey
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16
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Sipe CJ, Claudio Vázquez PN, Skeate JG, McIvor RS, Moriarity BS. Targeted genome editing for the correction or alleviation of primary Immunodeficiencies. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2021; 182:111-151. [PMID: 34175040 DOI: 10.1016/bs.pmbts.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Primary immunodeficiencies (PID) are a growing list of unique disorders that result in a failure of the innate/adaptive immune systems to fully respond to disease or infection. PIDs are classified into five broad categories; B cell disorders, combined B and T cell disorders, phagocytic disorders, complement disorders, and disorders with recurrent fevers and inflammation. Many of these disorders, such as X-SCID, WAS, and CGD lead to early death in children if intervention is not implemented. At present, the predominant method of curative therapy remains an allogeneic transplant from a healthy donor, however many complications and limitations exist with his therapy such as availability of donors, graft vs host disease, graft rejection, and infection. More recently, gene therapy using viral based complementation vectors have successfully been implemented to functionally correct patient cells in an autologous transplant, but these methods carry significant risks, including insertional mutagenesis, and provide non-physiological gene expression. For these reasons, gene-editing reagents such as targeted nucleases, base editors (BE), and prime editors (PE) are being explored. The BE and PE tools, sometimes referred to as digital editors, are of very high interest as they provide both enhanced molecular specificity and do not rely on DNA repair pathways after DSBs to change individual base pairs or directly replace DNA sequences responsible for pathogenic phenotypes. With this in mind the purpose of this chapter is to highlight some of the most common PIDs found within the human population, discuss successes and shortcomings of previous intervention strategies, and highlight how the next generation of gene-editing tools may be deployed to directly repair the underlying genetic causes of this class of disease.
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Affiliation(s)
- Christopher J Sipe
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States; Center for Genome Engineering, University of Minnesota, Minneapolis, MN, United States; Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States; Department of Genetics, Cell Biology and Development, University of Minnesota, Minneapolis, MN, United States
| | - Patricia N Claudio Vázquez
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States; Center for Genome Engineering, University of Minnesota, Minneapolis, MN, United States; Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States; Department of Genetics, Cell Biology and Development, University of Minnesota, Minneapolis, MN, United States
| | - Joseph G Skeate
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States; Center for Genome Engineering, University of Minnesota, Minneapolis, MN, United States; Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States
| | - R Scott McIvor
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States; Center for Genome Engineering, University of Minnesota, Minneapolis, MN, United States; Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States; Department of Genetics, Cell Biology and Development, University of Minnesota, Minneapolis, MN, United States
| | - Branden S Moriarity
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States; Center for Genome Engineering, University of Minnesota, Minneapolis, MN, United States; Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States; Department of Genetics, Cell Biology and Development, University of Minnesota, Minneapolis, MN, United States.
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17
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Inborn errors of immunity with atopic phenotypes: A practical guide for allergists. World Allergy Organ J 2021; 14:100513. [PMID: 33717395 PMCID: PMC7907539 DOI: 10.1016/j.waojou.2021.100513] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/22/2020] [Accepted: 01/11/2021] [Indexed: 12/19/2022] Open
Abstract
Inborn errors of immunity (IEI) are a heterogeneous group of disorders, mainly resulting from mutations in genes associated with immunoregulation and immune host defense. These disorders are characterized by different combinations of recurrent infections, autoimmunity, inflammatory manifestations, lymphoproliferation, and malignancy. Interestingly, it has been increasingly observed that common allergic symptoms also can represent the expression of an underlying immunodeficiency and/or immune dysregulation. Very high IgE levels, peripheral or organ-specific hypereosinophilia, usually combined with a variety of atopic symptoms, may sometimes be the epiphenomenon of a monogenic disease. Therefore, allergists should be aware that severe and/or therapy-resistant atopic disorders might be the main clinical phenotype of some IEI. This could pave the way to target therapies, leading to better quality of life and improved survival in affected patients.
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18
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Rivers E, Hong Y, Bajaj-Elliott M, Worth A, Thrasher AJ. IL-18: A potential inflammation biomarker in Wiskott-Aldrich syndrome. Eur J Immunol 2021; 51:1285-1288. [PMID: 33448368 PMCID: PMC8436742 DOI: 10.1002/eji.202049024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/08/2020] [Accepted: 12/23/2020] [Indexed: 12/05/2022]
Affiliation(s)
| | - Ying Hong
- UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Austen Worth
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Adrian J Thrasher
- UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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19
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Downes K, Borry P, Ericson K, Gomez K, Greinacher A, Lambert M, Leinoe E, Noris P, Van Geet C, Freson K. Clinical management, ethics and informed consent related to multi-gene panel-based high throughput sequencing testing for platelet disorders: Communication from the SSC of the ISTH. J Thromb Haemost 2020; 18:2751-2758. [PMID: 33079472 PMCID: PMC7589386 DOI: 10.1111/jth.14993] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 12/22/2022]
Abstract
Molecular diagnostics of inherited platelet disorders (IPD) has been revolutionized by the implementation of high-throughput sequencing (HTS) approaches. A conclusive diagnosis using HTS tests can be obtained quickly and cost-effectively in many, but not all patients. The expanding use of HTS tests has raised concerns regarding complex variant interpretation and the ethical implications of detecting unsolicited findings such as variants in IPD genes RUNX1, ETV6, and ANKRD26, which are associated with increased leukemic risk. This guidance document has been developed and written by a multidisciplinary team of researchers and clinicians, with expertise in hematology, clinical and molecular genetics, and bioethics, alongside a RUNX1 patient advocacy representative. We recommend that for clinical diagnostics, HTS for IPD should use a multigene panel of curated diagnostic-grade genes. Critically, we advise that an HTS test for clinical diagnostics should only be ordered by a clinical expert that is: (a) fully aware of the complexity of genotype-phenotype correlations for IPD; (b) able to discuss these complexities with a patient and family members before the test is initiated; and (c) able to interpret and appropriately communicate the results of a HTS diagnostic report, including the implication of variants of uncertain clinical significance. Each patient should know what an HTS test could mean for his or her clinical management before initiating a test. We hereby propose an exemplified informed consent document that includes information on these ethical concerns and can be used by the community for implementation of HTS of IPD in a clinical diagnostic setting. This paper does not include recommendations for HTS of IPD in a research setting.
