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Allogeneic hematopoietic stem cell transplantation (HSCT) is the only widely available curative treatment for sickle cell disease (SCD). Myeloablative conditioning regimens are associated with excellent outcomes in children with HLA-identical sibling donors but are limited by organ toxicity in adults. Here we report 48 children and adults who underwent HLA-identical sibling HSCT for SCD using a reduced toxicity conditioning (RTC) regimen (fludarabine, busulfan, and anti-thymocyte globulin), followed by cyclosporine plus methotrexate for graft-versus-host disease (GVHD) prophylaxis. Median (range) age at transplant and duration of follow-up were 16.5 (7–35) years and 77.5 (1-169) months, respectively. Indication for HSCT included neurological complications in 25 (52.1%) patients and 10 (20.8%) were alloimmunized against red blood cell antigens. All patients achieved engraftment, except one who died before engraftment period. Secondary graft failure, grade ≥ 2 acute GHVD and chronic GVHD were present in 7 (14.6%), 10 (20.8%) and 7 (14.6%) patients, respectively. Five-year overall survival (OS) and event-free survival (EFS) (95% CI) were 91% (77.8–96.5) and 80.3% (65.5–89.2), respectively. Survival curves were not different between children and adults (p = 0.37 and p = 0.33, respectively). RTC regimen is safe and effective, with acceptable toxicity and incidence of GVHD, in children and adults with SCD.

Brain injury in sickle cell disease (SCD) comprises a wide spectrum of neurological damage. Neurocognitive deficits have been described even without established neurological lesions. DTI is a rapid, noninvasive, and non-contrast method that enables detection of normal-appearing white matter lesions not detected by conventional magnetic resonance imaging (MRI). The aim of the study was to evaluate if stem cell transplantation can revert white matter lesions in patients with SCD. Twenty-eight SCD patients were evaluated with MRI and DTI before and after allogeneic hematopoietic stem cell transplantation (HSCT), compared with 26 healthy controls (HC). DTI metrics included fractional anisotropy (FA), mean diffusivity (MD), radial (RD), and axial (AD) diffusivity maps, global efficiency, path length, and clustering coefficients. Compared to HC, SCD patients had a lower FA (p = 0.0086) before HSCT. After HSCT, FA increased and was not different from healthy controls (p = 0.1769). Mean MD, RD, and AD decreased after HSCT (p = 0.0049; p = 0.0029; p = 0.0408, respectively). We confirm previous data of white matter lesions in SCD and present evidence that HSCT promotes recovery of brain injury with potential improvement of brain structural connectivity.

Brain injury in sickle cell disease (SCD) comprises a wide spectrum of neurological damage. Neurocognitive deficits have been described even without established neurological lesions. DTI is a rapid, noninvasive, and non-contrast method that enables detection of normal-appearing white matter lesions not detected by conventional magnetic resonance imaging (MRI). The aim of the study was to evaluate if stem cell transplantation can revert white matter lesions in patients with SCD. Twenty-eight SCD patients were evaluated with MRI and DTI before and after allogeneic hematopoietic stem cell transplantation (HSCT), compared with 26 healthy controls (HC). DTI metrics included fractional anisotropy (FA), mean diffusivity (MD), radial (RD), and axial (AD) diffusivity maps, global efficiency, path length, and clustering coefficients. Compared to HC, SCD patients had a lower FA (p = 0.0086) before HSCT. After HSCT, FA increased and was not different from healthy controls (p = 0.1769). Mean MD, RD, and AD decreased after HSCT (p = 0.0049; p = 0.0029; p = 0.0408, respectively). We confirm previous data of white matter lesions in SCD and present evidence that HSCT promotes recovery of brain injury with potential improvement of brain structural connectivity.

Degenerative retinal diseases such as retinitis pigmentosa, Stargardt’s macular dystrophy, and age-related macular degeneration are characterized by irreversible loss of vision due to direct or indirect photoreceptor damage. No effective treatments exist, but stem cell studies have shown promising results. Our aim with this review was to describe the types of stem cells that are under study, their effects, and the main clinical trials involving them.

Introduction: Treatment of diffuse large B cell lymphoma (DLBCL) may be a challenge for Latin American countries. Thus, novel strategies to reduce the economic burden of oncological care are necessary. In Brazil, the DLBCL annual incidence is approximately 6.000 cases, among which 30% will relapse or become refractory (R/R). In this scenario, the limited access to the new therapies reinforce the need to develop new local technologies and improve research initiatives. Here we report the development and clinical application of a Brazilian platform to manufacture genetically modified T-cells to treat patients with R/R leukemia and lymphomas, which may also help reverse the poor prognosis of these patients in low and middle-income countries. Patients and Methods: All patients were referred to our center to consider compassionate use of anti-CD19 CAR-T cell therapy. The treatment was authorized by the local medical ethical committee. Once patients were deemed to be eligible for CAR-T, they were scheduled for lymphopheresis and the cells were processed and cryopreserved. During the manufacturing process and after completion of lymphophersis, all three patients received bridging therapy. Prior to infusion of CAR-T, patients were given lymphodepletion chemotherapy with cyclophosphamide and fludarabine for 3 days. Patients were monitored daily for the occurrence of cytokine release syndrome (CRS) and immune effector cell associated neurotoxicity syndrome (ICANS), which were graduated according to the criteria of the American Society for Transplantation and Cellular Therapy. These treatments were only available because we developed a Brazilian platform to manufacture genetically modified T-cells. Firstly, we developed and validated in vitro and in vivo anti-CD19 CAR T cell expression, expansion, and cytotoxicity. Secondly, in-house lentiviral good-manufacturing practice (GMP) protocols were established for clinical purposes. Thirdly, we upscaled the manufacturing process into the GMP facility originally developed for MSCs and adapted it to genetically modified T-cells. Finally, in-house procedures to deliver anti-CD19 CAR T cells for clinical use were established according to the Brazilian Health Regulatory Agency (ANVISA) policies. Once these steps were implemented, we were able to treat the first three patients of a patient with CAR-T cells produced in Latin America. Results: Two patients presented CAR-T cell expansion after the procedure (Figure 1). Within thirty days after the infusion one patient achieved complete response, one had partial response and one was not evaluated (Table 1). All patients had CRS and only one had ICANS. Two patients died, one from infection and other from intracranial hemorrhage due to domestic accident, --- and --- days after CAR-T cell infusion, respectively. Discussion: At least two of the reported patients presented improvement of their disease. The other one died before the expected response could have been evaluated. None of the patients died from complications related to manufacturing or infusion procedures, highlighting an acceptable safety profile of the platform. Although these are preliminary results, the CAR-T cell expansion profile, presence of systemic inflammatory response and lack of early disease progression suggest the treatment effectiveness. Conclusion: Apart from all the scientific challenges, this experience highlights the feasibility to implement a viable and efficient CAR-T platform in middle-income countries. Besides, implementation of advanced cellular therapy can also contribute to enhancing the quality of other cellular therapies. Figure 1 Figure 1. Disclosures Guerino-Cunha: Novartis: Other: Speaker; BMS: Other: Speaker; Janssen: Other: Speaker. Calado: Instituto Butantan: Consultancy; Alexion Brasil: Consultancy; Team Telomere, Inc.: Membership on an entity's Board of Directors or advisory committees; Novartis Brasil: Honoraria; Agios: Membership on an entity's Board of Directors or advisory committees; AA&MDS International Foundation: Research Funding.

