Dose-adapted post-transplant cyclophosphamide for HLA-haploidentical transplantation in Fanconi anemia.

We developed a haploidentical transplantation protocol with post-transplant cyclophosphamide (CY) for in vivo T-cell depletion (TCD) using a novel adapted-dosing schedule (25 mg/kg on days +3 and +4) for Fanconi anemia (FA). With median follow-up of 3 years (range, 37 days to 6.2 years), all six patients engrafted. Two patients with multiple pre-transplant comorbidities died, one from sepsis and one from sepsis with associated chronic GVHD. Four patients without preexisting comorbidities and early transplant referrals are alive with 100% donor chimerism and excellent performance status. We conclude that adjusted-dosing post-transplant CY is effective in in vivo TCD to promote full donor engraftment in patients with FA.

Marrow grafts from HLA-identical siblings for severe aplastic anemia: does limiting the number of transplanted marrow cells reduce the risk of chronic GvHD?

A total of 21 patients with severe aplastic anemia (SAA) underwent marrow transplantation from HLA-identical siblings following a standard conditioning regimen with cyclophosphamide (50 mg/kg/day × 4 days) and horse antithymocyte globulin (30 mg/kg/day × 3 days). Post-grafting immunosuppression consisted of a short course of methotrexate (MTX) combined with cyclosporine (CSP). The transplant protocol tested the hypothesis that the incidence of chronic GvHD could be reduced by limiting the marrow grafts to ⩽2.5 × 108 nucleated marrow cells/kg. None of the patients rejected the graft, all had sustained engraftment and all are surviving at a median of 4 (range 1-8) years after transplantation. Chronic GvHD developed in 16% of patients given ⩽2.5 × 108 nucleated marrow cells/kg. Post-grafting immunosuppression has been discontinued in 20 of the 21 patients. In conclusion, limiting the number of transplanted marrow cells may have resulted in minimal improvement in the incidence and severity of chronic GvHD.

Cytomegalovirus infection and ganciclovir resistance caused by UL97 mutations in pediatric transplant recipients.

BACKGROUND: Cytomegalovirus (CMV) infection may cause serious disease after hematopoietic cell transplantation (HCT) and solid organ transplantation (SOT), but few reports describe ganciclovir (GCV) resistance in pediatric patients. OBJECTIVES: This study was performed to describe the clinical impact of CMV infection with UL97 mutation in pediatric transplant recipients. METHODS: Quantitative surveillance data for CMV infection in pediatric patients between October 2001 and February 2007 at the University of Washington were analyzed. Testing for UL97 mutation was performed in selected patients with prolonged CMV viremia despite therapy. Data associated with the detection of UL97 mutations were reviewed. RESULTS: CMV was detected in 89 pediatric transplant recipients. Among these, 39 had undergone HCT and 50 SOT (12 heart, 22 kidney, 15 liver, and 1 bilateral lung transplants). CMV with at least one UL97 sequence variation was detected in 5 patients: 4 HCT recipients (4/39, 10%) and 1 heart transplant recipient (1/50, 2%). All 5 pediatric patients were CMV seropositive before transplantation. Underlying conditions included chronic myelogenous leukemia, primary immunodeficiency disorders, and hypoplastic left heart syndrome. One known GCV drug-resistant mutation was detected in 2 HCT recipients (A594V). Three strain variants with mutations considered to have no significant impact on UL97 function (H469Y, N510S, and D605E) were detected. Two of these 5 patients died, 1 because of uncontrolled CMV infection and 1 with other complications. CONCLUSIONS: UL97 drug-resistant mutations occur in pediatric transplant recipients with CMV viremia and can cause serious disease. Screening for mutations conferring resistance to CMV antivirals should be considered for patients with persistent viremia during therapy and the sequences of UL97 mutations evaluated.

Intensive postgrafting immune suppression combined with nonmyeloablative conditioning for transplantation of HLA-identical hematopoietic cell grafts: results of a pilot study for treatment of primary immunodeficiency disorders.

This study was designed to determine the safety of a nonmyeloablative regimen in patients with primary immunodeficiency disorders (PID) who had infections, organ dysfunction or other risk factors that precluded conventional hematopoietic cell (HC) transplant. Fourteen patients received HLA-matched related (n=6) or unrelated (n=8) HC grafts from marrow (n=8), peripheral blood mononuclear cells (n=5) or umbilical cord blood (n=1), either without conditioning (n=1), or after 200 cGy total body irradiation alone (n=3) or with 90 mg/m2 fludarabine (n=10). All patients were given postgrafting immunosuppression with mycophenolate mofetil and cyclosporine. Mixed (n=5) or full (n=8) donor chimerism was established in 13 patients, and one patient rejected the graft. Eight patients developed acute grade III (n=1) and/or extensive chronic GVHD (n=8). With a median follow-up of 4.9 (range, 0.7-8.1) years, the 3-year overall survival, event-free survival and transplant-related mortality were 62, 62 and 23%, respectively. Correction of immune dysfunction was documented in 8 of 10 patients with stable donor engraftment. These preliminary results indicated that this approach was associated with stable donor engraftment and a low incidence of early mortality and, thus, can be considered for certain high-risk patients with PID. However, there was a risk of GVHD, which is an undesirable outcome for this group of patients.

