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Plasma concentrations and peripheral blood cells containing cytoplasmic cytokines were monitored during the post-transplant period in 10 patients who had received allogeneic bone marrow transplants (BMT) for the correction of inherited genetic disorders. The presence of CD14-positive cells containing cytoplasmic interleukin-1 alpha and beta in the peripheral blood was indicative of acute graft-versus-host disease (GVHD). Plasma concentrations of IL-1 alpha, IL-1 beta and TNF-alpha were significantly raised in the GVHD group when compared with the uneventful days. There was, however, poor temporal correlation between the plasma concentrations and clinical manifestations of acute GVHD. Cells containing cytoplasmic IL-6 were present in the peripheral blood when patients had clinically suspected and/or microbiologically confirmed infection. The results from this study demonstrate that analysis of peripheral blood cells for cytoplasmic IL-1 alpha and IL-1 beta are better markers of acute GVHD than is monitoring plasma concentrations of these cytokines.

Differential diagnosis of hepatic complications after bone marrow transplantation (BMT) is often difficult. To assess whether serum concentrations of the aminopropeptide of type III procollagen (PIIINP) could facilitate diagnosis, we measured serum PIIINP, corrected for age by conversion to standard deviation scores (SDS), serially after BMT in 27 children. A preliminary study of 11 patients showed that a PNIIINP-SDS cutoff of 8.0 was an optimum for diagnosis of veno-occlusive disease (VOD). PIIINP-SDS was increased above cut-off 1-25 days before the onset of clinical signs in the 12 patients (4 from the preliminary group, the others from a group of 16 studied prospectively) who developed VOD, with subsequent changes in PIIINP-SDS mirroring the course of VOD. By contrast, PIIINP-SDS remained below cut-off in all other patients, including 7 with liver graft-versus-host disease and 3 with drug hepatotoxicity. PIIINP-SDS values greater than 8.0 predict, diagnose, and monitor VOD after BMT.

A boy whose chronic granulomatous disease (CGD) manifested in infancy, and whose elder brother had died at 7 years of age, had phagocytes with complete lack of functional cytochrome B-245 and which could not be induced by interferon gamma to achieve adequate staphylococcal killing. He underwent an elective displacement bone marrow transplant from a volunteer unrelated donor at the age of 8 months. This has achieved 100% replacement of the CGD granulocytes by those of the normal volunteer and the boy has since had a normal childhood for 3 years. Six previous transplants for CGD are briefly reviewed and illustrate that the host abnormal marrow must be completely displaced using an adequate dose of busulphan to ensure 100% stable engraftment of the donor's marrow and that this is best done under elective conditions before septic foci and irreversible organ damage have occurred. Criteria need to be developed to identify early those patients likely to have severe morbidity.

The first paper [9] advocating the displacement use of bone marrow transplantation (DBMT) to treat a variety of genetic metabolic diseases (including thalassaemia major) was put before a European Working Party in 1978. It evolved from mainly Westminster experience which showed the need [6] for DBMT and first successfully used donors other than matched siblings [9]. The principles of using DBMT to install a donor marrow as a component factory which can last a lifetime are outlined. It is not a panacea, being applicable to only about 7% of known inborn errors. Worthwhile correction of some 50 previously disabling diseases in over 700 patients has already been achieved worldwide and for most of the survivors no further treatment is used after 1 year. Guidelines for future extension, including gene transplants, are offered. The superior results of elective DBMT (about 95%) should encourage paediatricians to aim for earlier diagnoses and evaluations for transplants.

A 12-year-old boy in third remission acute lymphoblastic leukaemia was given a mismatched transplant from his mother. He suffered prolonged neutropenia and pyrexia which was only finally diagnosed as toxoplasmosis using molecular biology methods and by his response to appropriate treatment. This was probably transmitted by bone marrow transplant since maternal immune T cells were removed by the use of Campath-1G and treatment with cyclosporin A probably prevented his IgM immune response and impeded the diagnosis.

The initial simple bone marrow transplants for genetic immunodeficiency diseases could hardly be rejected by the host, but required matched sibling donors, only available for about 1 in 5 patients. Improved inductions enabled alternative donors from the family or unrelated volunteers to be used. Measurement of the extent of engraftment by donor cell markers or their normal enzymes showed the need for displacement, which aims to obtain 100% donor-type marrow so that the future immune responses of the recipient become those of the donor and tolerant to donor cells or their products. Immunoprophylaxis can prevent residual host immune cells from surviving to impair the graft. The concept of DBMT with immunoprophylaxis has evolved either to replace abnormal host cells or to confer a component transferable from donor cells to deficient host tissues. Within 10 years over 40 previously fatal genetic diseases have been satisfactorily corrected and seven partially corrected, but for five there has been inadequate delivery of component to genetically defective tissues such as heart, cartilage and brain. The principles can be applied to some 40 other genetic diseases for which no suitable alternative treatments yet exist.

