Christopher H. Poynton

Parenteral glutamine protects hepatic function during bone marrow transplantation

Hepatic veno-occlusive disease (VOD) of the liver is a common complication following high-dose cytotoxic therapy for bone marrow transplantation (BMT). The major pathological changes are seen in centrilobular (zone 3) hepatocytes and adjacent endothelium. Glutathione (GSH) becomes depleted following chemotherapy and experimental evidence suggests reduced levels predispose to centrilobular hepatocyte and endothelial cell injury. Animal studies have shown that glutamine infusions can maintain GSH levels and protect against free radical injury. We have prospectively studied the effect of glutamine supplementation during BMT. Thirty-four patients undergoing BMT were randomised to receive either glycl-L-glutamine (n = 18) or an isonitrogenous mixture of non-essential amino acids (n = 16). Glutamine was shown to significantly preserve protein C (days +4 and +7, P < 0.05) and albumin levels (days 0 and +4, P < 0.02). markers of thrombin and plasmin generation (thrombin-antithrombin, prothrombin fragment f1+2 and plasmin-antiplasmin levels) were not significantly changed between the two groups. these findings suggest that glutamine preserves hepatic function but does not alter thrombin or plasmin generation during bmt. previous studies have shown reductions in protein c, albumin, factor x and factor vii levels post bmt. falling protein c levels have been shown to be predictive of severe vod. these data suggest a role for glutamine in the protection of hepatic function following bmt.

Effect of IgM-enriched intravenous immunoglobulin (Pentaglobin) on endotoxaemia and anti-endotoxin antibodies in bone marrow transplantation

Abstract. Endotoxin was measured in over 1000 plasma samples from bone marrow transplant patients in a randomized trial of the IgM‐enriched intravenous immunoglobulin (IVIG) Pentaglobin. Peak endotox aemia was significantly reduced (P = 0.02) in patients receiving Pentaglobin and 70% of all pyrexias of unknown origin were associated with endotoxaemia. Gut mucosal damage, assessed by lactulose/mannitol ratios, was significantly associated (P= 0.02) with endotoxaemia. Specific IgM antibody to endotoxin core‐glycolipid was significantly raised (P<0.01) in patients receiving the IVIG, and the IgM fraction of Pentaglobin was found to contain most of the antiendotoxin antibody activity of the IVIG. These results suggest a role for IgM‐enriched WIG as a prophylactic agent for the reduction of endotoxaemia and its consequences in bone marrow transplant patients.

Evaluation of erythropoiesis after bone marrow transplantation: quantitative reticulocyte counting

Erythroid regeneration is an important and separate element in the engraftment process in allogeneic and autologous bone marrow transplantation (alloBMT, autoBMT). Qualitative visual reticulocyte counting has proved inadequate in the evaluation of erythropoiesis after BMT but automated flow cytometry now allows the reliable quantitation of reticulocytes even to very low levels. Reticulocyte counts and highly fluorescent reticulocyte (HFR) counts (very early reticulocytes) were estimated daily in recipients of 22 autoBMT and 14 alloBMT using a Sysmex R‐1000 automated reticulocyte counter. Marrow ablation caused an immediate and rapid fall in both the reticulocyte count and the HFR. Measurable numbers of reticulocytes persisted throughout the hypoplastic period, but HFR fell to zero in the majority of both the autoBMT and alloBMT. HFR rose significantly after a median time of 14 d post‐autoBMT, and 12 d post‐alloBMT. Attainment of 15 × 109/l reticulocytes and 0·5 × 109/l HFR at day 21 post‐transplant was associated with ultimate engraftment in 100% cases. Inadequate engraftment was seen in the majority of patients whose responses fell below these levels. Graft‐versus‐host disease was associated with a transient slight reduction in reticulocyte count. Neither episodes of infection nor blood transfusions had any significant impact on trends of reticulocytes or HFR.

Fludarabine phosphate and melphalan : a reduced intensity conditioning regimen suitable for allogeneic transplantation that maintains the graft versus malignancy effect

Reduced intensity conditioning (RIC) for allogeneic stem cell transplantation allows stable donor cell engraftment with the maintenance of a graft versus malignancy effect. Many different regimens exist employing various combinations of chemotherapy, radiotherapy and T-cell depletion. We examined the role of non-T-cell depleted RIC regimens in 56 patients with haematological malignancies. Patients received fludarabine phosphate for 5 days (30 mg/m2 in 35 patients, 25 mg/m2 in 21 patients) and melphalan for 1 day (140 mg/m2 in 36 patients, 100 mg/m2 in 20 patients). Immunosuppression was with CyA alone in 33 patients and CyA/MTX in 23 patients. Twenty-four of the 26 patients with chimerism data showed >95% donor chimerism at 3 months post transplant. aGVHD occurred in 18% of patients receiving CyA/MTX compared to 53% of patients receiving CyA. The 100-day mortality rate was 0.16 (95%CI 0.08–0.28) and 1-year nonrelapse mortality was 0.24 (95%CI 0.13–0.38). Thirty-three patients remained alive and in CR at a median of 19 months post transplant (range 3–38 months). We have shown that patients transplanted with fludarabine phosphate, melphalan 100 mg/m2 and with CyA/MTX as post transplant immunosuppression can achieve good disease control with an acceptable level of toxicity. Further studies are required to confirm these findings.

A simple PCR/RFLP analysis can differentiate between Candida albicans, Aspergillus niger, and Aspergillus fumigatus.

The clinical management of immunocompromised patients depends on the rapid identification of infectious agents such as fungal pathogens. The procedure described here for accomplishing this uses a sensitive polymerase chain reaction method, previously reported, combined with restriction-enzyme digestion to distinguish between Candida and Aspergillus species and to classify Aspergillus strains.

HLA and Hogkin’s disease: reply to Taylor and Gokhale

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