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Jespersen F, Petersen SL, Andersen P, Sellebjerg F, Magyari M, Sørensen PS, Blinkenberg M. Autologous hematopoietic stem cell transplantation of patients with aggressive relapsing-remitting multiple sclerosis: Danish nation-wide experience. Mult Scler Relat Disord 2023; 76:104829. [PMID: 37364374 DOI: 10.1016/j.msard.2023.104829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/28/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Autologous hematopoietic stem cell treatment (AHSCT) is considered an effective treatment option for patients with aggressive relapsing-remitting multiple sclerosis (RRMS). Still there are few randomized and controlled studies of AHSCT to shed light on the safety and efficacy of the treatment, and therefore experiences from single centers are important. AIM To describe the Danish experience with AHSCT regarding patient characteristics, safety, and efficacy. METHOD Nationwide retrospective single center study of patients with multiple sclerosis (MS) treated with AHSCT. RESULTS A total of 32 patients were treated with AHSCT from May 2011 to May 2021. Seven were treated with carmustine, etoposide, cytarabine arabinoside, and melphalan (BEAM) as well as antithymocyte globulin (ATG). Twenty-five patients were treated with cyclophosphamide (CY) and ATG. In the whole cohort, relapse-free survival (RFS) was 77% (95% CI: 64-94%), worsening-free survival (WFS) was 79% (95% CI: 66-96%), MRI event-free survival (MFS) was 93% (95% CI: 85-100%), and no evidence of disease (NEDA-3) was 69% (95% CI: 54-89%) at the end of year two post-AHSCT. We had no treatment related mortality and only few severe adverse events (AEs). CONCLUSION AHSCT of patients with aggressive RRMS was an effective and relatively safe treatment with few serious AEs and no mortality in Danish patients.
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Affiliation(s)
- Freja Jespersen
- Danish Multiple Sclerosis Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Søren Lykke Petersen
- Department of Hematology Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Pernille Andersen
- Blood bank, Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Blinkenberg
- Danish Multiple Sclerosis Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Autologous Hematopoietic Stem-Cell Transplantation in Multiple Sclerosis: A Systematic Review and Meta-Analysis. Neurol Ther 2022; 11:1553-1569. [PMID: 35902484 PMCID: PMC9333355 DOI: 10.1007/s40120-022-00389-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/14/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION In 1995, the use of autologous hematopoietic stem-cell transplantation (AHSCT), which was previously used to treat hematological tumors, was introduced for severe autoimmune diseases such as multiple sclerosis (MS). AHSCT has proven its safety over the past few years due to technical advances and careful patient selection in transplant centers. While most studies have reported that AHSCT led to decreased Expanded Disability Status Scale (EDSS) scores, some patients reported increased EDSS scores following the procedure. Given the contradictory results, we aimed to conduct a comprehensive systematic review and meta-analysis to investigate the efficacy and safety of AHSCT. METHODS PubMed, Web of Science, and Scopus were searched in March 2022 using a predefined search strategy. We included cohort studies, clinical trials, case-control studies, and case series that investigated the efficacy or safety of AHSCT in patients with MS. PICO in the present study was defined as follows: problem or study population (P): patients with MS; intervention (I): AHSCT; comparison (C): none; outcome (O): efficacy and safety. RESULTS After a two-step review process, 50 studies with a total of 4831 patients with MS were included in our study. Our analysis showed a significant decrease in EDSS score after treatment (standardized mean difference [SMD]: -0.48, 95% CI -0.75, -0.22). Moreover, the annualized relapse rate was also significantly reduced after AHSCT compared to the pretreatment period (SMD: -1.58, 95% CI -2.34, -0.78). The pooled estimate of progression-free survival after treatment was 73% (95% CI 69%, 77). Furthermore, 81% of patients with MS who received AHSCT remained relapse-free (95% CI 76%, 86%). Investigating event-free survival, which reflects the absence of any disease-related event, showed a pooled estimate of 63% (95% CI 54%, 73%). Also, the MRI activity-free survival was 89% (95% CI 84%) among included studies with low heterogeneity. New MRI lesions seem to appear in nearly 8% of patients who underwent AHSCT (95% CI 4%, 12%). Our meta-analysis showed that 68% of patients with MS experience no evidence of disease activity (NEDA) after AHSCT (95% CI 59%, 77). The overall survival after transplantation was 94% (95% CI 91%, 96%). In addition, 4% of patients died from transplant-related causes (95% CI 2%, 6%). CONCLUSION Current data encourages a broader application of AHSCT for treating patients with MS while still considering proper patient selection and transplant methods. In addition, with increasing knowledge and expertise in the field of stem-cell therapy, AHSCT has become a safer treatment approach for MS.
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Stem Cell Therapy in Neuroimmunological Diseases and Its Potential Neuroimmunological Complications. Cells 2022; 11:cells11142165. [PMID: 35883607 PMCID: PMC9318423 DOI: 10.3390/cells11142165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/03/2022] [Accepted: 07/06/2022] [Indexed: 12/29/2022] Open
Abstract
Background: Since the 1990s, transplantations of hematopoietic and mesenchymal stem cells (HSCT and MSCT) and dendritic cell (DCT) have been investigated for the treatment of neurological autoimmune disorders (NADs). With the growing number of transplanted patients, awareness of neuroimmunolgical complications has increased. Therefore, an overview of SCT for the most common NADs and reports of secondary immunity after SCT is provided. Methods: For this narrative review, a literature search of the PubMed database was performed. A total of 86 articles reporting on different SCTs in NADs and 61 articles dealing with immune-mediated neurological complications after SCT were included. For multiple sclerosis (MS), only registered trials and phase I/II or II studies were considered, whereas all available articles on other disorders were included. The different transplantation procedures and efficacy and safety data are presented. Results: In MS patients, beneficial effects of HSCT, MSCT, and DCT with a decrease in disability and stabilization of disease activity have been reported. These effects were also shown in other NADs mainly in case reports. In seven of 132 reported patients with immune-mediated neurological complications, the outcome was fatal. Conclusions: Phase III trials are ongoing for MS, but the role of SCT in other NADs is currently limited to refractory patients due to occasional serious complications.
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The current standing of autologous haematopoietic stem cell transplantation for the treatment of multiple sclerosis. J Neurol 2022; 269:3937-3958. [PMID: 35399125 PMCID: PMC8995166 DOI: 10.1007/s00415-022-11063-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/01/2022]
Abstract
AbstractAutologous haematopoietic stem cell transplantation (aHSCT) is gaining traction as a valuable treatment option for patients affected by severe multiple sclerosis (MS), particularly the relapsing–remitting form. We describe the current literature in terms of clinical trials, observational and retrospective studies, as well as immune reconstitution following transplantation, with a focus on the conditioning regimens used for transplantation. The evidence base predominantly consists of non-randomised, uncontrolled clinical trials or data from retrospective or observational cohorts, i.e. very few randomised or controlled trials. Most often, intermediate-intensity conditioning regimens are used, with promising results from both myeloablative and lymphoablative strategies, as well as from regimens that are low and high intensity. Efficacy of transplantation, which is likely secondary to immune reconstitution and restored immune tolerance, is, therefore, not clearly dependent on the intensity of the conditioning regimen. However, the conditioning regimen may well influence the immune response to transplantation. Heterogeneity of conditioning regimens among studies hinders synthesis of the articles assessing post-aHSCT immune system changes. Factors associated with better outcomes were lower Kurtzke Expanded Disability Status Scale, relapsing–remitting MS, younger age, and shorter disease duration at baseline, which supports the guidance for patient selection proposed by the European Society for Blood and Marrow Transplantation. Interestingly, promising outcomes were described for patients with secondary progressive MS by some studies, which may be worth taking into account when considering treatment options for patients with active, progressive disease. Of note, a significant proportion of patients develop autoimmune disease following transplantation, with alemtuzumab-containing regimens associated with the highest incidence.
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Full Dose Cyclophosphamide with the Addition of Fludarabine for Matched Sibling Transplants in Severe Aplastic Anemia. Transplant Cell Ther 2021; 27:851.e1-851.e6. [PMID: 34126277 DOI: 10.1016/j.jtct.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/21/2021] [Accepted: 06/03/2021] [Indexed: 11/21/2022]
Abstract
The recommended therapy for severe aplastic anemia (SAA) in younger patients with a matched sibling donor (MSD) is allogeneic hematopoietic cell transplantation (allo-HCT). A number of conditioning regimens and protocols have been used for these patients. Here we report a homogeneous cohort of SAA patients receiving a uniform transplantation protocol. This study is a retrospective analysis of 82 consecutive patients with SAA who underwent MSD allo-HCT at a single center. The median duration of follow-up for survivors was 100 months, the 10-year overall survival (OS) was 87.5%, and the 10-year event-free survival was 75.3%. The OS was 97.4% for "mobilized" bone marrow (BM) graft recipients and 78.9% for "nonmobilized" BM graft recipients (P = .01. The cumulative incidence of acute graft-versus-host disease (GVHD) was 25.6%, that of chronic GVHD was 27.16%, and that of graft failure was 16.2%. Recipient age ≥30 years and transplantation at >6 months after SAA diagnosis were associated with a increased risk of events. In the presence of a fully matched sibling donor, allo-HCT with a mobilized BM graft and fludarabine-cyclophosphamide conditioning is an efficacious and safe approach. Early transplantation is associated with a better outcome, emphasizing the importance of not delaying transplantation in these patients. Prospective trials are needed to determine the optimal regimen.
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Mohammadi R, Aryan A, Omrani MD, Ghaderian SMH, Fazeli Z. Autologous Hematopoietic Stem Cell Transplantation (AHSCT): An Evolving Treatment Avenue in Multiple Sclerosis. Biologics 2021; 15:53-59. [PMID: 33688164 PMCID: PMC7936693 DOI: 10.2147/btt.s267277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/23/2021] [Indexed: 12/03/2022]
Abstract
Autologous hematopoietic stem cell transplantation (AHSCT) is considered as the novel approach to improve multiple sclerosis (MS) patients with disease-modifying therapies (DMTs)-resistance. The results obtained from different studies indicate that AHSCT increases the life quality of MS patients. Several factors are known to be influenced on the successful rate of AHSCT in patients with MS. The individuals aged <40 years with a short duration of MS disease have been demonstrated to show a better response to AHSCT administration. Furthermore, this treatment approach was more effective in relapsing remitting MS (RRMS) patients than progressive MS (PMS). Different clinical trials revealed that AHSCT with a low density conditioning regimen could be suggested as a suitable candidate approach in the management of MS. Several molecular and cellular mechanisms are known to be involved in the resetting of the immune system following the AHSCT infusion in MS patients. These mechanisms play a role in the depletion of auto-reactive lymphocytes and immune system renewal. In the present review, we discuss different clinical and molecular aspects of AHSCT application in the alleviation of MS symptoms.
