POS0774 ANTI-Sm AUTOANTIBODIES IDENTIFY A PHENOTYPE OF SEVERE SLE WITH AN ASSOCIATED SERUM BIOMARKER PROFILE

Background

Antibodies to Smith (Sm) have been described as one of the most specific autoantibodies for systemic lupus erythematosus (SLE). Other than its association with lupus nephritis, there is, however, limited understanding of its clinical significance1,2.

Objectives

To describe clinical associations and serum protein profiles of anti-Sm positivity in SLE.

Methods

Patients fulfilling SLE classification criteria who were followed longitudinally in a prospective multicentre cohort were studied according to their baseline anti-Sm antibody status. Comparison between Sm+ and Sm- patients was made using descriptive statistics. Clinical associations of Sm positivity with patient disease characteristics were studied using logistic regression. In a subset, 211 serum analytes were measured using Quantibody, Luminex and ELISA assays. Associations between serum proteins and Sm positivity were studied using Least Absolute Shrinkage and Selection Operator (LASSO) penalised regression, adjusting for demographics (age, sex, ethnicity) and medication use

Results

383 patients were studied with median (IQR) follow-up of 4.9 (2,9) years; 65 (17%) had positive anti-Sm antibodies. Sm+ patients were significantly more likely to be of non-European ancestry (OR 2.73, 95% CI 1.55-4.82, p<0.001), and to be positive for anti-dsDNA antibodies (OR 2.8, 95% CI 2.3-3.4, p<0.001), anti-RNP antibodies (OR 15.7, 95% CI 13.9-17.8, p<0.001), direct anti-globulin test (OR 2.36, 95% CI 2.07-2.7, p<0.001) and hypocomplementemia (OR 7.73, 95% CI 5.1-11.7, p<0.001). Sm+ patients were significantly more likely to have active disease during the observation period in a range of organ domains, including mucocutaneous, renal, vasculitis and fever.

More Sm+ patients had episodes of High Disease Activity Status (HDAS, SLEDAI-2K ≧10)3 (OR 3.07, 95% CI 1.70-5.54, p<0.001) and persistent active disease (time-adjusted mean SLEDAI-2K > 4) (OR 3.23. 95% CI 1.84-5.70, p<0.001). Conversely, fewer Sm+ patients attained LLDAS for ≥50% observed time (19.7% vs 41.8%, p=0.002). Sm+ patients were more likely to be treated with glucocorticoids, immunosuppressants, and rituximab. There was no significant difference in damage accrual between Sm + and Sm - patients.

In serum protein analysis (n=197, 29 Sm+), LASSO modelling retained 3 proteins associated with Sm+ status, CXCL13, IL1RL1 and FLT1, along with Asian ethnicity and age. In analysis including pairwise interaction between predictors, 28 Sm+ associated proteins were identified, including CCL4, VCAM1, IL1RL1, Fcg R IIB/C, TDGF1, CEACAM1, TIMP1, BMP5, GDF15, and TNFRSF17.

Conclusion

Anti-Sm autoantibodies, present in 17% of SLE patients, were strongly associated with classical disease manifestations, more severe disease activity, and a specific serological and proteomic profile. These findings suggest anti-Sm+ SLE as a specific disease subset.

References

[1]Barada, FA., B.S. Andrews, J.S. Davis, R.P. Taylor, Antibodies to Sm in patients with systemic lupus erythematosus. Correlation of Sm antibody titers with disease activity and other laboratory parameters. Arthritis Rheum, 1981. 24:1236-1244

[2]Arroyo-Avilla, M, Y. Santiago-Casas, G.McGwin, R.S. Cantor, M. Petri, R. Ramsey-Goldman, J.D. Reveille, R.P.Kimberly, G.S. Alarcon, L.M.Vila, E.E. Brown. Clinical Associations of anti-Smith antibodies in PROFILE: a multi-ethnic lupus cohort. 2015. 34:1217-1223

[3]Koelmeyer, R., H.T. Nim, M. Nikpour, Y.B. Sun, A. Kao, O. Guenther, E. Morand, and A. Hoi, High disease activity status suggests more severe disease and damage accrual in systemic lupus erythematosus. Lupus Sci Med, 2020. 7(1).

