Worldwide Network for Blood and Marrow Transplantation (WBMT) recommendations for establishing a hematopoietic stem cell transplantation program in countries with limited resources (Part II): Clinical, technical and socio-economic considerations.

The development of hematopoietic stem cell transplantation (HSCT) programs can face significant challenges in most developing countries because such endeavors must compete with other government health care priorities, including the delivery of basic services. While this is may be a limiting factor, these countries should prioritize development of the needed expertise to offer state of the art treatments including transplantation, by providing financial, technological, legal, ethical and other needed support. This would prove beneficial in providing successful programs customized to the needs of their population, and potentially provide long-term cost-savings by circumventing the need for their citizens to seek care abroad. Costs of establishing HSCT program and the costs of the HSCT procedure itself can be substantial barriers in developing countries. Additionally, socioeconomic factors intrinsic to specific countries can influence access to HSCT, patient eligibility for HSCT and timely utilization of HSCT center capabilities. This report describes recommendations from the Worldwide Network for Blood and Marrow Transplantation (WBMT) for establishing HSCT programs with a specific focus on developing countries, and identifies challenges and opportunities for providing this specialized procedure in the resource constrained setting.

Prevention of graft vs. host disease with alemtuzumab 'in the bag' decreases early toxicity of stem cell transplantation and in multiple myeloma is associated with improved long-term outcome.

BACKGROUND: Allogeneic stem cell transplantation in multiple myeloma (MM) is controversial because treatment-related mortality and relapse remain a substantial challenge. METHODS: Patients with symptomatic MM responsive to therapy received myeloablative conditioning with radiotherapy (n=12) or chemotherapy (n=10) followed by infusion of HLA-identical grafts from a sibling. Graft vs. host disease (GvHD) prophylaxis consisted of 'ex vivo' T-cell depletion with CAMPATH-1 antibody. The objective of the study was to determine transplant-related mortality (TRM), GvHD, overall survival (OS) and Disease free Survival (DFS). RESULTS: Twenty-two patients, median age 45 (range 37-56) years, had a median performance status of 1 (0-2). Patients received a median of 23.8 x 10(4)/kg CFU-GM and 4.31 x 10(6)/kg CD34. Median time to engraftment was 13 days. The day-100 and 1-year TRM was 9% and 20%, respectively. Ten patients suffered disease recurrence. Four of eight patients remained in remission after infusions of donor lymphocyte (DLI) containing a median total of 0.67 x 10(8)/kg CD3 cells. Three-year OS was 56%, and 50% remained disease free at a median of 1101 days (range 385-5309). Multiple regression analysis showed that bone marrow (vs. peripheral blood stem cell) (P=0.03), presentation of low albumin (P=0.02) and a higher dose of CAMPATH-1H (P=0.01) were adverse factors for survival. Cox analysis confirmed that a lower CAMPATH-1H dose was associated with improved outcome. DISCUSSION: In chemotherapy-responsive patients with myeloma, T-cell depletion of allogeneic grafts was associated with an acceptable 1-year TRM and seemed to have a favorable impact on long-term survival.

Hematopoietic stem cell transplantation for adults with acute promyelocytic leukemia in the ATRA era: a survey of the European Cooperative Group for Blood and Marrow Transplantation.

We performed a survey of the European Cooperative Group for Blood and Marrow Transplantation to analyze the outcome of 625 acute promyelocytic leukemia (APL) patients transplanted with auto- or allogeneic-hematopoietic stem cell transplantation (autoHSCT, alloHSCT) after 1993, in first (CR1) or in second complete remission (CR2). Leukemia-free survival (LFS) at 5 years in CR1 was 69% for 149 patients autografted and 68% for 144 patients allografted, whereas in CR2, LFS was 51% in 195 autoHSCT and 59% in 137 alloHSCT recipients, respectively. In the group of autoHSCT for CR1 (n=149), higher relapse incidence (RI) was associated with shorter time from diagnosis to transplant (<7.6 months); transplant-related mortality (TRM) was increased in older patients (>47 years), whereas for CR2, longer time from diagnosis to transplant (>18 months) was associated with increased LFS and decreased RI. In the alloHSCT group for CR1 (n=144), age (<33 years) was associated with increased LFS and decreased TRM and for CR2 (n=137), the use of mobilized peripheral blood stem cells was associated with decreased TRM. Female recipient, a female donor to male recipient and transplants performed before 1997 were associated with decreased RI. In conclusion, HSCT still appears to have a role in APL, especially for patients in CR2.

