Haploidentical stem cell transplantation in two children with mucopolysaccharidosis VI: clinical and biochemical outcome

Background: Mucopolysaccharidosis VI (MPS VI) is an autosomal recessive progressive multiorgan disorder due to mutation in the gene encoding the enzyme Arylsulfatase B (ARSB). Dysfunctional ARSB causes lysosomal accumulation of glycosaminoglycans (GAG). Currently, enzyme replacement therapy (ERT) is preferred to hematopoietic stem cell transplantation (SCT) due to the treatment-related risks of the latter. However, ERT constitutes an expensive life-long treatment. Increased experience and safety of SCT-procedures in recent years suggest that SCT should be further explored as a treatment option. This is the first report on haploidentical SCT in patients with MPS VI. The primary objective was to assess the treatment safety and clinical and biochemical outcome. Patients and methods: Two siblings diagnosed with MPS VI at 10 months of age and at birth with genotype p. C192R, reported as mild to intermediate phenotype, underwent unrelated umbilical cord blood transplantation pre-symptomatic. Due to graft failure, both patients were urgently re-transplantated with haploidentical SCT with the father as donor. Continuous clinical and biochemical status was monitored and concluded 3.8 and 4.6 years after the haploidentical SCT. Results: Haploidentical SCT resulted in prompt and sustained engraftment. Complete donor chimerism was achieved in both patients, apart from mixed B cells chimerism in patient 2. ARSB activity in leukocytes post transplant increased from 0.0 to 19.0 mu kat/kg protein (patient 1) and from 3.6 to 17.9 mu kat/kg protein (patient 2) (ref. 17-40). Total urinary GAG normalized in both patients, although patient 2's values slightly exceed normal range since 6 months. However, dermatan sulfaturia was substantially normalized since 16 months and 12 months post-SCT, respectively. Height was -1.85 SD and -1.27 SD at follow-up. Patient 1 had impaired visual acuity and discrete hepatomegaly. Patient 2 had elevated intraocular pressure and X-ray revealed steep acetabular angles and slightly flattened lumbar vertebrae. Conclusion: This study demonstrates that young children with MPS VI tolerate haploidentical SCT. Normalization of enzyme production and dermatan sulfaturia indicates correction of the inborn error of metabolism and coincide with no obvious symptoms of progressive MPS VI up to 4.6 years post-SCT

Bone-marrow cells in therapy of critical limb ischemia of lower extremities - own experience

