Wolfgang Hinterberger

Clinically demonstrable anti-autoimmunity mediated by allogeneic immune cells favorably affects outcome after stem cell transplantation in human autoimmune diseases.

To determine the role of allogeneic, autologous and syngeneic hemopoietic stem cell transplantation (SCTx) as a treatment for severe autoimmune disease (AID) we performed a literature search employing Medline, Cancer Lit and abstract books for reports on transplants for blood disorders and a concomitant AID. All reviews, case reports and abstracts available between June 1977 and September 2001 were used and attempts made to update them by e-mail by the corresponding authors. Disease-free survival (DFS) after allogeneic SCTx for 23 patients with severe aplastic anemia was 78% at 16 years and survival in unmaintained remission of concomitant AID was 64% at 13 years. DFS after allogeneic SCTx for 24 patients with hematologic malignancies was 87% at 15 years and survival in unmaintained remission for concomitant AID was 70% at 11 years. DFS after autologous SCTx for 24 patients with hematologic malignancies was 48% at 6 years and survival in unmaintained remission for concomitant AID was 29% at 3 years. Among 30 patients given allogeneic SCTx 19 developed graft-versus-host disease (GVHD) and 11 did not. Upon clinically justified discontinuation of all immunosuppressive therapy, 3/11 patients without GVHD relapsed with their concomitant AID (freedom of AID-relapse 69% at 9 years), whereas none of 19 patients with GVHD did so (log rank: P = 0.0135). Freedom of AID-relapse was superior after allo SCTx compared to autologous SCTx (89% at 18 years vs38% at 5 years; log rank: P = 0.0002). Our data suggest that a graft-versus-autoimmunity effect after allogeneic hemopoietic SCTx mediates elimination of autoimmunity.

Bone marrow transplants from mismatched related and unrelated donors for severe aplastic anemia

For patients with acquired severe aplastic anemia without a matched sibling donor and not responding to immunosuppressive treatment, bone marrow transplantation from a suitable alternative donor is often attempted. We examined risks of graft failure, graft-versus-host disease and overall survival after 318 alternative donor transplants between 1988 and 1998. Sixty-six patients received allografts from 1-antigen and 20 from >1-antigen mismatched related donors; 181 from matched and 51 from mismatched unrelated donors. Most patients were young, had had multiple red blood cell transfusions and poor performance score at transplantation. We did not observe differences in risks of graft failure and overall mortality by donor type. The probabilities of graft failure at 100 days after 1-antigen mismatched related donor, >1-antigen mismatched related donor, matched unrelated donor and mismatched unrelated donor transplants were 21, 25, 15 and 18%, respectively. Corresponding probabilities of overall survival at 5 years were 49, 30, 39 and 36%, respectively. Although alternative donor transplantation results in long-term survival, mortality rates are high. Poor performance score and older age adversely affect outcomes after transplantation. Therefore, early referral for transplantation should be encouraged for patients who fail immunosuppressive therapy and have a suitable alternative donor.

Long-term outcome and quality of life of patients who are alive and in complete remission more than two years after allogeneic and syngeneic stem cell transplantation.

We assessed long-term outcome in 155 patients who had undergone an allogeneic/syngeneic stem cell transplant (SCT) and were in complete remission for more than 2 years after transplant. Probability of late transplant-related mortality was 6%, and affected only patients with chronic graft-versus-host disease (cGVHD). Thirteen percent of patients experienced relapse. Overall survival projected at 10 and 15 years was 83% and 76%, respectively. Secondary malignancies occurred in two patients, 7.5 and 11 years after SCT. Three female and four male patients parented children 19 to 84 months after SCT. Quality of life (QoL) was assessed in a cross-sectional study by the means of a 30-item questionnaire (QLQ-C30) of the EORTC. The questionnaire was sent to 127 patients remaining alive and answered by 106 patients. Seventy-three percent reported a good to very good QoL within 5 years after SCT and 78% after this time point. However, patients with cGVHD had significant impairment of physical, role and social functioning and only 60% of them were fit for work. These results from long-term survivors show that high cure rates with good to very good QoL can be achieved by allogeneic or syngeneic SCT.