Acknowledgements

I would like to acknowledge participants and clinicians involved with the Australian Lupus Registry & Biobank

Disclosure of Interests

None declared

MO215: Intrarenal Single Cell Sequencing of MPO-Anca Associated Glomerulonephritis Patients Reveal Novel Targetable Treatment Options

BACKGROUND AND AIMS

The etiopathogenesis underlying myeloperoxidase anti-neutrophil cytoplasmic antibody-associated glomerulonephritis (MPO-ANCA-GN) remains incompletely understood. Furthermore, there are only limited treatment options and treatment resistance of MPO-ANCA-GN is still a common problem.

METHOD

To identify new targeted treatment options, intrarenal single-cell RNA sequencing (scRNA-seq) was applied to 11 kidney biopsies from MPO-ANCA-GN patients and 2 health kidney tissues to define the transcriptomic landscape at single-cell resolution. Intrarenal scRNAseq was also applied to a pre-clinical mouse model of MPO-ANCA-GN to show that this model of disease can be used to trial new targeted treatments.

RESULTS

We found that kidney endothelial cells in MPO-ANCA-GN patients displayed increased expression of several genes, including CD9 and SPARC, which were closely related to parietal epithelial hyperplasia and crescent formation. NF-κB pathway activation was confirmed in a variety of kidney cells in MPO-ANCA-GN patients. Kidney infiltrating immune cells of MPO-ANCA-GN patients were mainly enriched in inflammatory pathways including TNF signalling, IL-17 signalling and NOD-like receptor signalling. These findings were similar in our pre-clinical mouse model of MPO-ANCA-GN. Furthermore, there was an overexpression of inflammasome-related genes (AIM2, IFI16) in MPO-ANCA-GN patients. Treatment resistance was associated with increased infiltration of CD8+ T cells and elevated expression of SPARC, LAMA4, IL33 and CFL1 in mesangial cells when compared with patients who achieved remission after induction therapy.

CONCLUSION

These results offer new insight into the pathogenesis of MPO-ANCA-GN, treatment resistance and identify new therapeutic targets for MPO-ANCA-GN that can be tested in a pre-clinical model of disease.

1290 A Move to Magseed For Breast Conserving Surgery

Aim

Wire guided localisation(WGL) to localise non-palpable breast tumours has been the standard for years. WGL has limitations; patient discomfort, fixed scheduling to facilitate insertion on the day of surgery and wire migration. A 2015 audit in our department found that 51% of patients undergoing wide local excision (WLE) used preoperative localisation techniques; of which 84% was WGL. The overall re-excision rate for WLE was 27%. We altered our practice to Magseed localisation from July 2019 to improve patient experience, and surgical efficiency, as there are similar outcomes between WGL and Magseed in the literature. This audit aims to examine if there are improvements in our re-excision rate. We aim to evaluate which is the best method for localisation in our department.

Method

A retrospective audit was conducted following registration with the local audit office. Patients who underwent breast conserving surgery between September 2019 and September 2020 were identified. The surgical approach, re-excision and complications were recorded and compared to the 2015 results.

Results

100 patients underwent WLE in the study period. The percentage of patients undergoing therapeutic mammaplasty was 26% (14% in 2015). 63% underwent preoperative localisation; of which 71% used Magseed and 5% used wire. The overall re-excision rate was 20%.

Conclusions

Our re-audit has demonstrated an increase in patients requiring pre-operative localisation, probably due to the use of primary endocrine treatment during COVID-19. We gladly observed 26% improvement in re-excision rates suggesting success with Magseed.