Autologous hematopoietic stem cell transplantation (AHSCT) increases C-peptide levels and induces insulin-independence in patients with type 1 diabetes. This study aimed to investigate how clinical outcomes may associate with the immunological status, especially concerning the balance between immunoregulation and autoreactivity. Twenty-one type 1 diabetes patients were monitored after AHSCT, and assessed every six months for duration of insulin independence, C-peptide levels, frequencies of islet-specific autoreactive CD8+ T-cells, regulatory lymphocyte subsets, thymic function and T-cell repertoire diversity. In median follow-up of 78 (range 15-106) months, all patients became insulin-independent, resuming insulin after median of 43 (range 6-100) months. Patients were retrospectively divided into short- or prolonged-remission-groups, according to duration of insulin independence. For the entire follow-up, CD3+CD4+ T-cell numbers remained lower than baseline in both groups, whereas CD3+CD8+ T-cell levels did not change, resulting in a CD4/CD8 ratio inversion. Memory CD8+ T-cells comprehended most of T-cells detected on long-term follow-up of patients after AHSCT. B-cells reconstituted to baseline levels at 2-3 months post-AHSCT in both patient groups. In the prolonged-remission-group, baseline islet-specific T-cell autoreactivity persisted after transplantation, but regulatory T-cell counts increased. Patients with lower frequencies of autoreactive islet-specific T-cells remained insulin-free longer and presented greater C-peptide levels than those with lower frequencies of these cells. Therefore, immune monitoring identified a subgroup of patients with superior clinical outcome of AHSCT. Our study shows that improved immunoregulation may balance autoreactivity endorsing better metabolic outcomes in patients with lower frequencies of islet-specific T-cells. Development of new strategies of AHSCT is necessary to increase frequency and function of T and B regulatory cells and decrease efficiently autoreactive islet-specific T and B memory cells in type 1 diabetes patients undergoing transplantation.

Autologous haematopoietic stem-cell transplantation (AHSCT) has been experimented as a treatment in patients affected by severe forms of multiple sclerosis (MS) who failed to respond to standard immunotherapy. The rationale of AHSCT is to ‘reboot’ the immune system and reconstitute a new adaptive immunity. The aim of our study was to identify, through a robust and unbiased transcriptomic analysis, any changes of gene expression in T-cells potentially underlying the treatment effect in patients who underwent non-myeloablative AHSCT for treatment of MS. We evaluated by microarray DNA-chip technology the gene expression of peripheral CD4+ and CD8+ T-cell subsets sorted from patients with MS patients before AHSCT, at 6 months, 1 year and 2 years after AHSCT and from healthy control subjects. Hierarchical clustering analysis revealed that reconstituted CD8+ T-cells of MS patients at 2 years post-transplantation, aggregated together with healthy controls, suggesting a normalization of gene expression in CD8+ cells post-therapy. When we compared the gene expression in MS patients before and after therapy, we detected a large number of differentially expressed genes (DEG) in both CD8+ and CD4+ T-cell subsets at all time points after transplantation. We catalogued the biological function of DEG and we selected 27 genes known to be involved in immune function for accurate quantification of gene expression by real-time PCR. The analysis confirmed and extended with quantitative data, a number of significant changes in both the CD4+ and CD8+ T-cells subsets from MS post-transplant. Notably, CD8+ T-cells revealed more extensive changes in the expression of genes involved in effector immune responses.

