Experience with a cooperative bone marrow transplantation program in Stockholm.

Twenty-seven patients (age range from 1 to 55 years) were included in a cooperative bone marrow transplantation program in Stockholm. Of eight patients with severe aplastic anemia (SAA), two died following graft rejection and six (75%) are alive between 3 months and 4 1/2 years after transplantation. Two patients with end stage leukemia died of septicemia and bleeding shortly after transplantation. Thirteen of 17 patients (76%) with acute leukemia in their first or second remission are alive 1 to 16 months after transplantation. Death was caused by septicemia in two patients, interstitial Candida pneumonitis in one and gastrointestinal bleeding in association with graft-versus-host disease in one. Among the leukemic patients all deaths occurred in subjects over 17 years of age and all 10 children are alive. No relapse has yet been seen. Successful bone marrow transplantations were carried out utilizing ordinary hospital resources only. This justifies the practice of performing transplantations in subjects with SAA and acute leukemia in remission even outside specially equipped and designed bone marrow transplantation units.

Prevention of graft-versus-host disease with T cell depletion or cyclosporin and methotrexate. A randomized trial in adult leukemic marrow recipients.

In adult leukemic marrow recipients of HLA identical sibling marrow, 23 patients were randomized to T cell depletion and 25 received cyclosporin (CSA) and four doses of methotrexate (MTX) to prevent graft-versus-host disease (GVHD). Anti-CD8 and anti-CD6 antibodies plus complement depleted 95.3 +/- 5.8% (mean +/- SE) CD3 cells. All patients engrafted except one who died early. Patients receiving T cell-depleted marrow had a faster time to 0.2 x 10(9) WBC/l (p less than 0.001), but required more erythrocyte units (p = 0.03). Platelet transfusions, infections and time in hospital did not differ. The incidence of grade II-III acute GVHD was 23% following T cell depletion and 12% for those receiving CSA + MTX. Chronic GVHD occurred in 51% and 23% in the two groups, respectively (p = 0.06). Recipients of T cell-depleted marrow who developed grade I-III acute GVHD received more T cells compared to those without acute GVHD (p = 0.02). The major cause of death in both groups was relapse, the cumulative incidence of which, at 4 years, was 39% in the recipients of T cell-depleted marrow and 54% in the CSA + MTX group. The 3-year actuarial leukemia-free survival was 42% and 44% in the two respective groups.

Failure to prevent cytomegalovirus infection by cytomegalovirus hyperimmune plasma: a randomized trial by the Nordic Bone Marrow Transplantation Group.

Bone marrow transplantation recipients who were cytomegalovirus (CMV) seropositive and/or had a CMV seropositive donor were randomized for treatment with CMV hyperimmune plasma (n = 27) or no treatment at all (n = 27). The CMV hyperimmune plasma had neutralization titers greater than 250 and enzyme-linked immunosorbent assay titers greater than 18,000. Plasma (200 mg/kg body weight) was given on four occasions (during 2 days) from day 3 to day 76 after transplantation. Patient characteristics were similar in the two groups. After transplantation, the median CMV titers increased with greater than 100% in the group receiving the CMV plasma and decreased to less than 50% in the controls (p less than 0.01). Asymptomatic CMV infections occurred in 26% of the patients in the plasma group and 33% of the controls. The frequency of patients with symptomatic CMV infections was also the same in the two groups (51% vs 33%). Three patients each in the two groups developed CMV-associated interstitial pneumonitis. Patient survival and causes of death were similar in the two groups. To conclude, no beneficial effect of CMV hyperimmune plasma was seen in patients at high risk of developing CMV infections.

Effect of long-term anemia and retransfusion on central circulation during exercise.

