Chromatin mapping and single-cell immune profiling define the temporal dynamics of ibrutinib response in CLL

The Bruton tyrosine kinase (BTK) inhibitor ibrutinib provides effective treatment for patients with chronic lymphocytic leukemia (CLL), despite extensive heterogeneity in this disease. To define the underlining regulatory dynamics, we analyze high-resolution time courses of ibrutinib treatment in patients with CLL, combining immune-phenotyping, single-cell transcriptome profiling, and chromatin mapping. We identify a consistent regulatory program starting with a sharp decrease of NF-kappa B binding in CLL cells, which is followed by reduced activity of lineage-defining transcription factors, erosion of CLL cell identity, and acquisition of a quiescence-like gene signature. We observe patient-to-patient variation in the speed of execution of this program, which we exploit to predict patient-specific dynamics in the response to ibrutinib based on the pre-treatment patient samples. In aggregate, our study describes time-dependent cellular, molecular, and regulatory effects for therapeutic inhibition of B cell receptor signaling in CLL, and it establishes a broadly applicable method for epigenome/transcriptome-based treatment monitoring

Az első két sikeres, convalescens friss fagyasztott plazmával történő terápia hazai alkalmazása intenzív osztályon kezelt, kritikus állapotú, COVID–19-fertőzésben szenvedő betegekben (A COVID–19-pandémia orvosszakmai kérdései)

Introduction: At present, neither specific curative treatment nor vaccines for novel coronavirus 2019 (COVID-19) are available. There is an urgent need to look for alternative strategies for COVID-19 treatment especially in the case of severe and/or critically ill patients with cytokine release syndrome (CRS).Aim: Convalescent plasma proved to increase survival rates in other severe viral infections. Therefore, convalescent plasma could be a promising treatment option for severe COVID-19 patients.Method: In our article, we present the first two critically ill Hungarian patients with COVID-19 infection treated with convalescent fresh frozen plasma.Results: At the time of plasma therapy both patients were on mechanical ventilation and received antiviral agents and a full scale of supportive care. Each patient received 3 x 200 mL of convalescent plasma of recently recovered donors with sufficient novel anti-coronavirus IgG titers. Subsequent to convalescent plasma infusion, oxygenization improved and inflammatory markers decreased in both individuals. As compared to pretransfusion, lymphocyte counts increased and interleukin-6 level lessened. Both patients were weaned from mechanical ventilation within 2 weeks of treatment. No severe adverse effects were observed.Conclusions: Our experience indicates that convalescent plasma therapy is well tolerated and could potentially improve clinical outcomes. Optimal dose and timing as well as precise assessment of clinical benefit of convalescent plasma therapy will need further investigation in larger, well-controlled trials. This is the first report of the successful use of convalescent plasma in the treatment of critically ill patients with COVID-19 infection in Hungary

Elevated Systemic Pentraxin-3 Is Associated With Complement Consumption in the Acute Phase of Thrombotic Microangiopathies

Pentraxin-3 (PTX3) and C-reactive protein (CRP) have been shown to regulate complement activation in vitro, but their role has not been investigated in complement consumption in vivo. Thrombotic microangiopathies (TMA) are often accompanied by complement overactivation and consumption, therefore we analyzed the relation of the systemic pentraxin levels to the complement profile, laboratory parameters and clinical outcome of TMA patients. We determined the PTX3 and CRP levels, complement factor and activation product concentrations in blood samples of 171 subjects with the diagnosis of typical hemolytic uremic syndrome (STEC-HUS) (N = 34), atypical HUS (aHUS) (N = 44), secondary TMA (N = 63), thrombotic thrombocytopenic purpura (TTP) (N = 30) and 69 age-matched healthy individuals. Clinical data, blood count and chemistry were collected from medical records. To determine the in vitro effect of PTX3 on alternative pathway (AP) activation, sheep red blood cell-based hemolytic assay and AP activity ELISA were used. We found that PTX3 levels were elevated in the acute phase of STEC-HUS, aHUS and secondary TMA, whereas PTX3 elevation was exceptional is TTP. Conversely, a significantly higher median CRP was present in all patient groups compared to controls. PTX3, but not CRP was associated with signs of complement consumption in vivo, and PTX3 significantly decreased the AP hemolytic activity in vitro. Our results provide a detailed description of acute phase-TMA patients' complement profile linked to changes in the systemic pentraxin levels that may support further molecular studies on the function of PTX3 in disease pathogenesis and add to the laboratory assessment of complement consumption in TMA