Hematopoietic stem cell transplantation activity worldwide in 2012 and a SWOT analysis of the Worldwide Network for Blood and Marrow Transplantation Group including the global survey.

Data on 68 146 hematopoietic stem cell transplants (HSCTs) (53% autologous and 47% allogeneic) gathered by 1566 teams from 77 countries and reported through their regional transplant organizations were analyzed by main indication, donor type and stem cell source for the year 2012. With transplant rates ranging from 0.1 to 1001 per 10 million inhabitants, more HSCTs were registered from unrelated 16 433 donors than related 15 493 donors. Grafts were collected from peripheral blood (66%), bone marrow (24%; mainly non-malignant disorders) and cord blood (10%). Compared with 2006, an increase of 46% total (57% allogeneic and 38% autologous) was observed. Growth was due to an increase in reporting teams (18%) and median transplant activity/team (from 38 to 48 HSCTs/team). An increase of 167% was noted in mismatched/haploidentical family HSCT. A Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis revealed the global perspective of WBMT to be its major strength and identified potential to be the key professional body for patients and authorities. The limited data collection remains its major weakness and threat. In conclusion, global HSCT grows over the years without plateauing (allogeneic>autologous) and at different rates in the four World Health Organization regions. Major increases were observed in allogeneic, haploidentical HSCT and, to a lesser extent, in cord blood transplantation.

Myeloablative conditioning is well tolerated by older patients receiving T-cell-depleted grafts.

Older age has been linked to increased transplant-related mortality from graft-versus-host disease (GvHD). Depletion of T cells from stem cell grafts seems to protect from complications of GvHD particularly in older patients. After myeloablative conditioning, patients with haematological malignancies received allogeneic grafts from HLA identical siblings. For GvHD prophylaxis, PBPC grafts were treated ex vivo with anti-CD52, and therapeutic doses of cyclosporin until day +90. Survival of patients younger or older than the population age median was analysed. In all, 62 consecutive patients with a median age of 42.5 years were studied. Death was procedure related in 17% and from relapse of malignancy in five. At a median, follow-up is 662 (7-2316) days, 74% survive disease free. The rate of haematopoietic recovery and treatment-related mortality was similar in both groups. A total of 73% of 30 individuals in the younger group and 75% (P=0.8) in the older cohort survive at a median follow-up of 444 and 806 days (P=0.4). GvHD occurred in 13% and was the only adverse factor for survival (P<0.04). Myeloablative conditioning is well tolerated up to the age of 59 in patients receiving T-cell-depleted grafts. This information is useful to more precisely select patients who would benefit most from reduced intensity conditioning schedules.

Immunosuppressive therapy in bone marrow aplasia: the stroma functions normally to support hematopoiesis.

In aplastic anemia (AA) patients responsive to antilymphocyte globulin (ALG) therapy, abnormalities in both stroma and progenitor cell (PC) pool have been described. The relevance of each pathophysiologic defect was characterized in 16 individuals, and data were compared to results from seven normal volunteers. Bone marrow mononuclear cells were split into two fractions. Stromal layers (SL) were prepared from the first, and a CD34+ enriched population was obtained by immunomagnetic selection from the second. In cross-culture experiments, 1 x 10(4) of the latter from patients or controls were seeded on preformed SL, and adhesive PC were scored for the formation of blast colonies (CFU-Bl) on day 5 of culture. Nonadherent progenitors were recovered and quantitated in a standard clonogenic assay (CFU-GM). There were significantly fewer CD34+ cells in the AA group (median 0.65%, SD 0.39%, vs. 1.62%, SD 1.4%; p = 0.002). No morphological or cytologic differences between normal and aplastic SL were detected. Both equally supported the growth of CFU-Bl from normal progenitors (mean 117, SD 20.4, and 103.1, SD 30.4), while this value was reduced for the aplastic PC (mean 41.06, SD 42.9; p = 0.0002, exact two-tailed test). Similarly, the AA nonadherent PC had a decreased CFU-GM growth (mean 142.6, SD 104.8, vs. mean 361.7; SD 91.3), with a lower total clonogenic output (p = 0.0009). We conclude that aplastic stroma appropriately supports the growth of normal progenitors, whereas the depressed clonogenicity of the corresponsing population derived from AA is unrelated to their attachment to SL but intrinsic to the CD34+ cells, whether adherent or not.