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Affiliation(s)
- Kate Downes
- East Genomic Laboratory HubCambridge University Hospitals NHS Foundation TrustCambridgeUK
- Department of HaematologyUniversity of CambridgeCambridge Biomedical CampusCambridgeUK
| | - Pascal Borry
- Department of Public Health and Primary CareKU LeuvenLeuvenBelgium
| | | | - Keith Gomez
- Haemophilia Centre and Thrombosis UnitRoyal Free London NHS Foundation TrustLondonUK
| | - Andreas Greinacher
- Institut für Immunologie und TransfusionsmedizinUniversitätsmedizin GreifswaldGreifswaldGermany
| | - Michele Lambert
- Division of HematologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of PediatricsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPAUSA
| | - Eva Leinoe
- Department of HaematologyRigshospitaletNational University HospitalCopenhagenDenmark
| | - Patrizia Noris
- IRCCS Policlinico San Matteo Foundation and University of PaviaPaviaItaly
| | - Chris Van Geet
- Department of Cardiovascular SciencesCenter or Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
| | - Kathleen Freson
- Department of Cardiovascular SciencesCenter or Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
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20
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Muñoz P, Tristán-Manzano M, Sánchez-Gilabert A, Santilli G, Galy A, Thrasher AJ, Martin F. WAS Promoter-Driven Lentiviral Vectors Mimic Closely the Lopsided WASP Expression during Megakaryocytic Differentiation. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2020; 19:220-235. [PMID: 33102615 PMCID: PMC7558809 DOI: 10.1016/j.omtm.2020.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/11/2020] [Indexed: 01/10/2023]
Abstract
Transplant of gene-modified autologous hematopoietic progenitors cells has emerged as a new therapeutic approach for Wiskott-Aldrich syndrome (WAS), a primary immunodeficiency with microthrombocytopenia and abnormal lymphoid and myeloid functions. Despite the clinical benefits obtained in ongoing clinical trials, platelet restoration is suboptimal. The incomplete restoration of platelets in these patients can be explained either by a low number of corrected cells or by insufficient or inadequate WASP expression during megakaryocyte differentiation and/or in platelets. We therefore used in vitro models to study the endogenous WASP expression pattern during megakaryocytic differentiation and compared it with the expression profiles achieved by different therapeutic lentiviral vectors (LVs) driving WAS cDNA through different regions of the WAS promoter. Our data showed that all WAS promoter-driven LVs mimic very closely the endogenous WAS expression kinetic during megakaryocytic differentiation. However, LVs harboring the full-length (1.6-kb) WAS-proximal promoter (WW1.6) or a combination of the WAS alternative and proximal promoters (named AW) had the best behavior. Finally, all WAS-driven LVs restored the WAS knockout (WASKO) mice phenotype and functional defects of hematopoietic stem and progenitor cells (HSPCs) from a WAS patient with similar efficiency. In summary, our data back up the use of WW1.6 and AW LVs as physiological gene transfer tools for WAS therapy.
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Affiliation(s)
- Pilar Muñoz
- Genomic Medicine Department, GENYO, Centre for Genomics and Oncological Research, Pfizer-University of Granada-Andalusian Regional Government, Parque Tecnológico Ciencias de la Salud (PTS), Avenida de la Ilustracion 114, 18016 Granada, Spain.,University College London (UCL) Great Ormond Street Institute of Child Health (ICH), 30 Guilford Street, WC1N 1EH London, UK
| | - María Tristán-Manzano
- Genomic Medicine Department, GENYO, Centre for Genomics and Oncological Research, Pfizer-University of Granada-Andalusian Regional Government, Parque Tecnológico Ciencias de la Salud (PTS), Avenida de la Ilustracion 114, 18016 Granada, Spain
| | - Almudena Sánchez-Gilabert
- Genomic Medicine Department, GENYO, Centre for Genomics and Oncological Research, Pfizer-University of Granada-Andalusian Regional Government, Parque Tecnológico Ciencias de la Salud (PTS), Avenida de la Ilustracion 114, 18016 Granada, Spain
| | - Giorgia Santilli
- University College London (UCL) Great Ormond Street Institute of Child Health (ICH), 30 Guilford Street, WC1N 1EH London, UK
| | - Anne Galy
- Genethon, 91000 Evry, France.,Université Paris-Saclay, Univ Evry, Inserm, Genethon, Integrare research unit UMR_S951, 91000 Evry, France
| | - Adrian J Thrasher
- University College London (UCL) Great Ormond Street Institute of Child Health (ICH), 30 Guilford Street, WC1N 1EH London, UK
| | - Francisco Martin
- Genomic Medicine Department, GENYO, Centre for Genomics and Oncological Research, Pfizer-University of Granada-Andalusian Regional Government, Parque Tecnológico Ciencias de la Salud (PTS), Avenida de la Ilustracion 114, 18016 Granada, Spain
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21
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Haskoloğlu Ş, Öztürk A, Öztürk G, Kostel Bal S, İslamoğlu C, Baskın K, Ceylaner S, Tufan Satıroğlu L, Doğu F, İkincioğulları A. Clinical Features and Outcomes of 23 Patients with Wiskott-Aldrich Syndrome: A Single-Center Experience. Turk J Haematol 2020; 37:271-281. [PMID: 32812413 PMCID: PMC7702658 DOI: 10.4274/tjh.galenos.2020.2020.0334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objective Wiskott-Aldrich syndrome (WAS) is an X-linked primary immune deficiency characterized by microthrombocytopenia, eczema, and recurrent infections. We aimed to evaluate the clinical features and outcomes of a WAS cohort. Materials and Methods We retrospectively evaluated the clinical courses, immunological features, treatments, and outcomes in a total of 23 WAS patients together with data related to 11 transplanted cases among them between 1982 and 2019. Results Before admission, 11 patients (48%) were misdiagnosed with immune thrombocytopenia. WAS scores were mostly 4 or 5. Eleven patients were transplanted and they had an overall survival rate of 100% during a median follow-up period of 8.5 years (range: 8 months to 20 years). Five patients who were not transplanted died at a median of 7 years (range: 2-26 years). Nontransplanted patients had high morbidity due to organ damage, mostly caused by autoimmunity, bleeding, and infections. Two novel mutations were also defined. Conclusion All male babies with microthrombocytopenia should be evaluated for WAS. Hematopoietic stem cell transplantation should be performed at the earliest age with the best possible donors.