Serum C-reactive protein concentrations were measured serially during the early transplant period in 68 bone marrow recipients transplanted for leukaemia (34), chronic granulocytic leukaemia (2), severe aplastic anaemia (6), and various inborn errors of metabolism (26). There were 116 clearly documented episodes of infection or acute graft versus host disease or both. Serum C-reactive protein concentrations in patients with viral (11) or fungal infection (6) were normal or only slightly raised. In 32 patients with isolated acute graft versus host disease, only three (10%) showed serum C-reactive protein concentrations above 40 mg/l. Values greater than 40 mg/l were strongly suggestive of bacterial infections and values above 100 mg/l were seen only in patients (43) with bacterial infections with or without acute graft versus host disease. These findings suggest that serum C-reactive protein concentrations are valuable both for diagnosis and monitoring of such infections.

A one-year-old boy with type I H mucopolysaccharidosis (Hurler's disease) was given a bone-marrow transplant (BMT) from his mother in an attempt to replace the deficient enzyme, alpha-L-iduronidase (iduronidase). These is definite evidence of engraftment, the enzyme activity of the recipient's leucocytes reaching heterozygote levels within 37 days of the BMT. Graft-versus-host disease (GVHD) developed but was partially controlled by steroids. From 3-4 months after graft until the present (13 months after the graft) iduronidase activity has been present in the serum and the urine and there has been evidence of considerable degradation of glycosaminoglycans excreted in the urine. The hepatosplenomegaly has disappeared, corneal clouding has cleared, and deterioration in the child's development seems to have been arrested.

The details of the first successful bone marrow graft from father to son are described. The recipient developed an acute graft-versus-host reaction on the seventh day which was successfully treated with anit-lymphocyte globulin and methotrexate. This regime did not destroy the graft and the child is alive and well with normal immunological function some 2 1/2 years later.

Seventeen bone marrow recipients transplanted for acute leukaemia (8), chronic leukaemia (1), severe aplastic anaemia (3), and various inborn errors of metabolism (5) had 22 episodes of documented infection in the late (greater than 3 months) post-transplant period. Serum C-reactive protein concentrations were considerably increased in patients with bacterial infections, but not in those with viral or fungal infections. Serum C-reactive protein values were normal in 20 patients transplanted for acute leukaemia (12), chronic leukaemia (1), severe aplastic anaemia (2), and various inborn errors of metabolism (5) who had active chronic graft versus host disease but no evidence of infection. These findings indicate that serum C-reactive protein concentrations are useful in the diagnosis and monitoring of bacterial infections even in the presence of chronic graft versus host disease.

Oral Cyclosporin A (CyA) was given for the prophylaxis of graft-versus-host disease (GVHD) to sixty-seven patients receiving a bone marrow transplant, and was found to be extremely effective in reducing the severity of acute GVHD. Side-effects of CyA included hypertrichosis, gum hypertrophy, and a rare but serious 'capillary leak' syndrome.

A 15-year-old boy with Fanconi's anaemia, who required four units of blood each month, received a bone marrow graft from his 9-year-old brother, who has HLA identical and compatible on mixed lymphocyte reaction. Considerable immunosuppression was used and bacterial infection was prevented by vigorous decontamination in a Vickers-Trexler isolator. After the graft the patient's blood counts remained satisfactory for nine months, but it took six months before qualitative immune function was normal.

Fifty children were induced with busulphan and cyclophosphamide before bone marrow transplantation. Our standard dose of cyclophosphamide was 2 g/m2 daily for 4 days, but this dosage was reduced if necessary so as not to exceed 75 mg/kg/day. A basal pulse rate that increased by more than 20 beats/min or a reduction in ECG voltage were indications for stopping cyclophosphamide. As a consequence, the fourth dose of cyclophosphamide was omitted for four children. One child died of cardiac arrest related to cyclophosphamide. We used busulphan at a dosage of 4 mg/kg/day for 4 days; neither 'busulphan lung' nor veno-occlusive disease occurred in any patient. The use of busulphan and cyclophosphamide did not guarantee freedom from interstitial pneumonitis, but this seemed to be related rather to the nature of prior treatment and the cytomegalovirus antibody status of the patient. Thus, we have developed a safe chemotherapy schedule for transplantation that avoids the need for radiotherapy and can, if necessary, be repeated after a 3-month interval.

Twenty-four patients have received bone marrow transplantation for severe aplastic anaemia at the Westminster Hospitals since 1974. Twelve patients are long term survivors. Infectious complications in association with graft rejection, graft versus host disease or prolonged neutropenia were the major cause of death. In the last 18 months the introduction of more effective conditioning regimes and Cyclosporin A as graft versus host disease prophylaxis has improved the survival rate to 85%. One patient has required regrafting for late graft failure without evidence of graft rejection.