Peripheral Blood Stem Cell Mobilization and Engraftment after Autologous Stem Cell Transplantation with Biosimilar rhG-CSF

INTRODUCTION: Biosimilar versions of filgrastim [recombinant human granulocyte colony-stimulating factor (rhG-CSF)] are now widely available. To date, biosimilar rhG-CSF has demonstrated a comparable quality, safety and efficacy profile to the originator product (filgrastim [Neupogen((R))], Amgen Inc., CA, USA) in the prevention and management of neutropenia. Biosimilar rhG-CSFs have also been used to induce peripheral blood stem cell (PBSC) mobilization in patients undergoing autologous stem cell transplantation (AHSCT). The authors have examined the effectiveness of a biosimilar rhG-CSF (Zarzio((R)), Sandoz Biopharmaceuticals, Holzkirchen, Germany) in two retrospective studies across two medical centers in Hungary. METHODS: In Study 1, 70 patients with hematological malignancies scheduled to undergo AHSCT received chemotherapy followed by biosimilar rhG-CSF (2 x 5 mug) for facilitating neutrophil, leukocyte, and platelet engraftment. In study 2, 40 additional patients with lymphoid malignancies and planned AHSCT received chemotherapy followed by biosimilar rhG-CSF for PBSC mobilization. The effectiveness of treatment was assessed by the average yield of cluster of differentiation (CD) 34+ cells and the number of leukaphereses required. RESULTS: In Study 1 (patients undergoing AHSCT), the median age was 56 years and most patients were male (60%). The conditioning regimens were mainly high-dose melphalan (n = 41) and carmustine (BiCNU((R)), Bristol-Myers Squibb, NJ, USA), etoposide, cytarabine and melphalan BEAM (n = 21). Median times to absolute neutrophil and leukocyte engraftment were 9 (range 8-11 days) and 10 (8-12) days, respectively. Median time to platelet engraftment was 10.5 days (7-19 days). In Study 2, the patients' median age was 54 years and the majority (57.5%) were female. The median time interval between day 1 of mobilizing chemotherapy and first leukapheresis was 12 (9-27) days. In the autologous PBSC grafts, the median number of CD34+ cells harvested was 5.2 x 10(6)/kg (2.22-57.07 x 10(6)/kg). The median yield of CD34+ cells per leukapheresis product was 2.47 x 10(6)/kg. In total, 58 leukaphereses were performed in 40 successfully harvested patients. CONCLUSIONS: In line with previous studies with originator rhG-CSF, the findings of this study indicate that biosimilar rhG-CSF following AHSCT is effective and generally well tolerated in the engraftment setting. In addition, biosimilar rhG-CSF is comparable to the originator rhG-CSF in terms of kinetics of PBSC mobilization and yield of CD34+ cells. In conclusion, the authors have demonstrated that the use of biosimilar rhG-CSF is effective and safe in autologous PBSC mobilization and engraftment after AHSCT