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Affiliation(s)
- Şule Haskoloğlu
- Ankara University School of Medicine, Department of Pediatrics, Division of Immunology and Allergy, Ankara, Turkey
| | - Ayşenur Öztürk
- Ankara University School of Medicine, Department of Pediatrics, Division of Genetic Diseases, Ankara, Turkey
| | - Gökcan Öztürk
- Ankara University School of Medicine, Department of Pediatrics, Ankara, Turkey
| | - Sevgi Kostel Bal
- Ankara University School of Medicine, Department of Pediatrics, Division of Immunology and Allergy, Ankara, Turkey
| | - Candan İslamoğlu
- Ankara University School of Medicine, Department of Pediatrics, Division of Immunology and Allergy, Ankara, Turkey
| | - Kübra Baskın
- Ankara University School of Medicine, Department of Pediatrics, Division of Immunology and Allergy, Ankara, Turkey
| | | | - Lale Tufan Satıroğlu
- Ankara University School of Medicine, Department of Pediatrics, Division of Genetic Diseases, Ankara, Turkey
| | - Figen Doğu
- Ankara University School of Medicine, Department of Pediatrics, Division of Immunology and Allergy, Ankara, Turkey
| | - Aydan İkincioğulları
- Ankara University School of Medicine, Department of Pediatrics, Division of Immunology and Allergy, Ankara, Turkey
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22
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Burroughs LM, Petrovic A, Brazauskas R, Liu X, Griffith LM, Ochs HD, Bleesing JJ, Edwards S, Dvorak CC, Chaudhury S, Prockop SE, Quinones R, Goldman FD, Quigg TC, Chandrakasan S, Smith AR, Parikh S, Dávila Saldaña BJ, Thakar MS, Phelan R, Shenoy S, Forbes LR, Martinez C, Chellapandian D, Shereck E, Miller HK, Kapoor N, Barnum JL, Chong H, Shyr DC, Chen K, Abu-Arja R, Shah AJ, Weinacht KG, Moore TB, Joshi A, DeSantes KB, Gillio AP, Cuvelier GDE, Keller MD, Rozmus J, Torgerson T, Pulsipher MA, Haddad E, Sullivan KE, Logan BR, Kohn DB, Puck JM, Notarangelo LD, Pai SY, Rawlings DJ, Cowan MJ. Excellent outcomes following hematopoietic cell transplantation for Wiskott-Aldrich syndrome: a PIDTC report. Blood 2020; 135:2094-2105. [PMID: 32268350 PMCID: PMC7273831 DOI: 10.1182/blood.2019002939] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 03/20/2020] [Indexed: 01/14/2023] Open
Abstract
Wiskott-Aldrich syndrome (WAS) is an X-linked disease caused by mutations in the WAS gene, leading to thrombocytopenia, eczema, recurrent infections, autoimmune disease, and malignancy. Hematopoietic cell transplantation (HCT) is the primary curative approach, with the goal of correcting the underlying immunodeficiency and thrombocytopenia. HCT outcomes have improved over time, particularly for patients with HLA-matched sibling and unrelated donors. We report the outcomes of 129 patients with WAS who underwent HCT at 29 Primary Immune Deficiency Treatment Consortium centers from 2005 through 2015. Median age at HCT was 1.2 years. Most patients (65%) received myeloablative busulfan-based conditioning. With a median follow-up of 4.5 years, the 5-year overall survival (OS) was 91%. Superior 5-year OS was observed in patients <5 vs ≥5 years of age at the time of HCT (94% vs 66%; overall P = .0008). OS was excellent regardless of donor type, even in cord blood recipients (90%). Conditioning intensity did not affect OS, but was associated with donor T-cell and myeloid engraftment after HCT. Specifically, patients who received fludarabine/melphalan-based reduced-intensity regimens were more likely to have donor myeloid chimerism <50% early after HCT. In addition, higher platelet counts were observed among recipients who achieved full (>95%) vs low-level (5%-49%) donor myeloid engraftment. In summary, HCT outcomes for WAS have improved since 2005, compared with prior reports. HCT at a younger age continues to be associated with superior outcomes supporting the recommendation for early HCT. High-level donor myeloid engraftment is important for platelet reconstitution after either myeloablative or busulfan-containing reduced intensity conditioning. (This trial was registered at www.clinicaltrials.gov as #NCT02064933.).