The purpose of this study was to evaluate the effect of long-term anemia and subsequent retransfusion of erythrocytes on various circulatory parameters. Anemia was induced in nine healthy male subjects by repeated venesections. The stored blood was retransfused after 9 wk (range 8-11 wk). Exercise tests were performed before venesection in the control state (C), in the anemic state (A), and 48 h after retransfusion (R). Hemoglobin concentration levels were 146 +/- 10 g/l in C, 110 +/- 7 g/l in A, and 145 +/- 9 g/l in R. Maximal O2 uptake was 4.55 +/- 0.6, 3.74 +/- 0.7, and 4.45 +/- 0.6 l/min in C, A, and R, respectively. A decrease in heart rate of 7 beats/min (P less than 0.01) and in cardiac output of 2 l/min (P less than 0.05) at maximal exercise occurred in the anemic state compared with control values. These decreases were not reversed but, rather, were further accentuated after retransfusion. The adaptive response to submaximal exercise (cycling at 150-175 W) in anemia was mediated to the amount of 50% by an increase in cardiac output (mainly an increase in heart rate) and 50% was due to increased O2 extraction in the peripheral tissue. In conclusion, long-term anemia was found to decrease the heart rate and cardiac output at maximal exercise. Furthermore the close correlation between hemoglobin concentration and maximal O2 uptake in humans is confirmed.

Sensitive analytic ELISAs for subclass herpes virus IgG.

The subclass distribution of antiviral antibodies to three herpes viruses was studied in a population of healthy blood donors. Subclassification by monoclonal antibodies led to the identification of certain viral IgG patterns. IgG1 appeared to be formed in response to almost all CMV, HSV-1 and VZV infections. A higher frequency of virus-specific IgG3 to CMV and HSV-1 suggested that these infections may be reactivated subclinically more often than VZV. The presence of CMV and VZV IgG4 showed a familial relationship, while IgG4 responses to HSV-1 were common. Persons with IgG4 as the only subclass-reactive antibody to CMV showed cell-related reactivities in a high frequency. Patients with leukemias, myelomas and Crohn's disease had a near-normal subclass pattern to the herpes viruses.

Effects of blood transfusions on some hematological variables in endurance athletes.

Selected hematological variables (blood hemoglobin concentration [Hb], serum (s-) iron, s-bilirubin, s-ferritin, blood lactate, and s-erythropoietin [Epo]) were analyzed before and for 4 wk after autologous blood transfusions. A group of well-trained (8 male and 4 female) former endurance athletes was phlebotomized and 3-4 months later reinfused with the freezer-stored autologous red blood cells (RBC) from 1350 ml of blood. The [Hb] increased significantly (P less than 0.001 for both sexes) from 146.7 +/- 5.31 and 131.7 +/- 11.20 g. l-1 immediately before reinfusion to maximum values of 163.5 +/- 7.47 and 155.9 +/- 11.43 g.l-1 (mean +/- SD) in males and females, respectively, 2 d after reinfusion. S-iron increased transiently 5 h after reinfusion. S-bilirubin remained unchanged throughout the study. S-ferritin increased gradually (P less than 0.02) from 48 +/- 32.91 mmol.l-1 before reinfusion to a maximum of 80.8 +/- 39.52 mmol.l-1 2 wk after reinfusion. S-[Epo] increased transiently (P less than 0.01) from 8.83 +/- 2.51 (mean +/- SD) to 12.36 +/- 5.64 U.l-1, (mean +/- SD) 5 h after reinfusion. Subsequently, there was a significant marked decrease in s-[Epo] to 5.85 +/- 1.32 U.l-1, (mean +/- SD) 1 d after reinfusion (P less than 000.1, as compared to before reinfusion). Thereafter, s-[Epo] remained low throughout the study. Blood lactate was significantly decreased only the first 2 d after reinfusion (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of iron deficiency on endurance and muscle enzyme activity in man.

