[Autologous hematopoietic stem cell transplantation for autoimmune diseases : Current indications and mode of action, a review on behalf of the EBMT Autoimmune Diseases Working Party (ADWP)]. / Autologe hämatopoetische Stammzelltransplantation bei Autoimmunerkrankungen : Aktuelle Indikationen und Wirkungsweise, ein Review der EBMT Autoimmune Diseases Working Party (ADWP).

The recent introduction of biologic and targeted synthetic disease-modifying drugs has led to more specificity in the treatment of autoimmune diseases; however, they require continuous or intermittent administration, are associated with cumulative risks for side effects, result in high costs and provide no cure. In contrast, high-dose chemotherapy followed by transplantation of autologous hematopoietic stem cells (AHSCT) has been demonstrated to induce clinical remission in various autoimmune diseases that can persist over many years without continued maintenance therapy. The principle behind AHSCT is an elimination of important components of the autoreactive immunological memory with subsequent regeneration of the complete immune system. Several studies have indicated that such an immune reset is associated with fundamental changes in the immune repertoire leading to an induction of tolerance against self-antigens. This article presents the current indications of AHSCT for autoimmune diseases based on the registry data of the European Society of Blood and Marrow Transplantation (EBMT) and discusses the results from mechanistic studies, which provide detailed insights into the mode of action of this treatment.

[Autologous hematopoietic stem cell transplantation for systemic sclerosis : Position statement of the stem cell therapy working party of the German Society of Rheumatology]. / Autologe hämatopoetische Stammzelltransplantation bei systemischer Sklerose : Positionspapier des Arbeitskreises Stammzelltherapie der Deutschen Gesellschaft für Rheumatologie.

There have been three randomized controlled trials on autologous hematopoietic stem cell transplantation (AHSCT) in systemic sclerosis (SSc) that demonstrated significant superiority with respect to survival, improvement of cutaneous fibrosis, lung function and quality of life compared to standard treatment; however, these advantages must be carefully weighed against the transplantation-related risks. For this reason, an expert group from the stem cell therapy working party of the German Society for Rheumatology (DGRh) has now developed recommendations for the use of AHSCT in SSc. Based on the high-quality evidence, AHSCT is considered as the standard option for the treatment of selected SSc patients. Potential candidates for AHSCT are those with early, rapidly progressive, diffuse cutaneous SSc with visceral manifestations who have not yet developed severe damage to internal organs. A close cooperation between rheumatologists and transplantation centers is crucial for optimizing patient selection and treatment outcomes.

[Autologous hematopoietic stem cell transplantation in systemic lupus erythematosus]. / Autologe hämatopoetische Stammzelltransplantation bei systemischem Lupus erythematodes.

Although the treatment options for systemic lupus erythematosus (SLE) have significantly improved over the past years through the introduction of novel targeted biologic therapies, there are still some patients who suffer from refractory and potentially life-threatening courses of the disease. For these patients autologous hematopoietic stem cell transplantation (ASCT) after immunoablative chemotherapy provides a promising treatment option with curative potential. Based on preclinical models, ASCT was first introduced in 1996 and has since been carried out in approximately 300 patients worldwide. Clinical study results confirmed a disease-free survival in approximately 50 % of patients after 5 years despite termination of immunosuppressive treatment. By careful patient selection and improved anti-infection prophylaxis during stem cell therapy, transplantation-associated mortality could be reduced from an initial 13 % to currently an average of 6 %. Meanwhile, mechanistic studies have provided proof of concept that ASCT not only exerts intensified immunosuppressive effects but is also associated with fundamental qualitative changes of the immune system that may rewire a chronic autoimmune system into a naïve and self-tolerant state: in other words immune reset. Overall, ASCT for SLE is still reserved for patients who do not sufficiently respond to standard therapy. Treatment should be carried out in close cooperation with centers specializing in hematology and only within the framework of clinical studies.

Long-term follow-up of fertility and pregnancy in autoimmune diseases after autologous haematopoietic stem cell transplantation.