SUMMARY Sickle-cell diseases are the most common inherited hemoglobinopathies worldwide. Improvement in survival has been seen in the last decades with the introduction of careful screening and prevention of complications and the introduction of hydroxyurea. Stem-cell transplantation is currently the only curative option for these patients and has been indicated for patients with neurological events, repeated vaso-occlusive crisis, any organ damage or presence of red blood cell antibodies. Related bone-marrow or cord-blood transplant has shown an overall survival of more than 90% with a disease-free survival of 90% in 1,000 patients transplanted in the last decades. The use of unrelated donors unfortunately has not shown the same good results, but better typing methods and improved support may improve the outcome with this source of stem cells in the future. In Brazil, only recently stem cell transplant from related donors has been included in the procedures performed in the public health system. The use of related bone marrow or cord blood and a myeloablative conditioning regimen are considered standard of care for patients with sickle-cell diseases. Transplants with non-myeloablative regimens, unrelated donors or haploidentical donors should be performed only in controlled clinical trials. RESUMO As doenças falciformes são as hemoglobinopatias mais frequentes mundialmente. Nas últimas décadas vivenciamos melhora na sobrevida de portadores destas patologias com a introdução de medidas preventivas e o uso precoce da hidroxiurea. O transplante de medula óssea alogênico (alo TMO) é a única opção terapêutica curativa para as hemoglobinopatias. O mesmo tem sido indicado para pacientes com complicações neurológicas, crises vasoclusivas repetidas, alguma lesão orgânica e alosensibilizados. O uso de doadores relacionados de medula óssea ou cordão umbilical mostrou em 1000 procedimentos realizados sobrevida global de 95% e sobrevida livre de ventos de 90%. O uso de doadores não aparentados não mostrou resultados tão expressivos, mas no futuro métodos melhores de tipagem de HLA e de medidas de suporte podem melhorar estes resultados. No Brasil apenas recentemente o alo TMO foi incluído no âmbito do sistema único de saúde (SUS) como opção terapêutica para portadores de doenças falciformes. O uso de doadores aparentados de MO ou de SCU com regime mieloablativo é considerado hoje tratamento estabelecido, sendo que o uso de doadores alternativos não aparentados ou haploidenticos e o uso de transplante com regime não mieloablativo deve ser considerado apenas em estudos clínicos.

In this review, we present (1) the scientific basis for the use of high-dose immunosuppression followed by autologous peripheral blood hematopoietic stem cell transplantation for newly diagnosed type 1 diabetes (T1D); (2) an update of the clinical and laboratory outcome of 20 patients transplanted at the University Hospital of the Ribeirão Preto Medical School, University of São Paulo, Brazil, and followed up to January/2008, including 4 relapses among 19 patients without previous ketoacidosis; (3) a commentary on criticisms to our article that appeared in four articles from the scientific literature; and (4) a discussion of the prospectives for cellular therapy for T1D.

Seckel syndrome is a rare autosomal recessive disease, genetically heterogeneous, characterized by short stature, prenatal microcephaly, intellectual disability, dysmorphic features, chromosomal instability, and hematological disorders. We report the case of a six-yr-old boy with Seckel syndrome and aplastic anemia who underwent successful allogeneic bone marrow transplantation from ten of ten HLA matched unrelated donor. Currently the patient is on D+771, in good health conditions and with no further complications. In conclusion, this case indicates that bone marrow transplantation is an acceptable therapeutic option for Seckel syndrome complicated by hematological alterations.

The present review discusses the use of autologous hematopoietic stem cell transplantation (HSCT) for the treatment of diabetes mellitus type 1 (DM 1). It has been observed that high dose immunosuppression followed by HSCT shows better results among other immunotherapeutic treatments for the disease as the patients with adequate beta cell reserve achieve insulin independence. However, this response is not maintained and reoccurrence of the disease is major a major challenge to use HSCT in future to prevent or control relapse of DM 1.

Os distúrbios hereditários das hemoglobinas são as doenças genéticas mais frequentes do homem e mais difundidas no mundo, abrangendo sobretudo continentes como África, Américas, Europa e extensas regiões da Ásia. Estima-se que haja 270 milhões de portadores de hemoglobinopatias no mundo, dos quais 80 milhões são portadores de talassemia. Aproximadamente 60 mil crianças nascem anualmente no mundo com talassemia e 250 mil com anemia falciforme, dando uma frequência de 2,4 crianças afetadas para cada 1.000 nascimentos. No Brasil, a doenca falciforme é a doença hereditária monogênica mais comum, estimando-se que haja entre 20 a 30 mil pacientes portadores desta doenca. O transplante de células-tronco hematopoéticas alogênico (TCTH alo) é atualmente a única modalidade terapêutica capaz de curar pacientes com hemoglobinopatias. Neste artigo discutiremos os dados disponíveis na literatura e sugerimos os critérios para a indicação do TCTH nas hemoglobinopatias. Hemoglobinopathies are the most prevalent genetic diseases in man. Most cases are described in Europe, Africa and in the Americas. About 270 million hemoglobinopathy carriers are alive today with 80 million being carriers of thalassemia. We estimate that, throughout the world, about 60,000 children are born annually with thalassemia and 250,000 with sickle cell disease with an estimated frequency of 2.4 children in every 1000 births. Sickle cell disease is the most common monogenic hereditary disease in Brazil with a total of from 20,000 to 30,000 patients. Allogeneic stem cell transplantation is the only curative approach. Here we describe published data and propose criteria to indicate stem cell transplantation in thalassemia and sickle cell disease patients.

Studies have shown that autologous hematopoietic SCT (HSCT) can be used as an intensive immunosuppressive therapy to treat refractory patients and to prevent the progression of multiple sclerosis (MS). This is a prospective multicentric Brazilian MS trial comparing two conditioning regimens: BEAM/horse ATG and CY/rabbit ATG. Most (80.4%) of the 41 subjects in the study had the secondary progressive MS subtype and the mean age was 42 years. The baseline EDSS score in 58.5% of the subjects was 6.5 and 78% had a score of 6.0 or higher, respectively. The complication rate during the intra-transplantation period was 56% for all patients: 71.4% of the patients in the BEAM/hATG group and 40% in the CY/rATG group (P=0.04). Three subjects (7.5%) died of cardiac toxicity, sepsis and alveolar hemorrhage, all of them in the BEAM/ATG group. EFS was 58.54% for all patients: 47% in the BEAM/hATG group and 70% in the CY/rATG group (P=0.288). In conclusion, the CY/rATG regimen seems to be associated with similar outcome results, but presented less toxicity when compared with the BEAM/hATG regimen. Long-term follow-up would be required to fully assess the differences in therapeutic effectiveness between the two regimens.

Nesta revisao sao discutidas varias alternativas de regeneracao do conjunto de celulas produtoras de insulina do pâncreas, usando celulas-tronco embrionarias do cordao umbilical e adultas, e o trabalho que esta sendo realizado em nosso grupo de pesquisas utilizando imunossupressao em altas doses combinada com a infusao de celulas-tronco hematopoeticas autologas em diabete do tipo 1 recem-diagnosticado.

