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ZusammenfassungEine 60-jährige Patientin zeigte 2 Wochen nach Lungentransplantation mit anfänglich guter Organfunktion einen Abfall der Thrombozyten, intermittierendes Fieber unklarer Genese, Diarrhö und eine zunehmende Verschlechterung des Allgemeinzustands. Die laborchemische, mikrobiologische und bildgebende Diagnostik ergab keine Erklärung für die Symptome. Unter der Differenzialdiagnose einer Abstoßung konnte anhand der Lungenbiopsie keine zelluläre Abstoßung festgestellt werden. Im Gegensatz zum Serumbefund vor Transplantation konnten im Serum 3 Wochen nach Transplantation erstmalig HLA-Antikörper mit hohen Signalstärken nachgewiesen werden, aber nicht wie erwartet gegen den Lungendonor, sondern gegen die Lungenempfängerin gerichtet. Die parallel durchgeführte Chimärismusdiagnostik aus peripherem Blut ergab einen Spenderanteil von 0,6%. Die Aufarbeitung der Lungenspenderanamnese (Z. n. Lebertransplantation 4 Tage vor Organspende, Transfusionen und Schwangerschaften) erhärteten den Verdacht eines „Passenger Lymphocyte Syndrome“ (PLS) mit den klinischen Symptomen einer Graft-versus-Host-Reaktion (GvHD). In den weiteren Wochen nach Transplantation verringerten sich die Signalstärken der empfängerspezifischen HLA-Antikörper und es konnten zu keinem Messzeitpunkt donorspezifische HLA-Antikörper nachgewiesen werden. Der Spenderanteil im peripheren Blut ging ebenfalls in der Verlaufskontrolle zurück. Zwölf Wochen nach Transplantation wurde die Patientin in die Rehabilitation entlassen. Anhand dieser Kasuistik soll darauf aufmerksam gemacht werden, dass die im Rahmen einer Lungentransplantation ebenfalls transplantierten immunkompetenten Spenderlymphozyten ein mitunter komplikationsreiches PLS mit den klinischen Zeichen einer GvHD verursachen können.

ZusammenfassungÜber viele Dekaden hinweg war für die Behandlung hämatologischer Erkrankungen die einzige akzeptierte zelluläre Therapie die Transplantation von hämatopoetischen Stamm- und Progenitorzellpräparationen, autolog oder allogen, nach vorheriger Konditionierung als individualisierte Therapieform etabliert. Dabei impliziert diese Art der Therapie aus rechtlicher Sicht nur minimale Manipulationen der Transplantate (Zentrifugation, Konzentrierung, Verdünnung, immunmagnetische Anreicherung oder Depletionen, Kryokonservierung), sodass die Gewinnung, Verarbeitung, Qualitätskontrolle und Abgabe der Stammzell-/Immuntherapeutika zumeist komplett in der Hand transfusionsmedizinischer Institutionen liegen. Nach der Zulassung durch die Europäische Arzneimittelbehörde (EMA) im August 2018 sind erstmals kommerziell erhältliche, autologe chimäre Antigen-Rezeptor-T-Zellen (chimeric antigen-receptor-T-cells, CAR-T-cells) in Deutschland sowie einer Vielzahl anderer europäischer Länder für die individualisierte Therapie von Patienten mit ausgewählten malignen Neoplasien der B-Zell-Reihe verfügbar. Im Rahmen einer gemeinsamen Sitzung der Sektion „Stammzelltransplantation und Zelltherapie“ und der Sektion „Präparative und therapeutische Apherese“ der Deutschen Gesellschaft für Transfusionsmedizin und Immunhämatologie (DGTI) am 19.10.2018 in Frankfurt wurden mehrere Impulsvorträge zum Thema „Zugelassene CAR-T-Zell-Therapie ante portas: Rolle der Transfusionsmedizin“ gehalten. Dabei wurden die Themen Finanzierung und Kostenerstattung, regulatorische und rechtliche Rahmenbedingungen sowie verschiedene Aspekte der notwendigen Verantwortungsabgrenzung zwischen dem Hersteller des Ausgangsmaterials, dem pharmazeutischen Unternehmen und dem klinischen Anwender ausführlich diskutiert.