Issues of fertility and pregnancy require special attention in the long-term care of patients with autoimmune diseases (AD), who are candidates for haematopoietic stem cell transplantation (HSCT). In this single-centre observational study, we report fertility status and pregnancy outcomes in 15 patients (11 female and 4 male) after immunoablation with cyclophosphamide, antithymocyte globulin and autologous CD34+-selected HSCT for severe, refractory AD. The median follow-up after HSCT was 12 years (range 2-16 years). Impaired fertility was observed in six patients (five females and one male) before HSCT based on sexual hormone measurements. Higher age and cumulative cyclophosphamide dosage before HSCT correlated with fertility impairment. Median serum level of follicle-stimulating hormone (FSH) was significantly higher in female patients at 1 year after HSCT compared to baseline values, but premature ovarian failure developed in only one patient. Four women had five pregnancies and six healthy offsprings during follow-up, and no miscarriages were observed. The mothers were in treatment-free remissions during conception. No peripartal flare of their AD occurred. Although AD patients undergoing HSCT are at risk of developing infertility, pre-HSCT treatment and patients' age seem to have higher impact on long-term fertility status than HSCT itself. HSCT offers the opportunity to conceive during treatment-free remissions with favourable pregnancy outcomes.

[Plasma cells]. / Plasmazellen.

Plasma cells are specialized terminally differentiated B cells that synthesize and secrete antibodies to maintain humoral immunity. By the production of pathogenic antibodies, plasma cells contribute to the development of many conditions, such as autoimmune disorders, transplant rejection and allergies. Two different plasma cell compartments can independently generate different types of pathogenic antibodies: (1) short-lived plasmablasts (proliferating precursors of mature plasma cells) and plasma cells, which live only as long as B cells are activated. Consequently, these cells cause disease flares that respond to immunosuppressive drugs and B cell targeting therapies. (2) Long-lived non-proliferating memory plasma cells, which survive in niches in bone marrow and inflamed tissues for months, years or a lifetime independent of B or T cell help or antigen contact. Because they do not respond to immunosuppressants or treatment targeting B cells, they are responsible for refractory chronic conditions. Therefore, long-lived memory plasma cells in particular have emerged as important therapeutic targets and strategies to target these cells are discussed in this article. So far long-lived plasma cells can only be depleted by immunoablative therapy with antithymocyte globulin in the setting of stem cell transplantation or by treatment with proteasome inhibitors approved for multiple myeloma. These strategies provide options for treating refractory autoantibody-mediated diseases. One interesting approach aims at an antigen-specific elimination of target plasma cells without depleting the protective plasma cells responsible for maintaining humoral immunity.

SCT for severe autoimmune diseases: consensus guidelines of the European Society for Blood and Marrow Transplantation for immune monitoring and biobanking.

Over the past 15 years, SCT has emerged as a promising treatment option for patients with severe autoimmune diseases (ADs). Mechanistic studies recently provided the proof-of-concept that restoration of immunological tolerance can be achieved by haematopoietic SCT in chronic autoimmunity through eradication of the pathologic, immunologic memory and profound reconfiguration of the immune system, that is, immune 'resetting'. Nevertheless, a number of areas remain unresolved and warrant further investigation to refine our understanding of the underlying mechanisms of action and to optimize clinical SCT protocols. Due to the low number of patients transplanted in each centre, it is essential to adequately collect and analyse biological samples in a larger cohort of patients under standardized conditions. The European society for blood and marrow transplantation Autoimmune Diseases and Immunobiology Working Parties have, therefore, undertaken a joint initiative to develop and implement guidelines for 'good laboratory practice' in relation to procurement, processing, storage and analysis of biological specimens for immune reconstitution studies in AD patients before, during and after SCT. The aim of this document is to provide practical recommendations for biobanking of samples and laboratory immune monitoring in patients with ADs undergoing SCT, both for routine supportive care purposes and investigational studies.

[Systemic lupus erythematosus]. / Systemischer Lupus erythematodes.

Systemic lupus erythematosus (SLE) is the classical systemic autoimmune disease. Its prevalence is slightly below 1:1,000 in women and 10-fold lower in men. Typically, the disease manifests in women of childbearing age. While severe untreated SLE used to be a fatal disease, prognosis has improved stepwise with corticosteroids, cyclophosphamide and novel therapies. Deaths directly related to SLE are uncommon nowadays but infections, thromboses and accelerated atherosclerosis cause significant problems. The current review presents the state of the art in managing SLE patients.