Oral mucositis (OM) affects patients who are submitted to hematopoietic stem cell transplantation (HSCT) due to high doses of chemotherapy and/or radiotherapy. The purpose of this investigation was to perform a comparative study of the frequency and evolution of OM among patients subjected to therapeutic laser and to the conventional therapy (use of mouthwash called "Mucositis Formula"). The patients were subjected to a myeloablative conditioning regimen before the allogeneic HSCT. Twenty-two patients were selected and divided into 2 groups: group I was irradiated with InGaAlP laser (660 nm) and GaAlAs laser (780 nm), 25 mW potency, 6.3J/cm² dose, in 10-s irradiation time, followed to conventional treatment; group II was subjected only to the conventional treatment. Both World Health Organization (WHO) scale and the Oral Mucositis Assessment Scale (OMAS) were used to evaluate the results. Data were analyzed by the non-parametric Wilcoxon test, with p

In this review, we present 1) scientific basis for the use of high dose immunosuppression followed by autologous peripheral blood hematopoietic stem cell transplantation for newly diagnosed type 1 diabetes mellitus, 2) an update of clinical and laboratory outcomes in 21 patients transplanted at the University Hospital of the Ribeirão Preto Medical School, University of São Paulo, Brazil, including 6 relapses in patients without previous ketoacidosis and 3) a discussion of future prospectives of cellular therapy for type 1 diabetes mellitus. Nesta revisão, são apresentadas: 1) as bases científicas para o uso de imunossupressão em alta dose seguida de transplante autólogo de células-tronco hematopoéticas do sangue periférico no diabete melito do tipo 1 recém-diagnosticado; 2) uma atualização da evolução clínica e laboratorial de 21 pacientes transplantados no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, da Universidade de São Paulo, Brasil, incluindo recaídas em seis pacientes transplantados sem cetoacidose prévia; e 3) uma discussão das perspectivas futuras de terapia celular no diabete melito do tipo 1.

O único tratamento curativo para pacientes com doença falciforme é o transplante de células tronco hematopoéticas (TCTH). Neste artigo sumarizamos os resultados do TCTH em pacientes falciformes publicados na literatura e a experiência brasileira. As indicações atuais para o TCTH nestes pacientes serão discutidas. The only curative treatment approach for patients with sickle cell anemia is allogeneic stem cell transplantation. In this article we will review the published data about stem cell transplantation in patients with sickle cell disease and the small Brazilian experience in this field. The possible indications for stem cell patients will be discussed.

We report here the first six cases of leprosy associated with HLA-identical allogeneic SCT in different phases and with different findings and outcomes. Skin and peripheral nerves may be sites of leprosy associated with SCT, stressing the importance of differential diagnosis between leprosy and GVHD or drug reactions. Clinical manifestations of leprosy before or after transplantation did not influence the outcome of SCT in our cases.

ContextType 1 diabetes mellitus (DM) results from a cell-mediated autoimmune attack against pancreatic beta cells. Previous animal and clinical studies suggest that moderate immunosuppression in newly diagnosed type 1 DM can prevent further loss of insulin production and can reduce insulin needs.ObjectiveTo determine the safety and metabolic effects of high-dose immunosuppression followed by autologous nonmyeloablative hematopoietic stem cell transplantation (AHST) in newly diagnosed type 1 DM.Design, Setting, and ParticipantsA prospective phase 1/2 study of 15 patients with type 1 DM (aged 14-31 years) diagnosed within the previous 6 weeks by clinical findings and hyperglycemia and confirmed with positive antibodies against glutamic acid decarboxylase. Enrollment was November 2003-July 2006 with observation until February 2007 at the Bone Marrow Transplantation Unit of the School of Medicine of Ribeirao Preto, Ribeirao Preto, Brazil. Patients with previous diabetic ketoacidosis were excluded after the first patient with diabetic ketoacidosis failed to benefit from AHST. Hematopoietic stem cells were mobilized with cyclophosphamide (2.0 g/m2) and granulocyte colony-stimulating factor (10 μg/kg per day) and then collected from peripheral blood by leukapheresis and cryopreserved. The cells were injected intravenously after conditioning with cyclophosphamide (200 mg/kg) and rabbit antithymocyte globulin (4.5 mg/kg).Main Outcome MeasuresMorbidity and mortality from transplantation and temporal changes in exogenous insulin requirements (daily dose and duration of usage). Secondary end points: serum levels of hemoglobin A1c, C-peptide levels during the mixed-meal tolerance test, and anti–glutamic acid decarboxylase antibody titers measured before and at different times following AHST.ResultsDuring a 7- to 36-month follow-up (mean 18.8), 14 patients became insulin-free (1 for 35 months, 4 for at least 21 months, 7 for at least 6 months; and 2 with late response were insulin-free for 1 and 5 months, respectively). Among those, 1 patient resumed insulin use 1 year after AHST. At 6 months after AHST, mean total area under the C-peptide response curve was significantly greater than the pretreatment values, and at 12 and 24 months it did not change. Anti–glutamic acid decarboxylase antibody levels decreased after 6 months and stabilized at 12 and 24 months. Serum levels of hemoglobin A1c were maintained at less than 7% in 13 of 14 patients. The only acute severe adverse effect was culture-negative bilateral pneumonia in 1 patient and late endocrine dysfunction (hypothyroidism or hypogonadism) in 2 others. There was no mortality.ConclusionsHigh-dose immunosuppression and AHST were performed with acceptable toxicity in a small number of patients with newly diagnosed type 1 DM. With AHST, beta cell function was increased in all but 1 patient and induced prolonged insulin independence in the majority of the patients.Trial Registrationclinicaltrials.gov Identifier: NCT00315133

