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Longhurst HJ, Tarzi MD, Ashworth F, Bethune C, Cale C, Dempster J, Gompels M, Jolles S, Seneviratne S, Symons C, Price A, Edgar D. C1 inhibitor deficiency: 2014 United Kingdom consensus document. Clin Exp Immunol 2015; 180:475-83. [PMID: 25605519 PMCID: PMC4449776 DOI: 10.1111/cei.12584] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2014] [Indexed: 12/18/2022] Open
Abstract
C1 inhibitor deficiency is a rare disorder manifesting with recurrent attacks of disabling and potentially life-threatening angioedema. Here we present an updated 2014 United Kingdom consensus document for the management of C1 inhibitor-deficient patients, representing a joint venture between the United Kingdom Primary Immunodeficiency Network and Hereditary Angioedema UK. To develop the consensus, we assembled a multi-disciplinary steering group of clinicians, nurses and a patient representative. This steering group first met in 2012, developing a total of 48 recommendations across 11 themes. The statements were distributed to relevant clinicians and a representative group of patients to be scored for agreement on a Likert scale. All 48 statements achieved a high degree of consensus, indicating strong alignment of opinion. The recommendations have evolved significantly since the 2005 document, with particularly notable developments including an improved evidence base to guide dosing and indications for acute treatment, greater emphasis on home therapy for acute attacks and a strong focus on service organization.
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Affiliation(s)
- H J Longhurst
- Department of Immunology, Barts Health NHS Trust and Medical Adviser HAE, UK
| | - M D Tarzi
- Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - F Ashworth
- Department of Immunology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - C Bethune
- Department of Immunology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - C Cale
- Department of Immunology, Great Ormond Street Hospital for Children, London, UK
| | - J Dempster
- Department of Immunology, Barts Health NHS Trust and Medical Adviser HAE, UK
| | - M Gompels
- Department of Immunology, North Bristol NHS Trust, Bristol, UK
| | - S Jolles
- Department of Immunology, University Hospital of Wales, Cardiff, UK
| | - S Seneviratne
- Department of Immunology, Royal Free London NHS Trust, London, UK
| | - C Symons
- Department of Immunology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - A Price
- Herditary Angioedema, UK (HAE UK)
| | - D Edgar
- UK Primary Immunodeficiency Network (UK PIN), Newcastle upon Tyne, UK
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Shah T, Cale C, Hadzic N, Jones A. Dedicator of cytokinesis 8 deficiency: a predisposition to sclerosing cholangitis. Clin Immunol 2014; 155:71-73. [PMID: 25220305 DOI: 10.1016/j.clim.2014.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 08/19/2014] [Accepted: 09/01/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Tejshri Shah
- Immunology Department, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK.
| | - Catherine Cale
- Immunology Department, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK.
| | - Nedim Hadzic
- Paediatric Centre for Hepatology, Gastroenterology and Nutrition, King's College Hospital, Denmark Hill, London SE5 9RS, UK.
| | - Alison Jones
- Immunology Department, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK.
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Titman P, Allwood Z, Gilmour C, Malcolmson C, Duran-Persson C, Cale C, Davies G, Gaspar H, Jones A. Quality of life in children with primary antibody deficiency. J Clin Immunol 2014; 34:844-52. [PMID: 25005831 PMCID: PMC4165866 DOI: 10.1007/s10875-014-0072-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 06/20/2014] [Indexed: 01/25/2023]
Abstract
Primary antibody deficiency disorders (PADs) can have an excellent outlook if diagnosed early and treated appropriately, but require lifelong treatment with immunoglobulin replacement. Some carry risks of inflammatory complications even with optimal treatment. Quality of life (QoL) and the psychological impact of PADs has been relatively little studied, particularly in children. The purpose of this study was to evaluate QoL and psychological impact in a large group of children affected by a range of PADs, as well as a group with transient hypogammaglobulinemia of infancy (THI). Both parental and, where appropriate, child ratings, were collected using standardised questionnaires (PedsQL and SDQ). Higher rates of psychological difficulties, particularly emotional and peer-relationship difficulties were found in children with PAD when compared with healthy controls. Quality of life was poorer than in healthy controls, and also worse than in children affected by diabetes mellitus. Variations in QoL and the degree of psychological difficulties were found between specific diagnostic groups, with children affected by THI being amongst those with the lowest scores for QoL. Further studies are needed to corroborate and extend these findings, but this study confirms previous findings that primary antibody deficiency has a significant impact on quality of life and psychological well-being, and additionally suggests that the impact varies according to severity of the underlying condition. For those with significant difficulties psychological intervention at an early stage may be beneficial.