Infection with SARS-CoV-2 has a profound influence on the hematopoetic system that mediates clinical symptoms and mortality. Several studies have shown that treatment of the cytokine storm (CRS) with anti-inflammatory drugs like dexamethasone and tocilizumab can significantly improve survival. Systematic reviews confirm the safety of convalescent plasma administration and offer initial indications of its effectiveness in certain groups. COVID-associated coagulopathy (CAC) and vaccine-induced immune thrombotic thrombocytopenia (VITT) represent severe infection- or vaccination associated complications that require a specific diagnostic and therapeutic workup.

Natural killer group 2 member D (NKG2D) plays an important role in the regulation of natural killer (NK) cell cytotoxicity in cancer immune surveillance. With the aim of redirecting NK cell cytotoxicity against tumors, the NKG2D ligand UL-16 binding protein 2 (ULBP2) was fused to a single-chain fragment variable (scFv) targeting the human epidermal growth factor receptor 2 (HER2). The resulting bispecific immunoligand ULBP2:HER2-scFv triggered NK cell-mediated killing of HER2-positive breast cancer cells in an antigen-dependent manner and required concomitant interaction with NKG2D and HER2 as revealed in antigen blocking experiments. The immunoligand induced tumor cell lysis dose-dependently and was effective at nanomolar concentrations. Of note, ULBP2:HER2-scFv sensitized tumor cells for antibody-dependent cell-mediated cytotoxicity (ADCC). In particular, the immunoligand enhanced ADCC by cetuximab, a therapeutic antibody targeting the epidermal growth factor receptor (EGFR) synergistically. No significant improvements were obtained by combining cetuximab and anti-HER2 antibody trastuzumab. In conclusion, dual-dual targeting by combining IgG1 antibodies with antibody constructs targeting another tumor associated antigen and engaging NKG2D as a second NK cell trigger molecule may be promising. Thus, the immunoligand ULBP2:HER2-scFv may represent an attractive biological molecule to promote NK cell cytotoxicity against tumors and to boost ADCC.

CD4

The pandemic spread of an infectious disease poses a plethora of challenges to society, clinicians, health care providers and regulating authorities. In order to mount a rapid response and to provide hope in a potentially catastrophic situation as the current COVID-19 pandemic, emergency plans, regulations and funding strategies have to be developed on regional, national and international levels. The speed needed to establish rapid response programs is challenged by the dynamics of the spread of the disease, the concurrent and competing development of different and potentially more effective treatment options, and not the least by regulatory uncertainty. Convalescent plasma, that is plasma collected from patients who have recovered from COVID-19 infections, has emerged as one of the first potential treatment options in the absence of drugs or vaccines with proven efficacy against SARS-CoV-2. The societal aspects of convalescent plasma and the public awareness gave an additional boost to the rapid employment of convalescent plasma donation platforms immediately after the SARS-CoV-2 outbreak. At the same time, uncertainty remains as to the efficacy of convalescent plasma. With evidence mostly limited to empirical reports, convalescent plasma has been used for decades for the prophylaxis and treatment of various infectious diseases. Clinical trials have addressed different infectious agents, stages of disease, target groups of patients and yielded sometimes inconclusive results. The aim of this short review is to delineate the regulatory background for the emergency use of convalescent plasma in the USA, in the European Union and in Germany, and the transition to the setting of clinical trials. In addition, we describe observations made in the process of collecting COVID-19 convalescent plasma (herein referred to as CCP), and formulate proposals to further improve the framework for rapid responses in future emergency situations.