Allogén vérképzőőssejt-átültetés Magyarországon

INTRODUCTION AND AIM: The publication summarizes the 2548 stem cell transplantations performed in the period of 1993-2015 in Szent Laszlo Hospital, Budapest and provides a detailed discussion of the 425 allogeneic transplantations during 2007-2013. METHOD: The analysis explains the major steps of the evolution of allogeneic stem cell transplantation and compares the results of the unique Hungarian allogeneic center. RESULTS: The significant shift in the transplantation indications from chronic myeloid leukemia to myelodysplastic syndromes and the rising age of the recipients are in line with world wide tendencies. The latter one is the consequence of the introduction and improvement of the concept of reduced intensity conditioning regimens, originally arising from the idea of Endre Kelemen. The most limiting factor, the donor availability seems to be resolved with the use of a new immunomodulating regimen, the application of posttransplantation cyclophosphamide, which allows the transplantation through HLA barriers with haploidentical family donors with comparable results to the HLA matched volunteer unrelated donors. The above mentioned tendencies result the wider use of allogeneic stem cell transplantation less dependent from recipient age, comorbidities and even donor availability. CONCLUSIONS: The publication highlights the need of expanding the stem cell transplantation budget and the involvement of new centers in Hungary in allogeneic of stem cell transplantation. Orv. Hetil., 2017, 158(8), 291-297

Korszakváltás a gyermekkori szerzett csontvelő-elégtelenséggel járó kórképek kezelésében Magyarországon = Change in paradigm in the treatment of pediatric acquired bone marrow failure syndromes in Hungary

Absztrakt: Bevezetés: A gyermekkori szerzett csontvelő-elégtelenségek ritka, kezelés nélkül halálos betegségek. Egységes diagnosztikájukat és terápiájukat európai munkacsoport felügyeli. A munkacsoport bevezette a hypocellularis gyermekkori refrakter cytopenia entitást, melyet csökkentett intenzitású kondicionálással transzplantálva lényegesen jobb túlélési eredményeket kaptak. Célkitűzés: A protokollhoz csatlakozás előtt és az azóta eltelt 5 évben kezelt betegek eredményeinek ismertetése. Módszer: A 2013 és 2017 között eltelt 5 évben a Magyar Gyermekonkológiai Hálózat 8 központjában 55 gyermeket kezeltünk (súlyos aplasticus anaemia: 9, myelodysplasticus szindróma: 41, juvenilis myelomonocyter leukaemia: 5). Súlyos aplasticus anaemiában 7 esetben végeztünk őssejt-transzplantációt, egy esetben antithymocytaglobulin-kezelést, egy beteg a diagnózis előtt meghalt. Myelodysplasiában 37 esetben végeztünk transzplantációt, 4 esetben a szoros megfigyelést választhattuk. E transzplantációk 54%-a (20 eset) csökkentett intenzitású kondicionálással történt. A juvenilis myelomonocyter leukaemiában szenvedő 5 betegnél transzplantáció történt. Eredmények: A diagnózis és a kuratív kezelés között eltelt idő medián 92 (3–393) nap volt, súlyos aplasticus anaemia esetén 28 (3–327) nap. Akut graft versus host betegség II–IV. fokozatú súlyossággal 22,6%, III–IV. fokozatú súlyossággal 6,8%-ban jelentkezett, míg betegeink 11,2%-a krónikus graft versus host betegségben szenvedett. A súlyos aplasticus anaemiával kezelt 8 beteg mindegyike teljes remisszióban él (100%). A myelodysplasia miatt transzplantált betegek becsült túlélése 85,1%, juvenilis myelomonocyter leukaemiában 75%. A medián követési idő 30,4 (1,1–62,5) hónap volt. Jelen eredményeinket összevetettük az 1992 és 2012 között kezelt betegek eredményeivel. A túlélés az új szemlélet nyomán jelentősen javult, súlyos aplasticus anaemiában trendszerűen 70%-ról 100%-ra (p = 0,133), myelodysplasticus szindrómában szignifikánsan 31,3%-ról 85,1%-ra (p = 0,000026). Következtetés: Paradigmaváltás történt a gyermekkori szerzett csontvelő-elégtelenségek kezelésében, a betegcsoport túlélése szignifikánsan növekedett. Orv Hetil. 2018; 159(42): 1710–1719. | Abstract: Introduction: Acquired bone marrow failures are rare but fatal diseases in childhood. Since 2013, Hungary has been participating as a full member in the work of the European Working Group on uniform diagnostics and therapy in patients with acquired bone marrow failure syndromes. Hypocellular refractory cytopenia of childhood has been emphasized as a frequent entity, transplanted by reduced intensity conditioning with excellent outcomes. Aim: To analyse and compare the results of treatment before and after our joining. Method: A total of 55 patients have been treated in the 8 centres of the Hungarian Pediatric Oncology Network during 5 years between 2013 and 2017 (severe aplastic anemia: 9, myelodysplastic syndrome: 41, juvenile myelomonocytic leukemia: 5 patients). Allogeneic hematopoietic stem cell transplantation was performed in severe aplastic anemia in 7 cases, while antithymocyte globulin was administered in one case and one patient died before diagnosis. In patients with myelodysplastic syndromes, watch and wait strategy was applied in 4, while transplantation in 37 cases. Reduced intensity conditioning was used in 54 percent of these cases. Transplantation was the treatment of choice in all 5 patients with juvenile myelomonocytic leukemia. Results: In the whole patient cohort, the time from diagnosis to treatment was median 92 (3–393) days, while in severe aplastic anemia median 28 (3–327) days only. Grade II–IV acute graft versus host disease occurred in 22.6%, grade III–IV in 6.8% and chronic in 11.2%. All the patients treated with severe aplastic anemia are alive and in complete remission (100%). The overall estimated survival rate is 85.1% in myelodysplastic syndrome, while 75% in juvenile myelomonocytic leukemia. The median follow-up was 30.4 (1.1–62.5) months. There was a remarkable increase in overall survival comparing the data before (1992–2012) and after (2013) joining the international group, 70% vs. 100% (p = 0.133) in severe aplastic anemia and 31.3% vs. 85.1% (p = 0.000026) in myelodysplastic syndrome. Conclusion: Due to a change in the paradigm of the conditioning regimen in hypocellular refractory cytopenia of childhood, the overall survival rate has significantly increased. Orv Hetil. 2018; 159(42): 1710–1719