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Affiliation(s)
- Reihane Mohammadi
- Department of Medical Genetics, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alisam Aryan
- Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mir Davood Omrani
- Department of Medical Genetics, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Zahra Fazeli
- Department of Medical Genetics, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Mariottini A, De Matteis E, Muraro PA. Haematopoietic Stem Cell Transplantation for Multiple Sclerosis: Current Status. BioDrugs 2021; 34:307-325. [PMID: 32166703 DOI: 10.1007/s40259-020-00414-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Autologous haematopoietic stem cell transplantation (AHSCT) is a treatment option for aggressive forms of multiple sclerosis (MS) that has been derived from haematological indications and repurposed for treatment of refractory autoimmune diseases. In the present review, a search for clinical studies on AHSCT was performed on the PubMed website and ClinicalTrials.gov databases. Papers were selected according to the following criteria: text written in English language, publication date between 2014 and August 2019, and reports including more than five patients. Prospective randomised and uncontrolled trials and retrospective case series were reviewed to examine the safety and efficacy of the procedure. Treatment protocols, pathological data and economic aspects of AHSCT were also succinctly covered. Growing evidence suggests that long-term suppression of inflammatory activity with stabilization or improvement of disability can be achieved in a high proportion of properly selected patients. More sophisticated outcome measures recently adopted, including effect on brain atrophy and disease biomarkers, are giving further insight into the effectiveness of transplant. The risks of the procedure have decreased to levels that can be considered acceptable for treatment of individuals with aggressive forms of MS. Careful selection of patients with an expected good benefit/risk profile, which is maximal when AHSCT is performed in early phases of the disease, and the expertise of transplant centres are critical to the success of treatment. Higher efficacy of AHSCT than with conventional treatments has recently been demonstrated by one randomised trial and further evidence is awaited from ongoing and planned trials comparing AHSCT with the most effective disease-modifying therapeutic agents.
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Affiliation(s)
- Alice Mariottini
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.,Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
| | - Eleonora De Matteis
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.,Department of Neurosciences, Mental Health and Sensory Organs, Faculty of Medicine and Psychology, Centre for Experimental Neurological Therapies, Sapienza University, Rome, Italy
| | - Paolo A Muraro
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.
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Oliveira MC, Elias JB, Moraes DAD, Simões BP, Rodrigues M, Ribeiro AAF, Piron-Ruiz L, Ruiz MA, Hamerschlak N. A review of hematopoietic stem cell transplantation for autoimmune diseases: multiple sclerosis, systemic sclerosis and Crohn's disease. Position paper of the Brazilian Society of Bone Marrow Transplantation. Hematol Transfus Cell Ther 2021; 43:65-86. [PMID: 32418777 PMCID: PMC7910166 DOI: 10.1016/j.htct.2020.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 12/16/2022] Open
Abstract
Autoimmune diseases are an important field for the development of bone marrow transplantation, or hematopoietic stem cell transplantation. In Europe alone, almost 3000 procedures have been registered so far. The Brazilian Society for Bone Marrow Transplantation (Sociedade Brasileira de Transplantes de Medula Óssea) organized consensus meetings for the Autoimmune Diseases Group, to review the available literature on hematopoietic stem cell transplantation for autoimmune diseases, aiming to gather data that support the procedure for these patients. Three autoimmune diseases for which there are evidence-based indications for hematopoietic stem cell transplantation are multiple sclerosis, systemic sclerosis and Crohn's disease. The professional stem cell transplant societies in America, Europe and Brazil (Sociedade Brasileira de Transplantes de Medula Óssea) currently consider hematopoietic stem cell transplantation as a therapeutic modality for these three autoimmune diseases. This article reviews the evidence available.
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Affiliation(s)
- Maria Carolina Oliveira
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Juliana Bernardes Elias
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | | | - Belinda Pinto Simões
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | | | | | - Lilian Piron-Ruiz
- Associação Portuguesa de Beneficência de São José do Rio Preto, São José do Rio Preto, SP, Brazil
| | - Milton Arthur Ruiz
- Associação Portuguesa de Beneficência de São José do Rio Preto, São José do Rio Preto, SP, Brazil
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9
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Das J, Sharrack B, Snowden JA. Autologous hematopoietic stem-cell transplantation in neurological disorders: current approach and future directions. Expert Rev Neurother 2020; 20:1299-1313. [PMID: 32893698 DOI: 10.1080/14737175.2020.1820325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Autologous hematopoietic stem-cell transplantation (AHSCT) has become increasingly popular in recent years as an effective treatment of immune-mediated neurological diseases. Treatment-related mortality has significantly reduced primarily through better patient selection, optimization of transplant technique, and increased center experience. AREA COVERED Multiple sclerosis is the main indication, but people with neuromyelitis optica spectrum disorder, stiff-person spectrum disorder, chronic inflammatory demyelinating polyneuropathy, myasthenia gravis, and other immune-mediated neurological disorders also have been treated. The review herein discusses the use of AHSCT in these neurological disorders, the importance of patient selection and transplant technique optimization and future directions. EXPERT OPINION Phase II and III clinical trials have confirmed the safety and efficacy of AHSCT in multiple sclerosis and recent phase II clinical trials have also suggested its safety and efficacy in chronic inflammatory demyelinating polyneuropathy and neuromyelitis optica spectrum disorder, with the evidence in other neurological disorders limited to individual case reports, small case series, and registry data. Therefore, further randomized controlled clinical trials are required to assess its safety and efficacy in other neurological conditions. However, in rare neurological conditions, pragmatic treatment trials or registry-based studies may be more realistic options for gathering efficacy and safety data.
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Affiliation(s)
- Joyutpal Das
- Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust , Salford, UK.,Cardiovascular medicine, University of Manchester , Manchester, UK.,Department of Neuroscience, NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield , Sheffield, UK
| | - Basil Sharrack
- Department of Neuroscience, NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield , Sheffield, UK
| | - John A Snowden
- Department of Hematology, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK
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Autologous Haematopoietic Stem Cell Transplantation in Multiple Sclerosis: a Review of Current Literature and Future Directions for Transplant Haematologists and Oncologists. Curr Hematol Malig Rep 2020; 14:127-135. [PMID: 30828772 PMCID: PMC6510794 DOI: 10.1007/s11899-019-00505-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of Review We summarise the current development of autologous haematopoietic stem cell transplantation (AHSCT) in treating multiple sclerosis (MS) and discuss future directions for the general neurologist, transplant haematologist and oncologist. Recent Findings AHSCT was initially performed to treat MS over 20 years ago. Over recent years, the evidence base has grown, especially in relapsing-remitting MS (RRMS), with significant improvements in safety and efficacy through better patient selection, choice of transplant technique and increase in centre experience. Summary AHSCT is now a treatment option in very carefully selected patients with severe, treatment-resistant RRMS. However, it is important for transplant haematologists and oncologists to work closely with specialist MS neurologists in patient selection, during transplant and in long-term follow-up of patients. Data should be registered into international transplant registries and, ideally, patients should be enrolled on prospective clinical trials in order to build the evidence base and refine transplant techniques.
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11
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Lycke J, Lenhoff S. Intensive immunosuppression followed by autologous hematopoietic stem cell transplantation for the treatment of multiple sclerosis. Ther Adv Neurol Disord 2020; 13:1756286420929467. [PMID: 32636931 PMCID: PMC7315665 DOI: 10.1177/1756286420929467] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/22/2020] [Indexed: 12/20/2022] Open
Abstract
Autologous hematopoietic stem cell transplantation (AHSCT) to treat multiple sclerosis (MS) has mostly been used in devastating cases as the last option to stop further neurological deterioration. However, evidence from several retrospective clinical trials indicates that young, less disabled patients with highly inflammatory active MS are the most likely to benefit from AHSCT, and after moving from high-intensity to nonmyeloablative procedures the tolerability of AHSCT has increased and its associated risk and mortality have declined considerably. Recent meta-analyses and randomized clinical trials show that AHSCT is more effective than currently approved disease-modifying therapies (DMTs), with suppression of disease activity in 70–90% of patients and long-term cessation of disease activity in two-thirds of treated patients. The rationale for AHSCT is to eliminate autoimmunity and achieve immune resetting by intense immunosuppression followed by infusion of autologous hematopoietic stem cells. Similar effects on the immune system have been suggested for cladribine and alemtuzumab treatment and, together with AHSCT, they constitute the induction or immune-reconstitution therapies for MS. Although, further randomized controlled trials of AHSCT for MS are needed, it has become clear that improved patient selection and lower intensity conditioning regimens have reduced AHSCT associated risks and mortality and strengthened the position of AHSCT among other DMTs. Do we have enough experience and scientific support for AHSCT in MS to move from an exclusive treatment for aggressive, treatment-resistant MS and acquire broader indications, similar to other effective DMTs?
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Affiliation(s)
- Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gröna stråket 11, 3 tr, Sahlgrenska University Hospital, Gothenburg, 415 45, Sweden
| | - Stig Lenhoff
- Department of Hematology, Oncology and Radiophysics, Skane University Hospital, Lund, Sweden
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Bose G, Thebault S, Rush CA, Atkins HL, Freedman MS. Autologous hematopoietic stem cell transplantation for multiple sclerosis: A current perspective. Mult Scler 2020; 27:167-173. [PMID: 32364422 DOI: 10.1177/1352458520917936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The most effective treatment at halting inflammation in patients with highly active multiple sclerosis (MS) is immune ablation followed by autologous hematopoietic stem cell transplantation (AHSCT). Better patient selection and supportive management, as well as advances in conditioning regimens have resulted in improved safety with AHSCT. However, which comorbidities or prior therapies increase the risks associated with AHSCT still need to be determined. In addition, there is still debate as to which AHSCT conditioning regimen offers the best balance of long-term efficacy and safety. New studies comparing AHSCT with highly effective disease-modifying therapies will help to inform on the ideal placement of AHSCT in the treatment algorithm. Currently, many centers are experienced and use AHSCT to treat select patients with MS, contributing to ongoing registries and clinical trials which will help answer these questions.