Wstęp. W 2003 roku autorzy niniejszego artykułu rozpoczęli badania nad możliwościami leczenia chorych z krytycznym niedokrwieniem kończyn za pomocą implantacji własnych komórek macierzystych. Po okresie wstępnych przygotowań ustalono schemat postępowania, kryteria włączenia do leczenia i sposób prowadzenia badań kontrolnych oraz procedur bezpieczeństwa. Materiał i metody. Kryteria włączenia obejmowały krytyczne niedokrwienie kończyny niekwalifikujące się do leczenia chirurgicznego, po leczeniu zachowawczym nie krótszym niż 2 miesiące, w którym nie nastąpiła istotna poprawa zagrożonych zabiegiem amputacyjnym. Do kryteriów wyłączenia zaliczono: brak zgody chorego, inne powody niedokrwienia niż miażdżyca, znaczne zaawansowanie zmian zmuszające do pilnej amputacji, a także obecność choroby nowotworowej lub stan ogólny nierokujący przeżycia 6 miesięcy. Chorych po poinformowaniu i uzyskaniu od nich świadomej zgody losowo przydzielano do dwóch grup: kontrolnej (15 osób poddano terapii klasycznej) oraz badanej (14 pacjentów). Zastosowano następujący algorytm: w godzinach rannych wykonywano standardowy zabieg pobrania szpiku (z kości biodrowej), następnie przygotowywano w separatorze zawiesinę komórek za pomocą filtrowania szpiku, zagęszczania i separowania komórek CD34+ (frakcja zawierająca progenitory). Uzyskany materiał podawano chorym dwoma drogami miejscowo do tkanki mięśniowej niedokrwionej kończyny (n = 14) i podczas angiografii, do końcowego odcinka osiowego naczynia kończyny dostępnego cewnikiem (nad okluzję) (n = 4). W obserwacji uwzględniano parametry ogólne (RR, tętno, częstość oddechów, temperatura), wartość współczynnika kostka/ramię (ABI), makroskopowy obraz ewentualnych owrzodzeń i martwicy (fotografie), a także subiektywne odczucia pacjentów (VAS, skala jakości życia wg klasyfikacji WHO). Notowano parametry przed leczeniem, codziennie do momentu wypisu chorego ze szpitala, po 1., 3. i 6. miesiącu terapii. Wyniki. Angiografię wstępną wykonano u każdego pacjenta (wynik badania dyskwalifikował od przeprowadzenia zabiegu rewaskularyzacyjnego), natomiast badanie kontrolne przeprowadzono po 3 miesiącach u 5 chorych z grupy badanej (nie odnotowano różnic w ich obrazie). Punktami końcowymi obserwacji były amputacje (3 w grupie badanej i 7 w grupie kontrolnej) oraz śmierć pacjenta (nie odnotowano). W przypadku amputacji pobierano do badania histologicznego i w przypadku zastosowania komórek macierzystych obserwowano cechy angiogenezy. W większości przypadków uzyskano poprawę subiektywną (12 osób w grupie badanej vs. 7 w grupie kontrolnej). Zaobserwowano zmniejszenie owrzodzenia (8) oraz wygojenie w grupie leczonej komórkami szpiku (5) w stosunku do grupy kontrolnej (3). Amputacje przeprowadzono u 3 chorych (w grupie kontrolnej u 7 osób). Wnioski. Implantacja własnych komórek macierzystych uzyskanych ze szpiku kostnego jest bezpieczną i budzącą duże nadzieje metodą leczenia, pomimo znanych ograniczeń. Ze względu na możliwość jej rozwoju powinna stanowić przedmiot dalszych dociekań.Background. In 2003 we started investigations concerning the possibility of using new techniques, including bone-marrow cell implantation, in the therapy of critical leg ischaemia. Safety procedures, scheme of work and inclusion and exclusion criteria were established during the first faze in collaboration with various local departments and laboratories. Material and methods. Inclusion criteria consisted of critical leg ischaemia, no possibility of surgical operation, no effective 2 months conservative treatment or the possibility of limb amputation in the following months. Exclusive criteria included causes of ischaemia other than atherosclerosis, absence of consent, need for urgent amputation, cancer or poor general condition. After acquiring conscious consent, patients were randomized into two groups: conventional therapy (control group) (n = 15), and those treated with bone-marrow cells (n = 14). Standard bone marrow collection was performed as early as the first operation (usually about 8 a.m.) under general anaesthesia. Material was then prepared filtration and concentration in a separator - using standard procedure. Morphology and measurement of the amount of nuclear cells and CD34 cells were performed as well as microbiological examination. This material, including progenitor cells, was injected using two methods about 46 hours after bone marrow aspiration. In every case it involved several intramuscular injections into the ischemic limb (thigh and leg). In 4 cases we performed intravascular placement of progenitors using arteriography (in the distal part near the occluded part of the axial limb artery). Results. Observation was based on several parameters: vital parameters (blood pressure, heart rate, respiratory rate, temperature) measured every day during hospitalisation; ankle/brachial index (ABI), ulcerations or pedal necrosis documented by photography and subjective parameters: feeling of pain (VAS), self care (WHO scale) measured 1, 3 and 6 months after our procedure. Baseline angiography was performed in every case. Control angiography followed bone marrow collection after 3 months in 5 cases. No changes in angiograms were detected. Endpoints were: amputation (10) and death (no observations). In case of amputation, material was histologically examined and signs of angiogenesis (mostly new vein formation) were detected. In the group treated by stem cell implantation we reached greater subjective improvement in 12 cases compared to 7 in the control group; healing of ulcers in 8 cases (complete in 5 cases) compared to 3 cases in the control group. Amputations were performed in 3 patients in the index group compared to 7 in the control group.Conclusions. We think that implantation of patients' bone-marrow progenitor cells in cases of critical leg ischaemia is safe and is a prospective therapeutic method

Supportive Care During Pediatric Hematopoietic Stem Cell Transplantation : Prevention of Infections. A Report From Workshops on Supportive Care of the Paediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT)