Shipping is associated with various environmental impacts, such as pollutants discharged to air and sea. Much of this pollution appears to be unregulated, and global emissions from shipping are expected to more than triple between 2020 and 2050. This paper reviews global, national, regional and port-level legislative approaches that have been implemented to reduce emissions of carbon dioxide (CO2), nitrous oxides (NOx), sulphur oxides (SOx) and particulate matter (PM). Policies are identified on the basis of a systematic review of the literature in combination with a detailed analysis of the respective global, national and local policy initiatives. Findings suggest that many policies are voluntary or, in ports, incentive-based; regulatory approaches are largely limited to Emission Control Areas. Policies also focus on efficiencies, they are not concerned with absolute pollutant and greenhouse gas levels. No policies incentivizing or forcing the transition to zero-carbon fuels were identified. As ports can define limits to pollution, for instance by demanding shore power use, they can significantly affect the clean development of the sector. Further legislation will be needed nationally to counterbalance the lack of supranational ambition on pollutants and climate change mitigation.

Teaching sustainability presents challenges due to the inherent complexity and required behavioral change. A special pedagogical approach is needed. In this paper, we focus on the research question how students' awareness of sustainability issues can be improved significantly in a brief workshop. The presented workshop let the students autonomously addressing problems and possible solutions in small groups – with no patented recipes given, nor any "finger-pointing" from the outside. The educational basis for this workshop is the concept of discovery learning in combination with sketchnoting. This is especially appropriate to present acquired knowledge in a compact and meaningful way, to show relationships and allow schemas to be developed by the participants. This paper also describes the workshop results from several executions and the lessons learned.

During infection with the human immunodeficiency virus type 1 (HIV-1), latent reservoirs are established that circumvent full eradication of the virus by antiretroviral therapy (ART) and are the source for viral rebound after cessation of therapy. As these reservoirs are phenotypically indistinguishable from infected cells, current strategies aim to reactivate these reservoirs, followed by pharmaceutical and immunological destruction of the cells. Here, we employed a simple and convenient cell-based reporter system, which enables sample handling under biosafety level (BSL)-1 conditions, to screen for compounds that were able to reactivate latent HIV-1. The assay showed a high dynamic signal range and reproducibility with an average Z-factor of 0.77, classifying the system as robust. The assay was used for high-throughput screening (HTS) of an epigenetic compound library in combination with titration and cell-toxicity studies and revealed several potential new latency-reversing agents (LRAs). Further validation in well-known latency model systems verified earlier studies and identified two novel compounds with very high reactivation efficiencies and low toxicity. Both drugs, namely, N-hydroxy-4-(2-[(2-hydroxyethyl)(phenyl)amino]-2-oxoethyl)benzamide (HPOB) and 2′,3′-difluoro-[1,1′-biphenyl]-4-carboxylic acid, 2-butylhydrazide (SR-4370), showed comparable performances to other already known LRAs, did not activate CD4(+) T cells, and did not cause changes in the composition of peripheral blood mononuclear cells (PBMCs), as shown by flow cytometry analyses. Both compounds may represent effective new treatment possibilities for reversal of latency in HIV-1-infected individuals.

Background: Native cluster of differentiation (CD) 19 targeting antibodies are poorly effective in triggering antibody-dependent cell-mediated cytotoxicity (ADCC) and complement-dependent cytotoxicity (CDC), which are crucial effector functions of therapeutic antibodies in cancer immunotherapy. Both functions can be enhanced by engineering the antibody’s Fc region by altering the amino acid sequence (Fc protein-engineering) or the Fc-linked glycan (Fc glyco-engineering). We hypothesized that combining Fc glyco-engineering with Fc protein-engineering will rescue ADCC and CDC in CD19 antibodies. Results: Four versions of a CD19 antibody based on tafasitamab’s V-regions were generated: a native IgG1, an Fc protein-engineered version with amino acid exchanges S267E/H268F/S324T/G236A/I332E (EFTAE modification) to enhance CDC, and afucosylated, Fc glyco-engineered versions of both to promote ADCC. Irrespective of fucosylation, antibodies carrying the EFTAE modification had enhanced C1q binding and were superior in inducing CDC. In contrast, afucosylated versions exerted an enhanced affinity to Fcγ receptor IIIA and had increased ADCC activity. Of note, the double-engineered antibody harboring the EFTAE modification and lacking fucose triggered both CDC and ADCC more efficiently. Conclusions: Fc glyco-engineering and protein-engineering could be combined to enhance ADCC and CDC in CD19 antibodies and may allow the generation of antibodies with higher therapeutic efficacy by promoting two key functions simultaneously.