Alterations in both the hematopoietic microenvironment and the progenitor cell population follow the recovery from myeloablative therapy and bone marrow transplantation.

Experimental data are conflicting, but suggest that after recovery from bone marrow transplantation (BMT), alterations in clonogenic growth and myeloid microenvironment remain. To further characterize this abnormality, light-density marrow cells from 15 patients who were in remission from hematologic malignancies and had undergone BMT (eight allogeneic and seven autologous) were studied in two culture systems after their marrows had reconstituted and were compared to normal. The preconditioning regimen for transplantation was fractionated total-body irradiation (TBI) 12 Gy, cyclophosphamide 120 mg/kg, and total nodal irradiation 6 Gy. Bone marrow mononuclear cells (MNCs) from the patients and controls were divided in two fractions; stromal layers (SL) were prepared from the first fraction. To examine the attributes of the stroma, the petri dish surface covered by the SL was measured after 5 weeks in culture, and representative layers were trypsinized and stained with Sudan black, butirate esterase, and acid and alkaline phosphatases. Stromal layers were also studied for their support in the development of blastic colonies (CFU-BI). From the second fraction, the CD34+ population was selected with immunomagnetic beads, and 1 x 10(4) progenitors from patients or controls were seeded onto the opposite group of preformed stroma. Stroma-adhesive precursors were scored for the formation of CFU-BI (> 20 cells) on day 5 of culture. Nonadherent selected CD34+ cells were recovered by standardized washing and quantitated in clonogenic assays (CFU-GM). The median patient age was 26 (SD 6.65) years, and eight of 15 patients were female. The median infused bone marrow (BM) MNC number was 0.9 x 10(8)/kg (SD 0.31). Grafts were studied at a median of 37 (SD 48.43) months from transplant. SL from the patients failed to reach confluence by 5 weeks (median dish area covered 55.5% [SD 32.38] vs. control: 100% [SD 2.35]; p = 0.0001). BMT CD34+ progenitors gave 19.5 (SD 42.2) CFU-Bl, significantly lower than those from normal individuals (127 [SD 62.2]; p = 0.01) when panned on control stroma, while control CD34+ cells were poorly supported on BMT layers (corrected for surface, median 2.5 [SD 42.2] CFU-Bl; p = 0.039). Although numbers of stroma nonadherent CFU-GM were not different between the groups (median BMT 56 [SD 54.5] vs. control 62.5 [SD 60.76]; p > 0.05), the ratio of CFU-Bl to CFU-GM showed a significant reduction in adherent CD34+ progenitors in BMT patients (median 0.28 [SD 0.44] vs. normal 2.09 [SD 1.3]; p = 0.04). None of the values were significantly different between patients receiving allogeneic or autologous grafts. We conclude that post-BMT stroma is defective and supports CFU-Bl growth poorly. Moreover, we documented a significant reduction within the CD34+ cells in the adherent primitive clonogenic precursors that was compensated by a proportional increase in the more mature CFU-GM.

Alterations in the progenitor cell population follow recovery from myeloablative therapy and bone marrow transplantation.

In a previous study we showed that following recovery from bone marrow transplantation (BMT), there are persistent derangements in the clonogenic growth of hematopoietic progenitors and in the microenvironment. To characterize the abnormalities within the precursor cell population, selected BM CD34+ cells from 15 patients in remission from hematological malignancies who had received myeloablative therapy and grafts (eight allogeneic and seven autologous) were tested in dose-response studies with recombinant cytokines. Preconditioning for transplantation was accomplished with fractionated total body irradiation (fTBI) at 12 Gy, cyclophosphamide at 120 mg/kg and fractionated total lymphoid irradiation fTLI at 6 Gy. The median mononuclear cell number infused was 0.9 x 10(8)/kg (SD 0.31). At the time of BMT, the patient's median age was 26 (SD 8.65) years and eight were female. Grafts were studied at a median of 37 (SD 48.43) months from transplantation. The light density marrow population from the patients and controls was monocyte- and T-lymphocyte depleted; CD34+ precursors were then selected with immunomagnetic beads (median 90.2 and 92% blasts) and cultured in the progenitor cell assay at a cell density of 5 x 10(3) culture with incremental concentrations of recombinant human growth factors (rhGFs). BMT patients' cultures showed significantly lower colony scores at the lowest cytokine concentrations in both erythroid burst-forming units (BFU-Es) and erythroid colony forming units (CFU-Es) as well as in myeloid lineages; colony forming units-granulocyte macrophage (CFU-GM), and did not improve at the highest GF doses. No significant differences in the results were found between the autologous and allogeneic marrow sources. We conclude that following BMT, lineage restricted progenitors within the CD34+ population are significantly reduced, failing to recover even 8 years after transplantation.