Results of Transplanting Bone Marrow from Genetically Identical Twins into Patients with Aplastic Anemia

Considerable data suggest that aplastic anemia is heterogeneous: Some cases are caused by a lack of or a defect in hematopoietic stem cells, whereas others result from immune abnormalities [1-7]. In rare cases, aplastic anemia is caused by an abnormal bone marrow microenvironment [8]. The outcomes of transplanting bone marrow from genetically identical twins into patients with aplastic anemia may provide insight into the causes of bone marrow failure. The infusion of genetically identical bone marrow cells without pretransplantation conditioning should permanently correct bone marrow function in persons whose bone marrow failure has resulted from a lack of or defective hematopoietic stem cells. In contrast, persons whose bone marrow failure is caused by immune abnormalities may only improve when transplantation of genetically identical bone marrow is preceded by conditioning. Finally, persons with abnormal bone marrow microenvironments might never improve [8]. We addressed these issues using data on 40 patients with aplastic anemia who received transplants from their identical twins and were reported to the International Bone Marrow Transplant Registry. Methods Patients Forty patients with severe aplastic anemia who received one or more bone marrow transplants from their genetically identical twins between 1964 and 1992 were reported to the International Bone Marrow Transplant Registry by 31 centers worldwide. Severe aplastic anemia was defined according to published criteria [9]. Nineteen patients have been described in previous reports [4, 10-14]. Genetic identity was established by measuring concordance for HLA-A, -B, -C and -DR antigens (n = 39; HLA testing was not done in 1 patient); ABO blood group (n = 39); erythrocyte antigens (n = 1); and immunoglobulin allotypes (n = 1) and by a history of a single placenta (n = 40). Outcomes Hematologic response, graft-versus-host disease, and survival were the study outcomes. Complete response was defined as normalization of at least two of three hematologic variables (hemoglobin level > 12 g/dL, granulocyte count > 1.5 109/L, and platelet count > 150 109/L) and improvement in the third (hemoglobin level > 8 g/dL, granulocyte count > 0.5 109/L, and platelet count > 20 109/L without transfusion). Partial response was defined as improvement in two or more variables. Lack of response was defined as levels less than those indicated above and continuing dependence on transfusion. Responses were considered to be sustained if they persisted through the date of last contact. Diagnosis and grading of graft-versus-host disease were based on published criteria [15]. Persons at risk included those with complete or partial responses who survived 21 days or longer. Statistical Analysis We compared patient, disease, and transplantation variables using the Mann-Whitney and Fisher exact tests. Probabilities of survival were calculated using the Kaplan-Meier product limit estimator and were expressed as probabilities with 95% CIs. The latter were computed using the arcsine-square root transformation [16]. Survival distributions were compared using the log-rank test. Results Patients We studied 25 male patients and 15 female patients. The median patient age was 19 years (range, 4 to 69 years). Physicians at the transplantation centers ascribed aplastic anemia to drugs or toxins (7 patients), hepatitis (4 patients), or other causes (3 patients). We did not ascertain which criteria were used to make these designations. In 26 cases, no cause of aplastic anemia was identified. Treatments given between diagnosis and transplantation included corticosteroid therapy (9 patients), androgen therapy (1 patient), and both (7 patients). Twenty-three patients received no therapy other than transplantation. Thirty-seven patients received transfusions before transplantation (median number of transfusions, 14 [range, 1 to 263]). Median values for hematologic variables before transplantation were the following: hemoglobin level, 7.5 g/dL (range, 4.8 to 11.3 g/dL); leukocyte count, 1.7 109/L (range, 0.5 to 5.2 109/L); granulocyte count, 0.3 109/L (range, 0 to 1.6 109/L); and platelet count, 17 109/L (range, 1.5 to 101 109/L). Survivors were followed for a median of 7 years (range, 13 months to 29 years); all but one were followed for at least 2 years after transplantation. Transplantation First Transplantation Not Preceded by Conditioning Twenty-three patients received a first transplant without pretransplantation conditioning. Fifteen patients who did not have a sustained complete response received one or more additional transplants after first receiving conditioning with the following regimens: Ten patients received cyclophosphamide alone (150 to 200 mg/kg of body weight); 2 received cyclophosphamide (200 mg/kg) and total-body radiation (3 to 4.5 Gy); 1 received cyclophosphamide (194 mg/kg) and cyclosporine; 1 received nitrogen mustard and antilymphocyte globulin; and 1 received azathioprine. A sixteenth patient who did not have a sustained complete response after the first transplantation received the second transplant without first receiving conditioning. The median dose of nucleated bone marrow cells for the first transplant was 3.6 108/kg (range, 0.4 to 9.8 108/kg). Four of 15 female donors had had transfusion or at least one pregnancy before donating bone marrow. No patients received immunosuppressive therapy after transplantation. First Transplantation Preceded by Conditioning Seventeen patients received conditioning before the first transplantation. Thirteen received cyclophosphamide alone (100 to 200 mg/kg), 1 received cyclophosphamide (152 mg/kg) and cyclosporine, 2 received cyclophosphamide (156 and 219 mg/kg, respectively) and busulfan (12 and 16 mg/kg, respectively), and 1 received cyclophosphamide (200 mg/kg) with total-body radiation (3.0 Gy). The median dose of nucleated bone marrow cells was 3.6 108/kg (range, 1.6 to 4.9 108/kg). After transplantation, 6 patients received immunosuppressive therapy: One received methotrexate, 1 received corticosteroids, 2 received cyclosporine, and 2 received cyclosporine and corticosteroids. We did not ascertain the reasons why immunosuppressive therapy was given after transplantation. The likelihood that the first transplantation would be preceded by conditioning increased during the study years: Only 3 of the initial 20 (15%) patients receiving their first transplant received conditioning compared with 14 (70%) of the subsequent 20 patients receiving their first transplant (P = 0.05). Patients who had conditioning before receiving their first transplants had lower leukocyte, granulocyte, and platelet counts and had had more pretransplantation transfusions than the patients who did not have pretransplantation conditioning (Table 1). Table 1. Variables Correlated with Use of Conditioning before First Transplantation* Outcomes The results of transplantation are summarized in Figure 1. Figure 1. Outcome of transplanting bone marrow from genetically identical twins into 40 patients with aplastic anemia. Hematologic Response: First Transplantation Not Preceded by Pretransplantation Conditioning Seven of the 23 patients (30%) who received a first transplant without first receiving conditioning had a sustained complete response; 16 did not. Five of the 16 had a complete response but had relapse a median of 35 weeks after transplantation (range, 11 to 103 weeks). Seven other patients had a partial response; relapse occurred a median of 10 weeks after transplantation (range, 8 to 16 weeks). Four patients had no response. Granulocyte counts before transplantation were higher in the 12 complete responders than in the 11 patients who did not have a complete response (0.9 109/L [range, 0 to 1.6 109/L] compared with 0.3 109/L [range, 0 to 1.2 109/L]; P = 0.048). Granulocyte and platelet counts and number of transfusions before transplantation did not differ between the 7 patients who had sustained complete response and the 5 patients who had complete response and later had relapse. No correlation was seen between the likelihood of a sustained complete response and age, sex, cause of aplastic anemia, interval from diagnosis to transplantation, previous therapy, infections developing within 1 week before transplantation, previous transfusions, donor pregnancies, or number of cells transplanted. The 16 patients who did not have a sustained complete response after receiving the first transplant without first receiving conditioning had one to four additional transplantations. One patient who did not have conditioning before receiving a second transplant had a sustained complete response. Eleven of 15 patients (73%) who received conditioning before the second transplantation had a sustained complete response. One of the 15 patients died of treatment-related toxicity 1 month after transplantation. Three of the 15 did not have a sustained complete response after receiving a second transplant: Of these, one patient with a partial response and one patient with no response received a third transplant after conditioning. Both had sustained complete responses after the third transplantation. After each of five transplantations, one patient had transient hematologic responses that lasted 11 to 38 months. He died after receiving the fifth transplant. Hematologic Response: First Transplantation Preceded by Conditioning Seventeen patients received their first transplant after first receiving conditioning. Thirteen (76%) had a complete response, and 11 (64%) had a sustained complete response. One patient had relapse 20 months after transplantation; a second transplantation preceded by conditioning resulted in a sustained complete response. Patients who received conditioning before receiving the first transplant had a higher incidence of sustained complete responses than did patients who did not receive conditioning before receiving the first transplant (P = 0.033; Fisher exact tes