Specific protocols define eligibility, conditioning, donor selection, graft composition and prophylaxis of graft vs. host disease for children and young adults undergoing hematopoietic stem cell transplant (HSCT). However, international protocols rarely, if ever, detail supportive care, including pharmaceutical infection prophylaxis, physical protection with face masks and cohort isolation or food restrictions. Supportive care suffers from a lack of scientific evidence and implementation of practices in the transplant centers brings extensive restrictions to the child's and family's daily life after HSCT. Therefore, the Board of the Pediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT) held a series of dedicated workshops since 2017 with the aim of initiating the production of a set of minimal recommendations. The present paper describes the consensus reached within the field of infection prophylaxis.Peer reviewe

Supportive Care During Pediatric Hematopoietic Stem Cell Transplantation : Prevention of Infections. A Report From Workshops on Supportive Care of the Paediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT)

Specific protocols define eligibility, conditioning, donor selection, graft composition and prophylaxis of graft vs. host disease for children and young adults undergoing hematopoietic stem cell transplant (HSCT). However, international protocols rarely, if ever, detail supportive care, including pharmaceutical infection prophylaxis, physical protection with face masks and cohort isolation or food restrictions. Supportive care suffers from a lack of scientific evidence and implementation of practices in the transplant centers brings extensive restrictions to the child's and family's daily life after HSCT. Therefore, the Board of the Pediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT) held a series of dedicated workshops since 2017 with the aim of initiating the production of a set of minimal recommendations. The present paper describes the consensus reached within the field of infection prophylaxis. © Copyright © 2021 Ifversen, Meisel, Sedlacek, Kalwak, Sisinni, Hutt, Lehrnbecher, Balduzzi, Diesch, Jarisch, Güngör, Stein, Yaniv, Bonig, Kuhlen, Ansari, Nava, Dalle, Diaz-de-Heredia, Trigoso, Falkenberg, Hartmann, Deiana, Canesi, Broggi, Bertaina, Gibson, Krivan, Vettenranta, Matic, Buechner, Lawitschka, Peters, Yesilipek, Yalçin, Lucchini, Bakhtiar, Turkiewicz, Niinimäki, Wachowiak, Cesaro, Dalissier, Corbacioglu, Willasch and Bader

Clinical evolution, genetic landscape and trajectories of clonal hematopoiesis in SAMD9/SAMD9L syndromes

Germline SAMD9 and SAMD9L mutations (SAMD9/9Lmut) predispose to myelodysplastic syndromes (MDS) with propensity for somatic rescue. In this study, we investigated a clinically annotated pediatric MDS cohort (n = 669) to define the prevalence, genetic landscape, phenotype, therapy outcome and clonal architecture of SAMD9/9L syndromes. In consecutively diagnosed MDS, germline SAMD9/9Lmut accounted for 8% and were mutually exclusive with GATA2 mutations present in 7% of the cohort. Among SAMD9/9Lmut cases, refractory cytopenia was the most prevalent MDS subtype (90%); acquired monosomy 7 was present in 38%; constitutional abnormalities were noted in 57%; and immune dysfunction was present in 28%. The clinical outcome was independent of germline mutations. In total, 67 patients had 58 distinct germline SAMD9/9Lmut clustering to protein middle regions. Despite inconclusive in silico prediction, 94% of SAMD9/9Lmut suppressed HEK293 cell growth, and mutations expressed in CD34+ cells induced overt cell death. Furthermore, we found that 61% of SAMD9/9Lmut patients underwent somatic genetic rescue (SGR) resulting in clonal hematopoiesis, of which 95% was maladaptive (monosomy 7 ± cancer mutations), and 51% had adaptive nature (revertant UPD7q, somatic SAMD9/9Lmut). Finally, bone marrow single-cell DNA sequencing revealed multiple competing SGR events in individual patients. Our findings demonstrate that SGR is common in SAMD9/9Lmut MDS and exemplify the exceptional plasticity of hematopoiesis in children. © 2021, The Author(s), under exclusive licence to Springer Nature America, Inc

Novel treatment of severe combined immunodeficiency utilizing ex-vivo T-cell depleted haploidentical hematopoietic stem cell transplantation and CD45RA+ depleted donor lymphocyte infusions.