Basic fibroblast growth factor corrects proliferative derangement of bone marrow stroma and CD34(+) population following allogeneic stem cell transplantation.

OBJECTIVE: Following stem cell transplantation (SCT), the integrity of the hematopoietic microenvironment is important for the recovery of bone marrow. We studied the effects of basic fibroblast growth factor (bFGF) on the proliferation of clonogenic progenitors and bone marrow stroma from patients receiving cytokine-mobilized allogeneic stem cell transplants (SCT). MATERIALS AND METHODS: Patient bone marrow mononuclear cells were studied at a minimum of 6 months after transplantation. Control and patient samples were divided into two fractions, one to establish the adherent stroma layers (SL) and the other to select for the progenitor population. SL from normal subjects or from patients were supplemented with 0 (control), 2, or 20 ng/mL bFGF in combination with heparan sulfate, and the resulting area of the dish covered by stroma was quantitated in each group. At 3 weeks of culture, a monocellular suspension was prepared by exposing SL to 0.1% trypsin. Cells then were cultured in the colony-forming unit fibroblast (CFU-F) assay, which was supplemented with 0 (control), 2, or 20 ng/mL bFGF. With the second fraction, CD34(+) cells were selected with paramagnetic beads, and 1 x 10(4) cells were incubated in cross-culture studies on preformed SL from patient or control origin (with or without the addition of bFGF). SL adherent CD34(+) cells were covered with agar and cultured for 6 days. Aggregates of >20 cells were scored as blastic colonies (CFU-bl). RESULTS: At 3 weeks of culture, the median surface area of dishes covered by monoloayers from 13 patients was 40% (range 10-50% vs normal 55%, range 30-60%; p = 0.00006) and improved significantly, matching control values, in dishes supplemented with bFGF. Addition of bFGF to stroma monolayers had no effect on the number of CFU-F in both patient and control samples. Selected CD34(+) cells from patients receiving transplants and cultured on normal stroma gave significantly fewer CFU-bl than control samples (median 36, range 3-121 vs 147, range 10-184; p = 0.006), but colony numbers corrected following exposure to bFGF. Normal CD34(+) cells proliferated poorly on stroma from patients (median CFU-bl 37.5, range 6-84; p = 0.02), but also expanded significantly following bFGF supplementation (104, range 6-117; p = 0.001). CONCLUSIONS: Following SCT, poor SL and CD34(+) proliferation can be corrected by addition of bFGF.

Increased apoptosis of bone marrow cells and preserved proliferative capacity of selected progenitors predict for clinical response to anti-inflammatory therapy in myelodysplastic syndromes.

To determine the relation of apoptosis and clonal proliferation in the bone marrow (BM) to the effectiveness of a therapeutic protocol described to downmodulate monokine activity in patients with myelodysplastic syndromes (MDS). Prior to protocol therapy, BM stroma was cultivated and selected CD34(+) cells were studied in stroma and cytokine-dependent clonogenic assays. The TUNEL assay was used to establish the degree of apoptosis occurring in the marrow and CD34(+) population. The effectiveness of oral ciproloxacin 500 mg b. i.d., pentoxifylline 800 mg t.i.d., and dexamathasone 4 mg t.i.d. (CPD) antiinflammatory therapy was correlated with the intensity of cell apoptosis and proliferation of BM progenitor cells. Seventeen patients were studied. Twelve patients (10 transfusion dependent) received therapy for a median of 99 days (range 49-284). Toxicity caused four patients to discontinue the drug combination. Six patients fulfilled response criteria. Four patients became transfusion independent, and 50% reduction in the need for blood transfusions was noted in one patient. Blood parameters of one untransfused patient increased by >30%. Blood count remained unsupported in three patients, even at a median of 12 months after trial discontinuation. Apoptosis of marrow cells and selected CD34(+) progenitors was detected in a median of 49.5% (range 3. 6%-90%) and 10.6% (range 3.6%-100%; p < 0.01), respectively. In patients who responded to therapy, the median apoptosis rate in the bone marrow population was 71%, in contrast to the nonresponder's rate of 13% (p = 0.002). Overall clonogenic growth of selected precursors corresponded significantly with response to CPD protocol (p = 0.004). In some patients with MDS, ineffective hematopoiesis is related to high apoptotic index despite proliferation of the CD34(+) precursors. These patients seem to benefit from CPD cytokine modulatory therapeutic strategy.