HLA-DRhigh/CD27high plasmablasts indicate active disease in patients with systemic lupus erythematosus.

OBJECTIVES: Monitoring of peripheral B-cell subsets in patients with systemic lupus erythematosus (SLE) revealed an activity-related expansion of CD27(++)CD20(-)CD19(dim) Ig-secreting cells. A similar subset has also been identified 6-8 days after tetanus/diphtheria vaccination in normal individuals and in patients with infectious disease. METHODS: This subset was analysed further focussing on the HLA-DR surface expression in a cohort of 25 patients with SLE. RESULTS: This study revealed that 86% (range 59-97%) of CD27(++)CD20(-)CD19(dim) cells express high levels of HLA-DR, are also expanded in the bone marrow, and represent plasmablasts enriched with anti-dsDNA secreting cells. The remaining CD27(++)CD20(-)CD19(dim) cells were HLA-DR(low) and represent mature plasma cells. Importantly, HLA-DR(high) plasmablasts showed a closer correlation with lupus activity and anti-dsDNA levels than the previously identified CD27(++)CD20(-)CD19(dim) cells. CONCLUSION: HLA-DR(high)CD27(++)CD20(-)CD19(dim) plasmablasts represent a more precise indicator of lupus activity and suggest that there is an overproduction or lack of negative selection of these cells in SLE.

[Immunoablation followed by autologous stem cell transplantation in lupus: a clinical update]. / Immunablation in Kombination mit autologer Stammzelltransplantation bei Lupus: Eine Bilanz aus klinischer Sicht.

Systemic lupus erythematosus (SLE) is a classic systemic autoimmune disease. Standard treatment consists of chronic therapy with antimalarials, glucocorticoids and immunosuppressive/cytotoxic drugs, which is associated with considerable side effects. In contrast, immunoablation of autoreactive immunologic memory followed by autologous stem cell transplantation (ASCT) has been the only regimen capable of inducing long-term remission of up to 10 years after cessation of immunosuppressive therapy, even in severely affected patients. Introduced in 1996, the procedure has since been performed in 147 patients with severe SLE refractory to standard treatment in clinical studies worldwide. Most of these patients achieved clinical long-term remission. However, SLE relapses and secondary autoimmune disorders have been reported. Transplant-related mortality occurred in 6% of the 147 cases, with a wide center effect (2-13%). Here we summarise the results published in the literature on immunoablation followed by ASCT in SLE and discuss future perspectives for optimising this therapeutic approach. It may be possible to improve the outcome and reduce the risks of treatment by identifying patients with a poor prognosis at an early stage, before irreversible organ damage has taken place.

[Depletion of plasma cells - a novel strategy in the therapy of systemic lupus erythematosus in mice and man]. / Plasmazelldepletion - ein neuer Ansatz in der Lupustherapie bei Maus und Mensch.

Secretion of pathogenic antibodies by long-lived plasma cells which are resistant to conventional treatment may essentially contribute to refractory systemic lupus erythematosus (SLE). Here we introduce two novel therapies that also deplete long-lived plasma cells: 1. Immunoablation with anti-thymocyte globulin followed by autologous stem cell transplantation has already been successfully used in patients with SLE. 2. The proteasome inhibitor bortezomib, approved for the treatment of multiple myeloma, efficiently depletes short- and long-lived plasma cells and ameliorates lupus nephritis in mouse models. These novel therapies may improve the future treatment of SLE and other antibody-mediated diseases.

CXCR3+CD4+ T cells are enriched in inflamed kidneys and urine and provide a new biomarker for acute nephritis flares in systemic lupus erythematosus patients.