GILZ Regulates the Expression of Pro-Inflammatory Cytokines and Protects Against End-Organ Damage in a Model of Lupus

Glucocorticoid-induced leucine zipper (GILZ) mimics many of the anti-inflammatory effects of glucocorticoids, suggesting it as a point of therapeutic intervention that could bypass GC adverse effects. We previously reported that GILZ down-regulation is a feature of human SLE, and loss of GILZ permits the development of autoantibodies and lupus-like autoimmunity in mice. To further query the contribution of GILZ to protection against autoimmune inflammation, we studied the development of the lupus phenotype in Lyn-deficient (Lyn^-/-) mice in which GILZ expression was genetically ablated. In Lyn^-/- mice, splenomegaly, glomerulonephritis, anti-dsDNA antibody titres and cytokine expression were exacerbated by GILZ deficiency, while other autoantibody titres and glomerular immune complex deposition were unaffected. Likewise, in patients with SLE, GILZ was inversely correlated with IL23A, and in SLE patients not taking glucocorticoids, GILZ was also inversely correlated with BAFF and IL18. This suggests that at the onset of autoimmunity, GILZ protects against tissue injury by modulating pro-inflammatory pathways, downstream of antibodies, to regulate the cycle of inflammation in SLE.

Clinical outcomes of acute stroke thrombolysis in neurologist and non-neurologist centres - A comparative study in Malaysia

BACKGROUND

Thrombolytic therapy with intravenous alteplase is a well-established treatment for acute ischaemic stroke (AIS). However, in Malaysia, treatment prescription is often limited by the availability of neurologists. The objective was to compare the outcomes of acute stroke thrombolysis therapy prescribed by neurologists in the Seberang Jaya Hospital (SJH) and non-neurologists in the Taiping Hospital (TH).

METHODS

In this cross-sectional study, all AIS patients who received thrombolytic therapy in SJH and TH between January 2012 and September 2019 were included. Clinical data was extracted from admission records. The outcomes assessed were the percentage of patients who achieved excellent functional outcome at 3 months (modified Rankin scale of 0 to 1), rates of symptomatic intracranial haemorrhage (SICH), and mortality.

RESULTS

A total of 63 AIS patients who received thrombolytic therapy were included, of which 37 patients (58.7%) were treated in SJH. The median NIHSS on admission was 12 in SJH and 11.5 in TH. In all 21.6% of patients from SJH and 30.7% of patients from TH achieved favourable functional outcome at 3 months (p=0.412). There were no significant differences between the two centres in terms of the rates of SICH (10.8% in SJH and 3.8% in TH, p=0.314) and 3-month mortality (24.3% versus 12.5%, p=0.203).

CONCLUSION

The 3-month functional outcomes and complication rates of stroke thrombolysis in hospitals with or without neurologists are not significantly different. Thus non-neurologist hospitals may be able to provide thrombolysis service to AIS patients safely and effectively.

Treatment of supragastric belching with cognitive behavioral therapy improves quality of life and reduces acid gastroesophageal reflux

OBJECTIVES

Excessive supragastric belching (SGB) manifests as troublesome belching, and can be associated with reflux and significant impact on quality of life (QOL). In some GERD patients, SGB-associated reflux contributes to up to 1/3 of the total esophageal acid exposure. We hypothesized that a cognitive-behavioral intervention (CBT) might reduce SGB, improve QOL, and reduce acid gastroesophageal reflux (GOR). We aimed to assess the effectiveness of CBT in patients with pathological SGB.

METHODS

Patients with SGB were recruited at the Royal London Hospital. Patients attended CBT sessions focused on recognition of warning signals and preventative exercises. Objective outcomes were the number of SGBs, esophageal acid exposure time (AET), and proportion of AET related to SGBs. Subjective evaluation was by patient-reported questionnaires.