Functional Asplenia after Bone Marrow Transplantation: A Late Complication Related to Extensive Chronic Graft-Versus-Host Disease

STUDY OBJECTIVE To evaluate splenic function in bone marrow transplant recipients, with relation to chronic graft-versus-host disease and infections. DESIGN Survey, outpatients geographically accessible for voluntary participation. SETTING Bone marrow transplantation referral center. PATIENTS Fifteen bone marrow graft recipients (13 allogeneic, 2 autologous), out of a total of 33 patients who received transplants at the center and survived more than 6 months after grafting. MEASUREMENTS AND MAIN RESULTS In 6 of 15 patients impaired splenic function (functional asplenia) was indicated by the presence of Howell-Jolly bodies in peripheral blood smears, reduced spleen size (P less than 0.001), higher platelet counts (P less than 0.01), higher indium-111 labeled autologous platelet recovery (P less than 0.005), reduced splenic blood flow (P less than 0.001), and reduced accumulation of radioactivity at the splenic site (P less than 0.001). All patients with functional asplenia but only 2 patients without functional asplenia had extensive chronic graft-versus-host disease. The incidence of bacterial infections was four times higher in patients with impaired splenic function. CONCLUSIONS Functional asplenia is a late complication after allogeneic bone marrow transplantation and contributes to the high susceptibility to bacterial infections in patients with extensive chronic graft-versus-host disease.

Colony growth characteristics in chronic myelomonocytic leukemia.