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Affiliation(s)
- Gauruv Bose
- Department of Medicine, Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Simon Thebault
- Department of Medicine, Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Carolina A Rush
- Department of Medicine, Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Harold L Atkins
- Department of Medicine, Division of Hematology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Mark S Freedman
- Department of Medicine, Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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13
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Therapeutic potential of stem cells for treatment of neurodegenerative diseases. Biotechnol Lett 2020; 42:1073-1101. [DOI: 10.1007/s10529-020-02886-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 04/05/2020] [Indexed: 12/13/2022]
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14
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Effect of autologous hematopoietic stem cell transplantation on multiple sclerosis and neuromyelitis optica spectrum disorder: a PRISMA-compliant meta-analysis. Bone Marrow Transplant 2020; 55:1928-1934. [PMID: 32020080 DOI: 10.1038/s41409-020-0810-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 12/29/2022]
Abstract
We should consider both the treatment effects and adverse effects of autologous hematopoietic stem cell transplantation (AHSCT) on multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). Articles exploring the effect and safety of AHSCT in the treatment of MS and NMOSD and published before December 2019 were identified from the following databases (PubMed, Web of Science, Medline, EMBASE, Cochrane and Google Scholar). The study used STATA 13.0 software to compute the efficacy outcomes. Finally, the meta-analysis included 27 studies (including 1626 MS and 31 NMOSD patients). Regarding the effect of AHSCT on MS, the computed PFS was 74%. Subgroup analyses showed that intermediate-intensity regimen caused PFS 73%. Low-intensity regimen resulted in PFS 85%. High-intensity regimen resulted in PFS 58%. Subgroup analyses indicated that relapsing remitting MS (RRMS), primary progressive MS (PPMS) and secondary progressive MS (SPMS) patients showed PFS 81%, 78% and 60%, respectively. Computed transplant-related mortality (TRM) in MS was 1%. Regarding effect of AHSCT on NMOSD, the computed PFS and TRM was 76% and 0%, respectively. In conclusion, the study supported that AHSCT showed long-term effect on MS and NMOSD patients with a high safety. Low- and intermediate-intensity regimens and RRMS patients showed optimal benefit from AHSCT.
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Sharrack B, Saccardi R, Alexander T, Badoglio M, Burman J, Farge D, Greco R, Jessop H, Kazmi M, Kirgizov K, Labopin M, Mancardi G, Martin R, Moore J, Muraro PA, Rovira M, Sormani MP, Snowden JA. Autologous haematopoietic stem cell transplantation and other cellular therapy in multiple sclerosis and immune-mediated neurological diseases: updated guidelines and recommendations from the EBMT Autoimmune Diseases Working Party (ADWP) and the Joint Accreditation Committee of EBMT and ISCT (JACIE). Bone Marrow Transplant 2020; 55:283-306. [PMID: 31558790 PMCID: PMC6995781 DOI: 10.1038/s41409-019-0684-0] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 08/17/2019] [Indexed: 12/18/2022]
Abstract
These updated EBMT guidelines review the clinical evidence, registry activity and mechanisms of action of haematopoietic stem cell transplantation (HSCT) in multiple sclerosis (MS) and other immune-mediated neurological diseases and provide recommendations for patient selection, transplant technique, follow-up and future development. The major focus is on autologous HSCT (aHSCT), used in MS for over two decades and currently the fastest growing indication for this treatment in Europe, with increasing evidence to support its use in highly active relapsing remitting MS failing to respond to disease modifying therapies. aHSCT may have a potential role in the treatment of the progressive forms of MS with a significant inflammatory component and other immune-mediated neurological diseases, including chronic inflammatory demyelinating polyneuropathy, neuromyelitis optica, myasthenia gravis and stiff person syndrome. Allogeneic HSCT should only be considered where potential risks are justified. Compared with other immunomodulatory treatments, HSCT is associated with greater short-term risks and requires close interspeciality collaboration between transplant physicians and neurologists with a special interest in these neurological conditions before, during and after treatment in accredited HSCT centres. Other experimental cell therapies are developmental for these diseases and patients should only be treated on clinical trials.
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Affiliation(s)
- Basil Sharrack
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- NIHR Neurosciences Biomedical Research Centre, University of Sheffield, Sheffield, UK
| | - Riccardo Saccardi
- Cell Therapy and Transfusion Medicine Unit, Careggi University Hospital, Firenze, Italy
| | - Tobias Alexander
- Klinik fur Rheumatologie und Klinische Immunologie, Charite-Universitatsmedizin, Berlin, Germany
| | - Manuela Badoglio
- EBMT Paris study office, Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Dominique Farge
- Unité de Médecine Interne, Maladies Auto-immunes et Pathologie Vasculaire (UF 04), Hôpital St-Louis, AP-HP, Paris, France
- Centre de Référence des Maladies Auto-Immunes Systémiques Rares d'Ile-de-France, Filière, FAI2R, Paris, France
- EA 3518, Université Denis Diderot, Paris, France
- Department of Internal Medicine, McGill University, Montreal, QC, Canada
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico, San Raffaele Scientific Institute, Milan, Italy
| | - Helen Jessop
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Majid Kazmi
- Kings Health Partners, Department of Haematology, Guys Hospital, London, UK
| | - Kirill Kirgizov
- N.N. Blokhin National Medical Center of Oncology, Institute of Pediatric Oncology and Hematology, Moscow, Russia
| | - Myriam Labopin
- EBMT Paris study office, Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
| | - Gianluigi Mancardi
- Department of Neuroscience, University of Genova and Clinical Scientific Institutes Maugeri, Genoa, Italy
| | - Roland Martin
- Neuroimmunology and MS Research, Neurology Clinic, University Hospital, Zurich, Switzerland
| | - John Moore
- Haematology Department, St. Vincent's Health Network, Darlinghurst, NSW, Australia
| | - Paolo A Muraro
- Department of Brain Sciences, Imperial College London, London, UK
| | - Montserrat Rovira
- BMT Unit, Department of Hematology, IDIBAPS, Hospital Clinic, Institut Josep Carreras, Barcelona, Spain
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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Cuascut FX, Hutton GJ. Stem Cell-Based Therapies for Multiple Sclerosis: Current Perspectives. Biomedicines 2019; 7:biomedicines7020026. [PMID: 30935074 PMCID: PMC6631931 DOI: 10.3390/biomedicines7020026] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/22/2019] [Accepted: 03/25/2019] [Indexed: 12/29/2022] Open
Abstract
Multiple sclerosis (MS) is an inflammatory and neurodegenerative autoimmune disease of the central nervous system (CNS). Disease-modifying therapies (DMT) targeting inflammation have been shown to reduce disease activity in patients with relapsing–remitting MS (RRMS). The current therapeutic challenge is to find an effective treatment to halt disease progression and reverse established neural damage. Stem cell-based therapies have emerged to address this dilemma. Several types of stem cells have been considered for clinical use, such as autologous hematopoietic (aHSC), mesenchymal (MSC), neuronal (NSC), human embryonic (hESC), and induced pluripotent (iPSC) stem cells. There is convincing evidence that immunoablation followed by hematopoietic therapy (aHSCT) has a high efficacy for suppressing inflammatory MS activity and improving neurological disability in patients with RRMS. In addition, MSC therapy may be a safe and tolerable treatment, but its clinical value is still under evaluation. Various studies have shown early promising results with other cellular therapies for CNS repair and decreasing inflammation. In this review, we discuss the current knowledge and limitations of different stem cell-based therapies for the treatment of patients with MS.
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Affiliation(s)
- Fernando X Cuascut
- Baylor College of Medicine, Maxine Mesigner Multiple Sclerosis Center, Houston, TX 77030, USA.
| | - George J Hutton
- Baylor College of Medicine, Maxine Mesigner Multiple Sclerosis Center, Houston, TX 77030, USA.
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Ge F, Lin H, Li Z, Chang T. Efficacy and safety of autologous hematopoietic stem-cell transplantation in multiple sclerosis: a systematic review and meta-analysis. Neurol Sci 2018; 40:479-487. [PMID: 30535563 DOI: 10.1007/s10072-018-3670-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 11/29/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Autologous hematopoietic stem-cell transplantation (AHSCT) has been utilized as a treatment option for multiple sclerosis (MS) since 1995. However, this procedure has not been widely implemented in clinical practice owing to its mortality risk. Here, we conduct a meta-analysis to evaluate the long-term efficacy and safety of AHSCT in MS treatment, aiming to optimize the benefit/risk ratio of this therapeutic strategy. METHODS We searched the PubMed Web site and clinicaltrials.gov databases. The efficacy endpoints were progression-free survival (PFS) and disease activity-free survival. The safety outcomes were transplant-related mortality (TRM) and overall deaths. RESULTS Eighteen eligible studies with a total of 732 participants were enrolled. The PFS was 75% (95% CI, 0.69-0.81), and the estimate of disease activity-free survival was 61% with 48-month follow-up. Subgroups analysis showed that low- and intermediate-intensity regimens were associated with higher PFS 80%. Relapsing remitting MS (RRMS) benefited more from AHSCT than other MS subtypes with PFS 85%. Patients with Gd+ lesions at baseline MRI responded better to AHSCT with PFS 77%. The estimate of TRM was 1.34% (95% CI, 0.39-2.30), and the overall mortality was 3.58%. TRM was significantly higher in high-intensity regimen studies (3.13%) and in older studies (1.93%) performed before 2006. CONCLUSIONS This meta-analysis provides evidences that AHSCT can induce long-term remissions for MS patients with a high degree of safety. We indicate low- and intermediate-intensity regimens and RRMS patients with the presence of Gd+ lesions at baseline MRI can obtain the optimal benefit/risk ratio from AHSCT.
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Affiliation(s)
- Fangfang Ge
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, Shaanxi Province, People's Republic of China
| | - Hong Lin
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, Shaanxi Province, People's Republic of China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, Shaanxi Province, People's Republic of China
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, Shaanxi Province, People's Republic of China.