RESULTS

Of 51 patients who started treatment, 39 completed the protocol, of whom 31 had a follow-up MII-pH study. The mean number of SGBs decreased significantly after CBT (before: 116 (47-323) vs. after 45 (22-139), P<0.0003). Sixteen of 31 patients were shown to have a reduction in SGB by >50%. In patients with increased AET at baseline, AET after CBT was decreased: 9.0-6.1% (P=0.005). Mean visual analog scale severity scores decreased after CBT (before: 260 (210-320) mm vs. after: 140 (80-210) mm, P<0.0001).

CONCLUSIONS

Cognitive behavioral therapy reduced the number of SGB and improved social and daily activities. Careful analysis of MII-pH allows identification of a subgroup of GERD patients with acid reflux predominantly driven by SGB. In these patients, CBT can reduce esophageal acid exposure.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P &lt; 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

FcγRIIB regulates T cell autoreactivity, ANCA production and neutrophil activation to suppress anti-myeloperoxidase glomerulonephritis (THER5P.834)

Anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis involves innate and adaptive immune cells in the induction of autoimmunity and in autoimmune effector responses. Most Fcγ receptors (FcγRs) activate immune cells, but FcγRIIB, found in humans and mice on B cells and innate cells, is an inhibitory receptor. These studies tested the hypothesis that endogenous FcγRIIB negatively regulates autoreactivity and effector responses in experimental anti-myeloperoxidase (MPO) glomerulonephritis, using wild type and FcγRIIB-/- mice. After MPO immunization, FcγRIIB-/- mice developed higher MPO-ANCA titers and increased anti-MPO T cell responses. Transfer of FcγRIIB deficient dendritic cells loaded with a nephritogenic MPO peptide (MPO409-428) into wild type mice induced stronger autoimmunity than dendritic cells derived from wild type mice. Transferring anti-MPO antibodies into LPS primed mice resulted in increased glomerular neutrophil accumulation and injury in FcγRIIB-/- mice, showing a role for FcγRIIB in suppressing neutrophil activation. Inducing active autoimmunity to MPO followed by triggering T cell mediated glomerular injury by transfer of subnephritogenic doses of LPS and anti-MPO antibodies resulted in more disease in FcγRIIB-/- mice. Therefore endogenous FcγRIIB negatively regulates anti-MPO autoimmunity and glomerulonephritis via dendritic cells, B cells and neutrophils to limit MPO-ANCA production, T cell responses and neutrophil activation.

Acute kidney injury after myeloablative cord blood transplantation in adults: the efficacy of strict monitoring of vancomycin serum trough concentrations

BACKGROUND

Acute kidney injury (AKI) is a common medical complication after myeloablative allogeneic stem cell transplantation (SCT). We have previously performed a retrospective analysis of AKI after cord blood transplantation (CBT) in adults, and found that the maximum of vancomycin (VCM) trough levels were significantly higher in patients with AKI. Following these results, we have monitored VCM serum trough concentrations more strictly, to not exceed 10.0 mg/L, since 2008.

METHODS

In this report, we performed an analysis of AKI in a new group of 38 adult patients with hematological malignancies treated with unrelated CBT after myeloablative conditioning between January 2008 and July 2011.

RESULTS

Cumulative incidence of AKI at day 100 after CBT was 34% (95% confidence interval 19-50). The median of the maximum value of VCM trough was 8.8 (4.5-12.2) mg/L. In multivariate analysis, no factor was associated with the incidence of AKI. No transplant-related mortality was observed. The probability of disease-free survival at 2 years was 83%.

CONCLUSION

These findings suggest that strict monitoring of VCM serum trough concentrations has a beneficial effect on outcomes of CBT.