Introduction Venous thrombosis (VT) and inflammation are two closely related entities. In the present investigation we assessed whether there is a relation between genetic modifiers of the inflammatory response and the risk of VT. Materials and methods 420 consecutive and unrelated patients with an objective diagnosis of deep VT and 420 matched controls were investigated. The frequencies of the following gene polymorphisms were determined in all subjects: TNF-α− 308 G/A, LT-α+ 252 A/G, IL-6-174 G/C, IL1-ra 86 bp VNTR, IL-10-1082 A/G and CD-31 125 C/G. Results Overall odds ratio (OR) for VT related to TNF-α− 308 G/A, LT-α+ 252 A/G, IL-6-174 G/C, A1 allele (4 bp repeat) of the IL1-ra 86 bp VNTR, IL-10-1082 A/G and CD-31 125 C/G were respectively: 1.0 (CI95: 0.8–1.5), 1.3 (CI95: 1.0–1.7), 1.1 (CI95: 0.9–1.5), 1.6 (CI95: 1–2.5), 1.2 (CI95: 0.8–1.7) and 0.8 (CI95: 0.6–1.1). A possible interaction between polymorphisms was observed only for the co-inheritance of the mutant alleles of the LT-α+ 252 A/G and IL-10-1082 G/A polymorphisms (OR = 2; CI95: 1.1–3.8). The risk of VT conferred by factor V Leiden and FII G20210A was not substantially altered by co-inheritance with any of the cytokine gene polymorphisms. Conclusions Cytokine gene polymorphisms here investigated did not significantly influence venous thrombotic risk.

Nesta revisao, discutem-se os resultados dos transplantes de celulas-tronco hematopoeticas (TCTH) para doencas reumaticas graves e refratarias a terapia convencional realizados no Brasil. Sao analisados os resultados preliminares obtidos no Brasil com o TCTH autologo em casos esporadicos (N=3) e no protocolo cooperativo iniciado em 2001 (N=18). Neste protocolo, dentre os 8 casos de nefrite lupica, houve 3 remissoes sustentadas, 3 obitos, 1 falha de mobilizacao e 1 seguimento ainda muito curto; entre os 7 de esclerose sistemica, houve 3 remissoes apos o TCTH e 2 apos mobilizacao, um obito pos-mobilizacao das CTH e outro apos a primeira dose do condicionamento, este ultimo em uma superposicao com LES; em dois pacientes com vasculite, houve uma remissao em arterite de Takayasu e outra em doenca de Behcet; uma paciente com artrite inflamatoria juvenil foi incluida muito recentemente no protocolo. O seguimento dos pacientes sobreviventes variou de 0 a 48 meses, com uma mediana de 29 meses. Conclui-se com uma discussao do custo-beneficio do TCTH em face das novas formas de imunossupressao disponiveis e das perspectivas futuras em paises desenvolvidos, onde se iniciaram recentemente estudos prospectivos randomizados comparando o transplante com a melhor terapia medicamentosa disponivel, e no Brasil, onde o custo do transplante e muito inferior ao das novas terapias biologicas.

Nesta revisão, discutem-se os resultados dos transplantes de células-tronco hematopoéticas (TCTH) para doenças reumáticas graves e refratárias à terapia convencional realizados no exterior. Revêem-se brevemente as bases clínicas e experimentais para a realização desses transplantes e os resultados internacionais obtidos em lúpus eritematoso sistêmico (LES) (33/50 remissões completas no registro europeu, com dez recidivas posteriores e 12 óbitos; 41/45 remissões duradouras em um centro americano, com dois óbitos pós-mobilização e quatro óbitos pós-transplante), artrite reumatóide (AR) do adulto (58/73 remissões parciais com 85% de recidivas posteriores e apenas um óbito no registro europeu), artrite idiopática juvenil (AIJ) (18/34 remissões duradouras e cinco óbitos no registro europeu), esclerose sistêmica (ES) (46/50 respostas em um estudo europeu multicêntrico, com 35% de recidivas e 23% de mortalidade, enquanto num estudo americano, houve quatro óbitos e duas pneumopatias progressivas dentre 19 pacientes e melhora cutânea e da qualidade de vida em todos os sobreviventes) e em uma miscelânea de outras doenças, incluindo as vasculites (9/15 respostas completas no registro europeu). Conclui-se que, na experiência internacional, o TCTH autólogo induz remissões prolongadas na maioria das doenças graves e refratárias em que foi utilizado, com exceção da AR do adulto, justificando o início de estudos prospectivos randomizados comparando-o com a terapia convencional otimizada. In this review, we discuss the results of hematopoietic stem cell transplantation (HSCT) for severe and refractory rheumatic diseases performed abroad. We briefly review clinical and experimental basis for those transplants and the international results obtained in systemic lupus erythematosus (SLE) (33/50 complete remissions in the European registry with 10 relapses and 12 deaths, and 41 durable remissions in an American study with 2 deaths post-mobilisation and 4 deaths posttransplantation), adult rheumatoid arthritis (58/73 partial remissions with 85% of relapses and only one death in the European registry), juvenile idiopathic arthritis (18/34 durable remissions and 5 deaths in the European registry), systemic sclerosis (SSc) (46/50 responders in a multicentric European study with 35% of relapses and 23% of mortality, while in an US series, 4/19 patients died, 2 had progressive lung disease and all the survivors improved the skin scores and quality of life) and several other diseases, including vasculidities (9/15 complete responses in the European registry). We conclude that in the international experience, autologous HSCT induces sustained remission in most severe and refractory rheumatic diseases except for adult rheumatoid arthritis, and this finding justifies starting prospective randomized trials of HSCT compared to optimal conventional therapy.