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Ayasoufi K, Fan R, Valujskikh A. Depletion-Resistant CD4 T Cells Enhance Thymopoiesis During Lymphopenia. Am J Transplant 2017; 17:2008-2019. [PMID: 28397358 PMCID: PMC5519419 DOI: 10.1111/ajt.14309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/08/2017] [Accepted: 04/01/2017] [Indexed: 01/25/2023]
Abstract
Lymphoablation is routinely used in transplantation, and its success is defined by the balance of pathogenic versus protective T cells within reconstituted repertoire. While homeostatic proliferation and thymopoiesis may both cause T cell recovery during lymphopenia, the relative contributions of these mechanisms remain unclear. The goal of this study was to investigate the role of the thymus during T cell reconstitution in adult allograft recipients subjected to lymphoablative induction therapy. Compared with euthymic mice, thymectomized heart allograft recipients demonstrated severely impaired CD4 and CD8 T cell recovery and prolonged heart allograft survival after lymphoablation with murine anti-thymocyte globulin (mATG). The injection with agonistic anti-CD40 mAb or thymus transplantation only partially restored T cell reconstitution in mATG-treated thymectomized mice. After mATG depletion, residual CD4 T cells migrated into the thymus and enhanced thymopoiesis. Conversely, depletion of CD4 T cells before lymphoablation inhibited thymopoiesis at the stage of CD4- CD8- CD44hi CD25+ immature thymocytes. This is the first demonstration that the thymus and peripheral CD4 T cells cooperate to ensure optimal T cell reconstitution after lymphoablation. Targeting thymopoiesis through manipulating functions of depletion-resistant helper T cells may thus improve therapeutic benefits and minimize the risks of lymphoablation in clinical settings.
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Affiliation(s)
- Katayoun Ayasoufi
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Ran Fan
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Anna Valujskikh
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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Muraro PA, Martin R, Mancardi GL, Nicholas R, Sormani MP, Saccardi R. Autologous haematopoietic stem cell transplantation for treatment of multiple sclerosis. Nat Rev Neurol 2017; 13:391-405. [PMID: 28621766 DOI: 10.1038/nrneurol.2017.81] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Autologous haematopoietic stem cell transplantation (AHSCT) is a multistep procedure that enables destruction of the immune system and its reconstitution from haematopoietic stem cells. Originally developed for the treatment of haematological malignancies, the procedure has been adapted for the treatment of severe immune-mediated disorders. Results from ∼20 years of research make a compelling case for selective use of AHSCT in patients with highly active multiple sclerosis (MS), and for controlled trials. Immunological studies support the notion that AHSCT causes qualitative immune resetting, and have provided insight into the mechanisms that might underlie the powerful treatment effects that last well beyond recovery of immune cell numbers. Indeed, studies have demonstrated that AHSCT can entirely suppress MS disease activity for 4-5 years in 70-80% of patients, a rate that is higher than those achieved with any other therapies for MS. Treatment-related mortality, which was 3.6% in studies before 2005, has decreased to 0.3% in studies since 2005. Current evidence indicates that the patients who are most likely to benefit from and tolerate AHSCT are young, ambulatory and have inflammatory MS activity. Clinical trials are required to rigorously test the efficacy, safety and cost-effectiveness of AHSCT against highly active MS drugs.
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Affiliation(s)
- Paolo A Muraro
- Division of Brain Sciences, Imperial College London, Burlington Danes Building, 190 Du Cane Road, London W12 0NN, UK
| | - Roland Martin
- Neuroimmunology and Multiple Sclerosis Research, Neurology Clinic, University Hospital Zurich, University Zurich, Frauenklinikstrasse 26, 8091 Zurich, Switzerland
| | - Giovanni Luigi Mancardi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Largo Paolo Daneo 3, 16145 Genova, Italy
- Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132 Genoa, Italy
| | - Richard Nicholas
- Division of Brain Sciences, Imperial College London, Burlington Danes Building, 190 Du Cane Road, London W12 0NN, UK
| | - Maria Pia Sormani
- Biostatistics Unit, Department of Health Sciences (DISSAL), University of Genoa, Via Pastore 1, 16132, Genova, Italy
| | - Riccardo Saccardi
- Cell Therapy and Transfusion Medicine Unit, Careggi University Hospital, Largo Brambilla, 3-50134 Firenze, Italy
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Abstract
Cell therapy is considered a promising potential treatment for multiple sclerosis, perhaps particularly for the progressive form of the disease for which there are currently no useful treatments. Over the past two decades or more, much progress has been made in understanding the biology of MS and in the experimental development of cell therapy for this disease. Three quite distinct forms of cell therapy are currently being pursued. The first seeks to use stem cells to replace damaged myelin-forming oligodendrocytes within the CNS; the second aims, in effect, to replace the individual's misfunctioning immune system, making use of haematopoietic stem cells; and the third seeks to utilise endogenous stem cell populations by mobilisation with or without in vitro expansion, exploiting their various reparative and neuroprotective properties. In this article we review progress in these three separate areas, summarising the experimental background and clinical progress thus far made.
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21
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Sormani MP, Muraro PA, Schiavetti I, Signori A, Laroni A, Saccardi R, Mancardi GL. Autologous hematopoietic stem cell transplantation in multiple sclerosis. Neurology 2017; 88:2115-2122. [DOI: 10.1212/wnl.0000000000003987] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 02/06/2017] [Indexed: 12/29/2022] Open
Abstract
Objective:To summarize the evidence on immunoablative therapy followed by autologous hematopoietic stem cell transplantation (aHSCT) to manage severe and treatment-refractory multiple sclerosis (MS).Methods:We collected all the published studies of aHSCT in any form of MS from 1995 to 2016, carefully excluding reports that were updated in subsequent studies. Endpoints were transplant-related mortality (TRM), rate of disease progression, and no evidence of disease activity (NEDA) status. A weighted metaregression based on a Poisson model was run, assessing whether there were study-specific characteristics with an effect on TRM and progression.Results:Fifteen studies including 764 transplanted patients were pooled in the meta-analysis. The pooled estimate of TRM was 2.1% (95% confidence interval [CI] 1.3%–3.4%). TRM was higher in older studies (p = 0.014) and in studies with a lower proportion of patients with relapsing-remitting MS (RRMS) (p = 0.028). A higher baseline Expanded Disability Status Scale (p = 0.013) was also significantly associated with a higher TRM. Pooled rate of progression was 17.1% at 2 years (95% CI 9.7%–24.5%) and 23.3% (95% CI 16.3%–31.8%) at 5 years. Lower 2-year progression rate was significantly associated with higher proportions of patients with RRMS (p = 0.004). The pooled proportion of NEDA patients at 2 years was 83% (range 70%–92%) and at 5 years was 67% (range 59%–70%).Conclusions:The emerging evidence on this therapeutic approach in MS indicates that the largest benefit/risk profile form this therapeutic approach can be obtained in patients with aggressive MS with a relapsing-remitting course and who have not yet accumulated a high level of disability.
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22
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Cull G, Hall D, Fabis-Pedrini MJ, Carroll WM, Forster L, Robins F, Ghassemifar R, Crosbie C, Walters S, James I, Augustson B, Kermode AK. Lymphocyte reconstitution following autologous stem cell transplantation for progressive MS. Mult Scler J Exp Transl Clin 2017; 3:2055217317700167. [PMID: 28607754 PMCID: PMC5415040 DOI: 10.1177/2055217317700167] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/26/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Autologous stem cell transplantation (ASCT) for progressive multiple sclerosis (MS) may reset the immune repertoire. OBJECTIVE The objective of this paper is to analyse lymphocyte recovery in patients with progressive MS treated with ASCT. METHODS Patients with progressive MS not responding to conventional treatment underwent ASCT following conditioning with high-dose cyclophosphamide and antithymocyte globulin. Lymphocyte subset analysis was performed before ASCT and for two years following ASCT. Neurological function was assessed by the EDSS before ASCT and for three years post-ASCT. RESULTS CD4+ T-cells fell significantly post-transplant and did not return to baseline levels. Recent thymic emigrants and naïve T-cells fell sharply post-transplant but returned to baseline by nine months and twelve months, respectively. T-regulatory cells declined post-transplant and did not return to baseline levels. Th1 and Th2 cells did not change significantly while Th17 cells fell post-transplant but recovered to baseline by six months. Neurological function remained stable in the majority of patients. Progression-free survival was 69% at three years. CONCLUSION This study demonstrates major changes in the composition of lymphocyte subsets following ASCT for progressive MS. In particular, ablation and subsequent recovery of thymic output is consistent with the concept that ASCT can reset the immune repertoire in MS patients.