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Affiliation(s)
- Lauri M Burroughs
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Pediatrics, University of Washington-Seattle Children's Hospital, Seattle, WA
| | - Aleksandra Petrovic
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Pediatrics, University of Washington-Seattle Children's Hospital, Seattle, WA
| | - Ruta Brazauskas
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Xuerong Liu
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Linda M Griffith
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Hans D Ochs
- Department of Pediatrics, University of Washington-Seattle Children's Hospital, Seattle, WA
| | - Jack J Bleesing
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Stephanie Edwards
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Christopher C Dvorak
- Pediatric Allergy, Immunology, and Blood and Marrow Transplant Division, University of California, San Francisco Benioff Children's Hospital, San Francisco, CA
| | - Sonali Chaudhury
- Division of Hematology, Oncology, and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago-Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Susan E Prockop
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ralph Quinones
- Pediatric Bone Marrow Transplant (BMT) and Cellular Therapy Section, Department of Pediatrics, The University of Colorado School of Medicine, Aurora, CO
| | - Frederick D Goldman
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL
| | - Troy C Quigg
- Texas Transplant Institute, Methodist Children's Hospital, San Antonio, TX
| | | | - Angela R Smith
- Division of Pediatric Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN
| | | | - Blachy J Dávila Saldaña
- Division of Blood and Marrow Transplantation, Children's National Hospital-George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Monica S Thakar
- Center for Blood and Marrow Transplant Research-Division of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Medical College of Wisconsin, Milwaukee, WI
| | - Rachel Phelan
- Center for Blood and Marrow Transplant Research-Division of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Medical College of Wisconsin, Milwaukee, WI
| | - Shalini Shenoy
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Lisa R Forbes
- Department of Pediatrics, Baylor College of Medicine Section of Immunology, Allergy, and Retrovirology, Texas Children's Hospital, Baylor, TX
| | - Caridad Martinez
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital Cancer Center, Baylor, TX
| | - Deepak Chellapandian
- Blood and Marrow Transplant, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Evan Shereck
- Division of Pediatric Hematology/Oncology, Oregon Health and Science University, Portland, OR
| | | | - Neena Kapoor
- Transplantation and Cellular Therapy Program, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Hey Chong
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - David C Shyr
- Division of Pediatric Hematology/Oncology, Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, UT
| | - Karin Chen
- Division of Allergy and Immunology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Ami J Shah
- Division of Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford School of Medicine Pediatric Stem Cell Transplantation, Stanford University, Stanford, CA
| | - Katja G Weinacht
- Division of Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford School of Medicine Pediatric Stem Cell Transplantation, Stanford University, Stanford, CA
| | - Theodore B Moore
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - Avni Joshi
- Mayo Clinic Children's Center, Rochester, MN
| | - Kenneth B DeSantes
- American Family Children's Hospital, University of Wisconsin, Madison, WI
| | - Alfred P Gillio
- Institute for Pediatric Cancer and Blood Disorders, Hackensack University Medical Center, Hackensack, NJ
| | | | - Michael D Keller
- Division of Allergy & Immunology, Children's National Hospital, Washington, DC
- GW Cancer Center, George Washington University, Washington, DC
| | - Jacob Rozmus
- Children's & Women's Health Centre of British Columbia, Vancouver, BC, Canada
| | - Troy Torgerson
- Department of Pediatrics, University of Washington-Seattle Children's Hospital, Seattle, WA
| | - Michael A Pulsipher
- Transplantation and Cellular Therapy Program, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Elie Haddad
- Pediatric Immunology and Rheumatology Division, CHU Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, QC, Canada
| | - Kathleen E Sullivan
- Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Brent R Logan
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Donald B Kohn
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - Jennifer M Puck
- Pediatric Allergy, Immunology, and Blood and Marrow Transplant Division, University of California, San Francisco Benioff Children's Hospital, San Francisco, CA
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Sung-Yun Pai
- Division of Hematology-Oncology, Boston Children's Hospital, Boston, MA; and
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - David J Rawlings
- Department of Pediatrics, University of Washington-Seattle Children's Hospital, Seattle, WA
| | - Morton J Cowan
- Pediatric Allergy, Immunology, and Blood and Marrow Transplant Division, University of California, San Francisco Benioff Children's Hospital, San Francisco, CA
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Zaninetti C, Greinacher A. Diagnosis of Inherited Platelet Disorders on a Blood Smear. J Clin Med 2020; 9:jcm9020539. [PMID: 32079152 PMCID: PMC7074415 DOI: 10.3390/jcm9020539] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 02/08/2020] [Accepted: 02/12/2020] [Indexed: 12/12/2022] Open
Abstract
Inherited platelet disorders (IPDs) are rare diseases featured by low platelet count and defective platelet function. Patients have variable bleeding diathesis and sometimes additional features that can be congenital or acquired. Identification of an IPD is desirable to avoid misdiagnosis of immune thrombocytopenia and the use of improper treatments. Diagnostic tools include platelet function studies and genetic testing. The latter can be challenging as the correlation of its outcomes with phenotype is not easy. The immune-morphological evaluation of blood smears (by light- and immunofluorescence microscopy) represents a reliable method to phenotype subjects with suspected IPD. It is relatively cheap, not excessively time-consuming and applicable to shipped samples. In some forms, it can provide a diagnosis by itself, as for MYH9-RD, or in addition to other first-line tests as aggregometry or flow cytometry. In regard to genetic testing, it can guide specific sequencing. Since only minimal amounts of blood are needed for the preparation of blood smears, it can be used to characterize thrombocytopenia in pediatric patients and even newborns further. In principle, it is based on visualizing alterations in the distribution of proteins, which result from specific genetic mutations by using monoclonal antibodies. It can be applied to identify deficiencies in membrane proteins, disturbed distribution of cytoskeletal proteins, and alpha as well as delta granules. On the other hand, mutations associated with impaired signal transduction are difficult to identify by immunofluorescence of blood smears. This review summarizes technical aspects and the main diagnostic patterns achievable by this method.