Background Takayasu9s arteritis is a rare autoimmune vasculitis that affects medium and large vessels, especially the aorta and its main branches. Autologous stem cell transplantation for autoimmune disease has been shown to be effective in some refractory cases. Objectives Describe our experience with autologous hematopoietic stem cell transplantation (AHSCT) in Takayasu9s arteritis. Methods Three patients with refractory Takayasu9s arteritis were treated with AHSCT. Hematopoietic stem cells were mobilized with 2g/m2 cyclophosphamide plus G-CSF, and subsequently harvested by leukoapheresis and cryopreserved, nonmanipulated. Patients then received 200mg/kg IV cyclophosphamide and 4.5mg/kg rabbit anti-thymocyte globulin (ATG) over five consecutive days, followed by infusion of the cryopreserved cells. Results The procedure was well tolerated by all patients. Side effects included fever, rash, nausea, vomiting and neutropenic fever. None of the patients presented severe side effects during or after AHSCT. One patient presented CMV reactivation after transplant and was preemptively treated, without clinical manifestations of disease.Case 1: 41 year-old female, with a history of dizziness, claudication of upper and lower limbs, non-palpable right radial pulse and transient visual impairment for over 13 years. Arteriography showed irregularity and stenosis of abdominal aorta, right and left iliac arteries, left subclavian and carotid arteries. She had been unsuccessfully treated with steroids, methotrexate, cyclophosphamide, chlorambucil and mycophenolate mofetil. On follow-up of 127 months after AHSCT, she presented clinical and laboratory remission. Case 2: 30 year-old female, with intermittent visual deficits, upper limb claudication, subclavian steal syndrome and 3 episodes of transient ischemic strokes. Previous treatments included steroids, azathioprine, cyclophosphamide and mycophenolate mofetil, besides a stent placed in the right carotid artery. On 43 months follow-up, she remained symptomatic with high levels of acute phase reactants, indicating refractoriness to AHSCT. After transplant, she also failed etanercept injections, but disease activity was further controlled with tocilizumab. Case 3: 39 year-old male with intestinal claudication, renovascular hypertension, upper limb claudication and dizziness. Magnetic angioresonance (NMR) images evidenced right renal and mesenteric artery stenosis, and bilateral critical narrowing of carotid, subclavian, brachial and axilary arteries, and irregularities along the aorta. On 15 months follow-up, there was clinical and laboratorial improvement. Patients 1 and 3 presented partial reversal of vessel stenosis detected by NMR images. Conclusions Very few cases of vasculitides treated with AHSCT have been reported in the literature. To the best of our knowledge, this is the largest reported series of transplanted Takayasu9s patients. Although response to transplant was not universal, beneficial effects were verified in two out of three patients, who remained in remission for long periods. References Voltarelli JC et al. Haematopoietic stem cell transplantation for refractory Takayasu9s arteritis. Rheumatology 2004,43:1308-9. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5103

Development of donor cell derived acute myeloid leukemia after stem cell transplantation for chronic myeloid leukemia

Abstract 1064 Introduction: Sickle Cell Diseases (SCD) are the most frequent inherited monogenic diseases worldwide. Data from the neonatal screening program showed that about 4% of the brazilian population harbors the sickle cell trait, reaching until 10% in the afro-brazilians. In the northern states of Brazil this frequency is much higher, as an example in Bahia 1/17 births are of children with sickle cell trait. The neonatal screening program doesn't cover the whole country so the estimate of about 3500 newborns with SCD per year in Brazil is certainly underestimated. Nevertheless the first official document regarding the treatment of these patients was published by the brazilian ministry of health only in 2004. Hydroxiurea (HU) is already used in more severe forms of SCD by the public health system since several years but is not available for all patients yet. In a recent publication Machado et al (ASH 2010 #843) demonstrated for the first time that HU can prolong survival in SCD, although the mortality rate for this disease is still high in Brazil. Stem Cell Transplanation (SCT) is the only available curative treatment for the inherited hemoglobinopathies, in spite of this there is no such program for SCD in Brazil. Here we describe the first brazilian cases transplanted in 5 brazilian centers of severely affected patients with no other treatment options not responding to HU. Patients and Methods: Sixtheen patients (15 HbSS, 1 case Sbeta thalassemia), median age 16 years (3–39), all except for one with HLA identical sibling donors (3 donors with sickle cell trait)received a alo SCT. Indications consisted mainly of severe acute chest syndrome, priapism, alloimunization and silent cerebral infarctions and overt previous stroke. One patient transplanted because of advanced Hodgkin's disease. The conditioning consisted of BuCy or FluBu with ATG in all but 3 patients who received FluCy and ATG. The decision was based on the age of one of the patients (39 years old and grade IV liver fibrosis) and 2 patients with previous stroke. Results: Primary graft failure occurred only with the unrelated donor. All other patients engrafted, but one patient conditioned with FluCy lost the graft about 100 days after transplant. She received a second transplant 3 years after with BuCy from the same donor, had a 100% engraftment without any sign of GVHD but unfortunately died 3 years later in remission from a SNC bleeding caused by her acquired vascular abnormality. Median follow up for all surviving patients is 2 years (152 days – 12,2 years). Overall survival is 13/16. Death occurred in 3 cases (1 primary graft failure and sepsis, 1 Hodgkin disease, 1 hemorrhagic stroke in a patient with severe cerebral vasculopathy with MoyaMoya). No veno-occlusive disease was observed. Acute GVHD grade II were observed in 4 patients (gut and skin) easily treated with short time prednisone. All surviving patients but one are full chimeras and the 39 years old patient remain a stable mixed chimera 6 years after transplant. Quality of life has improved in all patients considerably referring extremely grateful to be free of pain. Conclusion: Different from thalassemia SCT can be offered safely for older patients with SCD in our opinion. Our data confirm the curative potential of SCT in SCD and reinforce us to offer this curative approach to patients not responding to HU. A prospective trial is planned in Brazil who should address also long term toxicities and quality of life. Disclosures: No relevant conflicts of interest to declare.