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Affiliation(s)
- G Cull
- Department of Haematology, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Australia
| | - D Hall
- Department of Haematology, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Australia
| | - M J Fabis-Pedrini
- Centre for Neuromuscular and Neurological Disorders, Western Australian Neuroscience Research Institute, The University of Western Australia, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Australia
| | - W M Carroll
- Centre for Neuromuscular and Neurological Disorders, Western Australian Neuroscience Research Institute, The University of Western Australia, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Australia
| | - L Forster
- Department of Haematology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Australia
| | - F Robins
- Department of Haematology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Australia
| | - R Ghassemifar
- Department of Haematology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Australia
| | - C Crosbie
- Department of Haematology, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Australia
| | - S Walters
- Centre for Neuromuscular and Neurological Disorders, Western Australian Neuroscience Research Institute, The University of Western Australia, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Australia
| | - I James
- Institute for Immunology and Infectious Diseases, Murdoch University, Australia
| | - B Augustson
- Department of Haematology, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Australia
| | - A K Kermode
- Centre for Neuromuscular and Neurological Disorders, Western Australian Neuroscience Research Institute, The University of Western Australia, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Australia
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23
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Collins F, Kazmi M, Muraro PA. Progress and prospects for the use and the understanding of the mode of action of autologous hematopoietic stem cell transplantation in the treatment of multiple sclerosis. Expert Rev Clin Immunol 2017; 13:611-622. [DOI: 10.1080/1744666x.2017.1297232] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Fredrika Collins
- School of Medical Education, King’s College London, London, UK
- Division of Hematology, King’s College Hospitals NHS Trust, London, UK
| | - Majid Kazmi
- Division of Hematology, King’s College Hospitals NHS Trust, London, UK
| | - Paolo A Muraro
- Division of Brain Sciences, Imperial College, London, UK
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de Castro FA, Simões BP, Coelho EB, Lanchote VL. Enantioselectivity in the Metabolism of Cyclophosphamide in Patients With Multiple or Systemic Sclerosis. J Clin Pharmacol 2017; 57:784-795. [PMID: 28083951 DOI: 10.1002/jcph.863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 11/30/2016] [Indexed: 12/20/2022]
Abstract
The aim of this study was to evaluate the enantioselective pharmacokinetics of cyclophosphamide and its metabolites 4-hydroxycyclophosphamide and carboxyethylphosphoramide mustard in patients with systemic or multiple sclerosis. Patients with systemic sclerosis (n = 10) or multiple sclerosis (n = 10), genotyped for the allelic variants of CYP2C9*2 and CYP2C9*3 and of the CYP2B6 G516T polymorphism, were treated with 50 mg cyclophosphamide/kg daily for 4 days. Serial blood samples were collected up to 24 hours after administration of the last cyclophosphamide dose. Cyclophosphamide, 4-hydroxycyclophosphamide, and carboxyethylphosphoramide enantiomers were analyzed in plasma samples using liquid chromatography-tandem mass spectrometry coupled to chiral column Chiralcel OD-R or Chiralpak AD-RH. Cytokines IL-2, IL-4, IL-6, IL-8, IL-10, IL- 12p70, IL-17, TNF-α, and INT-δ in the plasma samples collected before cyclophosphamide infusion were analyzed by Milliplex MAP human cytokine/chemokine. Pharmacokinetic parameters showed higher plasma concentrations of (S)-(-)-cyclophosphamide (AUC 215.0 vs 186.2 μg·h/mL for multiple sclerosis patients and 219.1 vs 179.2 μg·h/mL for systemic sclerosis patients) and (R)-4-hydroxycyclophosphamide (AUC 5.6 vs 3.7 μg·h/mL for multiple sclerosis patients and 6.3 vs 5.6 μg·h/mL for systemic sclerosis patients) when compared to their enantiomers in both groups of patients, whereas the pharmacokinetics of the carboxyethylphosphoramide metabolite was not enantioselective. Cytokines' plasma concentrations were similar between multiple and systemic sclerosis groups. The pharmacokinetics of cyclophosphamide is enantioselective in patients with systemic sclerosis and multiple sclerosis, with higher plasma concentrations of the (S)-(-)-cyclophosphamide enantiomer due to the preferential formation of the (R)-4-hydroxycyclophosphamide metabolite.
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Affiliation(s)
- Francine Attié de Castro
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Belinda Pinto Simões
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Eduardo Barbosa Coelho
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Vera Lucia Lanchote
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
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25
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de Oliveira GLV, Ferreira AF, Gasparotto EPL, Kashima S, Covas DT, Guerreiro CT, Brum DG, Barreira AA, Voltarelli JC, Simões BP, Oliveira MC, de Castro FA, Malmegrim KCR. Defective expression of apoptosis-related molecules in multiple sclerosis patients is normalized early after autologous haematopoietic stem cell transplantation. Clin Exp Immunol 2016; 187:383-398. [PMID: 28008595 DOI: 10.1111/cei.12895] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 10/23/2016] [Accepted: 11/02/2016] [Indexed: 12/14/2022] Open
Abstract
Defective apoptosis might be involved in the pathogenesis of multiple sclerosis (MS). We evaluated apoptosis-related molecules in MS patients before and after autologous haematopoietic stem cell transplantation (AHSCT) using BCNU, Etoposide, AraC and Melphalan (BEAM) or cyclophosphamide (CY)-based conditioning regimens. Patients were followed for clinical and immunological parameters for 2 years after AHSCT. At baseline, MS patients had decreased proapoptotic BAD, BAX and FASL and increased A1 gene expression when compared with healthy counterparts. In the BEAM group, BAK, BIK, BIMEL , FAS, FASL, A1, BCL2, BCLXL , CFLIPL and CIAP2 genes were up-regulated after AHSCT. With the exception of BIK, BIMEL and A1, all genes reached levels similar to controls at day + 720 post-transplantation. Furthermore, in these patients, we observed increased CD8+ Fas+ T cell frequencies after AHSCT when compared to baseline. In the CY group, we observed increased BAX, BCLW, CFLIPL and CIAP1 and decreased BIK and BID gene expressions after transplantation. At day + 720 post-AHSCT, the expression of BAX, FAS, FASL, BCL2, BCLXL and CIAP1 was similar to that of controls. Protein analyses showed increased Bcl-2 expression before transplantation. At 1 year post-AHSCT, expression of Bak, Bim, Bcl-2, Bcl-xL and cFlip-L was decreased when compared to baseline values. In summary, our findings suggest that normalization of apoptosis-related molecules is associated with the early therapeutic effects of AHSCT in MS patients. These mechanisms may be involved in the re-establishment of immune tolerance during the first 2 years post-transplantation.
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Affiliation(s)
- G L V de Oliveira
- Department of Clinical, Toxicological and Bromatological Analysis, Faculty of Pharmaceutical Sciences of Ribeirão Preto, São Paulo, Brazil.,Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, School of Medicine of Ribeirão Preto, São Paulo, Brazil, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - A F Ferreira
- Department of Clinical, Toxicological and Bromatological Analysis, Faculty of Pharmaceutical Sciences of Ribeirão Preto, São Paulo, Brazil.,Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, School of Medicine of Ribeirão Preto, São Paulo, Brazil, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - E P L Gasparotto
- Department of Clinical, Toxicological and Bromatological Analysis, Faculty of Pharmaceutical Sciences of Ribeirão Preto, São Paulo, Brazil
| | - S Kashima
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, School of Medicine of Ribeirão Preto, São Paulo, Brazil, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - D T Covas
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, School of Medicine of Ribeirão Preto, São Paulo, Brazil, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil.,Department of Clinical Medicine, School of Medicine of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - C T Guerreiro
- Department of Clinical Medicine, School of Medicine of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - D G Brum
- Department of Neurology, Psicology and Psiquiatry, School of Medicine of Botucatu, University of State of São Paulo (UNESP), Botucatu
| | - A A Barreira
- Department of Clinical Medicine, School of Medicine of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - J C Voltarelli
- Department of Clinical, Toxicological and Bromatological Analysis, Faculty of Pharmaceutical Sciences of Ribeirão Preto, São Paulo, Brazil.,Department of Clinical Medicine, School of Medicine of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - B P Simões
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, School of Medicine of Ribeirão Preto, São Paulo, Brazil, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil.,Department of Clinical Medicine, School of Medicine of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - M C Oliveira
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, School of Medicine of Ribeirão Preto, São Paulo, Brazil, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil.,Department of Clinical Medicine, School of Medicine of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - F A de Castro
- Department of Clinical, Toxicological and Bromatological Analysis, Faculty of Pharmaceutical Sciences of Ribeirão Preto, São Paulo, Brazil
| | - K C R Malmegrim
- Department of Clinical, Toxicological and Bromatological Analysis, Faculty of Pharmaceutical Sciences of Ribeirão Preto, São Paulo, Brazil.,Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, School of Medicine of Ribeirão Preto, São Paulo, Brazil, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
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Arruda LCM, de Azevedo JTC, de Oliveira GLV, Scortegagna GT, Rodrigues ES, Palma PVB, Brum DG, Guerreiro CT, Marques VD, Barreira AA, Covas DT, Simões BP, Voltarelli JC, Oliveira MC, Malmegrim KCR. Immunological correlates of favorable long-term clinical outcome in multiple sclerosis patients after autologous hematopoietic stem cell transplantation. Clin Immunol 2016; 169:47-57. [PMID: 27318116 DOI: 10.1016/j.clim.2016.06.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/13/2016] [Accepted: 06/13/2016] [Indexed: 12/29/2022]
Abstract
High dose immunosuppression followed by autologous hematopoietic stem cell transplantation (AHSCT) induces prolonged clinical remission in multiple sclerosis (MS) patients. However, how patient immune profiles are associated with clinical outcomes has not yet been completely elucidated. In this study, 37 MS patients were assessed for neurological outcomes, thymic function and long-term immune reconstitution after AHSCT. Patients were followed for a mean (SD) of 68.5 (13.9) months post-transplantation and were retrospectively clustered into progression- and non-progression groups, based on Expanded Disease Status Scale (EDSS) outcomes at last visit. After AHSCT, both patient groups presented increased regulatory T-cell subset counts, early expansion of central- and effector-memory CD8(+)T-cells and late thymic reactivation. However, the non-progression group presented early expansion of PD-1(+)CD8(+)T-cells and of PD-1-expressing CD19(+) B-cells. Here, we suggest that along with increased numbers of regulatory T-cell subsets, PD-1 inhibitory signaling is one possible immunoregulatory mechanism by which AHSCT restores immune tolerance in MS patients.
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Affiliation(s)
- Lucas C M Arruda
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Júlia T C de Azevedo
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Gislane L V de Oliveira
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Gabriela T Scortegagna
- Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Evandra S Rodrigues
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Patrícia V B Palma
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Doralina G Brum
- Department of Neuroscience and Behavioral Science, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Department of Neurology, Psychology and Psychiatry, School of Medicine of Botucatu, Universidade Estadual Paulista, UNESP, Botucatu, Brazil
| | - Carlos T Guerreiro
- Department of Neuroscience and Behavioral Science, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Vanessa D Marques
- Department of Neuroscience and Behavioral Science, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Amilton A Barreira
- Department of Neuroscience and Behavioral Science, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Dimas T Covas
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Belinda P Simões
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Júlio C Voltarelli
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Maria Carolina Oliveira
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Kelen C R Malmegrim
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Department of Clinical, Toxicological and Bromatological Analysis, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil.