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Affiliation(s)
- Carlo Zaninetti
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, 17489 Greifswald, Germany;
- University of Pavia, and IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy
- PhD Program of Experimental Medicine, University of Pavia, 27100 Pavia, Italy
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, 17489 Greifswald, Germany;
- Correspondence: ; Tel.: +49-3834-865482; Fax: +49-3834-865489
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Shah AJ, Sokolic R, Logan B, Yin Z, Iyengar S, Scalchunes C, Mangurian C, Albert M, Cowan MJ. Quality of Life of Patients with Wiskott Aldrich Syndrome and X-Linked Thrombocytopenia: a Study of the Primary Immune Deficiency Consortium (PIDTC), Immune Deficiency Foundation, and the Wiskott-Aldrich Foundation. J Clin Immunol 2019; 39:786-794. [PMID: 31620947 DOI: 10.1007/s10875-019-00689-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/10/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND We undertook a study to determine the impact of Wiskott Aldrich Syndrome (WAS) and X-linked thrombocytopenia (XLT) and their therapies upon the health-related quality of life (HRQOL) of patients and their families. MATERIALS AND METHODS We undertook a survey of patients and their families, who self-identified as having either WAS or XLT. We assessed the PedsQL™ 4.0, the parent proxy form, and the family impact module. These results were compared with normative data from previously published reports. RESULTS Sixty-eight patients (29 patients completed both the PedsQL™ 4.0 and the parent proxy form; 21 completed only the PedsQL™ 4.0; and 18 completed only the parent proxy form) were included. In contrast to patient-reported outcomes, parents of patients who had a bone marrow transplant (BMT) reported that their children had better QOL scores compared with those who did not (82.6 vs. 73.3, p = 0.023). The QOL of patients vs. previously published normative data showed decreases in patient scores for psychosocial health (72.62 vs. 86.58, p = < 0.001), emotional functioning (69.91 vs. 82.64, p = < 0.001), social functioning (77.55 vs. 91.56, p = < 0.001), and school functioning (70.46 vs. 85.67, p = < 0.001). The family impact study revealed deficits in emotional, social, and cognitive functioning, communication, and worry. CONCLUSION These results show that patients with WAS/XLT are significantly impacted with respect to QOL. BMT offered a better QOL for patients according to parents, but not as reported by the patients. Future studies should incorporate QOL to provide more data and a better understanding of outcomes for long-term survivors and decision-making regarding BMT.
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Affiliation(s)
- Ami J Shah
- Division of Stem Cell Transplantation and Regenerative Medicine, Lucille Packard Children Hospital, Stanford School of Medicine, Stanford, USA.
| | - Robert Sokolic
- Lifespan Cancer Institute, Alpert Medical School of Brown University, Providence, USA
| | - Brent Logan
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, USA
| | - Ziyan Yin
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, USA
| | | | | | - Christina Mangurian
- Department of Psychiatry, University of California-San Francisco, San Francisco, USA
| | - Michael Albert
- Hauner University Children's Hospital, Ludwig-Maximilians Universitat Munich Germany, Munich, Germany
| | - Morton J Cowan
- Division of Allergy, Immunology and Blood and Marrow Transplantation, Benioff Children's Hospital, University of California-San Francisco, San Francisco, USA
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25
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Candotti F. Gene therapy for Wiskott-Aldrich syndrome: here to stay. LANCET HAEMATOLOGY 2019; 6:e230-e231. [DOI: 10.1016/s2352-3026(19)30066-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 01/21/2023]
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26
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Ferrua F, Cicalese MP, Galimberti S, Giannelli S, Dionisio F, Barzaghi F, Migliavacca M, Bernardo ME, Calbi V, Assanelli AA, Facchini M, Fossati C, Albertazzi E, Scaramuzza S, Brigida I, Scala S, Basso-Ricci L, Pajno R, Casiraghi M, Canarutto D, Salerio FA, Albert MH, Bartoli A, Wolf HM, Fiori R, Silvani P, Gattillo S, Villa A, Biasco L, Dott C, Culme-Seymour EJ, van Rossem K, Atkinson G, Valsecchi MG, Roncarolo MG, Ciceri F, Naldini L, Aiuti A. Lentiviral haemopoietic stem/progenitor cell gene therapy for treatment of Wiskott-Aldrich syndrome: interim results of a non-randomised, open-label, phase 1/2 clinical study. LANCET HAEMATOLOGY 2019; 6:e239-e253. [PMID: 30981783 PMCID: PMC6494976 DOI: 10.1016/s2352-3026(19)30021-3] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 01/13/2023]
Abstract
Background Wiskott-Aldrich syndrome is a rare, life-threatening, X-linked primary immunodeficiency characterised by microthrombocytopenia, infections, eczema, autoimmunity, and malignant disease. Lentiviral vector-mediated haemopoietic stem/progenitor cell (HSPC) gene therapy is a potentially curative treatment that represents an alternative to allogeneic HSPC transplantation. Here, we report safety and efficacy data from an interim analysis of patients with severe Wiskott-Aldrich syndrome who received lentiviral vector-derived gene therapy. Methods We did a non-randomised, open-label, phase 1/2 clinical study in paediatric patients with severe Wiskott-Aldrich syndrome, defined by either WAS gene mutation or absent Wiskott-Aldrich syndrome protein (WASP) expression or a Zhu clinical score of 3 or higher. We included patients who had no HLA-identical sibling donor available or, for children younger than 5 years of age, no suitable 10/10 matched unrelated donor or 6/6 unrelated cord blood donor. After treatment with rituximab and a reduced-intensity conditioning regimen of busulfan and fludarabine, patients received one intravenous infusion of autologous CD34+ cells genetically modified with a lentiviral vector encoding for human WAS cDNA. The primary safety endpoints were safety of the conditioning regimen and safety of lentiviral gene transfer into HSPCs. The primary efficacy endpoints were overall survival, sustained engraftment of genetically corrected HSPCs, expression of vector-derived WASP, improved T-cell function, antigen-specific responses to vaccinations, and improved platelet count and mean platelet volume normalisation. This interim analysis was done when the first six patients treated had completed at least 3 years of follow-up. The planned analyses are presented for the intention-to-treat population. This trial is registered with ClinicalTrials.gov (number NCT01515462) and EudraCT (number 2009-017346-32). Findings Between April 20, 2010, and Feb 26, 2015, nine patients (all male) were enrolled of whom one was excluded after screening; the age range of the eight treated children was 1·1–12·4 years. At the time of the interim analysis (data cutoff April 29, 2016), median follow-up was 3·6 years (range 0·5–5·6). Overall survival was 100%. Engraftment of genetically corrected HSPCs was successful and sustained in all patients. The fraction of WASP-positive lymphocytes increased from a median of 3·9% (range 1·8–35·6) before gene therapy to 66·7% (55·7–98·6) at 12 months after gene therapy, whereas WASP-positive platelets increased from 19·1% (range 4·1–31·0) to 76·6% (53·1–98·4). Improvement of immune function was shown by normalisation of in-vitro T-cell function and successful discontinuation of immunoglobulin supplementation in seven patients with follow-up longer than 1 year, followed by positive antigen-specific response to vaccination. Severe infections fell from 2·38 (95% CI 1·44–3·72) per patient-year of observation (PYO) in the year before gene therapy to 0·31 (0·04–1·11) per PYO in the second year after gene therapy and 0·17 (0·00–0·93) per PYO in the third year after gene therapy. Before gene therapy, platelet counts were lower than 20 × 109 per L in seven of eight patients. At the last follow-up visit, the platelet count had increased to 20–50 × 109 per L in one patient, 50–100 × 109 per L in five patients, and more than 100 × 109 per L in two patients, which resulted in independence from platelet transfusions and absence of severe bleeding events. 