The correction of immunodeficiency requires T-cells, B-cells and antigen-presenting cells, all cooperating with each other in a balanced manner, and able to protect the tissues of the host from intracellular viral infections. Full B-cell function may require more than one genetic haplotype, and has only been achieved between host and donor cells when these are very well matched. Otherwise it has been necessary for the donor T- and B-cells to displace the host B-cells. In infants, displacement is better achieved using Busulphan rather than irradiation, (which also impairs the tolerising influence of the host thymus). Full correction has been achieved in 4 kinds of lymphopaenic SCID (+/- reticular dysgenesis or cartilage-hair dysplasia) without induction. For 16 other errors of lymphocyte function, displacement induction is preferred to ensure donor T-B-cell cooperation, although Cyclophosphamide alone has worked for matched sibling donors. For 9 other defects all expressed in phagocytes, which nevertheless occupy bone marrow space, displacement induction is essential. Elective transplants into fit hosts (e.g. no bronchiectasis) from matched sibling donors enabled 74 of 75 patients to leave hospital alive and well, with only 1 fatal acute GvHD. Currently, experienced teams can therefore consider another 20 diseases which might be better treated by bone marrow transplantation from matched siblings. In contrast, emergency transplants into unfit recipients produce only 60% survival. Transplants from donors sharing one genetic haplotype have reached 50% survival and there is room for improvement, but they are preferred to the use of unrelated donors or foetal tissues.

The technique of bone marrow transplantation (BMT) is now well established. Of now over 90 inborn errors of metabolism at least 45 have been treated by BMT. Among these some 35 have been proven to be curable by this procedure. The present paper reviews the respective literature and considers in particular the pertinent experiences of the Westminster Bone Marrow Transplantation Team.

Twenty patients have undergone bone marrow transplantation for acute lymphoblastic leukaemia (ALL). Eighteen patients were in complete remission and two had less than 10% leukaemic blasts in the marrow aspirate in the week prior to transplantation. Eighteen patients were grafted from HLA/MLC compatible siblings. One identical twin and one fully compatible parent were also used as donors. Two patients died of graft-versus-host disease and one of radiation-induced pneumonitis. Four have subsequently relapsed. Thirteen patients remain well and in remission from 202 to 1126 d post transplantation. These results show that morbidity and mortality from the bone marrow transplantation procedure is low. However, the major obstacle to permanent success in marrow transplantation of patients with ALL is recurrence of the disease (35% actuarial disease free survival at 1126 d).

Results of bone marrow transplantation (BMT) in 63 adults and children with ALL transplanted in the 5-year period 1979-83 were analysed. Twenty-one patients (33%) relapsed, 25% of the group died in relapse and 19% died from complications of BMT. The actuarial disease-free survival at 6 years was 38%. Relapse after BMT could be predicted by standard prognostic diagnostic features such as age, sex, cell type and presenting blast cell count. Patients transplanted in first remission selected for their poor prognosis had a lower relapse risk than a similar group of poor prognosis patients transplanted in second or subsequent remission (P less than 0.05). Relapse following second and subsequent remission BMT was predicted by a score based on standard prognostic features or by the pace of the disease: patients with an interval of less than 2 years between diagnosis and first relapse having a 15% actuarial disease-free survival, compared with 81% for patients with an interval greater than 2 years (P less than 0.001). These results emphasize that ALL is a heterogeneous disease and establishes the importance of determining relapse risk when selecting BMT and other treatment schedules for ALL patients.

The use of busulphan and cyclophosphamide permitted engraftment in 44 of 49 children receiving 'displacement' bone marrow transplants. Three patients who received T-cell-depleted marrow cells from HLA-haploidentical donors failed to engraft and other graft failures were due to inadequate induction dosage. Our standard schedule comprises busulphan 80 mg/m2/day x 4 days (adjusted if necessary to a minimum of 4 mg/kg/day or a maximum of 5 mg/kg/day) followed by cyclophosphamide 2 g/m2/day x 4 days but reduced so as not to exceed 75 mg/kg/day, a maximum dose preferred for patients with full marrows (e.g. those with thalassaemia major). Of 21 recipients of mixed lymphocyte culture (MLC)-negative donor marrow cells with full engraftment at 100 days, there were three late rejections. Of patients transplanted with marrow from MLC-positive donors, one had late rejection after cyclosporin A toxicity had necessitated withdrawal of the drug at day + 146 but six other patients, whose cyclosporin A was stopped routinely 1 year, remain well with full grafts. Ten patients died as a result of graft-versus-host disease. We are therefore exploring new approaches to T-cell depletion and storing autologous marrow for use in the event of graft failure. If necessary, a second transplant with busulphan and cyclophosphamide is best performed at 3 months after full recovery of the host. We conclude that elective transplants can be performed successfully in children with normal immune function without the need for irradiation.