Allogeneic hematopoietic stem cell transplantation (HSCT) is the only curative treatment available for severe combined immunodeficiency (SCID); although, there is a high incidence of severe infections and an increased risk of graft-versus host-disease (GvHD) with HSCT. Early intervention is a crucial prognostic factor and a HLA-haploidentical parental donor is often available. Haploidentical HSCT protocols utilizing extensively ex vivo T-cell depleted grafts (CliniMACs system) have proven efficient in preventing GvHD, but cause a delay in early T-cell recovery that increases the risk of viral infections. Here, we present a novel approach for treating SCID that combines selective depletion of GvHD-inducing alpha/beta (α/β) T-cells from the haploidentical HSCT graft with a subsequent donor lymphocyte infusion (DLI) enriched for CD45RO+ memory T-cells

Wenancjusz Fortunat, Wiersze opisowo-laudacyjne (Carmina I 19; I 20; III 12, CPL 1033)

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Disruption of Circadian Rhythm Genes in Obstructive Sleep Apnea Patients—Possible Mechanisms Involved and Clinical Implication

Obstructive sleep apnea (OSA) is a chronic condition characterized by recurrent pauses in breathing caused by the collapse of the upper airways, which results in intermittent hypoxia and arousals during the night. The disorder is associated with a vast number of comorbidities affecting different systems, including cardiovascular, metabolic, psychiatric, and neurological complications. Due to abnormal sleep architecture, OSA patients are at high risk of circadian clock disruption, as has been reported in several recent studies. The circadian clock affects almost all daily behavioral patterns, as well as a plethora of physiological processes, and might be one of the key factors contributing to OSA complications. An intricate interaction between the circadian clock and hypoxia may further affect these processes, which has a strong foundation on the molecular level. Recent studies revealed an interaction between hypoxia-inducible factor 1 (HIF-1), a key regulator of oxygen metabolism, and elements of circadian clocks. This relationship has a strong base in the structure of involved elements, as HIF-1 as well as PER, CLOCK, and BMAL, belong to the same Per-Arnt-Sim domain family. Therefore, this review summarizes the available knowledge on the molecular mechanism of circadian clock disruption and its influence on the development and progression of OSA comorbidities

High-dose iodine-131-metaiodobenzylguanidine with haploidentical stem cell transplantation and posttransplant immunotherapy in children with relapsed/refractory neuroblastoma.

We evaluated the feasibility and efficacy of using high-dose iodine-131-metaiodobenzylguanidine ((131)I-MIBG) followed by reduced-intensity conditioning (RIC) and transplantation of T cell-depleted haploidentical peripheral blood stem cells (designated haplo-SCT) to treat relapsing/refractory neuroblastoma (RRNB). Five RRNB patients were enrolled: 4 with relapse (3 after autologous SCT) and 1 with induction therapy failure. The preparative regimen included high-dose (131)I-MIBG on day -20, followed by fludarabine (Flu), thiotepa, and melphalan (Mel) from day -8 to -1. Granulocyte-colony stimulating factor (G-CSF)-mobilized, T cell-depleted haploidentical paternal stem cells were infused on day 0 together with cultured donor mesenchymal stem cells. A single dose of rituximab was given on day +1. After cessation of short immunosuppression (mycophenolate, OKT3), 4 children received donor lymphocyte infusion (DLI). (131)I-MIBG infusion and RIC were well tolerated. All patients engrafted. No primary acute graft-versus-host disease (aGVHD) was observed. Four children developed aGVHD after DLI and were successfully treated. Analysis of immunologic recovery showed fast reappearance of potentially immunocompetent natural killer (NK) and T cells, which might have acted as effector cells responsible for the graft-versus-tumor (GVT) effect. Two children are alive and well, with no evidence of disease 40 and 42 months after transplantation. One patient experienced late progression with new bone lesions (sternum) 38 months after haplo-SCT, and is being treated with local irradiation and reinstituted DLI. One patient rejected the graft, was rescued with autologous backup, and died of progressive disease 5 months after transplantation. Another child relapsed 7 months after transplantation and died 5 months later. High-dose (131)I-MIBG followed by RIC and haplo-SCT for RRNB is feasible and promising, because 2 of 5 children on that regimen achieved long-lasting remission. Further studies are needed to evaluate targeted therapy and immune-mediated tumor control in high-risk neuroblastoma