27 serious adverse events in six patients occurred after gene therapy, 23 (85%) of which were infectious (pyrexia [five events in three patients], device-related infections, including one case of sepsis [four events in three patients], and gastroenteritis, including one case due to rotavirus [three events in two patients]); these occurred mainly in the first 6 months of follow-up. No adverse reactions to the investigational drug product and no abnormal clonal proliferation or leukaemia were reported after gene therapy. Interpretation Data from this study show that gene therapy provides a valuable treatment option for patients with severe Wiskott-Aldrich syndrome, particularly for those who do not have a suitable HSPC donor available. Funding Italian Telethon Foundation, GlaxoSmithKline, and Orchard Therapeutics.
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Affiliation(s)
- Francesca Ferrua
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Pia Cicalese
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefania Galimberti
- Center of Biostatistics for Clinical Epidemiology, University of Milano-Bicocca, Monza, Italy
| | - Stefania Giannelli
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Dionisio
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Barzaghi
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maddalena Migliavacca
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Ester Bernardo
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valeria Calbi
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Angelo Assanelli
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marcella Facchini
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Claudia Fossati
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elena Albertazzi
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Samantha Scaramuzza
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Immacolata Brigida
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Serena Scala
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Basso-Ricci
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberta Pajno
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Miriam Casiraghi
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daniele Canarutto
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Federica Andrea Salerio
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michael H Albert
- Department of Pediatric Hematology/Oncology, Dr von Haunersches University Children's Hospital, Munich, Germany
| | | | - Hermann M Wolf
- Immunology Outpatient Clinic, and Sigmund Freud Private University-Medical School, Vienna, Austria
| | - Rossana Fiori
- Department of Anesthesia and Critical Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Silvani
- Department of Anesthesia and Critical Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Salvatore Gattillo
- Blood Transfusion Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Villa
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Milan Unit, Istituto di Ricerca Genetica e Biomedica, Consiglio Nazionale delle Ricerche, Milan, Italy
| | - Luca Biasco
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; University College London, Great Ormond Street Institute of Child Health, Faculty of Population Health Sciences, London, UK
| | - Christopher Dott
- CSD Pharma Consulting, Redhill, UK; Orchard Therapeutics, London, UK
| | - Emily J Culme-Seymour
- Rare Diseases Unit, GlaxoSmithKline, Brentford, UK; Sangamo Therapeutics, London, UK
| | | | - Gillian Atkinson
- Rare Diseases Unit, GlaxoSmithKline, Brentford, UK; Sangamo Therapeutics, London, UK
| | - Maria Grazia Valsecchi
- Center of Biostatistics for Clinical Epidemiology, University of Milano-Bicocca, Monza, Italy
| | - Maria Grazia Roncarolo
- Division of Stem Cell Transplantation and Regenerative Medicine and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA, USA
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Luigi Naldini
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Aiuti
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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Sereni L, Castiello MC, Di Silvestre D, Della Valle P, Brombin C, Ferrua F, Cicalese MP, Pozzi L, Migliavacca M, Bernardo ME, Pignata C, Farah R, Notarangelo LD, Marcus N, Cattaneo L, Spinelli M, Giannelli S, Bosticardo M, van Rossem K, D'Angelo A, Aiuti A, Mauri P, Villa A. Lentiviral gene therapy corrects platelet phenotype and function in patients with Wiskott-Aldrich syndrome. J Allergy Clin Immunol 2019; 144:825-838. [PMID: 30926529 PMCID: PMC6721834 DOI: 10.1016/j.jaci.2019.03.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/12/2019] [Accepted: 03/18/2019] [Indexed: 12/15/2022]
Abstract
Background Thrombocytopenia is a serious issue for all patients with classical Wiskott-Aldrich syndrome (WAS) and X-linked thrombocytopenia (XLT) because it causes severe and life-threatening bleeding. Lentiviral gene therapy (GT) for WAS has shown promising results in terms of immune reconstitution. However, despite the reduced severity and frequency of bleeding events, platelet counts remain low in GT-treated patients. Objective We carefully investigated platelet defects in terms of phenotype and function in untreated patients with WAS and assessed the effect of GT treatment on platelet dysfunction. Methods We analyzed a cohort of 20 patients with WAS/XLT, 15 of them receiving GT. Platelet phenotype and function were analyzed by using electron microscopy, flow cytometry, and an aggregation assay. Platelet protein composition was assessed before and after GT by means of proteomic profile analysis. Results We show that platelets from untreated patients with WAS have reduced size, abnormal ultrastructure, and a hyperactivated phenotype at steady state, whereas activation and aggregation responses to agonists are decreased. GT restores platelet size and function early after treatment and reduces the hyperactivated phenotype proportionally to WAS protein expression and length of follow-up. Conclusions Our study highlights the coexistence of morphologic and multiple functional defects in platelets lacking WAS protein and demonstrates that GT normalizes the platelet proteomic profile with consequent restoration of platelet ultrastructure and phenotype, which might explain the observed reduction of bleeding episodes after GT. These results are instrumental also from the perspective of a future clinical trial in patients with XLT only presenting with microthrombocytopenia.
