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Трансплантация гемопоэтических стволовых клеток
KM Transplantat.JPEG
Пересадка костного мозга
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MeSHD018380
MedlinePlus003009

Гемопоэтические стволовые клетки трансплантация ( ГСК ) является трансплантацией из мультипотентных кроветворных стволовых клеток , как правило , полученных из костного мозга , периферической крови или пуповинной крови . [1] [2] [3] Он может быть аутологичным (используются собственные стволовые клетки пациента), аллогенным (стволовые клетки поступают от донора) или сингенным (от однояйцевого близнеца ). [1] [2]

Это наиболее часто выполняется для пациентов с определенными рака в крови или костного мозга , таких как множественная миелома или лейкоз . [2] В этих случаях иммунная система реципиента обычно разрушается радиацией или химиотерапией перед трансплантацией. Инфекция и реакция «трансплантат против хозяина» являются основными осложнениями аллогенного ТГСК. [2]

ТГСК остается опасной процедурой со многими возможными осложнениями; он предназначен для пациентов с опасными для жизни заболеваниями. Поскольку выживаемость после процедуры увеличилась, ее использование расширилось за пределы рака до аутоиммунных заболеваний [4] [5] и наследственных дисплазий скелета ; особенно злокачественный детский остеопетроз [6] [7] и мукополисахаридоз . [8]

Медицинское использование [ править ]

См. Также: Список состояний, при которых проводится трансплантация гемопоэтических стволовых клеток.
Спектр антигенов-мишеней, связанных с опухолевым иммунитетом и аллоиммунитетом после аллогенного ТГСК: Т- и В-клетки, полученные от хозяина, могут быть индуцированы для распознавания ассоциированных с опухолью антигенов, тогда как донорские В- и Т-клетки могут распознавать как ассоциированные с опухолью антигены, так и аллоантигены.

Показания [ править ]

Показаниями к трансплантации стволовых клеток являются:

Злокачественные (раковые) [ править ]

  • Острый миелоидный лейкоз
  • Хронический миелоидный лейкоз
  • Острый лимфобластный лейкоз
  • Лимфома Ходжкина (рецидивирующая, рефрактерная)
  • Неходжкинская лимфома (рецидивирующая, рефрактерная)
  • Нейробластома
  • Саркома Юинга
  • Множественная миелома
  • Миелодиспластические синдромы
  • Глиомы , другие солидные опухоли

Незлокачественные (доброкачественные) [ править ]

  • Талассемия
  • Серповидноклеточная анемия
  • Апластическая анемия
  • Анемия Фанкони
  • Злокачественный детский остеопетроз
  • Мукополисахаридоз
  • Дефицит пируваткиназы
  • Синдромы иммунодефицита
  • Аутоиммунные заболевания [9]

Многие получатели HSCTs являются множественной миеломы [10] или лейкемии у пациентов [11] , которые не выиграли бы от длительного лечения, или уже являются устойчивыми к, химиотерапией . Кандидатами на ТГСК являются педиатрические случаи, когда у пациента имеется врожденный дефект, такой как тяжелый комбинированный иммунодефицит или врожденная нейтропения с дефектными стволовыми клетками, а также дети или взрослые с апластической анемией [12] , которые потеряли свои стволовые клетки после рождения. Другие состояния [13], которые лечатся с помощью трансплантации стволовых клеток, включают серповидно-клеточную анемию ,миелодиспластический синдром , нейробластома , лимфома , саркома Юинга , десмопластическая мелкоклеточная опухоль , хроническая гранулематозная болезнь , болезнь Ходжкина и синдром Вискотта – Олдрича . Совсем недавно были разработаны немиелоаблативные »процедуры « мини-трансплантации (микротрансплантации) », требующие меньших доз препаративной химиотерапии и лучевой терапии. Это позволило проводить ТГСК у пожилых людей и других пациентов, которые в противном случае считались бы слишком слабыми для выдерживают обычную схему лечения.

Количество процедур [ править ]

По данным глобального опроса 1327 центров в 71 стране, проведенного Всемирной сетью трансплантации крови и костного мозга, в 2006 году во всем мире было зарегистрировано 50 417 первых ТГСК. Из них 28 901 (57%) были аутологичными и 21 516 (43%) были аллогенными (11 928 от семейных доноров и 9 588 от неродственных доноров). Основными показаниями к трансплантации были лимфопролиферативные заболевания (55%) и лейкемии (34%), многие из которых имели место либо в Европе (48%), либо в Америке (36%). [14]

Всемирная сеть по трансплантации крови и костного мозга сообщила, что в декабре 2012 года была проведена миллионная трансплантация [15].