The immunodominant CD4+ T cell epitope of myeloperoxidase induces cell mediated injury in murine anti-myeloperoxidase glomerulonephritis (159.14)

Microscopic polyangiitis, characterized by pathogenic autoantibodies to neutrophil cytoplasmic proteins (ANCA), including myeloperoxidase (MPO), frequently targets the glomerulus. Although the pathogenicity of ANCA has been established, the role of CD4+ cells, cell mediated effector responses and MPO T cell epitopes are not known. By screening overlapping peptides of 20aa spanning the entire MPO molecule, we identified an immunodominant MPO CD4+ cell epitope (MPO409-428). Immunization with MPO409-428 induced disease similar to that seen with whole MPO when disease was triggered with anti-glomerular basement membrane antibodies. A CD4+ MPO409-428 specific clone transferred into Rag1-/- mice induced necrotizing glomerulonephritis with renal impairment when MPO409-428 was planted in glomeruli, or when whole MPO was deposited in glomeruli after neutrophil recruitment induced by transfer of anti-MPO antibodies with LPS. MPO409-428 also induced biologically active anti-MPO antibodies in mice. The MPO409-428 T cell epitope has a minimum immunogenic core region of 11 aa, MPO415-426, with several critical residues. These studies identify an immunodominant MPO T cell epitope and redefine how effector responses induce injury in MPO-ANCA associated microscopic polyangiitis. ANCA activate neutrophils not only induce injury, but also lodge the autoantigen MPO in glomeruli, where autoreactive CD4+ cells act to induce delayed-type hypersensitivity like necrotizing glomerular lesions.

Cell mediated injury in autoimmune anti-glomerular basement membrane disease is defined by a critical T cell epitope in humanized mice (123.33)

Human anti-glomerular basement membrane (GBM) disease has strong associations with HLA DRB1*1501. The target autoantigen is the non-collagenous domain of the α3 chain of Type IV collagen, α3(IV)NC1. T cell epitopes of α3(IV)NC1 were identified by immunizing mouse MHC-/-, HLA DRB1*1501 transgenic (1501tg) mice with overlapping 20mers. They defined a HLA DRB1*1501 restricted epitope (aa128-147) not reactive in HLA DRB1*0101 transgenic (0101tg) or C57BL/6 mice. 1501tg mice were immunized with α1(IV)NC1, α3(IV)NC1 or α1/α3 chimeric molecules, made by inserting the α3 aa17-31 (C2) or aa127-141 (C6) into the non-immunogenic α1 backbone. 1501tg mice immunized with α3(IV)NC1 or C6 responded to aa128-147 but not to aa8-27, but α1(IV)NC1 or C2-immunized mice did not respond to either peptide. CD4+ T cell clones, made from 1501tg mice and transferred into naive 1501tg mice, induced disease with necrotizing and crescentic glomeruli, albuminuria and renal failure, and glomerular CD4+ T cell and macrophage infiltrates. To determine if immunization with the restricted epitope causes disease, 1501tg or 0101tg mice were crossed with FcγRIIB-/- mice (Fcγ receptors are implicated in disease susceptibility). Immunization with either whole α3(IV)NC1 or the identified restricted epitope induced glomerulonephritis in 1501tg.FcγRIIB-/- mice but not in 0101tg.FcγRIIB-/- mice. These studies demonstrate that T cell responses in anti-GBM disease are defined by a HLA DRB1*1501 restricted T cell epitope.

Unrelated cord blood transplantation after myeloablative conditioning in adults with ALL

We analyzed the disease-specific outcomes of adult ALL treated with cord blood transplantation (CBT) after myeloablative conditioning. Between October 2000 and November 2007, 27 adult patients with ALL were treated with unrelated CBT. All patients received four fractionated 12 Gy TBI and chemotherapy as myeloablative conditioning. The median age was 36 years, the median weight was 57 kg and the median number of nucleated cells was 2.47 x 10(7)/kg. All patients received a single and HLA-mismatched cord blood unit. The cumulative incidence of neutrophil recovery at day 30 and platelet recovery at day 200 was 92.6 and 92.3%, respectively. With a median follow-up of 47 months, the probability of EFS at 5 years was 57.2%. The 5-year cumulative incidence of TRM and relapse was 3.7 and 27.4%, respectively. These results suggest that unrelated CBT after myeloablative conditioning could be safely and effectively used for adult patients with ALL.