Purification and characterization of an Ah receptor binding factor in chromatin.

Dioxin induces biological responses through interaction with a specific intracellular receptor, the Ah receptor, and the subsequent interaction of the Ah receptor with chromatin. We previously reported the binding of the Ah receptor, partially purified form rabbit liver, to receptor binding factors (termed AhRBFs) in chromatin. Rabbit liver chromatin proteins (CP) were isolated by absorption of chromatin to hydroxylapatite followed by sequential extraction with 3 M NaCl and 1-8 M guanidine hydrochloride (GdnHCl). In the present study, we continued the purification of the CP5 fraction, which exhibited AhRBF activity. The proteins in CP5 were separated by CL-Sepharose 6B column chromatography resolving lower molecular weight fractions. To assay for receptor binding, a portion of each Cl-Sepharose 6B fraction was reconstituted to rabbit double-stranded DNA (dsDNA) using a reverse gradient dialysis of 7.5 to 0.0 M GdnHCl. These reconstituted chromatins were then examined for binding to [3H]-2,3,7,8-tetrachlorodibenzo-p-dioxin ([3H]TCDD)-receptor complexes by the streptomycin filter binding assay. Two protein fractions with a molecular weight in the range of 10,000-14,000 demonstrated high affinity binding to the Ah receptor. The binding of AhRBFs reconstituted to dsDNA was shown, by competition experiments with Ah receptor bound by unlabeled TCDD (TCDD-R), to be > 90% specific for [3H]TCDD-R. Further purification was achieved by preparative ADS-PAGE, and AhRBF activity was attributed to two fractions with molecular weights between 12,000 and 10,000. A kDa protein with AhRBF activity was found to have an isoelectric point (pI) of > or = 10. The 12 kDa AhRBF was sequenced by Edman degradation after cyanogen bromide cleavage and identified as histone H4. Although histone H4 has been postulated to interact with transcription factors in a variety of systems, this is the first report of a specific interaction of AhR with histone H4.

Neuropeptide Y in hamster limbic nuclei: lack of colocalization with substance P.

The medial nucleus of the amygdala (Me), bed nucleus of the stria terminalis (BNST), and medial preoptic area (MPOA) regulate copulation in the male hamster. The present study identified neuropeptide Y-immunoreactive (NPY-IR) neurons in the BNST and Me with the greatest concentration in the posteromedial and posteriordorsal subdivisions of these nuclei, respectively. NPY-IR filters are found in all three nuclei with dense plexi of NPY-IR varicosities in the most medial subdivisions. Substance P neurons are also densely concentrated in the posterior BNST and Me; however, no neurons contained both peptides. Thus, NPY and substance P neurons comprise two distinct populations within the BNST and Me of the hamster.

The role of dietary fiber in satiety, glucose, and insulin: studies with fruit and fruit juice.

Healthy volunteers ingested sugar-equivalent meals of oranges and orange juice and of grapes and grape juice. Satiety, assessed by two subjective scoring systems, was greater after whole fruit than after juice and the return of appetite was delayed. With oranges, as previously reported with apples, there was a significantly smaller insulin response to fruit than to juice and less postabsorptive fall in plasma glucose. With grapes, the insulin response to the whole fruit was, paradoxically, more than that to the juice, while postabsorptive glucose values were similar. The glucose in grapes appeared to be more insulinogenic than that in oranges and apples. Conversely, grape juice evoked less insulin than expected, possibly because its high osmolality delayed gastric emptying. However, diluting it did not increase its insulinogenicity. The plasma insulin and glucose responses to fruit appear to depend on the fiber as well as the glucose content of the fruit.

Depletion and disruption of dietary fibre. Effects on satiety, plasma-glucose, and serum-insulin.

Ten normal subjects ingested test meals based on apples, each containing 60 g available carbohydrate. Fibre-free juice could be consumed eleven times faster than intact apples and four times faster than fibre-disrupted purée. Satiety was assessed numerically. With the rate of ingestion equalised, juice was significantly less satisfying than purée, and purée than apples. Plasma-glucose rose to similar levels after all three meals. However, there was a striking rebound fall after juice, and to a lesser extent after purée, which was not seen after apples. Serum-insulin rose to higher levels after juice and purée than after apples. The removal of fibre from food, and also its physical disruption, can result in faster and easier ingestion, decreased satiety, and disturbed glucose homoeostasis which is probably due to inappropriate insulin release. These effects favour overnutrition and, if often repeated, might lead to diabetes mellitus.

Stability of patulin to sulfur dioxide and to yeast fermentation.

The affinity of patulin for sulfur dioxide (SO2) is much less than was previously reported and is of little significance at the SO2 concentrations (below 200 ppm) used in the processing of apple juice and cider. However, at concentrations of 2000 ppm SO2 and 15 ppm patulin, combination was 90% complete in 2 days. Removal of SO2 liberated only part of the patulin, which suggests that 2 mechanisms are involved: one reversible (opening the hemiacetal ring) and one irreversible (SO2 addition at the double bond). Test with 2 yeasts used in English commercial cider making confirmed that patulin is effectively removed during yeast fermentation.