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Affiliation(s)
- P Titman
- Immunology Department, Great Ormond Street Hospital, London, WC1N 3JH, United Kingdom
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Hassan A, Lee P, Maggina P, Xu JH, Moreira D, Slatter M, Nademi Z, Worth A, Adams S, Jones A, Cale C, Allwood Z, Rao K, Chiesa R, Amrolia P, Gaspar H, Davies EG, Veys P, Gennery A, Qasim W. Host natural killer immunity is a key indicator of permissiveness for donor cell engraftment in patients with severe combined immunodeficiency. J Allergy Clin Immunol 2014; 133:1660-6. [PMID: 24794685 PMCID: PMC4048544 DOI: 10.1016/j.jaci.2014.02.042] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 02/21/2014] [Accepted: 02/25/2014] [Indexed: 12/27/2022]
Abstract
Background Severe combined immunodeficiency (SCID) can be cured by using allogeneic hematopoietic stem cell transplantation, and the absence of host immunity often obviates the need for preconditioning. Depending on the underlying genetic defect and when blocks in differentiation occur during lymphocyte ontogeny, infants with SCID have absent or greatly reduced numbers of functional T cells. Natural killer (NK) cell populations are usually absent in the SCID-X1 and Janus kinase 3 forms of SCID and greatly reduced in adenosine deaminase deficiency SCID but often present in other forms of the disorder. Objective To determine if SCID phenotypes indicate host permissiveness to donor cell engraftment. Methods A retrospective data analysis considered whether host NK cells influenced donor T-cell engraftment, immune reconstitution, and long-term outcomes in children who had undergone nonconditioned allogeneic stem cell transplantation between 1990 and 2011 in the United Kingdom. Detailed analysis of T- and B-cell immune reconstitution and donor chimerism was compared between the NK+ (n = 24) and NK− (n = 53) forms of SCID. Results Overall, 77 children underwent transplantation, with survival of 90% in matched sibling donor/matched family donor transplants compared with 60% when alternative donors were used. Infants with NK−SCID were more likely to survive than NK+ recipients (87% vs 62%, P < .01) and had high-level donor T-cell chimerism with superior long-term recovery of CD4 T-cell immunity. Notably, 33% of children with NK+SCID required additional transplantation procedures compared with only 8% of children with NK−SCID (P < .005). Conclusions NK−SCID disorders are highly permissive for donor T-cell engraftment without preconditioning, whereas the presence of NK cells is a strong indicator that preparative conditioning is required for engraftment of T-cell precursors capable of supporting robust T-cell reconstitution.
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Affiliation(s)
- Amel Hassan
- Immunology and Bone Marrow Transplant Units, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Pamela Lee
- Cellular & Molecular Immunology, Institute of Child Health, University College London, London, United Kingdom
| | - Paraskevi Maggina
- Bone Marrow Transplant Unit, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Jin Hua Xu
- Immunology and Bone Marrow Transplant Units, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Diana Moreira
- Bone Marrow Transplant Unit, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Mary Slatter
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, United Kingdom
| | - Zohreh Nademi
- Bone Marrow Transplant Unit, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Austen Worth
- Immunology and Bone Marrow Transplant Units, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Stuart Adams
- Immunology and Bone Marrow Transplant Units, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Alison Jones
- Immunology and Bone Marrow Transplant Units, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Catherine Cale
- Immunology and Bone Marrow Transplant Units, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Zoe Allwood
- Immunology and Bone Marrow Transplant Units, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Kanchan Rao
- Immunology and Bone Marrow Transplant Units, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Robert Chiesa
- Immunology and Bone Marrow Transplant Units, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Persis Amrolia
- Cellular & Molecular Immunology, Institute of Child Health, University College London, London, United Kingdom
| | - Hubert Gaspar
- Cellular & Molecular Immunology, Institute of Child Health, University College London, London, United Kingdom
| | - E Graham Davies
- Cellular & Molecular Immunology, Institute of Child Health, University College London, London, United Kingdom
| | - Paul Veys
- Immunology and Bone Marrow Transplant Units, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Andrew Gennery
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, United Kingdom
| | - Waseem Qasim
- Cellular & Molecular Immunology, Institute of Child Health, University College London, London, United Kingdom.