Background The anti-CD19 CAR T-cell products Axicabtagene Ciloleucel (Axi-cel) and Tisagenlecleucel have been approved by the EMA for the treatment of patients (pts) with relapse/refractory (r/r) diffuse large B-cell lymphoma (DLBCL) in August 2018. In clinical trials, both cell products induced ongoing complete responses in heavily pretreated patients. However, this activity was associated with significant toxicity. We evaluated the outcomes of DLBCL pts treated with Axi-cel and Tisagenlecleucel at the LMU Munich. Materials and Methods CAR T cell product characteristics, toxicity and response rates of pts treated at our center between January and October 2019 were retrospectively assessed. Results As of October 2019, 24 out of 34 r/r DLBCL pts (71%) with confirmed CAR T cell treatment indication were leukapheresed. Four apheresed pts died before CAR T cell therapy due to rapidly progressive disease. So far, 17 DLBCL pts have been treated. Median age was 60 years (range 19–74). ECOG was 0–1 in eleven, and 2–3 in six pts. Eight pts had undergone prior stem cell transplant (6 autologous, 2 allogeneic SCT). 13 pts received bridging chemotherapy between leukapheresis and CAR T cell transfusion. Only 6 (35%) of the 17 transfused pts would have met the inclusion criteria of the pivotal clinical trials (JULIET, ZUMA-1). CRS occurred in all pts (53% CRS °1, 29% °2 and 18% °3) with a median onset on day 2 (range days 0–7) and a median duration of 4 days (range 1–21). Tocilizumab was administered at least once in all pts. Ten pts (59%) experienced Immune Effector Cell associated Neurotoxicity Syndrome (ICANS, 30% °1, 10% °2, 30% °3, 20% °4 and 10% °5) with a median onset between day 7 and 8 and a median duration of 8 days (range 3–49). Cytopenia was significant following CAR T-cell treatment: all but one pts had neutropenia Response assessment four weeks after CAR T-cell transfusion was available for 15 pts. Objective response rate (ORR) at this early follow-up was 67%, with complete remission (CR) in four (27%) and partial remission (PR) in six pts (40%). Interestingly, ORR was higher in the four pts not receiving bridging chemotherapy between leukapheresis and CAR T-cell therapy than in pts in which bridging was applied (100% vs. 55%). Responders had significantly higher LDH levels at apheresis, start of lymphodepletion and CAR T-cell transfusion than non-responders. Conclusions Since January 2019, the CAR T cell program has been successfully initiated at the LMU Munich, and 17 r/r DLBCL pts have been treated at our center to date. CAR T cells induced responses in heavily pretreated pts with response rates within the expected range. Toxicity was significant but manageable in most pts. Involvement of a multidisciplinary ImmunoTaskforce was a key element for adequate patient care. Preliminary data supports the hypothesis that low tumor dynamics are associated with favorable outcomes of CD19 CAR T cell therapy. Disclosure Information V. Bucklein: None. V. Blumenberg: None. C. Schmidt: None. K. Rejeski: None. M. Ruzicka: None. N. Muller: None. A. Reischer: None. L. von Baumgarten: None. A. Volkl: None. B. Wagner: None. A. Humpe: None. J. Tischer: None. H. Stemmler: None. M. von Bergwelt: None. M. Subklewe: None.