В 2014 году, по данным Всемирной ассоциации доноров костного мозга , количество продуктов стволовых клеток, предоставляемых для неродственной трансплантации, во всем мире увеличилось до 20 604 (4 149 пожертвований костного мозга, 12 506 пожертвований стволовых клеток периферической крови и 3949 единиц пуповинной крови). [16]

Типы трансплантатов [ править ]

Автологичный [ править ]

Аутологичный HSCT требует экстракции ( афереза ) гемопоэтических стволовых клеток (HSC) у пациента и хранения собранных клеток в морозильной камере. Затем пациента лечат высокодозной химиотерапией с лучевой терапией или без нее с целью искоренения популяции злокачественных клеток пациента за счет частичного или полного костного мозга.абляция (нарушение способности костного мозга пациента выращивать новые клетки крови). Собственные сохраненные стволовые клетки пациента затем переливаются в его / ее кровоток, где они заменяют разрушенную ткань и возобновляют нормальное производство клеток крови пациента. Преимущество аутологичных трансплантатов заключается в более низком риске инфицирования во время части лечения с ослабленным иммунитетом, поскольку восстановление иммунной функции происходит быстро. Кроме того, случаи отторжения у пациентов очень редки (и невозможна реакция «трансплантат против хозяина») из-за того, что донор и реципиент являются одним и тем же человеком. Эти преимущества сделали аутологичную ТГСК одним из стандартных методов лечения второй линии при таких заболеваниях, как лимфома . [17]

Однако для других видов рака, таких как острый миелоидный лейкоз , снижение смертности от аутогенного по сравнению с аллогенным ТГСК может быть перевешено повышенной вероятностью рецидива рака и связанной с ним смертности, поэтому аллогенное лечение может быть предпочтительным для этих состояний. [18]

Исследователи провели небольшие исследования с использованием немиелоаблативных ТГСК в качестве возможного лечения диабета I типа (инсулинозависимого) у детей и взрослых. Результаты были многообещающими, но по состоянию на 2019 год предполагать, приведут ли эти эксперименты к эффективному лечению диабета, преждевременно. [19] [20] [21]

Аллогенный [ править ]

В аллогенной ТГСК участвуют два человека - (здоровый) донор и (пациент) реципиент. Доноры аллогенных HSC должны иметь тип ткани ( человеческий лейкоцитарный антиген , HLA), который соответствует реципиенту. Сопоставление выполняется на основе вариабельности в трех или более локусах гена HLA, и предпочтительно идеальное совпадение по этим локусам. Даже если существует хорошее совпадение этих критических аллелей , реципиенту потребуются иммунодепрессанты для смягчения реакции трансплантат против хозяина. Аллогенные доноры трансплантата могут быть родственниками (обычно близкие по HLA братьям и сестры), сингенные ( монозиготныеили идентичный близнец пациента - обязательно крайне редко, поскольку у немногих пациентов есть идентичный близнец, но предлагающий источник стволовых клеток, полностью соответствующих HLA) или неродственный (донор, который не является родственником и имеет очень близкую степень соответствия HLA). Неродственных доноров можно найти через реестр доноров костного мозга, такой как Национальная программа доноров костного мозга в США. Люди, которые хотели бы пройти тестирование на конкретного члена семьи или друга, не присоединяясь ни к одному из банков данных реестра костного мозга, могут обратитесь в частную лабораторию тестирования HLA и пройдите анализ крови или мазок изо рта, чтобы узнать, подходят ли они друг другу. [22] « Родной брат-спаситель » может быть намеренно выбран с помощью преимплантационной генетической диагностики. чтобы соответствовать ребенку как по типу HLA, так и без каких-либо очевидных наследственных заболеваний. Аллогенные трансплантаты также выполняются с использованием пуповинной крови в качестве источника стволовых клеток. В целом, путем переливания здоровых стволовых клеток в кровоток реципиента для реформирования здоровой иммунной системы аллогенные ТГСК, по-видимому, повышают шансы на излечение или долгосрочную ремиссию после разрешения немедленных осложнений, связанных с трансплантацией. [23] [24] [25]