The purpose of the present study was to evaluate the effects of iron deficiency on enzyme activities and endurance. Iron deficiency was induced in 9 healthy male subjects by repeated venesections. After a period of 9 wk (range, 8-11 wk) when the subjects had become iron deficient as defined by laboratory parameters, blood was retransfused to reestablish the control hemoglobin concentration. In this state it was possible to evaluate the effect of iron deficiency isolated from anemia. In samples secured by muscle biopsies, glycolytic, oxidative, and iron depending enzymes were analyzed in the control (C) and anemic (A) states and after retransfusion (R). There were no significant changes in the maximal activities of any of the enzymes studied. The capillary/fiber ratio remained unchanged between C (1.92) and R (1.94). Times to exhaustion on treadmill tests were 49 min, 11 s in C, 26 min, 33 s in A, and 52 min, 3 s in R. Vo2max was 4.55 1 X min-1 in C, 3.74 1 X min-1 in A, and 4.45 1 X min-1 in R. An artificially induced iron deficiency defined by conventional laboratory parameters did not affect endurance when transfusion of red blood cells was performed in order to exclude the influence of a low hemoglobin concentration. A 4-wk period of severely depleted or absent tissue iron stores did not affect the maximal activities of various enzymes in human skeletal muscle.

Isolation and characterization of autologous blood mononuclear cells used for auto-infusion together with monoclonal antibodies in tumor treatment.

CO17-1A is a tumor associated antigen on colorectal carcinoma cells. A mouse monoclonal antibody of subclass IgG2A (MAb 17-1A) has been previously produced against the antigen for therapy. In a phase II study in patients with metastasizing colorectal carcinomas, leukapheresis was performed and isolated cells armed in vitro with MAb 17-1A. The mixture of MAb 17-1A and cells were infused into the patients. The aim of this procedure was to increase the number of cytotoxic cells in the tumor lesion. Two cell purification techniques (A and B) using an IBM 2991 Blood Cell Processor are described. Procedure B gave the highest yield of mononuclear cells (7.52 x 10(9) vs 5.17 x 10(9), p less than 0.01) as well as significantly higher total numbers of monocytes and NK cells. The relative ADCC activity of the two cell isolates were similar. A positive correlation between the frequency of Leu-M5+ cells (monocytes) and 51Cr release was observed. Increasing amounts of OKM1+ (CD11) cells suppressed ADCC. 35-40% of the cells bound MAb 17-1A after 1h incubation at room temperature. There was no substantial increase in cells binding MAb 17-1A upon further incubation. A strong positive correlation between the numbers of monocytes and cells binding MAb 17-1A was seen but also B lymphocytes, T lymphocytes and NK cells bound MAb 17-1A. More than 97% of the added MAb was unbound.

Bone marrow transplantation for aplastic anemia and acute leukemia at Huddinge Hospital.

Eight patients with aplastic anemia were transplanted with marrow from HLA-identical donors. Two patient rejected their grafts and died while 5 patients (71%) show no ill effects 3 months, 10 months, and more than 1, 2 and 4 years after the transplantation. Three of the patients who received unirradiated donor buffy coat after transplantation developed chronic graft-versus-host disease (GVHD) which, however, resolved following treatment with Prednisolone and Azathioprine. One patient with end-stage acute myeloid leukemia, who was transplanted with marrow from an identical twin, died 6 days after the transplantation of bleedings and sepsis. Eight patients with acute non-lymphoblastic leukemia (ANL) were transplanted, while in remission, with marrow from HLA-identical siblings. One patient died of interstitial pneumonia 3 months after transplantation, while another patient recovered from GVHD of the gut at 5 months after the transplantation. Seven out of 8 patients with ANL (88%) are home and well between 2 and 12 months after the transplantation.

Plasma exchange and moderate dose of cytostatics in advanced macro(cryo)globulinemia. A report on three cases.

Three cases of advanced macroglobulinemia (two with severe cryoglobulinemia) have been treated for 6, 4 and 3 years, respectively, with regular plasma exchange and, during the last two years, also with short courses of cytostatics. The plasma exchange regimen has given the patients a marked relief from hyperviscosity symptoms and may have contributed to the improved peripheral blood values and lowered P-IgM levels. Addition of cytostatics, however, was necessary to obtain a lasting remission.

Freezing of plasma and recovery of factor VIII.