Infection with SARS-COV-2 leads to a number of pathologies in the hematopoetic system that have significant impact on clinical symptoms and mortality. There are 3 stages of infection: (1) early upper respiratory tract infection with fever and lymphopenia (2) pulmonary phase and (3) hyperinflammatory phase with the clinical signs of organ failure such as ARDS/shock. Hyperinflammation, which is triggered by activation of T cells and monocytes/macrophages, is essential for organ pathologies. Interferon IFN-ɣ, tumor necrosis factor (TNF)-α, IL-10 and interleukin-6 (IL-6) play important roles as mediators of inflammation. In analogy to the cytokine release syndrome (CRS) after CAR-T cell therapy, the therapeutic activity of the IL-6 receptor antibody tocilizumab is investigated in clinical studies.The coagulation system is activated during the inflammatory phase of COVID infection, most likely on the pathophysiological basis of immune thrombosis. Clinically, there is a significantly increased incidence of venous (especially pulmonary artery embolism), but also arterial thromboembolism (TE). In laboratory chemistry, the D-dimer, fibrinogen but also vWF and FVIII are significantly increased. Guidelines for the prophylaxis and therapy of COVID-associated coagulopathy have been developed. Analogous to other viral infections, there are approaches to passive immunization using convalescent plasma. Its administration has shown promising activity in first uncontrolled case series and is currently being examined in clinical studies worldwide for its therapeutic activity.

Infection with SARS-COV-2 leads to a number of pathologies in the hematopoetic system that have significant impact on clinical symptoms and mortality. There are 3 stages of infection: (1) early upper respiratory tract infection with fever and lymphopenia (2) pulmonary phase and (3) hyperinflammatory phase with the clinical signs of organ failure such as ARDS/shock. Hyperinflammation, which is triggered by activation of T cells and monocytes/macrophages, is essential for organ pathologies. Interferon IFN-ɣ, tumor necrosis factor (TNF)-α, IL-10 and interleukin-6 (IL-6) play important roles as mediators of inflammation. In analogy to the cytokine release syndrome (CRS) after CAR-T cell therapy, the therapeutic activity of the IL-6 receptor antibody tocilizumab is investigated in clinical studies.The coagulation system is activated during the inflammatory phase of COVID infection, most likely on the pathophysiological basis of immune thrombosis. Clinically, there is a significantly increased incidence of venous (especially pulmonary artery embolism), but also arterial thromboembolism (TE). In laboratory chemistry, the D-dimer, fibrinogen but also vWF and FVIII are significantly increased. Guidelines for the prophylaxis and therapy of COVID-associated coagulopathy have been developed. Analogous to other viral infections, there are approaches to passive immunization using convalescent plasma. Its administration has shown promising activity in first uncontrolled case series and is currently being examined in clinical studies worldwide for its therapeutic activity.

For years, cancer treatment was dominated by chemotherapy, radiation therapy, and stem cell transplantation. New insights into genetic characteristics of leukemic cells have initiated the development of the chimeric antigen receptor (CAR) T-cell therapy. This type of adoptive cell immunotherapy has been a breakthrough in the treatment of aggressive B-cell lymphoma and B-cell precursor acute lymphoblastic leukemia. In August 2018, the European Commission has approved the first CAR T-cell products – tisagenlecleucel (Kymriah®, Novartis) and axicabtagene ciloleucel (Yescarta®, Gilead) – for hematological neoplasms in Europe. As CAR T cells are a living drug, its benefits can last for many years. The administration of CAR T cells is a complex and costly endeavor involving cell manufacture, shipping of apheresis products, and management of novel and severe adverse reactions. The most common toxicities observed after CAR T-cell therapy are cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome. Current research focuses on improved safety and efficacy in hematological malignancies as well as the translation of CAR T-cell therapy to solid tumors. This review covers the development and current status of CAR T-cell therapy in a clinical setting with focus on challenges and future opportunities.

Company cars have received considerable attention because of their partial tax-exemption and the changes in travel behaviour they stimulate, including car model choices, distances driven, and car o...