Using cell culture studies specific in-vitro characteristics have been reported for Philadelphia chromosome positive myelogenous leukemia (Ph+ CML) and for juvenile chronic myelogenous leukemia (JCML) previously. We performed cell culture studies in four patients with chronic myelomonocytic leukemia (CMML) and demonstrated the following in-vitro features: excessively increased circulating CFU-C, while BFU-E and CFU-mix were either moderately increased or not detectable; CFU-C colony formation from CMML mononuclear cells (MNC) without addition of exogenous colony stimulating activity (CSA), even after depletion from adherent cells; failing inhibition of CMML MNC on normal BFU-E colony formation. These in-vitro characteristics point to CMML as a distinct entity. In two CMML-patients investigated CFU-C proliferation appeared to some extent inhibited by the addition of IFN-alpha, IFN-gamma and TNF-alpha to cell cultures.

Factors affecting long-term outcome after allogeneic haematopoietic stem cell transplantation for acute myelogenous leukaemia: a retrospective study of 172 adult patients reported to the Austrian Stem Cell Transplantation Registry.

Summary. Between 1982 and 2000, 172 patients with acute myelogenous leukaemia (AML) received haematopoietic stem cell transplants (SCT) from related (n = 132) or unrelated (n = 40) donors at four Austrian transplant centres and their results were reported to the Austrian Stem Cell Transplantation Registry. Conditioning for SCT consisted of cyclophosphamide and total body irradiation in 156 (91%) patients. Graft‐versus‐host disease (GVHD) prophylaxis was with standard cyclosporine and methotrexate in 95 (55%) patients. Median post‐transplant follow‐up was 5·6 years (range, 0·2‐‐16·7). Multivariate analysis of transplant‐related mortality (TRM) identified four variables associated with a lower risk: disease status of first complete remission (CR) at SCT, patient age of 45 years and younger, transplant performed during or after 1995, and lack of acute GVHD. Variables associated with significantly improved leukaemia‐free survival were: bone marrow as the stem cell source, disease status of first CR at SCT, and occurrence of chronic GVHD. In multivariate analysis, transplantation performed during or after 1995, first CR at SCT, occurrence of limited chronic GVHD and lack of acute GVHD grades III to IV were associated with increased overall survival. Based on these analyses, options for the improvement of results obtained with allogeneic SCT in patients with AML could be defined.

Detection of engraftment and mixed chimerism following bone marrow transplantation using PCR amplification of a highly variable region-variable number of tandem repeats (VNTR) in the von Willebrand factor gene

SummaryDetection of host cells in peripheral blood and/or bone marrow (mixed chimerism) of patients who have undergone bone marrow transplantation (BMT) is possible using either immunological methods or cytogenetic or molecular genetic analysis. We shall report a new method for the detection of mixed chimerism, which makes use of the fact, that the von Willebrand factor (vWF) gene has a highly variable region-variable number of tandem repeats (VNTR) — within intron 40. vWF-VNTR amplification by the polymerase chain reaction (PCR) was performed as described by Peake et al. [5]. We have studied 185 peripheral blood and/or bone marrow samples of 26 patients. Median time after BMT was 14 months (range 1–83 months). Of the 11 patients who were studied sequentially during the first 100 days following BMT, mixed chimerism was detected in four, but only transiently. None of these patients has relapsed so far. Of 18 patients who were studied more than 100 days after BMT mixed chimerism was found in three; two of these patients have subsequently relapsed. The advantages of this new method are: (a) it is informative in a high percentage of patients; (b) it requires only small amounts (200μl) of peripheral blood; (c) reliable results can be obtained at leukocyte counts of even less than 50 perμl. The clinical relevance and sensitivity of the method compared with established methods for detection of mixed chimerism remain to be determined.

Immune thrombocytopenia more than a year after allogeneic marrow transplantation due to antibodies against donor platelets with anti-PlA1 specificity: evidence for a host-derived immune reaction.

Summary We report on a male patient transplanted from his HLA‐matched sister for Ph1‐chromosome positive chronic myelogenous leukaemia who developed immune thrombocytopenia more than 1 year after transplantation. The platelet antibody reacted with the platelet specific antigen PIA1 on donor platelets, and also on recipient platelets after engraftment. A presumed host‐versus‐donor induced thrombocytopenia was supported by Southern blot analysis using a Y‐chromosome specific probe demonstrating residual hostorigin cells in the patients excised spleen.

Low incidence of peripheral blood haematopoietic stem cells in patients with anorexia nervosa

Abstract Myeloid (CFU-GM) and erythroid (BFU-E) stem cells were determined in the peripheral blood (PB) from 13 female patients with severe malnutrition due to anorexia nervosa (AN). When compared to age-matched female controls, PB CFU-GM as well as BFU-E were significantly decreased in number. The reduction of the stem cell compartment indicated a more pronounced haematopoietic abnormality than was hitherto conferred from PB cell counts in AN. The clinical relevance of our finding remains to be established.