2 patients with fast and 4 with medium varieties of Gaucher's syndrome were treated by displacement bone marrow transplantation to install a donor enzyme factory for life. Immunoprophylaxis was given to prevent host impairment of normal enzymes. 5 patients showed rapid and remarkable improvement and were leading fully active lives at 310-1207 days postgraft. Hypersplenism caused the death of 1 patient and a stormy time for another. Pre-transplant elective splenectomy hastened recovery.

Matched sibling transplants enjoy over 95% survival of the grafting procedure, but are only available for 1:5 patients. A sibling sharing one genetic haplotype is today our next choice of donor (67% survival) faring better than other relatives (50% survival), providing total body irradiation (of the thymus) has been avoided. The latter, without increasing the attack rate (64%) of GvHD more than doubles the deaths (57% as against 27%) attributable to it. Rejection is avoided by (a) suicide of host responders to donor buffy coat; (b) Cyclosporin-A; (c) displacement induction; (d) a higher dose of marrow. Prevention of GvHD is essential, using either Cyclosporin-A or removing donor T-cells from marrow prior to infusion or, probably better, both. Autoblast immunisation should be further explored. Tolerization seems an active process, easier in the very young, and nonirradiation of the thymus is believed important. An assay to assess tolerization (to guide cessation of immunosuppressive measures) is badly needed. Selection of a donor whose lymphocytes can deal with intracellular infections of the host's fibroblasts is now possible. The required increased immunosuppressive measures appear to increase the risk of leukemic relapse, and perhaps should be first improved in the more cost-effective fields of inborn error transplants.

Total and allergen-specific serum IgE were measured in relation to allergic response pattern before and after bone marrow transplant (BMT) in seven sibling donor/recipient pairs. Two non-atopic recipients developed persistently raised total serum IgE levels but no apparent allergic response after BMT from non-atopic donors; three non-atopic recipients showed raised total serum IgE after BMT, with allergen-specific IgE to the same allergens as their respective atopic donors. A penicillin-tolerant recipient showed clinical sensitivity and specific IgE to penicillin after BMT from a penicillin-sensitive donor, but with this case both donor and recipient showed raised serum IgE levels. One atopic recipient showed decreased total IgE after BMT from a mildly atopic donor. These allergic response patterns could occur as a result of repopulation in the recipient with IgE-specific T lymphocytes having similar regulatory influences as in the donor. The pattern of acquired responses would also be consistent with reconstitution by primed B lymphocytes of donor origin.

Allogenic bone marrow transplantation was carried out on a 3 year old girl with Niemann-Pick disease type B. Successful engraftment was achieved, and nine months after the procedure there was definite clearing of the sphingomyelin from the liver and pronounced clearing from the bone marrow. Any patient with Niemann-Pick disease type B complicated by early or severe hepatic impairment should be considered for bone marrow transplantation.

Serum IgE concentrations estimated in 25 bone marrow transplant recipients during episodes of infection or graft versus host disease, or both, were raised not only in some patients with acute graft versus host disease but also in many patients with infection. Raised values were not seen in chronic graft versus host disease. The routine estimation of serum IgE in bone marrow transplant recipients had minimal value because of the lack of specificity of the IgE response.

Seven children with Type I Gaucher's disease have been treated with bone marrow transplantation (BMT). One patient died from the complications of BMT. In five patients computed tomography (CT) of the femora showed initially high attenuation in the marrow, returning towards normal after successful BMT. One of these patients also showed clearing of pulmonary infiltrates following treatment. In the first patient in the series no pre-transplant CT measurements were carried out but plain radiographs have demonstrated a return to normal shape of her femora 21/2 years after BMT. It is hoped that CT of the marrow cavities may provide a simple, non-invasive method for monitoring progress following BMT.

Westminster experience had by 1973 evolved the concept of displacement bone marrow transplantation and extended the donors from matched siblings to other family and unrelated donors. The principles of its use to install donor bone marrow as a component factory for the life of the recipient, together with the importance of immunoprophylaxis are detailed. Satisfying correction has been achieved for 48 previously fatal genetic diseases, partial correction for another 5 with failure for 3 diseases. Displacement bone marrow transplantation is not a panacea, but could be applied to about 7% of known inborn errors, devising in vitro tests which can predict in vivo donor effects, especially since some 80% of our patients are not found in known families and could not have been prevented.

When an apparently identical HL-A donor can be found and satisfactorily checked by the mixed lymphocyte reaction, it is worth attempting simple bone marrow grafting in a patient with combined immune deficiency syndrome who otherwise would die. Immunocompetence was given in this way to a baby girl by her 4-year-old brother and was confirmed by the presence of Y-chromosome in most of the transforming lymphocytes. IgA was late to emerge, presumably owing to the immaturity for IgA of the donor's bone marrow.