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Abstract
Multiple sclerosis (MS) is an autoimmune disease of the central nervous system and represents a major cause of disability in young adults. Nowadays, the dichotomy between demyelination and neurodegeneration has been challenged, and both processes are believed to occur independently early in the disease process. ‘Relapsing-remitting’ MS is the most common subtype which generally shifts to a ‘secondary progressive’ form; MS progression is usually accompanied by a worsening of the motor, cognitive and emotional symptoms, as well as an increase in the disability level. Primary progressive MS represents a third subtype with severe disability scores, poor prognosis, and usually symptomatic management. In this perspective, an ideal therapy should have immunomodulatory, neuroprotective, regenerative and remyelinating potentials. Here, we discuss the promising abilities of stem cells therapies in patients with MS. The available data are tackled aiming to overcome the previously faced limitations and pave the way for larger scale randomized and controlled studies.
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Affiliation(s)
- Samar S Ayache
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil, France; Service de Physiologie - Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique - Hôpitaux de Paris, France; Neurology Division, University Medical Center Rizk Hospital, Beirut, Lebanon
| | - Moussa A Chalah
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil, France; Service de Physiologie - Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique - Hôpitaux de Paris, France
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Currò D, Mancardi G. Autologous hematopoietic stem cell transplantation in multiple sclerosis: 20 years of experience. Neurol Sci 2016; 37:857-65. [DOI: 10.1007/s10072-016-2564-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 03/17/2016] [Indexed: 12/29/2022]
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Meamar R, Nematollahi S, Dehghani L, Mirmosayyeb O, Shayegannejad V, Basiri K, Tanhaei AP. The role of stem cell therapy in multiple sclerosis: An overview of the current status of the clinical studies. Adv Biomed Res 2016; 5:46. [PMID: 27110543 PMCID: PMC4817403 DOI: 10.4103/2277-9175.178791] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 08/19/2014] [Indexed: 01/01/2023] Open
Abstract
The complexity of multiple sclerosis (MS) and the incompetence of a large number of promised treatments for MS urge us to plan new and more effective therapeutic approaches that aim to suppress ongoing autoimmune responses and induction of local endogenous regeneration. Emerging data propose that hematopoietic, mesenchymal, and neural stem cells have the potential to restore self-tolerance, provide in situ immunomodulation and neuroprotection, as well as promote regeneration. Thus, in this article, we will first provide an overview of the cell sources for proposed mechanisms that contribute to the beneficial effects of stem cell transplantation, the ideal route and/or timing of stem cell-based therapies for each main stem cell group, and finally, an overview of the current status of stem cell research in clinical trial stages in MS by comparable and healthy therapeutic effects of different stem cell therapies for MS patients.
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Affiliation(s)
- Rokhsareh Meamar
- Department of Medical Sciences, Islamic Azad University, Najafabad Branch, Tehran, Iran
- Isfahan Neurosciences Research Center, Al Zahra Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahrzad Nematollahi
- PhD Candidate in Epidemiology, School of Public Health and Institute of Public Health Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Dehghani
- Department of Medical Sciences, Islamic Azad University, Najafabad Branch, Tehran, Iran
- Isfahan Neurosciences Research Center, Al Zahra Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Omid Mirmosayyeb
- Isfahan Neurosciences Research Center, Al Zahra Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahid Shayegannejad
- Isfahan Neurosciences Research Center, Al Zahra Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Keivan Basiri
- Isfahan Neurosciences Research Center, Al Zahra Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Pouya Tanhaei
- Isfahan Neurosciences Research Center, Al Zahra Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Pandit AK, Prasad K, Seth T. Autologous hematopoietic stem cell transplantation in progressive severe multiple sclerosis. Ann Indian Acad Neurol 2015; 18:459-63. [PMID: 26713025 PMCID: PMC4683892 DOI: 10.4103/0972-2327.165482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
UNLABELLED Multiple sclerosis (MS) is a chronic inflammatory disease of central nervous system (CNS), which is disabling and majorly involves younger population. Various available treatments in forms of immunomodulation are not very effective; however, stem cell transplantation seems to be promising in recent literature. The current case report is a novel evidence for autologous hematopoietic stem cell transplantation (HSCT) in progressive MS. CASE SUMMARY A 33 year old male with secondary progressive MS (SPMS), after being failed and/or intolerance to standard approved interferon (IFN) and mitoxantrone therapy, autologous HSCT was administered. At 2years of post-stem cell transplantation follow-up, he has remained stable with some improvement in functional status (Expanded Disability Status Scale (EDSS) reduced by 1.5), with no relapse, no treatment related complications, and no fresh magnetic resonance imaging (MRI) lesions. CONCLUSION Autologous stem cell transplantation may be beneficial in progressive forms of MS, but needs to be tested in well-designed randomized trial.
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Affiliation(s)
- Awadh Kishor Pandit
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Kameshwar Prasad
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Tulika Seth
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
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Autologous bone marrow transplantation for the treatment of multiple sclerosis. Curr Neurol Neurosci Rep 2015; 14:478. [PMID: 25037718 DOI: 10.1007/s11910-014-0478-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system and represents one of the leading causes of neurologic disability in young adults. Current treatments for MS have shown limited efficacy in patients with either a progressive or an aggressive disease course. Hematopoietic stem cell transplantation (HSCT) has been proposed to control or even cure refractory cases of MS. Indeed, HSCT is able to temporarily eradicate the autoreactive cells and to reset the aberrant immune response to self-antigens. In the last decade, owing to the growing experience in selecting the most appropriate patients to transplant and the recent advances in chemotherapeutic and support regimens, the transplant-related mortality of autologous HSCT in MS patients dropped down to 1,3 % and the progression-free survival ranges from 47 % to 100 %. Altogether, these data support autologous HSCT as a possible second-line therapy for refractory MS.
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Long-term outcomes of autologous hematopoietic stem cell transplantation with reduced-intensity conditioning in multiple sclerosis: physician’s and patient’s perspectives. Ann Hematol 2015; 94:1149-57. [DOI: 10.1007/s00277-015-2337-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 02/10/2015] [Indexed: 12/29/2022]
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De Oliveira GLV, De Lima KWA, Colombini AM, Pinheiro DG, Panepucci RA, Palma PVB, Brum DG, Covas DT, Simões BP, De Oliveira MC, Donadi EA, Malmegrim KCR. Bone Marrow Mesenchymal Stromal Cells Isolated from Multiple Sclerosis Patients have Distinct Gene Expression Profile and Decreased Suppressive Function Compared with Healthy Counterparts. Cell Transplant 2015; 24:151-65. [DOI: 10.3727/096368913x675142] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease of the central nervous system, due to an immune reaction against myelin proteins. Multipotent mesenchymal stromal cells (MSCs) present immunosuppressive effects and have been used for the treatment of autoimmune diseases. In our study, gene expression profile and in vitro immunomodulatory function tests were used to compare bone marrow-derived MSCs obtained from MS patients, at pre- and postautologous hematopoietic stem cell transplantation (AHSCT) with those from healthy donors. Patient MSCs comparatively exhibited i) senescence in culture; ii) similar osteogenic and adipogenic differentiation potential; iii) decreased expression of CD105, CD73, CD44, and HLA-A/B/C molecules; iv) distinct transcription at pre-AHSCT compared with control MSCs, yielding 618 differentially expressed genes, including the downregulation of TGFB1 and HGF genes and modulation of the FGF and HGF signaling pathways; v) reduced antiproliferative effects when pre-AHSCT MSCs were cocultured with allogeneic T-lymphocytes; vi) decreased secretion of IL-10 and TGF-β in supernatants of both cocultures (pre- and post-AHSCT MSCs); and vii) similar percentages of regulatory cells recovered after MSC cocultures. The transcriptional profile of patient MSCs isolated 6 months posttransplantation was closer to pre-AHSCT samples than from healthy MSCs. Considering that patient MSCs exhibited phenotypic changes, distinct transcriptional profile and functional defects implicated in MSC immunomodulatory and immunosuppressive activity, we suggest that further MS clinical studies should be conducted using allogeneic bone marrow MSCs derived from healthy donors. We also demonstrated that treatment of MS patients with AHSCT does not reverse the transcriptional and functional alterations observed in patient MSCs.
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Affiliation(s)
- Gislane L. V. De Oliveira
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
- Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Kalil W. A. De Lima
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
- Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Amanda M. Colombini
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Daniel G. Pinheiro
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Rodrigo A. Panepucci
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Patrícia V. B. Palma
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Doralina G. Brum
- Department of Neurology, Psychology and Psychiatry, School of Medicine of Botucatu, University of State of São Paulo (UNESP), Botucatu, São Paulo, Brazil
| | - Dimas T. Covas
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
- Department of Clinical Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Belinda P. Simões
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
- Department of Clinical Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Maria C. De Oliveira
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
- Department of Clinical Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Eduardo A. Donadi
- Department of Clinical Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Kelen C. R. Malmegrim
- Center for Cell-Based Research, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
- Department of Clinical, Toxicological and Bromatological Analysis, Faculty of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
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Arruda LCM, Lorenzi JCC, Sousa APA, Zanette DL, Palma PVB, Panepucci RA, Brum DS, Barreira AA, Covas DT, Simões BP, Silva WA, Oliveira MC, Malmegrim KCR. Autologous hematopoietic SCT normalizes miR-16, -155 and -142-3p expression in multiple sclerosis patients. Bone Marrow Transplant 2014; 50:380-9. [PMID: 25486582 DOI: 10.1038/bmt.2014.277] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 10/17/2014] [Accepted: 10/21/2014] [Indexed: 12/29/2022]
Abstract
Autologous hematopoietic SCT (AHSCT) has been investigated in the past as a therapeutic alternative for multiple sclerosis (MS). Despite advances in clinical management, knowledge about mechanisms involved with clinical remission post transplantation is still limited. Abnormal microRNA and gene expression patterns were described in MS and have been suggested as disease biomarkers and potential therapeutic targets. Here we assessed T- and B-cell reconstitution, microRNAs and immunoregulatory gene expression after AHSCT. Early immune reconstitution was mainly driven by peripheral homeostatic proliferation. AHSCT increased CD4(+)CD25(hi)FoxP3(+) regulatory T-cell counts and expression of CTLA-4 and GITR (glucocorticoid-induced TNFR) on CD4(+)CD25(hi) T cells. We found transient increase in exhausted PD-1(+) T cells and of suppressive CD8(+)CD28(-)CD57(+) T cells. At baseline, CD4(+) and CD8(+) T cells from MS patients presented upregulated miR-16, miR-155 and miR-142-3p and downregulated FOXP3, FOXO1, PDCD1 and IRF2BP2. After transplantation, the expression of FOXP3, FOXO1, PDCD1 and IRF2BP2 increased, reaching control levels at 2 years. Expression of miR-16, miR-155 and miR-142-3p decreased towards normal levels at 6 months post therapy, remaining downregulated until the end of follow-up. These data strongly suggest that AHSCT normalizes microRNA and gene expression, thereby improving the immunoregulatory network. These mechanisms may be important for disease control in the early periods after AHSCT.