No occurrence of Pneumocystis jiroveci (carinii) pneumonia in 120 adults undergoing myeloablative unrelated cord blood transplantation

The incidence of pneumonia caused by Pneumocystis carinii (PCP) (organism now renamed Pneumocystis jiroveci) during the early period after cord blood transplantation (CBT) was studied in 120 adults. Initially 89 patients (74%) received oral administration of 2 single-strength trimethoprim-sulfamethoxazole (TMP-SMZ) tablets twice daily from day -21. In 45 of 89 patients (51%), TMP-SMZ administration for a scheduled duration was completed. In the remaining 44 patients (49%), however, TMP-SMZ administration was discontinued prior to day -3 because of toxicity. Among these patients, 42 subsequently received aerosolized pentamidine (AP) on a median of day -13 (range, -20 to -6). Thirty-one patients (26%) received AP without TMP-SMZ administration on a median of day -14 (range, -21 to -9). None of the 120 patients were diagnosed with PCP within 100 days or 2 years after CBT; however, one patient who received AP before CBT but no prophylaxis after CBT developed cerebral toxoplasmosis on day +91. Pre-transplant prophylaxis against PCP did not significantly affect transplantation-related mortality or disease-free survival at 2 years after CBT. The results suggest that PCP during the early period after CBT can be effectively prevented by any pre-transplant prophylactic method.

Impact of ABO incompatibility on engraftment and transfusion requirement after unrelated cord blood transplantation: a single institute experience in Japan

The impact of ABO incompatibility between donor and recipient on engraftment and transfusion requirement was studied in 95 adults who underwent unrelated cord blood transplantation (CBT). The patients included 27 ABO-identical, 29 minor, 21 major and 18 bidirectional ABO-incompatible recipients. Neutrophil engraftment did not differ between ABO-identical/minor ABO-incompatible and major/bidirectional ABO-incompatible recipients (hazard ratio (HR) 1.17, P=0.48). Cumulative incidence of platelet engraftment in ABO-identical/minor ABO-incompatible recipients was higher than in major/bidirectional ABO-incompatible recipients (HR 1.88, P=0.013). In addition, fewer platelet transfusions were required during the first 60 days after CBT in ABO-identical/minor ABO-incompatible recipients (HR 0.80, P=0.040). RBC engraftment did not differ between the two groups (HR 1.25, P=0.33). However, fewer RBC transfusions were required in ABO-identical/minor ABO-incompatible recipients than in major/bidirectional ABO-incompatible recipients (HR 0.74, P<0.005). No patients developed pure red-cell aplasia after CBT. These results indicate that ABO incompatibility affected platelet engraftment and transfusion requirement of RBC and platelet in CBT recipients. Further studies including larger patient numbers are required to elucidate the impact of ABO incompatibility on the clinical outcome of CBT.

Herpes simplex virus infection in adult patients after unrelated cord blood transplantation: a single-institute experience in Japan

Herpes simplex virus (HSV) infection in adult patients who underwent cord blood transplantation (CBT) from unrelated donors was studied. None of nine HSV-seronegative patients developed HSV disease after CBT. Of 28 HSV-seropositive patients, seven (25%) developed HSV disease at a median of 92 days after CBT (range, 52-239 days). The cumulative incidence of HSV disease in HSV-seropositive patients was 27% at 12 months after CBT. The manifestations of HSV disease included gingivostomatitis (three patients), herpes labialis (two patients), localized herpes facialis of the nose (one patient), and disseminated eczema herpeticum (one patient). HSV disease recurred in two patients as gingivostomatitis and disseminated eczema herpeticum. All the patients responded to antiviral therapy. The presence of grade II-IV acute graft-versus-host disease (GVHD) was significantly associated with a higher rate of HSV disease after CBT (51 vs 8%, P=0.015). These results suggest that the recovery of HSV-specific immune responses is delayed in patients who develop grade II-IV acute GVHD after CBT.