OBJECTIVE: The high frequency of CD4+ T cells in interstitial infiltrates of patients with lupus nephritis suggests a contribution of these cells to local pathogenesis. The aim of this study was to examine the role of CXCR3 and the chemokine CXCL10 in recruiting these cells into the kidney and to determine whether the infiltrating T cells could be monitored in the urine to provide a reliable biomarker for acute lupus nephritis. METHODS: The frequencies of CD3+ T cells, CXCR3+ cells, and CXCL10+ cells were determined by immunohistochemical and immunofluorescence analyses of kidney sections from 18 patients with lupus nephritis. The frequency of CXCR3+CD4+ T cells was determined by flow cytometry of peripheral blood and urine from 38 patients with systemic lupus erythematosus (SLE), and the values were compared with disease activity as determined by the Systemic Lupus Erythematosus Disease Activity Index. RESULTS: In renal biopsy tissues from patients with lupus nephritis, a mean of 63% of the infiltrating cells expressed CXCR3, approximately 60% of them were T cells, and the CXCR3+ cells colocalized with CXCL10-producing cells. In biopsy tissues from SLE patients with acute nephritis, approximately 50% of the urinary CD4+ T cells were CXCR3+, as compared with 22% in the peripheral blood, and the frequency of urinary CXCR3+CD4+ T cells correlated with disease activity. Moreover, the number of urinary CD4+ T cells reflected nephritis activity, and elevation above 800 CD4+ T cells per 100 ml of urine sharply delineated active from inactive nephritis. CONCLUSION: CXCR3+ T cells are recruited into the inflamed kidneys, are enriched in the urine, and are a valuable marker of nephritis activity in SLE. They also present a potential target for future therapies.

How to cope with pathogenic long-lived plasma cells in autoimmune diseases.

Recently, it has been shown that plasma cells secreting antibodies can be long lived and as such constitute an independent component of immunological memory. They are generated in the context of memory immune reactions and migrate to the bone marrow, where they persist for years and decades. Their survival is dependent on receiving distinct signals provided by cells forming a plasma cell survival niche. They also can migrate to, and survive in, inflamed tissue. In autoimmune diseases long-lived plasma cells secreting autoantibodies provide an as yet unmet therapeutic challenge, because they are resistant to conventional treatments, in particular to immunosuppression and anti-inflammatory drugs. They are eliminated by immunoablation with antithymocyte globulin. This may be the reason why immunoablation followed by reconstitution of the patient's immune system from haematopoietic stem cells induces long-term remissions in many patients with autoimmune diseases. However, more specific treatments for the elimination of autoreactive, long-lived plasma cells are needed, to avoid the complete temporary immunoincomptence induced by immunoablation, and to decipher the role of long-lived autoreactive plasma cells in human autoimmune diseases in more detail.

Differential effects of epratuzumab on peripheral blood B cells of patients with systemic lupus erythematosus versus normal controls.

OBJECTIVE: B lymphocytes have been implicated in the pathogenesis of lupus and other autoimmune diseases, resulting in the introduction of B cell-directed therapies. Epratuzumab, a humanised anti-CD22 monoclonal antibody, is currently in clinical trials, although its effects on patients' B cells are not completely understood. METHODS: This study analysed the in vivo effect of epratuzumab on peripheral B cell subsets in 12 patients with systemic lupus erythematosus, and also addressed the in vitro effects of the drug by analysing anti-immunoglobulin-induced proliferation of isolated B cells obtained from the peripheral blood of 11 additional patients with lupus and seven normal subjects. RESULTS: Upon treatment, a pronounced reduction of CD27(-) B cells and CD22 surface expression on CD27(-) B cells was observed, suggesting that these cells, which mainly comprise naïve and transitional B cells, are preferentially targeted by epratuzumab in vivo. The results of in vitro studies indicate additional regulatory effects of the drug by reducing the enhanced activation and proliferation of anti-immunoglobulin-stimulated lupus B cells after co-incubation with CD40L or CpG. Epratuzumab inhibited the proliferation of B cells from patients with systemic lupus erythematosus but not normal B cells under all culture conditions. CONCLUSIONS: Epratuzumab preferentially modulates the exaggerated activation and proliferation of B cells from patients with lupus in contrast to normal subjects, thus suggesting that epratuzumab might offer a new therapeutic option for patients with systemic lupus erythematosus, as enhanced B cell activation is a hallmark of this disease.

Effect of dsDNA binding to SmD-derived peptides on clinical accuracy in the diagnosis of systemic lupus erythematosus.