Elevated plasma neutrophil elastase concentration is associated with disease activity in patients with thrombotic thrombocytopenic purpura.

INTRODUCTION: Genetic and autoimmune risk factors contribute to the development of thrombotic thrombocytopenic purpura (TTP) but triggers are needed to bring about acute disease. The aim of the study was to investigate the association of neutrophil activation with acute TTP, to assess whether neutrophil activation changes during plasma exchange therapy and to show if complement- and neutrophil activation are parallel, characteristic processes in acute TTP. MATERIALS AND METHODS: Altogether 49 EDTA-plasma samples of 21 TTP patients with acute disease and 17 in remission were investigated along with 20 healthy controls. A stable complex of PMNE-proteinase-inhibitor was measured by ELISA (Calbiochem, Merck-Millipore, Darmstadt, Germany). RESULTS: Acute disease was associated with significantly increased PMNE levels, the group medians were similarly low in TTP patients in remission and in healthy controls. Increased PMNE levels were characteristic for hematologically active and ADAMTS13 deficient form of TTP. PMNE concentration inversely correlated to disease activity markers platelet count (r=-0.349, p=0.032) and hemoglobin levels (p=-0.382 p=0.018). Achievement of remission was associated with significant reduction of plasma PMNE levels (p=0.031, Wilcoxon test). There was positive correlation between PMNE levels and complement activation markers C3a and Bb. CONCLUSIONS: We report increased PMNE levels in acute TTP and showed its association to activity markers of acute TTP and complement activation. Effective treatment of an acute TTP episode resulted in marked decrease in PMNE levels. Our data support and extend previous observations that neutrophil extracellular traps may be released in acute TTP and potentially contribute to the pathophysiology of this disease