Совместимого донора находят путем проведения дополнительного HLA-тестирования крови потенциальных доноров. Гены HLA делятся на две категории (типы I и II). В целом несоответствие генов типа I (например, HLA-A , HLA-B или HLA-C ) увеличивает риск отторжения трансплантата. Несоответствие гена HLA типа II (то есть HLA-DR или HLA-DQB1 ) увеличивает риск реакции "трансплантат против хозяина". Кроме того, генетическое несоответствие размером с одну пару оснований ДНК имеет большое значение, поэтому для идеального совпадения требуется знание точной последовательности ДНК этих генов как для донора, так и для реципиента. Ведущие центры трансплантологии в настоящее время проводят тестирование всех пяти этих генов HLA, прежде чем объявить, что донор и реципиент идентичны по HLA.

Известно, что раса и этническая принадлежность играют важную роль в привлечении доноров, поскольку члены одной и той же этнической группы с большей вероятностью будут иметь совпадающие гены, включая гены HLA. [26]

По состоянию на 2013 год было разработано по крайней мере два коммерческих метода лечения аллогенными клетками: Prochymal и Cartistem . [27]

Источники и хранилище ячеек [ править ]

To limit the risks of transplanted stem-cell rejection or of severe graft-versus-host disease in allogeneic HSCT, the donor should preferably have the same HLA-typing as the recipient. About 25 to 30% of allogeneic HSCT recipients have an HLA-identical sibling. Even so-called "perfect matches" may have mismatched minor alleles that contribute to graft-versus-host disease.

Bone marrow[edit]

Bone marrow harvest

In the case of a bone-marrow transplant, the HSCs are removed from a large bone of the donor, typically the pelvis, through a large needle that reaches the center of the bone. The technique is referred to as a bone-marrow harvest and is performed under local or general anesthesia.

Peripheral blood stem cells[edit]

Main article: Peripheral stem cell transplantation
Peripheral blood stem cells

Peripheral blood stem cells[28] are now the most common source of stem cells for HSCT. They are collected from the blood through a process known as apheresis. The donor's blood is withdrawn through a sterile needle in one arm and passed through a machine that removes white blood cells. The red blood cells are returned to the donor. The peripheral stem cell yield is boosted with daily subcutaneous injections of granulocyte-colony stimulating factor, serving to mobilize stem cells from the donor's bone marrow into the peripheral circulation.

Amniotic fluid[edit]

Extracting stem cells from amniotic fluid is possible for both autologous and heterologous uses at the time of childbirth.

Umbilical cord blood[edit]

Umbilical cord blood is obtained when a mother donates her infant's umbilical cord and placenta after birth. Cord blood has a higher concentration of HSCs than is normally found in adult blood, but the small quantity of blood obtained from an umbilical cord (typically about 50 ml) makes it more suitable for transplantation into small children than into adults. Newer techniques using ex vivo expansion of cord blood units or the use of two cord blood units from different donors allow cord blood transplants to be used in adults.

Cord blood can be harvested from the umbilical cord of a child being born after preimplantation genetic diagnosis for HLA matching (see PGD for HLA matching) to donate to an ill sibling requiring HSCT.

Storage of HSC[edit]

Unlike other organs, bone-marrow cells can be frozen (cryopreserved) for prolonged periods without damaging too many cells. This is a necessity with autologous HSCs because the cells must be harvested from the recipient months in advance of the transplant treatment. In the case of allogeneic transplants, fresh HSCs are preferred to avoid cell loss that might occur during the freezing and thawing process. Allogeneic cord blood is stored frozen at a cord blood bank because it is only obtainable at the time of childbirth. To cryopreserve HSCs, a preservative, dimethyl sulfoxide, must be added, and the cells must be cooled very slowly in a controlled-rate freezer to prevent osmotic cellular injury during ice-crystal formation. HSCs may be stored for years in a cryofreezer, which typically uses liquid nitrogen.