Systemic lupus erythematosus is characterized by antibodies to a variety of intracellular self-antigens, such as dsDNA and Sm, and these serve as hallmarks in the diagnosis of systemic autoimmune diseases. Several studies have shown that SmD1 and SmD3 synthetic peptides represent highly functional antigens for autoantibody detection and thus for diagnostic applications. The present study analysed the technical and clinical accuracy of an anti-SmD1 (amino acids 83-119) and an anti-SmD3 (amino acids 108-122) ELISA for the detection of anti-Sm antibodies. Depending on the cut-off value of the SmD1 ELISA, we found a high degree of concordance between the two tests. At an optimized cut-off value of 100 units for SmD1 we found the same clinical sensitivity (12.5%) and specificity (100%) in a group of systemic lupus erythematosus patients (n = 48) and in controls (n = 99). The concordance at this cut-off value was 100% (P < 0.0001; chi2 = 127.61). Using a second panel of sera (n = 65) preselected based on positive anti-Sm results, we confirmed the high degree of concordance between the two assays. Using dsDNA-coated ELISA plates and biotinylated peptides we confirmed the high dsDNA binding properties for SmD1, which were significantly higher than the SmD3-derived peptide. However, no cross-linking of anti-dsDNA antibodies to SmD1 was observed after adding increasing amounts of dsDNA to anti-dsDNA positive, anti-SmD1 negative serum. We therefore conclude that the reported difference in the sensitivity is related to the different cut-off levels and not to the detection of anti-dsDNA antibodies bridged via dsDNA to the SmD1 peptide. Moreover, we found that a subpopulation of anti-Sm antibodies cross-reacted with SmD1 and SmD3. Taken together, the data indicate that both SmD peptide ELISAs represent accurate assays and may be used as important standards for the detection of anti-Sm antibodies.

The systemic and SmD183-119-autoantigen-specific cytokine memory of Th cells in SLE patients.

OBJECTIVES: The aim of the study was to analyse the cytokine memory of T-cells derived from systemic lupus erythematosus (SLE) patients and healthy donors enriched for autoantigen-specific T-cells by in vitro stimulation with SmD1(83-119), a common autoantigen in SLE. METHODS: Autoreactive CD3+ T-cells derived from 37 SLE patients and 14 healthy donors were enriched by repetitive ex vivo stimulation of peripheral blood mononuclear cells (PBMCs) with SmD1(83-119). For control, PBMCs were stimulated only with interleukin-2 (IL-2). After two rounds of antigenic stimulation, cultures were stimulated with PMA/ionomycin to probe the cytokine memory by intracellular cytokine staining. Frequencies of cytokine-expressing T-cells were analysed and, in SLE patients, compared with disease activities and autoantibody levels. RESULTS: Comparing the cytokine memory in the cultures, SLE patients displayed higher frequencies of tumour necrosis factor-alpha (TNF-alpha)+ T-cells than healthy donors and the frequencies correlated with disease activity. Frequencies of SmD1(83-119)-specific TNF-alpha+ T-cells and of memory T-cells expressing interferon-gamma (IFN-gamma) correlated with serum anti-dsDNA antibody levels. The frequencies of IL-10 expressing SmD1(83-119)-specific T-cells were lower among PBMCs of SLE patients. Relatively higher frequencies of IL-10+ T-cells in SLE patients correlated with low disease activities, and low anti-dsDNA and anti-SmD1(83-119) antibody concentrations in culture supernatants. CONCLUSIONS: The memory of autoreactive SmD1(83-119)-specific and unspecific stimulated peripheral Th cells for re-expression of cytokines is shifted towards more cells expressing TNF-alpha and less IL-10+ cells, when compared SLE patients with normal donors. This shift towards proinflammatory memory effector Th cells correlates with disease severity and humoral autoimmunity.

Autologous stem cell transplantation in the treatment of systemic sclerosis: report from the EBMT/EULAR Registry.