The freezing procedure and its influence on the plasma quality was studied with a new plasma container and freezing bath and compared with the results from those obtained with commonly used equipment. Cryoprecipitation was performed on plasma pools frozen at three different rates, and quality and recovery of the cryoprecipitates were determined by analysis of factor VIII, factor VIII-related antigen (vWF:Ag), and fibrinogen. The plasma freezing time was 95 and 65 percent shorter with a new -40 degrees C freezing bath as compared to -25 and -80 degrees C freezing boxes, respectively. A further 30 percent reduction of the plasma freezing time was gained by the introduction of a new flat 750-ml plasma container. Rapid plasma freezing prevented substantial loss of factor VIII in frozen plasma. Cryoprecipitate purity measured as factor VIII-to-fibrinogen ratio increased from 0.50 to 0.82 (IU/mg) when the freezing time was decreased from 10 hours to 45 minutes, although the recovery of factor VIII increased less. In summary, freezing of plasma in small flat containers in an effective ethanol bath resulted in rapid freezing with high recovery of factor VIII in plasma, and increased purity and recovery of subsequently processed cryoprecipitate. This freezing concept, adapted at Swedish blood banks, has contributed to higher source plasma quality and increased self-sufficiency.

Effects of anaemia and stepwise-induced polycythaemia on maximal aerobic power in individuals with high and low haemoglobin concentrations.

Increasing the haemoglobin concentration ([Hb]) improves the oxygen transport capacity but it also increases the viscosity of the blood. The influence of changes in [Hb] and viscosity on submaximal exercise capacity and maximal aerobic power was investigated in eight healthy males in varying states of training and with a normal resting [Hb] ([Hb]r), ranging from 123 to 178 g l-1. The subjects were venesected five times (450 ml per unit) and exercise tests were performed in the anaemic state. After 5-7 weeks, when [Hb] had returned to the 'normal' value, a stepwise re-transfusion of three to five units of blood was performed with exercise tests after each transfusion. The [Hb]r was 137 +/- 15 g l-1 in the anaemic state (A) and 170 +/- 16 g l-1 after the last re-transfusion (LT). The VO2max rose from 3.94 +/- 0.35 in A to 4.68 +/- 0.30 l min-1 after LT. Individual regression lines for [Hb] and VO2max revealed a mean increase in VO2max of 19 +/- 6 ml min-1 per g l-1 change in [Hb]. This value did not differ between individuals with high and low normal [Hb]. Furthermore, in intra-individual comparisons the relationship between [Hb] and VO2max in high and low individual [Hb] ranges was not found to be statistically different despite a 40% increase in the in vitro viscosity from the anaemic to the polycythaemic state.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood transfusion in marrow graft recipients.

Of 182 consecutive patients undergoing allogeneic bone marrow transplantation (BMT), the relative numbers of those who received red blood cells (RBC), platelets (PLT), and granulocytes were 82%, 96%, and 26%, respectively. The transfused patients received an average of 1.26 (SD +/- 2.0) RBC units, 9.41 (SD +/- 13.2) PLT transfusions, and 0.33 (SD +/- 1.1) granulocyte concentrates per week per 50 kg body wt. in the period starting on the day of bone marrow transplantation (BMT) up to 60 days post BMT. The total number of units per transfused patient was 7.7 (range 1-63) RBC, 55.2 (range 2-394) PLT and 6.2 (range 1-36) granulocytes in the same period. Patients with grades II-IV acute graft-versus-host disease (GVHD) needed more RBC and PLT (p less than 0.001) than patients with grades 0-I acute GVHD. Patients with late engraftment required more granulocyte and PLT transfusion than those with early engraftment (p less than 0.05). Patients with high-risk malignancy had greater need for RBC and PLT than "low-risk patients" (p less than 0.02 and p less than 0.01), respectively). Patients with major ABO-incompatible donors showed a greater need for RBC than patients with minor ABO incompatibility (p = 0.02) or ABO identical donors (p = 0.01). Patients with relatively poor estimated survival required the most RBC and PLT.

Simplified long term large scale production of highly active human LAK cells for therapy.