Conditioning regimens[edit]

Myeloablative[edit]

The chemotherapy or irradiation given immediately prior to a transplant is called the conditioning regimen, the purpose of which is to help eradicate the patient's disease prior to the infusion of HSCs and to suppress immune reactions. The bone marrow can be ablated (destroyed) with dose-levels that cause minimal injury to other tissues. In allogeneic transplants, a combination of cyclophosphamide with total body irradiation is conventionally employed. This treatment also has an immunosuppressive effect that prevents rejection of the HSCs by the recipient's immune system. The post-transplant prognosis often includes acute and chronic graft-versus-host disease that may be life-threatening. In certain leukemias, though, this can coincide with protection against cancer relapse owing to the graft-versus-tumor effect.[29] Autologous transplants may also use similar conditioning regimens, but many other chemotherapy combinations can be used depending on the type of disease.

Nonmyeloablative[edit]

A newer treatment approach, nonmyeloablative allogeneic transplantation, also termed reduced-intensity conditioning (RIC), uses doses of chemotherapy and radiation too low to eradicate all the bone-marrow cells of the recipient.[30]:320–21 Instead, nonmyeloablative transplants run lower risks of serious infections and transplant-related mortality while relying upon the graft versus tumor effect to resist the inherent increased risk of cancer relapse.[31][32] Also significantly, while requiring high doses of immunosuppressive agents in the early stages of treatment, these doses are less than for conventional transplants.[33] This leads to a state of mixed chimerism early after transplant where both recipient and donor HSC coexist in the bone marrow space.

Decreasing doses of immunosuppressive therapy then allow donor T-cells to eradicate the remaining recipient HSCs and to induce the graft-versus-tumor effect. This effect is often accompanied by mild graft-versus-host disease, the appearance of which is often a surrogate marker for the emergence of the desirable graft versus tumor effect, and also serves as a signal to establish an appropriate dosage level for sustained treatment with low levels of immunosuppressive agents.

Because of their gentler conditioning regimens, these transplants are associated with a lower risk of transplant-related mortality, so allow patients who are considered too high-risk for conventional allogeneic HSCT to undergo potentially curative therapy for their disease. The optimal conditioning strategy for each disease and recipient has not been fully established, but RIC can be used in elderly patients unfit for myeloablative regimens, for whom a higher risk of cancer relapse may be acceptable.[30][32]

Engraftment[edit]

After several weeks of growth in the bone marrow, expansion of HSCs and their progeny is sufficient to normalize the blood cell counts and reinitiate the immune system. The offspring of donor-derived HSCs have been documented to populate many different organs of the recipient, including the heart, liver, and muscle, and these cells had been suggested to have the abilities of regenerating injured tissue in these organs. However, recent research has shown that such lineage infidelity does not occur as a normal phenomenon.[citation needed]

Chimerism monitoring is a method to monitor the balance between the patient's own stem cells and the new stem cells from a donor. In cases where the patient's own stem cells are increasing in number after treatment, the treatment may potentially not have worked as intended.

Complications[edit]

HSCT is associated with a high treatment-related mortality in the recipient, which limits its use to conditions that are themselves life-threatening. (The one-year survival rate has been estimated to be roughly 60%, although this figure includes deaths from the underlying disease, as well as from the transplant procedure.)[34] Major complications include veno-occlusive disease, mucositis, infections (sepsis), graft-versus-host disease, and the development of new malignancies.

Infection[edit]

Bone-marrow transplantation usually requires that the recipient's own bone marrow be destroyed (myeloablation). Prior to the administration of new cells (engraftment), patients may go for several weeks without appreciable numbers of white blood cells to help fight infection. This puts a patient at high risk of infections, sepsis, and septic shock, despite prophylactic antibiotics. However, antiviral medications, such as acyclovir and valacyclovir, are quite effective in prevention of HSCT-related outbreak of herpetic infection in seropositive patients.[35] The immunosuppressive agents employed in allogeneic transplants for the prevention or treatment of graft-versus-host disease further increase the risk of opportunistic infection. Immunosuppressive drugs are given for a minimum of 6 months after a transplantation, or much longer if required for the treatment of graft-versus-host disease. Transplant patients lose their acquired immunity, for example immunity to childhood diseases such as measles or polio. So, transplant patients must be retreated with childhood vaccines once they are off immunosuppressive medications.

Veno-occlusive disease[edit]

Severe liver injury can result from hepatic veno-occlusive disease (VOD), newly termed sinusoidal obstruction syndrome (SOS).[36] Elevated levels of bilirubin, hepatomegaly, and fluid retention are clinical hallmarks of this condition. The appreciation of the generalized cellular injury and obstruction in hepatic vein sinuses is now greater. Severe cases of SOS are associated with a high mortality rate. Anticoagulants or defibrotide may be effective in reducing the severity of VOD but may also increase bleeding complications. Ursodiol has been shown to help prevent VOD, presumably by facilitating the flow of bile.