Introduction: Multiple sclerosis (MS) is a chronic, inflammatory and demyelinating disease of the central nervous system (CNS) leading to gradual axonal degeneration. It is a classical auto-immune disease, thus high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (AHSCT) could “reset” the immune disorder by controlling autoreactive clones and by restoring self-tolerance after immunological recovery. Objectives: Describe the experience of the Brazilian Cooperative Group of AHSCT for Autoimmune Diseases in 41 MS patients followed-up to five years. Methods: Stem cells were mobilized from the bone marrow with Cy (2g/m2) and Filgrastim (10μg/kg/d SC), collected by leukapheresis and cryopreserved. Patients were conditioned with BEAM (BCNU 300 mg/m2, cytarabine 200 mg/m2, etoposide 200 mg/m2 ×4, melphalan 140 mg/m2) and horse antilymphocyte globulin (ATG) 90 mg/kg) or cyclophosphamide (CY) 50 mg/kg ×4 and rabbit ATG (rATG) 4.5 mg/kg, followed by stem cell infusion. Quality of life was assessed by the Short Form-36 Health Survey Questionnaire (SF-36). Results: Between January 2001 and June 2006, 21 patients received BEAM/ATG and 20 received CY/ATG. Medium age was 42 years (27–53 years), 24 (58.5%) were females, 33 (80.4%) had secondary progressive MS form, 80.95% had EDSS (Expanded Disability Status Scale) 6.0 or higher. No significant difference was seen between the groups regarding age, sex, disease presentation and EDSS. The mean number of CD34+ infused cells was 8.8×106/kg (2,5– 25.13×106/kg). Mean engraftment was 9,3 days (7–10 days) for neutrophils and 13 days (7–24 days) for platelets. 18 patients (46%) had neutropenic fever, 8 (20.0%) had pneumonia and 5 (12.5%) had allergic reactions to lymphoglobulin. Three patients (14.3%) died in the BEAM group due to conditioning regiment toxicity, sepsis and alveolar hemorrhage. Mean hospital stay was 35.47 days (20–168 days) in the BEAM group and 20.15 days (14–32 days) in the CY group (p Conclusion: In our study, a less intensive conditioning regimen (CY + rATG) was associated with similar neurological outcomes but also with less toxicity when compared to BEAM regimen. The majority of patients had an improvement in their quality of live. Longer follow-up is required to assess the therapeutic effectiveness of both regimens in MS progression.

Fludarabine in combination with intravenous Busulfan has been used to reduce treatment related mortality (TRM) in allogeneic stem cell transplantation (SCT). Considering that busulfan has erratic bioavailability and unpredictable intestinal absorption, previous investigations have used intravenous busulfan with plasma-targeted levels dosing. In Brazil neither intravenous Busulfan nor routine plasma level measurement of Busulfan are available. In this report we retrospectively analyze 74 patients (median age 32 y.o.) submitted to SCT using a Fludarabine and oral Busulfan based conditioning regimen. Forty three patients had acute myeloid leukaemia (AML, age range 5 to 58) and 31 patients chronic myeloid leukemia (CML, age range 19 to 58). Among the AML patients, 44% were in first remission (CR1), 23% in second remission (CR2) and 33% patients had active disease (AD) at the time of transplant. Among CML patients, 65% were in chronic phase (CML-CP), 29% in accelerated phase (CML-AP) and 6% in blast crisis (CML-BC). Fludarabine 30 mg/m2 and oral Busulfan 4 mg/kg was given for 4 days with Cyclosporine A and Methotrexate GVHD prophylaxis. For patients with unrelated donors, ATG were added. All patients engrafted (median 14 days). At a median follow up time of 180 days non-relapse mortality was 5%. Seventeen patients (23%) died (12 AML and 5 CML patients). Among survivors (57 patients), 56 remain in complete remission. One patient with a refractory AML and a complex karyotype relapsed on day +90. One patient died of severe sinusoidal obstruction syndrome (SOS). Acute GVHD occurred in 14 (19%) patients (10 AML and 4 CML) none of them grade III or IV. Chronic GVHD occurred in 11 patients so far, being the cause of death in 2 patients. Major cause of death was relapse of disease in patients transplanted with active disease. Only three AML patients in CR1 died (chronic GVHD, sepsis and fulminant hepatic failure) in contrast to 60% of patients with active disease (88% relapsed). One patient with CML-CP died with a relapse in CML-BC, the remaining 19 (92%) patients are alive in complete remission. One patient transplanted in CML-AP died (cGVHD and zygomykosis) and all patients transplanted in BC died of their disease. Actuarial 1-year overall survival for CML is 92% and 54% (CP and AP/BC respectively, p=0,04) and for AML 72% and 23% (CR1/CR2 and AD, respectively, p=0,005). These preliminary data show that oral Busulfan and Fludarabine can safely be used without plasma level monitoring. The follow up time is short and the effect on the control of CML cannot be concluded. However AML has been effectively controlled as far as patients were transplanted in remission (AML-CR1 and CR2). For patients in more advanced disease stages this regimen is not optimal. However, this regimen is safe and may improve the results in early stages of AML and CML even in countries with limited resources in health care.

In this review, we present (1) a brief discussion of hematopoietic stem cell transplantation (HSCT) for severe and refractory autoimmune diseases (AIDs) from its beginning in 1996 through recently initiated prospective randomized clinical trials; (2) an update (up to July 2009) of clinical and laboratory outcomes of 23 patients with newly diagnosed type 1 diabetes mellitus (T1DM), who underwent autologous HSCT at the Bone Marrow Transplantation Unit of the Ribeirao Preto Medical School, University of Sao Paulo, Brazil; (3) a discussion of possible mechanisms of action of HSCT in AIDs, including preliminary laboratory data obtained from our patients; and (4) a discussion of future perspectives of stem cell therapy for T1DM and type 2 DM, including the use of stem cell sources other than adult bone marrow and the combination of cell therapy with regenerative compounds.