Intravenous gammaglobulin has no advantages over oral corticosteroids as primary therapy for adults with immune thrombocytopenia: a prospective randomized clinical trial.

Symptomatic immune thrombocytopenia in adults is potentially lethal, and, when conventionally treated with oral corticosteroid agents, approximately two thirds of patients will have some response in platelet count, but this is seldom durable. Since cytotoxic drugs are of limited benefit at this stage, splenectomy becomes necessary in 70% of patients. Intravenous gammaglobulin has been advocated as an alternative to prednisone as the primary form of treatment. A prospective, randomized comparison was carried out between oral prednisone (1 mg/kg/day; group 1; n = 17), high-dose intravenous gammaglobulin (400 mg/kg on days 1 through 5; group 2; n = 13), or a combination of both agents given on the same schedule (group 3; n = 13). The groups were well matched clinically and hematologically. No mortality occurred after initiating therapy, but one patient experienced a cerebrovascular accident. Response, defined as a platelet count greater than 50 x 10(9)/L, was achieved in 82%, 54%, and 92% of patients in groups 1, 2, and 3, respectively, but was only significant between groups 2 and 3 (P = 0.0365). The median times to peak platelet counts were 8.5 days (range 7 to 21 days), 7 (range 5 to 10 days), and 7 (range 3 to 23 days), respectively. Although there was a trend in favor of the steroid-administered groups, relapse was not significantly different, which occurred at a median of 184, 32, and 76 days, respectively, nor was the average time to splenectomy different at 339, 59, and 98 days, respectively. At a minimum of 2 years of follow-up, 5 of 17 in group 1, 2 of 13 in group 2, and 1 of 13 in group 3 had achieved platelet counts of greater than 100 x 10(9)/L and, therefore, did not require splenectomy. In contrast, where this indication was present for failure to respond, 8 of 12 (67%) in group 1, 4 of 8 (50%) in group 2, and 9 of 12 (75%) in group 3 remain in complete remission. Significantly more patients in group 2 than group 3 experienced a relapse (P = 0.0365). It is concluded that in previously untreated adults with symptomatic immune thrombocytopenia, gammaglobulin offers no advantage over conventional corticosteroid administration as the primary form of therapy. Additionally, more intense immunosuppression, resulting from the use of both agents combined, is no better than single agent corticosteroid agents and appears to be an unnecessary and unwarranted expense.

Ex vivo depletion of T cells from bone marrow grafts with CAMPATH-1 in acute leukemia: graft-versus-host disease and graft-versus-leukemia effect.

BACKGROUND: Preventing graft-versus-host disease (GVHD) by depletion of T lymphocytes from the stem cell graft for transplantation remains controversial, mainly because of the perceived increase in disease recurrence. METHODS: We retrospectively analyzed the outcome of 50 consecutive individuals in remission of acute lymphoblastic leukemia (n=13; 8 in complete remission [CR]1) or acute myeloblastic leukemia (n=37; 33 in CR1), who had received marrow grafts from HLA-identical siblings. The conditioning regimen included six 2-Gy fractions of total body irradiation, succeeded by cyclophosphamide at 120 mg/kg (with mesna) followed by four fractions of 1.5 Gy to lymphoid areas. Bone marrow (n=38) or peripheral blood mobilized donor mononuclear cells (n=12) were exposed ex vivo to CAMPATH-1 (IgM and complement, or IgG; antiCD52) antibodies, without any further posttransplantation immunosuppression. RESULTS: Median patient age was 31 (range 14-51) years; 12 patients were 40 or older. Thirty-two patients were male. One patient died of pulmonary hemorrhage on day 10; another died on day 29 of interstitial pneumonitis. Except for one early death, all patients engrafted. Ten (21%) of the remaining 48 who were at risk, developed GVHD. In none was it greater than grade II. Eight patients developed serious viral infections. Four died of cytomegalovirus pneumonia, adenovirus hepatitis, and human immunodeficiency. Overall, 11 patients (22%) relapsed (4 of 33 acute myeloblastic leukemia in CR1) at a median of 235 (range 46-528) days. Mean posttransplantation follow-up was 1062 (median 560; range 10-4177) days. Thirty-three patients (66%) remained disease free at a mean of 1,118 (median 1439; range 159-4,177) days. For all patients, the performance status was between 82% and 100% (median 100). CONCLUSION: T-cell depletion with CAMPATH-1 effectively prevents GVHD, particularly the severe acute forms, without leading to excessive risk of relapse in acute leukemia.