Mucositis[edit]

The injury of the mucosal lining of the mouth and throat is a common regimen-related toxicity following ablative HSCT regimens. It is usually not life-threatening, but is very painful, and prevents eating and drinking. Mucositis is treated with pain medications plus intravenous infusions to prevent dehydration and malnutrition.

Hemorrhagic cystitis[edit]

The mucosal lining of the bladder could also be involved in about 5% of children undergoing HSCT. This causes hematuria (blood in urine), frequent urination, abdominal pain, and thrombocytopenia.[37]

Graft-versus-host disease[edit]

Main article: Graft-versus-host disease

Graft-versus-host disease (GVHD) is an inflammatory disease that is unique to allogeneic transplantation. It is an attack by the "new" bone marrow's immune cells against the recipient's tissues. This can occur even if the donor and recipient are HLA-identical because the immune system can still recognize other differences between their tissues. It is aptly named graft-versus-host disease because bone-marrow transplantation is the only transplant procedure in which the transplanted cells must accept the body rather than the body accepting the new cells.[38]

Acute GVHD typically occurs in the first 3 months after transplantation and may involve the skin, intestine, or liver. High-dose corticosteroids, such as prednisone, are a standard treatment, but this immunosuppressive treatment often leads to deadly infections. Chronic GVHD may also develop after allogeneic transplant. It is the major source of late treatment-related complications, although it less often results in death. In addition to inflammation, chronic GVHD may lead to the development of fibrosis, or scar tissue, similar to scleroderma; it may cause functional disability and require prolonged immunosuppressive therapy. GVHD is usually mediated by T cells, which react to foreign peptides presented on the major histocompatibility complex of the host.[citation needed]

Further research is needed to determine whether mesenchymal stromal cells can be use for prophylaxis and treatment of a GVHD.[39]

Graft-versus-tumor effect[edit]

Main article: Graft-versus-tumor effect

Graft-versus-tumor effect (GVT), or "graft versus leukemia", effect is the beneficial aspect of the GVHD phenomenon. For example, HSCT patients with either acute, or in particular chronic, GVHD after an allogeneic transplant tend to have a lower risk of cancer relapse.[40][41] This is due to a therapeutic immune reaction of the grafted donor T lymphocytes against the diseased bone marrow of the recipient. This lower rate of relapse accounts for the increased success rate of allogeneic transplants, compared to transplants from identical twins, and indicates that allogeneic HSCT is a form of immunotherapy. GVT is the major benefit of transplants that do not employ the highest immunosuppressive regimens.

Graft versus tumor is mainly beneficial in diseases with slow progress, e.g. chronic leukemia, low-grade lymphoma, and in some cases multiple myeloma, but is less effective in rapidly growing acute leukemias.[42]

If cancer relapses after HSCT, another transplant can be performed, infusing the patient with a greater quantity of donor white blood cells (donor lymphocyte infusion).[42]

Malignancies[edit]

Patients after HSCT are at a higher risk for oral carcinoma. Post-HSCT oral cancer may have more aggressive behavior with poorer prognosis, when compared to oral cancer in non-HSCT patients.[43]

A meta-analysis showed that the risk of secondary cancers such as bone cancer, head and neck cancers, and melanoma, with standardized incidence ratios of 10.04 (3.48–16.61), 6.35 (4.76–7.93), and 3.52 (2.65–4.39), respectively, was significantly increased after HSCT. So, diagnostic tests for these cancers should be included in the screening program of these patients for the prevention and early detection of these cancers.[44]

Prognosis[edit]

Prognosis in HSCT varies widely dependent upon disease type, stage, stem-cell source, HLA-matched status (for allogeneic HSCT), and conditioning regimen. A transplant offers a chance for cure or long-term remission if the inherent complications of graft versus host disease, immunosuppressive treatments and the spectrum of opportunistic infections can be survived.[23][24] In recent years, survival rates have been gradually improving across almost all populations and subpopulations receiving transplants.[45]

Mortality for allogeneic stem cell transplantation can be estimated using the prediction model created by Sorror et al.,[46] using the Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI). The HCT-CI was derived and validated by investigators at the Fred Hutchinson Cancer Research Center in the U.S. The HCT-CI modifies and adds to a well-validated comorbidity index, the Charlson comorbidity index (CCI) (Charlson, et al.)[47] The CCI was previously applied to patients undergoing allogeneic HCT, but appears to provide less survival prediction and discrimination than the HCT-CI scoring system.