In 2007, the effects of the autologous nonmyeloablative hematopoietic stem cell transplantation (HSCT) in 15 patients with type 1 diabetes mellitus (DM) were reported. Most patients became insulin free with normal levels of glycated hemoglobin A(1c) (HbA(1c)) during a mean 18.8-month follow-up. To investigate if this effect was due to preservation of beta-cell mass, continued monitoring was performed of C-peptide levels after stem cell transplantation in the 15 original and 8 additional patients.To determine C-peptide levels after autologous nonmyeloablative HSCT in patients with newly diagnosed type 1 DM during a longer follow-up.A prospective phase 1/2 study of 23 patients with type 1 DM (aged 13-31 years) diagnosed in the previous 6 weeks by clinical findings with hyperglycemia and confirmed by measurement of serum levels of anti-glutamic acid decarboxylase antibodies. Enrollment was November 2003-April 2008, with follow-up until December 2008 at the Bone Marrow Transplantation Unit of the School of Medicine of Ribeirão Preto, Ribeirão Preto, Brazil. Hematopoietic stem cells were mobilized via the 2007 protocol.C-peptide levels measured during the mixed-meal tolerance test, before, and at different times following HSCT. Secondary end points included morbidity and mortality from transplantation, temporal changes in exogenous insulin requirements, and serum levels of HbA(1c).During a 7- to 58-month follow-up (mean, 29.8 months; median, 30 months), 20 patients without previous ketoacidosis and not receiving corticosteroids during the preparative regimen became insulin free. Twelve patients maintained this status for a mean 31 months (range, 14-52 months) and 8 patients relapsed and resumed insulin use at low dose (0.1-0.3 IU/kg). In the continuous insulin-independent group, HbA(1c) levels were less than 7.0% and mean (SE) area under the curve (AUC) of C-peptide levels increased significantly from 225.0 (75.2) ng/mL per 2 hours pretransplantation to 785.4 (90.3) ng/mL per 2 hours at 24 months posttransplantation (P.001) and to 728.1 (144.4) ng/mL per 2 hours at 36 months (P = .001). In the transient insulin-independent group, mean (SE) AUC of C-peptide levels also increased from 148.9 (75.2) ng/mL per 2 hours pretransplantation to 546.8 (96.9) ng/mL per 2 hours at 36 months (P = .001), which was sustained at 48 months. In this group, 2 patients regained insulin independence after treatment with sitagliptin, which was associated with increase in C-peptide levels. Two patients developed bilateral nosocomial pneumonia, 3 patients developed late endocrine dysfunction, and 9 patients developed oligospermia. There was no mortality.After a mean follow-up of 29.8 months following autologous nonmyeloablative HSCT in patients with newly diagnosed type 1 DM, C-peptide levels increased significantly and the majority of patients achieved insulin independence with good glycemic control.clinicaltrials.gov Identifier: NCT00315133.

Background. Type 1 diabetes mellitus (T1DM) is an autoimmune disease. A safe induction of an autoimmunity-free status may become a promising therapy. We hypothesize that intense immuno- and myelosuppression followed by autologous hematopoietic stem cell (HSC) rescue is an option to establish a lasting immunetolerance by eliminating auto-reactive lymphocytes and thus facilitate a possible recovery of autologous insulin production. Aims. Evaluate the HSC mobilization, infusion and engraftment in T1DM patients. Patients and Methods. Between January of 2004 and July of 2006 15 T1DM patients (12 male/3 female), with no more than 6 weeks after the first episode of hyperglycemia, were selected and enrolled. Their median age was 17 years old (range 14–31). HSC were mobilized into the peripheral blood (PB) by cyclophosphamide (Cy) 2g/m2 and filgrastim (G-CSF) 10 μg/kg/day. Peripheral blood stem cells (PBSC) were collected by leukapheresis using COBE Spectra (Gambro BCT, Lakewood, CO) blood cell separator. Collected PBSC were mixed with a cryoprotectant solution (autologous plasma and 10% dimethyl-sulfoxide (DMSO)), then frozen and stored in a mechanical freezer (−80°C). The CD34+ cell were counted using the ISHAGE protocol by a FACSort flow cytometer and CellQuest software packages (Becton Dickinson, San Jose, CA, USA). The conditioning regimen was Cy 200mg/kg and anti-lymphocyte globulin (4.5mg/kg). The protocol and the consent form were approved by the institution and the national ethics committees. Results. All results are expressed as median (range), except when specified. The collection was done on the 7th day (7–9) after the chemotherapy. The pre-apheresis values were: WBC (×103/μL) 7.9 (2.6–56.0); Hct (%) 37.4 (30.9–44.7); platelets (×103/μL) 177 (87–295); CD34+ (μL) 80.9 (36.5–167.6). The blood volemia processed and apheresis duration (min) were 2.8 (2.0–3.1) and 235 (177–280), respectively. Five patients (33.3%) experienced mild adverse reactions related to G-CSF administration (osteo-muscular pain and headache) and six (40%) related to citrate infusion (paresthesia and tremors), although thirteen (86%) had received prophylactic intravenous calcium infusion. The final yield values were: volume (mL) 210 (170–273); WBC (×108/Kg) 6.0 (3.0–14.9); Hct (%) 5.0 (3.3–9.0); CD34+ (×106/kg) 9.6 (5.8–22.5). Fourteen patients have already been transplanted. The time between cryopreservation and infusion was 21 days (13–35). The dose of DMSO infused was 0.4 mL/kg (0.0–0.5) (one patient received washed PBSC). All patients presented mild complications related to infusion: 13 (93%) nausea or vomiting, 8 (57%) flushing, 5 (36%) abdominal pain, 4 (29%) headache and 3 (21%) dyspnea, but only one needed oxygen supplementation. None of the patients presented complications like renal failure, hepatic insufficiency or cardiac arrhythmias. The time to reach granulocytes recovery (500/μL) was 9 days (7–10). Conclusions. The present data suggest that HSC mobilization in T1DM patients are very effetive, precocious and provide a good collection of CD34+ cells. The infusion of PBSC is a safe and reliable procedure with a low incidence of severe side effects and early engraftment. These results could be explained by a good bone marrow function as these patients had never been submitted to any kind of myelo or immunosuppressive therapy.