Cells obtained by leukapheresis and separated without or with a Ficoll-Isopaque (FIP) gradient were cultured for 4 or 20 days to determine whether a more effective LAK cell population could be obtained compared to LAK cells generated by the commonly used method (FIP separated cells cultured for 4 days). After leukapheresis the cells were separated on a FIP gradient (FIP cells) or only washed to minimize platelet contamination (non-FIP cells). In some experiments, the cells were also pretreated with phenylalanine-methylester (PheOMe) to reduce monocytes. After culturing for 20 days in the presence of IL-2 (100 BRMP U ml-1) a significantly higher total number of CD3+ and CD56+ cells was noted in the non-FIP fraction compared to the FIP fraction. The total lytic activity of non-FIP cells (LU/tot. no. of cells) against Daudi targets after 4 days of culture was 11,820 +/- 624 versus 4770 +/- 550 of FIP cells (P less than 0.05). After 20 days of culture the non-FIP fraction exhibited a higher cytotoxic activity than the FIP cell fraction, 76,291 +/- 20,053 compared to 7169 +/- 1148 LU (P less than 0.05). Pretreatment of the cells with PheOMe induced a significantly more effective cytotoxic population when cultured for 4 days. However, at 20 days PheOMe did not enhance the LAK cell activity. Large scale production of LAK cells can be accomplished without FIP separation with an increased cell yield and cytotoxicity compared to FIP separated cells both in short and long time cultures.

Induction of immunoglobulin secretion and DNA synthesis in human lymphocytes in vitro by cytomegalovirus preparations.

Immunoglobulin secretion as evidenced by plaque-forming cells (PFC) in an indirect haemolysis-in-gel assay, and DNA synthesis were induced in human blood lymphocytes by the following preparations of cytomegalovirus (CMV): Nucleocapside Nc-CMV antigen, membrane M-CMV antigen, crude C-CMV preparations and CMV-incubated adherent cells. Peak stimulations occurred around day 6 in culture. Nc-CMV and M-CMV only stimulated PFC and DNA synthesis in lymphocytes from CMV seropositive individuals. C-CMV also stimulated lymphocytes from CMV seronegative individuals but gave better responses in lymphocytes from CMV seropositive individuals. CMV-incubated adherent cells occasionally stimulated lymphocytes from CMV seronegative individuals but always in CMV seropositive blood donors. Nc-, M-, and C-CMV gave high numbers of PFC in B cells enriched by sheep erythrocyte sedimentation and in co-cultures of enriched T and B cells. Almost no PFC were induced in enriched T cells. DNA synthesis induced by all the three antigenic CMV preparations increased after removal of adherent cells. Strong DNA synthesis was induced in enriched T cells compared to almost none in enriched B cells. It is concluded that some pure CMV preparations act as antigens and more crude preparations induce polyclonal activation. Different CMV preparations may be used to diagnose CMV, to study immune reactivity against CMV and as a model for CMV infections in vitro.

Tumour imaging of indium-111 oxine-labelled autologous lymphocytes as a staging method in Hodgkin's disease.

Following indium-111 oxine-labelled autologous lymphocyte infusion, 39 lymphocyte scintigraphies were performed in 35 patients with Hodgkin's disease (HD). Lymphocytes were obtained after leukapheresis and Lymphoprep gradient centrifugation and were further purified by an adherence step to eliminate monocytes. A median of 1.2 (0.2-3.7) X 10(9) cells were labelled with 6.7 (range 1.9-16.6) Mbq indium-111 oxine and reinfused to the patients. Gamma camera imaging was performed with a GE 400 AT. An accumulation of radioactivity was seen at 54 of 61 sites with enlarged lymph nodes. Increased radioactivity was also seen at 16 sites with no previous clinical evidence of tumour involvement. These data seem very promising and with further methodological improvement lymphoscintigraphy may prove to be an important complement in the staging procedure and follow-up of patients with HD.

Beneficial effects of plasma exchange in acute inflammatory polyradiculoneuropathy.

The results of a controlled trial in which 38 patients with severe acute inflammatory polyradiculoneuropathy took part indicate that plasma exchange favourably influenced the course of the disease. Significant benefits were seen in time until onset of improvement, course of muscular weakness, improvement in disability grades over the first 2 months, and working capacity after 1 month. Cost-benefit analysis showed that the exchange treatment resulted in net financial savings. The results suggest that plasma exchange may have a role in the treatment of severe acute inflammatory polyradiculoneuropathy.