Risks to donor[edit]

The risks of a complication depend on patient characteristics, health care providers, and the apheresis procedure, and the colony-stimulating factor used (G-CSF). G-CSF drugs include filgrastim (Neupogen, Neulasta), and lenograstim (Graslopin).

Drug risks[edit]

Filgrastim is typically dosed in the 10 microgram/kg level for 4–5 days during the harvesting of stem cells. The documented adverse effects of filgrastim include splenic rupture, acute respiratory distress syndrome, alveolar hemorrhage, and allergic reactions (usually experienced in first 30 minutes).[48][49][50] In addition, platelet and hemoglobin levels dip postprocedurally, not returning to normal until after a month.[50]

The question of whether geriatrics (patients over 65) react the same as patients under 65 has not been sufficiently examined. Coagulation issues and inflammation of atherosclerotic plaques are known to occur as a result of G-CSF injection. G-CSF has also been described to induce genetic changes in agranulocytes of normal donors.[49] There is no statistically significant evidence either for or against the hypothesis that myelodysplasia (MDS) or acute myeloid leukaemia (AML) can be induced by G-CSF in susceptible individuals.[51]

Access risks[edit]

Blood is drawn from a peripheral vein in a majority of patients, but a central line to the jugular, subclavian, and femoral veins may be used. Adverse reactions during apheresis were experienced in 20% of women and 8% of men, these adverse events primarily consisted of numbness/tingling, multiple line attempts, and nausea.[50]

Clinical observations[edit]

A study involving 2,408 donors (aged 18–60 years) indicated that bone pain (primarily back and hips) as a result of filgrastim treatment is observed in 80% of donors.[50] Donation is not recommended for those with a history of back pain.[50] Other symptoms observed in more than 40 percent of donors include muscle pain, headache, fatigue, and difficulty sleeping.[50] These symptoms all returned to baseline 1 month after donation in the majority of patients.[50]

In one meta-study that incorporated data from 377 donors, 44% of patients reported having adverse side effects after peripheral blood HSCT.[51] Side effects included pain prior to the collection procedure as a result of G-CSF injections, and postprocedural generalized skeletal pain, fatigue, and reduced energy.[51]

Severe reactions[edit]

A study that surveyed 2,408 donors found that serious adverse events (requiring prolonged hospitalization) occurred in 15 donors (at a rate of 0.6%), although none of these events was fatal.[50] Donors were not observed to have higher than normal rates of cancer with up to 4–8 years of follow-up.[50]One study based on a survey of medical teams covered about 24,000 peripheral blood HSCT cases between 1993 and 2005, and found a serious cardiovascular adverse reaction rate of about one in 1,500.[49] This study reported a cardiovascular-related fatality risk within the first 30 days of HSCT of about two in 10,000.[49]

History[edit]

In 1939, a woman with aplastic anaemia received the first human bone marrow transfusion. This patient received regular blood transfusions, and an attempt was made to increase her leukocyte and platelet counts by intravenous bone marrow injection without unexpected reaction.[52]

Stem-cell transplantation was pioneered using bone marrow-derived stem cells by a team at the Fred Hutchinson Cancer Research Center from the 1950s through the 1970s led by E. Donnall Thomas, whose work was later recognized with a Nobel Prize in Physiology or Medicine. Thomas' work showed that bone-marrow cells infused intravenously could repopulate the bone marrow and produce new blood cells. His work also reduced the likelihood of developing a life-threatening graft-versus-host disease.[53] Collaborating with University of Washington Professor Eloise Giblett, he discovered genetic markers that could confirm donor matches.