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Affiliation(s)
- L C M Arruda
- 1] Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil [2] Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - J C C Lorenzi
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - A P A Sousa
- 1] Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil [2] Division of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK
| | - D L Zanette
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - P V B Palma
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - R A Panepucci
- 1] Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil [2] Division of Hematology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - D S Brum
- Department of Neuroscience and Behavioral Science, Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - A A Barreira
- Department of Neuroscience and Behavioral Science, Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - D T Covas
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - B P Simões
- 1] Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil [2] Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - W A Silva
- Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - M C Oliveira
- 1] Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil [2] Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - K C R Malmegrim
- 1] Center for Cell-based Therapy, Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil [2] Department of Clinical, Toxicological and Bromatological Analyses, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
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Current Role of Chemotherapy and Bone Marrow Transplantation in Multiple Sclerosis. Curr Treat Options Neurol 2014; 17:324. [DOI: 10.1007/s11940-014-0324-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Karussis D, Vaknin-Dembinsky A. Hematopoietic stem cell transplantation in multiple sclerosis: a review of the clinical experience and a report of an international meeting. Expert Rev Clin Immunol 2014; 6:347-52. [DOI: 10.1586/eci.10.7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Karussis D, Petrou P, Vourka-Karussis U, Kassis I. Hematopoietic stem cell transplantation in multiple sclerosis. Expert Rev Neurother 2013; 13:567-78. [PMID: 23621313 DOI: 10.1586/ern.13.36] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
It is widely accepted that the main common pathogenetic pathway in multiple sclerosis (MS) involves an immune-mediated cascade initiated in the peripheral immune system and targeting CNS myelin. Logically, therefore, therapeutic approaches to the disease include modalities aiming at downregulation of the various immune elements that are involved in this immunological cascade. Since the introduction of interferons in 1993, more specific immunoactive drugs have been introduced, but still most of them can, at best, effectively modulate only the early relapsing phases of MS. The more progressed phases of the disease are not efficiently amendable by the existing immunomodulatory drugs. Moreover, localized and compartmentized inflammation in the CNS, which seems to be mostly responsible for the chronic axonal damage and resulting progression of disability, is less affected by the current drugs. A more radical approach to suppress all the inflammation in MS, including that into the CNS, could theoretically be achieved with high-dose immunosuppression using strong cytotoxic medications and resetting of the immune system by hematopoietic stem cell transplantation (HSCT). HSCT, both allogeneic and autologous, has been tried as a novel therapeutic approach in various autoimmune diseases. During the last 15 years several (mostly open) clinical studies evaluated the effect of HSTC on MS patients; the published papers showed that a high proportion of the HSCT-treated MS patients were stabilized, or even improved after the transplantation and have generally indicated a beneficial effect on disease progression. In this review, the rationale of HSCT and the summary of the results of the existing clinical trials are presented. Despite the fact that it is difficult to collectively summarize the results of all the trials, due to lack of uniformity in the conditioning and treatment protocols and of completed controlled studies, these clinical studies have provided a strong 'proof of concept' for HSCT in MS and have significantly contributed to our understanding of the advantages and disadvantages of each approach and HSCT protocol.
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Affiliation(s)
- Dimitrios Karussis
- Department of Neurology, Multiple Sclerosis Center and Laboratory of Neuroimmunology, The Agnes-Ginges Center for Neurogenetics, Hadassah University Hospital, Jerusalem, Ein-Kerem, Israel.
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Pfender N, Saccardi R, Martin R. Autologous hematopoietic stem cell transplantation as a treatment option for aggressive multiple sclerosis. Curr Treat Options Neurol 2013; 15:270-80. [PMID: 23637027 DOI: 10.1007/s11940-013-0234-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OPINION STATEMENT Despite the development of several injectable or oral treatments for relapsing-remitting multiple sclerosis (RRMS), it remains difficult to treat patients with aggressive disease, and many of these continue to develop severe disability. During the last two decades autologous hematopoietic stem cell transplantation (aHSCT) has been explored with the goal to eliminate an aberrant immune system and then re-install a healthy and tolerant one from hematopoietic precursor cells that had been harvested from the patient prior to chemotherapy. Clinical studies have shown that aHSCT is able to completely halt disease activity in the majority of patients with aggressive RRMS. Research on the mechanisms of action supports that aHSCT indeed leads to renewal of a healthy immune system. Below we will summarize important aspects of aHSCT and mention the currently best-examined regimen.
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Affiliation(s)
- Nikolai Pfender
- Neuroimmunology and MS Research, Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland
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Rodrigues MCDO, Hamerschlak N, de Moraes DA, Simões BP, Rodrigues M, Ribeiro AAF, Voltarelli JC. Guidelines of the Brazilian society of bone Marrow transplantation on hematopoietic stem cell transplantation as a treatment for the autoimmune diseases systemic sclerosis and multiple sclerosis. Rev Bras Hematol Hemoter 2013; 35:134-43. [PMID: 23741192 PMCID: PMC3672124 DOI: 10.5581/1516-8484.20130035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 02/27/2013] [Indexed: 12/21/2022] Open
Affiliation(s)
| | | | | | - Belinda Pinto Simões
- Hospital das Clínicas de Ribeirão Preto, Universidade de
São Paulo - USP, Ribeirão Preto, SP, Brazil
| | | | | | - Júlio César Voltarelli
- Hospital das Clínicas de Ribeirão Preto, Universidade de
São Paulo - USP, Ribeirão Preto, SP, Brazil
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Shevchenko JL, Kuznetsov AN, Ionova TI, Melnichenko VY, Fedorenko DA, Kartashov AV, Kurbatova KA, Gorodokin GI, Novik AA. Autologous hematopoietic stem cell transplantation with reduced-intensity conditioning in multiple sclerosis. Exp Hematol 2012; 40:892-8. [DOI: 10.1016/j.exphem.2012.07.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 06/25/2012] [Accepted: 06/27/2012] [Indexed: 12/29/2022]
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41
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Burt RK, Balabanov R, Voltarelli J, Barreira A, Burman J. Autologous hematopoietic stem cell transplantation for multiple sclerosis--if confused or hesitant, remember: 'treat with standard immune suppressive drugs and if no inflammation, no response'. Mult Scler 2012; 18:772-5. [PMID: 22619224 DOI: 10.1177/1352458512442993] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Pasquini MC, Voltarelli J, Atkins HL, Hamerschlak N, Zhong X, Ahn KW, Sullivan KM, Carrum G, Andrey J, Bredeson CN, Cairo M, Gale RP, Hahn T, Storek J, Horowitz MM, McSweeney PA, Griffith LM, Muraro PA, Pavletic SZ, Nash RA. Transplantation for autoimmune diseases in north and South America: a report of the Center for International Blood and Marrow Transplant Research. Biol Blood Marrow Transplant 2012; 18:1471-8. [PMID: 22705497 DOI: 10.1016/j.bbmt.2012.06.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 06/05/2012] [Indexed: 12/29/2022]
Abstract
Hematopoietic cell transplantation (HCT) is an emerging therapy for patients with severe autoimmune diseases (AID). We report data on 368 patients with AID who underwent HCT in 64 North and South American transplantation centers reported to the Center for International Blood and Marrow Transplant Research between 1996 and 2009. Most of the HCTs involved autologous grafts (n = 339); allogeneic HCT (n = 29) was done mostly in children. The most common indications for HCT were multiple sclerosis, systemic sclerosis, and systemic lupus erythematosus. The median age at transplantation was 38 years for autologous HCT and 25 years for allogeneic HCT. The corresponding times from diagnosis to HCT were 35 months and 24 months. Three-year overall survival after autologous HCT was 86% (95% confidence interval [CI], 81%-91%). Median follow-up of survivors was 31 months (range, 1-144 months). The most common causes of death were AID progression, infections, and organ failure. On multivariate analysis, the risk of death was higher in patients at centers that performed fewer than 5 autologous HCTs (relative risk, 3.5; 95% CI, 1.1-11.1; P = .03) and those that performed 5 to 15 autologous HCTs for AID during the study period (relative risk, 4.2; 95% CI, 1.5-11.7; P = .006) compared with patients at centers that performed more than 15 autologous HCTs for AID during the study period. AID is an emerging indication for HCT in the region. Collaboration of hematologists and other disease specialists with an outcomes database is important to promote optimal patient selection, analysis of the impact of prognostic variables and long-term outcomes, and development of clinical trials.
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Affiliation(s)
- Marcelo C Pasquini
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, WI, USA.
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43
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Snowden JA, Saccardi R, Allez M, Ardizzone S, Arnold R, Cervera R, Denton C, Hawkey C, Labopin M, Mancardi G, Martin R, Moore JJ, Passweg J, Peters C, Rabusin M, Rovira M, van Laar JM, Farge D. Haematopoietic SCT in severe autoimmune diseases: updated guidelines of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 2012; 47:770-90. [PMID: 22002489 PMCID: PMC3371413 DOI: 10.1038/bmt.2011.185] [Citation(s) in RCA: 210] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 07/04/2011] [Accepted: 07/04/2011] [Indexed: 12/13/2022]
Abstract
In 1997, the first consensus guidelines for haematopoietic SCT (HSCT) in autoimmune diseases (ADs) were published, while an international coordinated clinical programme was launched. These guidelines provided broad principles for the field over the following decade and were accompanied by comprehensive data collection in the European Group for Blood and Marrow Transplantation (EBMT) AD Registry. Subsequently, retrospective analyses and prospective phase I/II studies generated evidence to support the feasibility, safety and efficacy of HSCT in several types of severe, treatment-resistant ADs, which became the basis for larger-scale phase II and III studies. In parallel, there has also been an era of immense progress in biological therapy in ADs. The aim of this document is to provide revised and updated guidelines for both the current application and future development of HSCT in ADs in relation to the benefits, risks and health economic considerations of other modern treatments. Patient safety considerations are central to guidance on patient selection and HSCT procedural aspects within appropriately experienced and Joint Accreditation Committee of International Society for Cellular Therapy and EBMT accredited centres. A need for prospective interventional and non-interventional studies, where feasible, along with systematic data reporting, in accordance with EBMT policies and procedures, is emphasized.