Effect of cyclophosphamide on serum cyclosporine levels at the conditioning of hematopoietic stem cell transplantation

We retrospectively analyzed the factors that affect serum cyclosporine (CsA) concentrations up to day 14 after allogeneic hematopoietic stem cell transplantation (HSCT). In all, 103 transplant recipients who received MTX and CsA for acute GVHD prophylaxis were analyzed. No significant relationships between serum CsA concentrations and gender, age, serum creatinine levels, AST/ALT levels, or antibiotic/fluconazole administration were found by comparing median CsA concentrations or by using longitudinal or regression multivariate analyses. However, the mean of the median serum CsA concentration in patients (n=54) receiving the regimen containing cyclophosphamide (CY) (149.7 ng/ml; 95% confidence interval (CI): 132.1-167.4) was significantly (P<0.0001) lower than that in patients (n=49) receiving the non-CY regimen (217.3 ng/ml; 95% CI: 198.9-235.6). Longitudinal analysis and regression multivariate analysis showed that only administration of CY had a significant effect on the serum CsA concentration. Our results suggest that administration of CY during conditioning can reduce the effects on serum CsA concentrations during the 2 weeks following HSCT. The mechanism of this effect is not clear, but it may be due to the autoinduction of CY.

MxA expression in patients with viral infection after allogeneic stem cell transplantation

Many patients suffer febrile diseases soon after allogeneic stem cell transplantation (SCT). Some of the symptoms of viral infections and acute GVHD are often difficult to distinguish. However, an accurate diagnosis is important since the treatments for these conditions are different. It is known that MxA protein is specifically induced in patients with several viral infections. We investigated the cytoplasmic expression of MxA in the peripheral blood mononuclear cells (PBMCs) of patients with fever after allogeneic SCT using a newly generated monoclonal antibody (KM1135) and flow cytometry. The level of MxA expression was significantly higher in patients diagnosed with viral infections (n=6, cytomegalovirus in three, Epstein-Barr virus in one, human herpesvirus-6 in one, adenovirus in one) than control individuals (n=9) (P<0.05, Mann-Whitney test). The level of MxA in patients with aGVHD (n=7) was identical to that in controls. The level of MxA correlated well with the amount of the cytomegalovirus antigen-positive cells in the presence of acute GVHD in two patients. The measurement of MxA is simple and useful in distinguishing viral disease from acute GVHD after allogeneic SCT.

Acute disseminated encephalomyelitis (ADEM) after allogeneic bone marrow transplantation for acute myeloid leukemia

Acute disseminated encephalomyelitis (ADEM) is a rare inflammatory demyelinating disease of the central nervous system. We describe here a patient who developed ADEM after allogeneic bone marrow transplantation (BMT). A 48-year-old woman with acute myeloid leukemia (M2) underwent allogeneic BMT from her HLA-identical sister. Cyclosporin for prophylaxis of acute graft-versus-host disease (GVHD) was discontinued from day 15 because of its toxicity. She was relatively well after the resolution of cytomegalovirus reactivation and chronic GVHD. Nine months after BMT, she suddenly developed diplopia, dysarthria, and gait disturbance. Computed tomography of the brain at that time revealed no abnormal findings. Leukemia recurrence was not revealed. The neurological symptoms were very mild without further deterioration. Her clinical course was carefully watched without therapy. Two weeks after onset, fluid attenuated inversion recovery magnetic resonance imaging (MRI) revealed multifocal abnormal high-signal intensity mainly in the white matter of the cerebrum as well as in the cerebellum and brainstem. Cerebrospinal fluid examination showed no abnormal findings. No laboratory findings suggested the presence of infectious agents. The typical MRI findings and an acute monophasic clinical course of this patient led to a diagnosis of ADEM. Twelve weeks after onset, the symptoms had almost resolved. Follow-up MRI showed a substantial improvement of the previous lesions without any new lesions. The symptoms had completely resolved 5 months after onset. This is a rare case of ADEM developing after allogeneic BMT.