OBJECTIVE: To analyse the durability of the responses after haematopoietic stem cell transplantation (HSCT) for severe systemic sclerosis (SSc) and determine whether the high transplant related mortality (TRM) improved with experience. This EBMT/EULAR report describes the longer outcome of patients originally described in addition to newly recruited cases. METHODS: Only patients with SSc, treated by HSCT in European phase I-II studies from 1996 up to 2002, with more than 6 months of follow up were included. Transplant regimens were according to the international consensus statements. Repeated evaluations analysed complete, partial, or non-response and the probability of disease progression and survival after HSCT (Kaplan-Meier). RESULTS: Given as median (range). Among 57 patients aged 40 (9.1-68.7) years the skin scores improved at 6 (n = 37 patients), 12 (n = 30), 24 (n = 19), and 36 (n = 10) months after HSCT (p<0.005). After 22.9 (4.5-81.1) months, partial (n = 32) or complete response (n = 14) was seen in 92% and non-response in 8% (n = 4) of 50 observed cases. 35% of the patients with initial partial (n = 13/32) or complete response (n = 3/14) relapsed within 10 (2.2-48.7) months after HSCT. The TRM was 8.7% (n = 5/57). Deaths related to progression accounted for 14% (n = 8/57) of the 23% (n = 13/57) total mortality rate. At 5 years, progression probability was 48% (95% CI 28 to 68) and the projected survival was 72% (95% CI 59 to 75). CONCLUSION: This EBMT/EULAR report showed that response in two thirds of the patients after HSCT was durable with an acceptable TRM. Based on these results prospective, randomised trials are proceeding.

[Wegener's granulomatosis (WG) presented with hearing loss and without positive serologic ANCA]. / Innenohrschwerhörigkeit bei oligosymptomatischer Vaskulitis im Kopf-Hals-Bereich: eine limitierte Wegenersche Granulomatose.

BACKGROUND: Wegener's granulomatosis (WG) is a granulomatous inflammation involving the upper and lower respiratory tract and necrotizing vasculitis affecting small to medium-sized vessels. In contrast to a generalised WG with glomerulonephritis initial or isolated forms of the upper respiratory tract may be a diagnostic challenge. PATIENT: We report the case of a 33 year old man with clinical signs of a limited WG exhibiting an imminent irreversible hearing loss, negative PR3-ANCA (anti neutrophil cytoplasmic antibodies with proteinase 3 as target) in serum and an ambiguous histology. CONCLUSION: In case of a chronic otitis media and rhinitis as well as signs of a labyrinthine deafness a limited form of a WG has to be taken into account, even with an ambiguous histology and negative PR3-ANCA. This diagnosis is supported by high inflammation parameters, e. g. ESR and CRP, exclusion of infectious cause and response to corticosteroids. A quick therapeutic intervention with corticosteroids and cyclophosphamide is required in order to interrupt the vasculitis of the inner ear with consequential deafness.

Perturbations of peripheral B lymphocyte homoeostasis in children with systemic lupus erythematosus.

OBJECTIVE: To investigate the distribution of peripheral B cell subpopulations of children with active and inactive systemic lupus erythematosus (SLE) compared with healthy controls. METHODS: Peripheral B cell subpopulations of 11 children with SLE (6 with active and 5 with inactive disease) and 14 age matched normal healthy children were analysed. Active disease was diagnosed in children with a flare of SLE, who received treatment by i.v. cyclophosphamide or i.v. methylprednisolone pulse to control the disease. Additionally, the peripheral B cells of the children with SLE were compared with those of 13 consecutive patients with adult onset SLE. RESULTS: No major difference was found in the frequency and total number of CD27(-)/CD19(+) naïve B cells and CD27(+)/CD19(+) memory B cells between patients with active and inactive lupus and healthy controls, but there was a significant increase in CD27(high) expressing plasma blasts in patients with active SLE. These cells coexpress CD38(+), HLA-DR(dim), surface Ig(low) and lack the expression of CD20 but are clearly positive for intracellular Ig, indicative of early plasma cells. Most CD138(+) cells coexpress CD27(high)/CD19(+). The enhanced frequency of peripheral plasma blasts in children with active SLE is consistent with previous findings in adult patients with SLE, whereas a relative predominance of CD27(+) memory B cells was only identified in the adult patients. CONCLUSIONS: Profound abnormalities in the distribution of B cell compartments are more pronounced in older patients with SLE, but an enhanced frequency and cell number of peripheral plasma blasts is characteristic of both diseases during active stages. Thus detection of CD27(high) plasma blasts significantly correlates with active lupus in both children and adults.