Immune reconstitution after allogeneic bone marrow transplantation depleted of T cells.

BACKGROUND: Immune reconstitution following transplantation in individuals who had received T-cell-depleted marrow from HLA identical siblings was serially documented and correlated with the clinical recovery. METHODS: Patients were preconditioned with radiation containing programs. GvHD prophylaxis was by T-cell depletion with CAMPATH 1G (ex vivo; median dose 20 mg). After transplantation lymphoid development was studied by flow cytometry and serum Ig concentrations were determined. Charts were reviewed to determine the effects of the immune reconstitution on the clinical performance. RESULTS: The mean donor mononuclear cell number infused was 0.89x10(8)/kg. Within 6 months all the patients recovered their blood parameters and only one required therapy for GvHD. However, despite normal blood counts, 15 suffered life-threatening opportunistic infections, developing at a median of 24 weeks post grafting, but occurring even after 11 months. At 8 weeks from marrow infusion when leukocyte values had normalized in 15/20, compared to normal, immunophenotyping of blood cells from BMT revealed a significantly reduced mean lymphocyte count (1.06, SD 0.83x10(9)/l; P = 0.01), cells expressing CD3 (0.7x10(9)/l, SD 0.68; P = 0.05), CD4 (0.13x10(9)/l, SD 0.21; P = 0.0001) and CD19 (0.04x10(9)/l, SD 0.05; P = 0.001). Populations expressing CD8 and CD56 remained within normal range throughout the study. Normalization of cell numbers displaying CD2, CD3 and CD19 was delayed until 52, 52 and 24 weeks respectively, while CD4 counts persisted subnormal even at 72 weeks. Serum IgA levels were significantly decreased for the entire study period. CONCLUSIONS: T-cell depletion with CAMPATH 1G while effectively preventing GvHD, also causes clinically significant and prolonged immunosuppression with apparently important clinical implications.

Bone marrow transplantation depleted of T cells followed by repletion with incremental doses of donor lymphocytes for relapsing patients with chronic myeloid leukemia: a therapeutic strategy.

BACKGROUND: For patients with chronic myeloid leukemia (CML), long-term survival after stem cell transplantation requires adequate control of graft-versus-host disease (GVHD) and disease recurrence. Relapsing patients respond to donor lymphocyte infusion (DLI) but develop life-threatening complications. METHODS: Patients with CML in first chronic phase received bone marrow (n = 14) or peripheral blood progenitor cell transplants (n = 4) from HLA-identical siblings. GVHD prophylaxis was by ex vivo T-cell depletion with CAMPATH 1G. If disease recurred, donors' mononuclear cells were collected by apheresis, the CD3 samples commencing at 10(6)/kg were aliquoted at half-log increment intervals, cryopreserved, and infused until disease clearance. RESULTS: Eighteen patients (median age: 32.5 years) received transplants. All engrafted without procedure-related mortality. Fourteen patients relapsed, and 13 entered the DLI program. Two developed extensive GVHD after single schedule infusions ranging from 89x10(6) to 670x10(6) mononuclear cells/kg, and one survives in complete remission (CR). The rest, treated with incremental dose DLI, experienced no acute toxicities. One, who had developed grade III steroid-responsive GVHD, died in CR2 from opportunistic infections. Steroids reversed limited cutaneous GVHD and elevated liver enzymes in five patients. Three others developed pancytopenia, and two restored blood counts only after donor peripheral blood progenitor cell infusions. Molecular CR2 was established in 12/13 patients, occurring in 10/11 (91%) on the incremental program at a median accumulation of 67 (range: 5-166) x10(6) CD3 cells/kg. Sixteen of 18 (89%) survive at median of 854.5 days from bone marrow transplantation, 4 in CR1 and 10 in CR2 at a median disease-free survival (for remission 2) duration of 341 days. The median combined disease-free survival of the 14 patients in CR 1+2 is 660 days, with 99% average performance status. CONCLUSIONS: Escalating DLI leads to safe new molecular CR in most CML relapse patients. These results raise the possibility of using "safe" transplantation programs of T-cell depletion, that include graded DLI as prevention against disease recurrence.