Transient hematopoietic stem cell rescue using umbilical cord blood for a lethally irradiated nuclear accident victim

We performed stem cell rescue and allogeneic skin transplantation on a lethally neutron-irradiated nuclear accident victim. HLA-DRB1 mismatched unrelated umbilical cord blood cells (2.08 x 10(7)/kg recipient body weight) were transplanted to an 8-10 Gy equivalent neutron-irradiated patient because of a lack of a suitable bone marrow or peripheral blood donor. Pre-transplant conditioning consisted of anti-thymocyte gamma-globulin alone, and GVHD prophylaxis was a combination of cyclosporine (CYA) and methylprednisolone (mPSL). Granulocyte colony-stimulating factor (G-CSF), erythropoietin (EPO), and thrombopoietin (TPO) were concurrently administered after transplantation. The absolute neutrophil count reached 0.5 x 10(9)/l on day 15, the reticulocyte count rose above 1% on day 23, and the platelet count was over 50 x 10(9)/l on day 27, respectively. Cytogenetic studies of blood and marrow showed donor/recipient mixed chimerism. Rapid autologous hematopoietic recovery was recognized after withdrawal of CYA and mPSL. Repeated pathological examinations of the skin revealed no evidence of acute GVHD. Eighty-two days after the irradiation, skin transplantation was performed to treat radiation burns. Almost 90% of the transplanted skin engrafted. Immunological examination after autologous hematopoietic recovery revealed an almost normal T cell count. However, immune functions were severely impaired. The patient died from infectious complication 210 days after the accident.

Unrelated cord blood transplantation for adult patients with myelodysplastic syndrome-related secondary acute myeloid leukaemia

Seven adult patients with myelodysplastic syndrome (MDS)-related secondary acute myeloid leukaemia (AML) were treated with total body irradiation (TBI), cytosine arabinoside (Ara-C) and cyclophosphamide (CY), followed by unrelated human leucocyte antigen (HLA)-mismatched cord blood transplantation (CBT). Granulocyte colony-stimulating factor (G-CSF) was infused continuously from 12 h before until the end of Ara-C therapy to enhance the antileukaemia effect of Ara-C. Five patients are alive and free of disease at 7-31 months after transplantation. These preliminary results suggest that adult MDS-related secondary AML patients without suitable related or unrelated bone marrow donors should be considered as candidates for CBT.

Severe autoimmune thrombocytopenia after allogeneic bone marrow transplantation for aplastic anemia

Autoimmune thrombocytopenia (AITP) after bone marrow transplantation (BMT) was suggested to occur by immune dysregulation mainly in association with graft-versus-host disease (GVHD). Here we present a patient who developed severe AITP after BMT. A 40-year-old woman with severe aplastic anemia received a BMT from a partially HLA-matched brother. Despite myeloid and erythroid engraftments, platelet recovery was delayed. All bone marrow cells were 46,XY and were derived from the donor. Grade I acute GVHD involving skin developed from day 34 posttransplantation, but promptly responded to prednisolone in addition to a prophylactic dose of tacrolimus. With the tapering of prednisolone, thrombocytopenia progressed without substantial changes in the white blood cell count, hemoglobin concentration, or reticulocyte count. On day 188, the patient developed chronic GVHD involving skin and liver, which promptly responded to the readministration of prednisolone and increased tacrolimus. However, the patient's platelet count decreased to 9 x 10(9) cells/L on day 222. The platelet-associated immunoglobulin G (PAIgG) values were elevated. Bone marrow examination showed hypercellularity with plentiful megakaryocytes. The number of colony-forming units-megakaryocyte was within the normal range. The elevated PAIgG values and a correlation between thrombocytopenia and the intensity of the immunosuppressive agents strongly suggested a causative role of the autoimmune mechanisms for thrombocytopenia in this patient.