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Affiliation(s)
- J A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
- Department of Oncology, University of Sheffield, Sheffield, UK
| | - R Saccardi
- Department of Haematology, Careggi University Hospital, Firenze, Italy
| | - M Allez
- Service de Gastroentérologie, INSERM U 662, Hôpital St Louis, Paris, France
| | - S Ardizzone
- Department of Gastroenterology, Sacco University Hospital, Milan, Italy
| | - R Arnold
- Charite Hospital Berlin, Berlin, Germany
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - C Denton
- Centre for Rheumatology, Royal Free and University College Medical School, Hampstead, London, UK
| | - C Hawkey
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - M Labopin
- Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, AP-HP, UPMC Univ Paris 06, Paris, France
| | - G Mancardi
- Department of Neuroscience, Ophthalmology and Genetics, University of Genova, Genova, Italy
| | - R Martin
- Institute for Neuroimmunology and Clinical MS Research, Hamburg, Germany
| | - J J Moore
- St Vincent's Hospital, Sydney, NSW, Australia
| | - J Passweg
- Universitaetsspital Basel, Basel, Switzerland
| | - C Peters
- BMT Unit, St Anna Children's Hospital, Vienna, Austria
| | - M Rabusin
- BMT Unit, Department of Pediatrics, Institute of Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - M Rovira
- SCT Unit, Hematology Department, Hospital Clinic, Barcelona, Spain
| | | | - D Farge
- Department of Internal Medicine, INSERM U 796, Hôpital St Louis, Paris, France
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44
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Autologous hematopoietic stem cell transplantation for autoimmune disease--is it now ready for prime time? Biol Blood Marrow Transplant 2012; 18:S177-83. [PMID: 22226104 DOI: 10.1016/j.bbmt.2011.11.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Current systemic therapies are rarely curative for patients with severe life-threatening forms of autoimmune disease (AID). During the past 15 years, autologous hematopoietic stem cell transplantation (HCT) has been demonstrated to cure some patients with severe AID refractory to all other available therapies, and thus AID has become an emerging indication for cell therapy. The sustained clinical effects after autologous HCT are better explained by qualitative change in the reconstituted immune repertoire rather than transient depletion of immune cells. Since 1996, more than 1300 AID patients have been registered by the European Group for Blood and Marrow Transplantation (EBMT) and almost 500 patients by the Center for International Blood and Marrow Transplant Research (CIBMTR). Autologous HCT is most commonly performed for patients with multiple sclerosis (MS) or systemic sclerosis (SSc). Systemic lupus, Crohn's disease, type I diabetes, and juvenile idiopathic arthritis are other common indications. Allogeneic transplants are still considered too toxic for use in AID, except for cases of immune cytopenia. Although biologic therapies have been effective at controlling the manifestations of the disease, they require continuous administration, thus raising questions about their increasing costs, morbidity, and mortality related to prolonged therapy. Perhaps it is a reasonable time to ask, "Is autologous HCT for severe AID now ready for prime time?" Yet, the paucity of controlled studies, the short-term toxicities, and the upcoming availability of second-generation biologic and targeted immunotherapies argues that perhaps HCT for AID should be still limited to clinical trials. In this article, we focus on the results of autologous HCT for MS and SSc because these are the two most commonly transplanted diseases. The promising data that is emerging may establish these diseases as standard indications for HCT.
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Saccardi R, Freedman MS, Sormani MP, Atkins H, Farge D, Griffith LM, Kraft G, Mancardi GL, Nash R, Pasquini M, Martin R, Muraro PA. A prospective, randomized, controlled trial of autologous haematopoietic stem cell transplantation for aggressive multiple sclerosis: a position paper. Mult Scler 2012; 18:825-34. [PMID: 22383228 PMCID: PMC3389500 DOI: 10.1177/1352458512438454] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Haematopoietic stem cell transplantation (HSCT) has been tried in the last 15 years as a therapeutic option in patients with poor-prognosis autoimmune disease who do not respond to conventional treatments. Worldwide, more than 600 patients with multiple sclerosis (MS) have been treated with HSCT, most of them having been recruited in small, single-centre, phase 1–2 uncontrolled trials. Clinical and magnetic resonance imaging outcomes from case series reports or Registry-based analyses suggest that a major response is achieved in most patients; quality and duration of response are better in patients transplanted during the relapsing–remitting phase than in those in the secondary progressive stage. Objectives: An interdisciplinary group of neurologists and haematologists has been formed, following two international meetings supported by the European and American Blood and Marrow Transplantation Societies, for the purpose of discussing a controlled clinical trial, to be designed within the new scenarios of evolving MS treatments. Conclusions: Objectives of the trial, patient selection, transplant technology and outcome assessment were extensively discussed. The outcome of this process is summarized in the present paper, with the goal of establishing the background and advancing the development of a prospective, randomized, controlled multicentre trial to assess the clinical efficacy of HSCT for the treatment of highly active MS.
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Affiliation(s)
- R Saccardi
- Hematology Department, Careggi University Hospital, Florence, Italy.
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46
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Gosselin D, Rivest S. Immune mechanisms underlying the beneficial effects of autologous hematopoietic stem cell transplantation in multiple sclerosis. Neurotherapeutics 2011; 8:643-9. [PMID: 21904792 PMCID: PMC3250285 DOI: 10.1007/s13311-011-0062-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
A recent phase I/II clinical trial drew serious attention to the therapeutic potential of autologous hematopoietic stem cell transplantation (AHSCT) in multiple sclerosis. However, questions were raised as to whether these beneficial effects should be attributed to the newly reconstituted immune system per se, or to the lymphoablative conditioning regimen-induced immunosuppression, given that T-cell depleting combinational drug therapies were used in the study. We discuss here the possibility that both AHSCT and T-cell depleting therapies may re-program alternatively the immune system, and why transplantation of CD34+ hematopoietic stem cells may offer AHSCT a possible advantage regarding long-term remission.
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Affiliation(s)
- David Gosselin
- Laboratory of Endocrinology and Genomics, CHUQ Research Center and Department of Molecular Medicine, Faculty of Medicine, Laval University, Québec, Canada G1V 4G2
| | - Serge Rivest
- Laboratory of Endocrinology and Genomics, CHUQ Research Center and Department of Molecular Medicine, Faculty of Medicine, Laval University, Québec, Canada G1V 4G2
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Recent progress in cell therapy for basal ganglia disorders with emphasis on menstrual blood transplantation in stroke. Neurosci Biobehav Rev 2011; 36:177-90. [PMID: 21645544 DOI: 10.1016/j.neubiorev.2011.05.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 04/25/2011] [Accepted: 05/20/2011] [Indexed: 12/13/2022]
Abstract
Cerebrovascular diseases are the third leading cause of death and the primary cause of long-term disability in the United States. The only approved therapy for stroke is tPA, strongly limited by the short therapeutic window and hemorrhagic complications, therefore excluding most patients from its benefits. Parkinson's and Huntington's disease are the other two most studied basal ganglia diseases and, as stroke, have very limited treatment options. Inflammation is a key feature in central nervous system disorders and it plays a dual role, either improving injury in early phases or impairing neural survival at later stages. Stem cells can be opportunely used to modulate inflammation, abrogate cell death and, therefore, preserve neural function. We here discuss the role of stem cells as restorative treatments for basal ganglia disorders, including Parkinson's disease, Huntington's disease and stroke, with special emphasis to the recently investigated menstrual blood stem cells. We highlight the availability, proliferative capacity, pluripotentiality and angiogenic features of these cells and explore their present and future experimental and clinical applications.
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Abstract
PURPOSE OF REVIEW Immunomodulatory medications for multiple sclerosis provide only modest control of this potentially debilitating auto-immune disease of the central nervous system. The immunosuppression provided by high-dose chemotherapy has been studied to address treatment-refractory disease. In this review, we discuss the recent significant work in this field and its associated controversies. RECENT FINDINGS Conclusive evidence for the efficacy of high-dose chemotherapy with stem cell rescue is lacking given the lack of uniform patient populations and varying treatment protocols. Moreover, the significant toxicity associated with this procedure has dampened enthusiasm for its widespread use. High-dose chemotherapy without stem cell rescue has been trialed as a less toxic approach that eliminates the possibility of re-infusing autoreactive lymphocytes found in the stem cell product. SUMMARY Before high-dose chemotherapy with or without stem cell rescue can be adopted for clinical practice, both approaches require testing in randomized clinical trials. Both procedures have the possibility of decreasing disease activity but high-dose chemotherapy without stem cell rescue having a more favorable safety profile, may prove a more significant advance in the field of high-dose therapy for multiple sclerosis.
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Current world literature. Curr Opin Oncol 2011; 23:227-34. [PMID: 21307677 DOI: 10.1097/cco.0b013e328344b687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Multiple sclerosis (MS) is the leading autoimmune indication for autologous hematopoietic SCT (aHSCT). Patient selection criteria and transplant interventions have been refined through a series of cohort and registry studies. High- and low-intensity chemotherapy-based conditioning regimens have been used, creating trade-offs between toxicity and effectiveness. TBI has been associated with greater toxicity and poor outcomes. aHSCT stops MS relapses and lessens the disability in malignant MS, which otherwise rapidly incapacitates patients. Better responses occur in progressive MS earlier in the disease when it has a more inflammatory nature. aHSCT prevents further disability in many patients, but some actually recover from their infirmities. Current regimens and supportive care result in very low morbidity and mortality. MS patients experience unique complications in addition to the expected toxicities. Cytokines used alone for stem-cell mobilization may induce MS flares but are safe to be used in combination with steroids or cytotoxic agents. Urinary tract infections, herpes virus reactivation and an engraftment syndrome may occur early after aHSCT. Rarely secondary autoimmune diseases have been reported late after HSCT. Increasing experience in caring for patients with MS has reduced the frequency and severity of toxicity. Conceived as an opportunity to 'reboot' a tolerant immune system, aHSCT is successful in treating patients with MS that is refractory to conventional immunomodulatory drugs.
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