CD52 antibodies for prevention of graft-versus-host disease and graft rejection following transplantation of allogeneic peripheral blood stem cells.

Graft-versus-host disease (GVHD) is a major cause of mortality and morbidity after allogeneic bone marrow transplantation, but can be avoided by removing T lymphocytes from the donor bone marrow. However, T cell depletion increases the risk of graft rejection. In this study, two strategies are used to overcome rejection: (1) use of high doses of stem cells obtained from peripheral blood (PBSC), (2) admixture with a CD52 monoclonal antibody in order to deplete both donor and residual recipient lymphocytes. Two antibodies are compared: CAMPATH-1G (rat IgG2b) and its humanized equivalent CAMPATH-1H (human IgG1). A total of 187 consecutive patients at six centers received PBSC transplants from HLA-matched siblings between 1997 and 1999. A wide spectrum of diseases, both malignant and non-malignant, was included. The recovery of CD34+ cells after antibody treatment was close to 100%. The risk of acute GVHD (grade 2 to 4) was 11% in the CAMPATH-1G group and 4% in the CAMPATH-1H group (P = NS). The risk of chronic GVHD (any grade) was 11% in the CAMPATH-1G group and 24% in the CAMPATH-1H group (P = 0.03) but the risk of extensive chronic GVHD was only 2%. The overall risk of graft failure/rejection was 2%, not significantly different between the two antibodies. Antibody treatment was equally effective at concentrations between 10 microg/ml and 120 microg/ml and it made no significant difference to the outcome whether the patients received post-transplant immunosuppression or not (87% did not). Transplant-related mortality in this heterogenous group of patients (including high-risk and advanced disease) was 22% at 12 months. It is proposed that treatment of peripheral blood stem cells with CAMPATH-1H is a simple and effective method for depleting T cells which may be applicable to both autologous and allogeneic transplants from related or unrelated donors. Special advantages of this approach are the simultaneous depletion of donor B cells (which reduces the risk of EBV-associated lymphoproliferative disease) and the concomitant infusion of CAMPATH-1H to deplete residual recipient T cells and thus prevent graft rejection.

Recommendations for the use of immunoglobulin therapy for immunomodulation and antibody replacement.

Polyvalent immunoglobin, derived from pooled human plasma, can be administered via the intravenous, subcutaneous or intramuscular route. Therapy is standard of care in the treatment of a number of immune-mediated pathologies across disciplines. By volume, the majority is used in neurology (~40%). In primary immunodeficiencies, therapy reconstitutes humoral immunity at replacement doses (0.4 - 0.6 g/kg/month), decreasing infections, and is usually lifelong. However, high doses, usually 2 g/kg total dose over five days, are required for immunomodulation in autoimmune and inflammatory indications. A high-quality evidence base supports use in primary antibody failure, Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, acute idiopathic thrombocytopenia, Kawasaki disease andimmunobullous diseases. Low-quality evidence shows benefit in many other uncommon autoimmune and immunodeficient conditions.In South Africa, use of immunoglobulin therapy is restricted and, given the cost involved, will likely remain so. Therefore, the incremental benefit over other forms of immunosuppression, particularly corticosteroids, must be assessed carefully on a case-by-case basis. In most cases, therapy will be second-line or 'rescue' and motivation will be required. This short review aims to provide clinicians with the necessary understanding of the therapy, general considerations for use, and evidence base and quality thereof for well-established indications.

Recommendations for the management of sickle cell disease in South Africa.