The first physician to perform a successful human bone-marrow transplant on a disease other than cancer was Robert A. Good at the University of Minnesota in 1968.[54]In 1975, John Kersey, M.D., also of the University of Minnesota, performed the first successful bone-marrow transplant to cure lymphoma. His patient, a 16-year-old-boy, is today the longest-living lymphoma transplant survivor.[55]

Donor registration and recruitment[edit]

At the end of 2012, 20.2 million people had registered their willingness to be a bone-marrow donor with one of the 67 registries from 49 countries participating in Bone Marrow Donors Worldwide. Around 17.9 million of these registered donors had been ABDR typed, allowing easy matching. A further 561,000 cord blood units had been received by one of 46 cord blood banks from 30 countries participating. The highest total number of bone-marrow donors registered were those from the U.S. (8.0 million), and the highest number per capita were those from Cyprus (15.4% of the population).[56]

Within the U.S., racial minority groups are the least likely to be registered, so are the least likely to find a potentially life-saving match. In 1990, only six African Americans were able to find a bone-marrow match, and all six had common European genetic signatures.[57]

Africans are more genetically diverse than people of European descent, which means that more registrations are needed to find a match. Bone marrow and cord blood banks exist in South Africa, and a new program is beginning in Nigeria.[57] Many people belonging to different races are requested to donate as a shortage of donors exists in African, mixed race, Latino, aboriginal, and many other communities.

Two registries in the U.S. recruit unrelated allogeneic donors: NMDP or Be the Match, and the Gift of Life Marrow Registry.

Research[edit]

HIV[edit]

In 2007, a team of doctors in Berlin, Germany, including Gero Hütter, performed a stem-cell transplant for leukemia patient Timothy Ray Brown, who was also HIV-positive.[58] From 60 matching donors, they selected a [CCR5]-Δ32 homozygous individual with two genetic copies of a rare variant of a cell surface receptor. This genetic trait confers resistance to HIV infection by blocking attachment of HIV to the cell. Roughly one in 1,000 people of European ancestry have this inherited mutation, but it is rarer in other populations.[59][60] The transplant was repeated a year later after a leukemia relapse. Over three years after the initial transplant, and despite discontinuing antiretroviral therapy, researchers cannot detect HIV in the transplant recipient's blood or in various biopsies of his tissues.[61] Levels of HIV-specific antibodies have also declined, leading to speculation that the patient may have been functionally cured of HIV, but scientists emphasise that this is an unusual case.[62] Potentially fatal transplant complications (the "Berlin patient" suffered from graft-versus-host disease and leukoencephalopathy) mean that the procedure could not be performed in others with HIV, even if sufficient numbers of suitable donors were found.[63][64]

In 2012, Daniel Kuritzkes reported results of two stem-cell transplants in patients with HIV. They did not, however, use donors with the Δ32 deletion. After their transplant procedures, both were put on antiretroviral therapies, during which neither showed traces of HIV in their blood plasma and purified CD4+ T cells using a sensitive culture method (less than 3 copies/ml). The virus was once again detected in both patients some time after the discontinuation of therapy.[65]

In 2019, a British man became the second to be cleared of HIV after receiving a bone-marrow transplant from a virus-resistant (Δ32) donor. This patient is being called "the London patient" (a reference to the famous Berlin patient).[66]

Multiple sclerosis[edit]

Since McAllister's 1997 report on a patient with multiple sclerosis (MS) who received a bone-marrow transplant for CML,[67] over 600 reports have been published describing HSCTs performed primarily for MS.[68] These have been shown to "reduce or eliminate ongoing clinical relapses, halt further progression, and reduce the burden of disability in some patients" who have aggressive, highly active MS, "in the absence of chronic treatment with disease-modifying agents".[68] A randomized clinical trial including 110 patients showed that HSCT significantly prolonged time to disease progression compared to disease-modifying therapy.[69] Long-term outcome in patients with severe disease has showed that complete disease remission after HSCT is possible.[70]

Other autoimmune neurological diseases[edit]

HSCT can also be used for treating selected, severe cases of other autoimmune neurological diseases such as neuromyelitis optica, chronic inflammatory demyelinating polyneuropathy, and myasthenia gravis.[71]

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Further reading[edit]

  • Cote GM, Hochberg EP, Muzikansky A, Hochberg FH, Drappatz J, McAfee SL, et al. (January 2012). "Autologous stem cell transplantation with thiotepa, busulfan, and cyclophosphamide (TBC) conditioning in patients with CNS involvement by non-Hodgkin lymphoma". Biology of Blood and Marrow Transplantation. 18 (1): 76–83. doi:10.1016/j.bbmt.2011.07.006. PMID 21749848.

External links[edit]

  • Bone marrow transplant – How it is performed on NHS Choices
  • HCT-CI (Sorror et al. 2005) online calculator