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Affiliation(s)
| | | | | | | | - Paul Brogan
- UCL Institute of Child Health; London United Kingdom
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Hiwarkar P, Gaspar HB, Gilmour K, Jagani M, Chiesa R, Bennett-Rees N, Breuer J, Rao K, Cale C, Goulden N, Davies G, Amrolia P, Veys P, Qasim W. Impact of viral reactivations in the era of pre-emptive antiviral drug therapy following allogeneic haematopoietic SCT in paediatric recipients. Bone Marrow Transplant 2012. [PMID: 23178547 DOI: 10.1038/bmt.2012.221] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
While pre-emptive rituximab therapy for EBV has substantially reduced the incidence of post-transplant lymphoproliferative disorder, following allogeneic haematopoietic SCT (HSCT), cytomegalovirus (CMV) and adenovirus (ADV) still contribute to significant morbidity and mortality after HSCT. We therefore aimed to identify high-risk children who could benefit from recent advances in virus-specific immunotherapy, define the impact of viral reactivations on survival and estimate the economic burden of pre-emptive antiviral drug therapy. Between 2005 and 2010, prospective monitoring of 291 paediatric HSCT procedures revealed that reactivation of CMV (16%), ADV (15%) and EBV (11%) was frequent during period of CD4 T-cell lymphopenia (0.15 × 10(9) L(-1); P<0.05). We report significant risk factors for reactivation, most notably the use of serotherapy and development of GVHD (grade II) in the presence of pre-existing infection (ADV) or donor and/or recipient seropositivity (CMV, EBV). Most interestingly, CMV and ADV viraemia were the major independent predictors of mortality (P<0.05). CMV, ADV or EBV viral reactivation caused prolonged hospitalization (P<0.05), accounted for 15% of all mortality and substantially increased the cost of transplantation by ∼£22 500 ($34 000). This provides an economic rationale for targeting high-risk HSCT recipients with interventions such as virus-specific cell therapy.
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Affiliation(s)
- P Hiwarkar
- Molecular Immunology Unit, Institute of Child Health London, UK.
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Chiesa R, Gilmour K, Qasim W, Adams S, Worth AJJ, Zhan H, Montiel-Equihua CA, Derniame S, Cale C, Rao K, Hiwarkar P, Hough R, Saudemont A, Fahrenkrog CS, Goulden N, Amrolia PJ, Veys P. Omission of in vivo T-cell depletion promotes rapid expansion of naïve CD4+ cord blood lymphocytes and restores adaptive immunity within 2 months after unrelated cord blood transplant. Br J Haematol 2012; 156:656-66. [PMID: 22224700 DOI: 10.1111/j.1365-2141.2011.08994.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Umbilical cord blood transplant (UCBT) is associated with impaired early immune reconstitution. This might be explained by a lower T-cell dose infused, the naivety of cord blood T-cells and the use of in vivo T-cell depletion. We studied the pattern of early immune reconstitution and the clinical outcome of children undergoing unrelated UCBT when in vivo T-cell depletion was omitted. Thirty children affected by malignancies (46%) or immunodeficiencies (54%) underwent an unrelated UCBT. Prospective assessment of immune reconstitution and clinical outcome was performed. We observed an unprecedented CD4(+) T-cell reconstitution, with a median cell count at 30 and 60 d post UCBT of 0.3 × 10(9) /l and 0.56 × 10(9) /l, respectively. Early T-cell expansion was thymic-independent, with a rapid shift from naïve to central memory phenotype and early regulatory T-cell recovery. Viral infections were frequent (63%) but resolved rapidly in most cases and virus-specific T-lymphocytes were detected within 2 months post-UCBT. Acute graft-versus-host disease (GvHD) was frequent (grade II = 34%, grade III-IV = 16%) but steroid responsive, and the incidence of chronic GvHD was low (14%). The omission of in vivo T-cell depletion promotes a unique thymic-independent CD4(+) T-cell reconstitution after unrelated UCBT in children. We postulate that this relates to the specific immunological and ontological qualities of fetal-derived lymphocytes.