The spectrum of sickle cell disease (SCD) encompasses a heterogeneous group of disorders that include: (I) homozygous SCD (HbSS), also referred to as sickle cell anaemia; (ii) heterozygous SCD (HbAS), also referred to as sickle cell trait; and (iii) compound heterozygous states such as HbSC disease, HbSß thalassaemia, etc. Homozygous or compound heterozygous SCD patients manifest with clinical disease of varying severity that is influenced by biological and environmental factors, whereas subject with sickle cell trait are largely asymptomatic. SCD is characterized by vaso-occlusive episodes that result in tissue ischaemia and pain in the affected region. Repeated infarctive episodes cause organ damage and may eventually lead to organ failure. For effective management, regular follow-up with support from a multidisciplinary healthcare team is necessary. The chronic nature of the disease, the steady increase in patient numbers, and relapsing acute episodes have cost implications that are likely to impact on provincial and national health budgets. Limited resources mandate local management protocols for the purposes of consistency and standardisation, which could also facilitate sharing of resources between centres for maximal utility. These recommendations have been developed for the South African setting, and it is intended to update them regularly to meet new demands and challenges.

In the absence of clinically significant graft vs. host disease, myeloablative conditioning may allow an effective graft vs. leukaemia effect.

In AML, prevention of GvHD leads to better tolerance of myeloablative therapy. 66 individuals with AML in CR underwent myeloablative conditioning and transplantation with allogeneic PBPC grafts. Median presentation age was 44.5 years. Karyotyping was intermediate in 48% and of unfavourable risk in 36%. For GvHD prophylaxis, PBPC harvests were incubated ex vivo with anti CD52 antibodies. TRM at day 100 and 1 year was 9% and 17%. At a median of 1018 days 65% are alive. Grade >1 GvHD was seen in 11%. GvHD and adverse karyotype were associated with treatment failure. In younger patients preservation of the dose intensity may improve cure rates.

The diagnostic utility of bone marrow biopsies performed for the investigation of fever and/or cytopenias in HIV-infected adults at Groote Schuur Hospital, Western Cape, South Africa.

INTRODUCTION: A bone marrow biopsy is frequently requested in the work-up of patients with human immunodeficiency virus (HIV) infection who present with fever and/or cytopenias in the search for opportunistic infections and malignancies. METHODS: This is a retrospective review of the results of consecutive bone marrow biopsies performed at our institution over a three-year period on HIV-positive patients for the investigation of fever and/or cytopenias. Clinical data, haematological parameters, morphological features, Ziehl-Neelsen staining and microbiological culture results were analysed. The aim of the study was to determine the diagnostic yield of this investigation. RESULTS: Sixty-three males and 84 female patients were included for analysis. The bone marrow biopsy gave a high diagnostic yield of 47% (70 patients) and a unique diagnosis in 33% (49 patients). Immune thrombocytopenic purpura and disseminated mycobacterial infections were the most common unique diagnoses made (14%, respectively), followed by malignancies (4%). In this cohort, four cases of primary bone marrow involvement by Hodgkin lymphoma and one case of involvement by non-Hodgkin lymphoma were diagnosed. CONCLUSION: In our study group, a bone marrow biopsy was a useful investigation with a high diagnostic yield.

Recommendations for the management of adult chronic myeloid leukaemia in South Africa.

INTRODUCTION: Chronic myeloid leukaemia (CML) is a chronic myeloproliferative disorder characterised by a chromosomal translocation between the long arms of chromosomes 9 and 22 [corrected] resulting in the formation of the BCR-ABL fusion gene. The management of CML has undergone major changes over the past decade. Novel treatment approaches have had a dramatic impact on patient outcomes and survival. Nevertheless, these outcomes can only be achieved in the context of expert management, careful monitoring of disease response, appropriate management of adverse events and timeous adjustments to therapy when responses are not achieved within stated time-frames. AIM: With the advent of novel treatments providing molecular responses, both the monitoring and management of CML have become more complicated. The aim of these recommendations was to provide a pragmatic yet comprehensive roadmap to negotiate these complexities. METHODS: Recommendations were developed based on local expert opinion from both the academic and private medical care arenas after careful review of the relevant literature and taking into account the most widely used international guidelines. About five meetings were held at which these recommendations were discussed and debated in detail. RESULTS: A comprehensive set of recommendations was compiled with an emphasis on diagnosis, investigation, treatment and monitoring of disease. Careful attention was given to circumstances unique to South Africa, funding constraints, availability and access to laboratory resources, as well as the effects of concurrent HIV infection. CONCLUSION: Most patients with CML can live a reasonably normal life if their disease is appropriately managed. These recommendations should be of value to all specialists involved in the treatment of haematological disorders.