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Affiliation(s)
- Lucia Sereni
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Carmina Castiello
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dario Di Silvestre
- Proteomic and Metabolomic Laboratory, Institute of Biomedical Technologies, National Research Council (ITB-CNR), Segrate, Italy
| | - Patrizia Della Valle
- Coagulation Service & Thrombosis Research Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Brombin
- University Centre for Statistics in the Biomedical Sciences (CUSSB), Vita-Salute San Raffaele University, Milan, Italy
| | - Francesca Ferrua
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Pediatric Immunohematology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Maria Pia Cicalese
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy; Pediatric Immunohematology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Loris Pozzi
- Coagulation Service & Thrombosis Research Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Maddalena Migliavacca
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy; Pediatric Immunohematology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Maria Ester Bernardo
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy; Pediatric Immunohematology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Pignata
- Pediatric Section, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Roula Farah
- Department of Pediatrics, Division of Hematology-Oncology, Saint George Hospital University Medical Centre, Beirut, Lebanon
| | - Lucia Dora Notarangelo
- Pediatric Onco-Haematology and BMT Unit, Children's Hospital, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Nufar Marcus
- Department of Pediatrics, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Kipper Institute of Immunology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Marco Spinelli
- Pediatric Clinic, MBBM Foundation, Maria Letizia Verga Center, Monza, Italy
| | - Stefania Giannelli
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marita Bosticardo
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Koen van Rossem
- Rare Diseases Unit, GlaxoSmithKline, Brentford, United Kingdom
| | - Armando D'Angelo
- Coagulation Service & Thrombosis Research Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Aiuti
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Pediatric Immunohematology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Pierluigi Mauri
- Proteomic and Metabolomic Laboratory, Institute of Biomedical Technologies, National Research Council (ITB-CNR), Segrate, Italy
| | - Anna Villa
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy; Milan Unit, Istituto di Ricerca Genetica e Biomedica, Consiglio Nazionale delle Ricerche, Milan, Italy.
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28
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Rivers E, Worth A, Thrasher AJ, Burns SO. How I manage patients with Wiskott Aldrich syndrome. Br J Haematol 2019; 185:647-655. [DOI: 10.1111/bjh.15831] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Elizabeth Rivers
- University College London Great Ormond Street Institute of Child Health LondonUK
- Great Ormond Street Hospital for Children NHS Foundation Trust LondonUK
| | - Austen Worth
- Great Ormond Street Hospital for Children NHS Foundation Trust LondonUK
| | - Adrian J. Thrasher
- University College London Great Ormond Street Institute of Child Health LondonUK
- Great Ormond Street Hospital for Children NHS Foundation Trust LondonUK
| | - Siobhan O. Burns
- Department of Immunology Royal Free London NHS Foundation Trust LondonUK
- University College London Institute of Immunity and Transplantation London UK
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Simplifying the diagnosis of inherited platelet disorders? The new tools do not make it any easier. Blood 2019; 133:2478-2483. [PMID: 30858232 DOI: 10.1182/blood-2019-01-852350] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/28/2019] [Indexed: 12/25/2022] Open
Abstract
The molecular causes of many inherited platelet disorders are being unraveled. Next-generation sequencing facilitates diagnosis in 30% to 50% of patients. However, interpretation of genetic variants is challenging and requires careful evaluation in the context of a patient's phenotype. Before detailed testing is initiated, the treating physician and patient should establish an understanding of why testing is being performed and discuss potential consequences, especially before testing for variants in genes associated with an increased risk for hematologic malignancies.
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30
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Albert MH, Freeman AF. Wiskott-Aldrich Syndrome (WAS) and Dedicator of Cytokinesis 8- (DOCK8) Deficiency. Front Pediatr 2019; 7:451. [PMID: 31750279 PMCID: PMC6848221 DOI: 10.3389/fped.2019.00451] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/17/2019] [Indexed: 01/04/2023] Open
Abstract
Both Wiskott-Aldrich syndrome (WAS) and dedicator of cytokinesis 8 (DOCK8) deficiency are primary immunodeficiency diseases caused by mutations in genes that result in defective organization of the cytoskeleton in hematopoietic tissues. They share some overlapping features such as a combined immunodeficiency, eczema and a predisposition to autoimmunity and malignancy, but also have some unique features that make them relatively easy to diagnose by clinical means. Both diseases can be cured by HSCT in a large proportion of patients. In WAS it is sometimes difficult to establish an indication for HSCT due to the large variability of disease severity, while HSCT is probably indicated in all patients affected by DOCK8 deficiency. There is considerably more published HSCT experience for WAS than for DOCK8 deficiency, but many open questions remain, which will be discussed in this review.