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Affiliation(s)
- Robert Chiesa
- Bone Marrow Transplantation Department, Great Ormond Street Hospital, London, UK
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Kampmann B, Cubitt D, Walls T, Naik P, Depala M, Samarasinghe S, Robson D, Hassan A, Rao K, Gaspar H, Davies G, Jones A, Cale C, Gilmour K, Real M, Foo M, Bennett-Rees N, Hewitt A, Amrolia P, Veys P. Improved outcome for children with disseminated adenoviral infection following allogeneic stem cell transplantation. Br J Haematol 2005; 130:595-603. [PMID: 16098075 DOI: 10.1111/j.1365-2141.2005.05649.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Adenovirus (AdV) infections are a frequent cause of morbidity and mortality following allogeneic stem cell transplantation (SCT), and disseminated infection is associated with high mortality, particularly in paediatric SCT. Here, we describe an approach to reduce mortality from adenoviraemia by combining prospective monitoring for the occurrence of adenoviraemia using a sensitive polymerase chain reaction method, early antiviral therapy and prompt withdrawal of immunosuppression. A total of 155 consecutive paediatric SCT procedures were prospectively monitored, of which 113 (73%) transplants involved donors other than matched siblings and 126 (83%) employed T-cell depletion. Adenoviraemia was detected in 26/155 (17%) transplants and developed exclusively in patients who had received T-cell-depleted grafts. Withdrawal of immunosuppression coupled with early antiviral therapy led to resolution of adenoviraemia in 19/26 (81%) patients with only five patients succumbing to disseminate AdV infection. Survival from adenoviraemia was associated with lymphocyte recovery to above 0.3x10(9)/l. Mortality was closely linked with the absence of lymphocyte recovery because of profound T-cell depletion of the graft with CD34+ magnetic-activated cell sorting. Mortality from disseminated AdV infection was 5/26 (19%) in this study, which is significantly lower than previously reported.
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Affiliation(s)
- B Kampmann
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children NHS Trust, London, UK
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Jentjens RLPG, Cale C, Gutch C, Jeukendrup AE. Effects of pre-exercise ingestion of differing amounts of carbohydrate on subsequent metabolism and cycling performance. Eur J Appl Physiol 2003; 88:444-52. [PMID: 12527976 DOI: 10.1007/s00421-002-0727-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2002] [Indexed: 10/22/2022]
Abstract
Studies on the effect of the pre-exercise ingestion of carbohydrate on metabolism and performance have produced conflicting results, perhaps because of differences in the designs of the studies. The purpose of the present study was to examine the effects of ingesting differing amounts of glucose pre-exercise on the glucose and insulin responses during exercise and on time-trial (TT) performance. Nine well-trained male cyclists completed four exercise trials separated by at least 3 days. At 45 min before the start of exercise subjects consumed 500 ml of a beverage containing either 0 g (PLAC), 25 g (LOW), 75 g (MED) or 200 g (HIGH) of glucose. The exercise trials consisted of 20 min of submaximal steady-state exercise (SS) at 65% of maximal power output immediately followed by a [mean (SEM)] 691 (12) kJ TT. Plasma insulin concentrations at the onset of exercise were significantly higher ( P<0.05) in MED and HIGH compared with LOW and PLAC. Plasma glucose concentration fell rapidly ( P<0.05) during SS exercise in all glucose trials, but remained steady in PLAC. No difference in plasma glucose concentration was observed between the glucose trials at any time. Hypoglycaemia (less than 3.5 mmol.l(-1)) was observed in six subjects during SS but only after ingesting glucose pre-exercise. However, there was no difference in TT performance between the four trials. The ingestion of 0, 25, 75 or 200 g of glucose 45 min before a 20 min submaximal exercise bout did not affect subsequent TT performance. In addition, mild rebound hypoglycaemia following pre-exercise glucose ingestion did not negatively affect performance.
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Affiliation(s)
- R L P G Jentjens
- Human Performance Laboratory, School of Sport and Exercise Sciences, University of Birmingham, Edgbaston, B15 2TT, Birmingham, UK
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Winyard P, Chaudhry B, Cale C. A new college, a new direction in academic paediatrics? Arch Dis Child 1998; 78:399. [PMID: 9623420 PMCID: PMC1717537 DOI: 10.1136/adc.78.4.395h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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