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Affiliation(s)
- Michael H Albert
- Dr. von Hauner University Children's Hospital, Ludwig-Maximilians Universität, Munich, Germany
| | - Alexandra F Freeman
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, United States
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Castagnoli R, Delmonte OM, Calzoni E, Notarangelo LD. Hematopoietic Stem Cell Transplantation in Primary Immunodeficiency Diseases: Current Status and Future Perspectives. Front Pediatr 2019; 7:295. [PMID: 31440487 PMCID: PMC6694735 DOI: 10.3389/fped.2019.00295] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/03/2019] [Indexed: 12/29/2022] Open
Abstract
Primary immunodeficiencies (PID) are disorders that for the most part result from mutations in genes involved in immune host defense and immunoregulation. These conditions are characterized by various combinations of recurrent infections, autoimmunity, lymphoproliferation, inflammatory manifestations, atopy, and malignancy. Most PID are due to genetic defects that are intrinsic to hematopoietic cells. Therefore, replacement of mutant cells by healthy donor hematopoietic stem cells (HSC) represents a rational therapeutic approach. Full or partial ablation of the recipient's marrow with chemotherapy is often used to allow stable engraftment of donor-derived HSCs, and serotherapy may be added to the conditioning regimen to reduce the risks of graft rejection and graft versus host disease (GVHD). Initially, hematopoietic stem cell transplantation (HSCT) was attempted in patients with severe combined immunodeficiency (SCID) as the only available curative treatment. It was a challenging procedure, associated with elevated rates of morbidity and mortality. Overtime, outcome of HSCT for PID has significantly improved due to availability of high-resolution HLA typing, increased use of alternative donors and new stem cell sources, development of less toxic, reduced-intensity conditioning (RIC) regimens, and cellular engineering techniques for graft manipulation. Early identification of infants affected by SCID, prior to infectious complication, through newborn screening (NBS) programs and prompt genetic diagnosis with Next Generation Sequencing (NGS) techniques, have also ameliorated the outcome of HSCT. In addition, HSCT has been applied to treat a broader range of PID, including disorders of immune dysregulation. Yet, the broad spectrum of clinical and immunological phenotypes associated with PID makes it difficult to define a universal transplant regimen. As such, integration of knowledge between immunologists and transplant specialists is necessary for the development of innovative transplant protocols and to monitor their results during follow-up. Despite the improved outcome observed after HSCT, patients with severe forms of PID still face significant challenges of short and long-term transplant-related complications. To address this issue, novel HSCT strategies are being implemented aiming to improve both survival and long-term quality of life. This article will discuss the current status and latest developments in HSCT for PID, and present data regarding approach and outcome of HSCT in recently described PID, including disorders associated with immune dysregulation.
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Affiliation(s)
- Riccardo Castagnoli
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States.,Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Ottavia Maria Delmonte
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Enrica Calzoni
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States.,Department of Molecular and Translational Medicine, A. Nocivelli Institute for Molecular Medicine, University of Brescia, Brescia, Italy
| | - Luigi Daniele Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
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Neven B, Ferrua F. Hematopoietic Stem Cell Transplantation for Combined Immunodeficiencies, on Behalf of IEWP-EBMT. Front Pediatr 2019; 7:552. [PMID: 32039114 PMCID: PMC6992555 DOI: 10.3389/fped.2019.00552] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 12/17/2019] [Indexed: 12/29/2022] Open
Abstract
Combined immunodeficiencies (CIDs) are a clinically and genetically heterogeneous group of primary immunodeficiencies (PIDs) that affect T-lymphocyte immunity with abnormal development or function. As compared to severe combined immune deficiencies (SCID), these patients are usually diagnosed later. They display a broad infectious susceptibility; immune dysregulation manifestations and chronic lymphoproliferation are also frequent. These complications and their specific treatments can lead to persistent damage to several organs. Prognosis of CIDs is worse as compared to other PIDs. The curative treatment is usually hematopoietic stem cell transplantation (HSCT), but difficult questions remain regarding the definitive indication of HSCT and its timing; the final decision depends on a conjunction of factors such as immunological parameters, severity of clinical manifestations, and natural history of the disease, when molecular diagnosis is known. CD40L deficiency, a CID caused by mutations in CD40LG gene, well illustrates the dilemma between HSCT vs. long-term supportive treatment. This disease leads to higher risk of developing infections from bacterial and intracellular pathogens, especially Pneumocystis and Cryptosporidium spp. While supportive care allows improved survival during childhood, organ damages may develop with increasing age, mainly chronic lung disease and biliary tract disease (secondary to Cryptosporidium spp. infection) that may evolve later to sclerosing cholangitis, a severe complication associated with increased mortality. Early HSCT before organ damage development is associated with best survival and cure rate, while HSCT remains a risky therapeutic option for older patients, for those with organ damage, especially severe liver disease, and/or for those with limited or no donor availability. Prospective studies are needed to analyze risks of HSCT compared to those of life-long supportive therapy, including quality of life measures.
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Affiliation(s)
- Benedicte Neven
- Université de Paris, Paris, France.,Pediatric Hematology-Immunology and Rheumatology Unit, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.,INSERM U1163 and Imagine Institute, Paris, France
| | - Francesca Ferrua
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Pediatric Immunohematology and Bone Marrow Transplantation Unit, San Raffaele Scientific Institute, Milan, Italy
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Immunosuppression for immunodeficiency: Getting smarter. J Allergy Clin Immunol 2018; 142:1762-1764.e1. [PMID: 30339850 DOI: 10.1016/j.jaci.2018.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 09/20/2018] [Accepted: 10/01/2018] [Indexed: 11/22/2022]
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