Haematopoietic cell transplantation with non-myeloablative conditioning in Denmark: disease-specific outcome, complications and hospitalization requirements of the first 100 transplants.

We analysed the outcome and hospitalization requirements of the first 100 patients (Hodgkin's disease (HD), N=13; multiple myeloma (MM), N=14; CLL, N=12; non-Hodgkin's lymphoma (NHL), N=17; myelodysplastic syndrome (MDS), N=18; AML, N=24 and CML, N=2) treated in Denmark with haematopoietic cell transplantation after non-myeloablative conditioning with TBI 2 Gy+/-fludarabine. The cumulative incidence of acute GVHD grade II-IV and extensive chronic GVHD was 67 and 49%. After a median follow-up of 534 days, the overall survival, PFS, relapse-related mortality and treatment-related mortality were 59, 50, 25 and 17%, respectively. Patients with CLL, NHL, AML and MDS with <5% blasts at any time had a favourable outcome with a PFS of 61-71%. Patients with MM, HD and MDS and a history of > or =5% blasts had a less favourable outcome with a PFS of 19-38% (P=0.001). The cumulative incidence of discontinuation of immunosuppression was 37%. During the first and second year post transplant, patients experienced a mean of 41 and 13 outpatient clinic visits, and 53 and 16 days of hospitalization. Sixteen patients were admitted to the intensive care unit, of whom eight are still alive. In conclusion, transplantation outcomes were encouraging, but complications requiring admission and outpatient clinic visits occur frequently post transplant.

Transfusion-related inhibition of cytokines (TRICK). Experimental transfer of neutralizing autoantibodies to interleukin-6 by plasma transfusions.

BACKGROUND: For some unknown reason humans may 'spontaneously' produce high amounts of neutralizing autoantibodies to a number of growth factors and cytokines. Reaching a certain high level the antibodies render the person cytokine deficient, mostly without overt clinical manifestations. The autoantibodies in question are detectable in normal immunoglobulin preparations and correspondingly in normal human plasma for transfusion. High affinity neutralizing autoantibodies to interleukin-6 (aAb-IL-6) are present in high titres in 0.1% of plasma from blood donors. Using aAb-IL-6 as a model we here report the first study addressing transfer of cytokine autoantibodies with blood components. MATERIALS AND METHODS: We transferred high amounts of aAb-IL-6 to two patients suffering from end-stage disease of multiple myeloma. This was done by serial transfusions with normal human plasma highly positive for aAb-IL-6. We assessed recovery and kinetics of the transferred aAb-IL-6 and exposed how the recipients' plasma IL-6 bound to aAb-IL-6. RESULTS: Free IL-6 was detectable in plasma of the recipients before transfusion. After the first transfusion IL-6 became immune complexed to aAb-IL-6 the molar plasma concentrations of which exceeded total IL-6 at least 500 times. CONCLUSION: The observations signify that high amounts of neutralizing autoantibodies to cytokines (in this context aAb-IL-6) are occasionally transferred by transfusion. Although neither beneficial nor obvious detrimental effects of the plasmas were observed in this study our measurements evidently uncover a hitherto unknown form of transfusion-related immune modulation: transfusion-related inhibition of cytokines (TRICK). Depending on the cytokine autoantibody in question, the phenomenon might affect immune responses to infection and recovery after stem cell transplantation.

Pluripotent and myeloid-committed CD34+ subsets in hematopoietic stem cell allografts.

The present study compared the contents of pluripotent and lineage-committed hematopoietic progenitor cells (HPCs) in various types of allografts. Bone marrow (BM) allografts and single leukapheresis products (LPs) collected from G-CSF-mobilized donors contained similar amounts of pluripotent HPCs (CD34(+)CD38(-)) and total CD34(+) cells. However, the content of late-myeloid HPCs (CD34(+)CD33(+)CD15(+)) were significantly higher in BM grafts compared to LPs (P>0.02), whereas the contents of early-myeloid HPCs (CD34(+)CD33(+)CD15-) were 2.5-fold higher in LPs (P<0.03). In comparison to grafts from adult donors, cord blood (CB) grafts contained 26-65-fold lower amounts of early-myeloid HPCs (P<0.001), but only 8-12-fold lower contents of pluripotent HPCs (P<0.04). Additional findings demonstrated that among all tested parameters the numbers of early-myeloid HPCs were the most accurate measure of the total colony-forming cell (CFC) numbers in allografts. Hence, the earlier engraftment observed after transplantation of LPs compared to BM grafts might be explained by the higher content of early-myeloid HPCs/CFCs in LPs. Moreover, the slow engraftment following CB transplantation might not be affected essentially by the low number of myeloid HPCs, but rather by pluripotent HPCs. Finally, this study reports a new gating strategy for the enumeration of pluripotent CD34(+)CD38(-) subsets.

Virological and immunological profiles among patients with undetectable viral load followed prospectively for 24 months.

OBJECTIVE: To quantify HIV-RNA in plasma, in lymphoid tissue and proviral DNA in peripheral blood mononuclear cells and to relate these to immunological markers among patients with plasma viral load counts of /= 1 measurement with 21-200 and 25% had >/= 1 sample with plasma HIV-RNA > 200 copies/mL. Lymphoid tissue viral load was low at enrolment and declined further during follow-up. Baseline HIV-DNA and immunoglobulin (IgA) differed significantly between the plasma viral load rebound groups (P < 0.05). CONCLUSION: In this cohort, selected solely on the basis of having a plasma viral load of

[Screening of donor blood for viral markers. Anti-HIV, HBsAg and anti-HTLV-I/II in Denmark 1990-1999]. / Screening af donorblod for virale markører. Anti-HIV, anti-HCV, HBsAg samt anti-HTLV-I/II i Danmark 1990-1999.

INTRODUCTION: We describe the results of donor blood screening in Denmark for anti-HIV-1/2 in the period 1990-1999 and for anti-HCV, HBsAg, and anti-HTLV-I/II in the period 1994-1999. METHODS: Danish blood banks report the results of donor blood screening to the State Serum Institute on a monthly basis. This study concerns the data reported in the above two period. Reports from the years given above are worked out in the present study. RESULTS: The frequencies of infection among candidate donors are for HIV: 4.8 per 100,000; hepatitis C: 52.7 per 100,000; and hepatitis B: 60 per 100. The yearly incidences of new infections among the 260,000 regular donors in Denmark are for HIV: 0.42 per 100,000 regular donors; hepatitis C: 0.64 per 100,000 regular donors; and hepatitis B: 0.70 per 100,000 regular donors. All donations in Denmark were tested for anti-HTLV-I/II in the period 1 April 1994 to 1 October 1997, after which only candidate donors were tested. The frequency of HTLV-I infection in previously untested donors was 1 in 60,000 and that of HTLV-II infection 1 in 150,000. The frequency of HTLV-I infection among candidate donors was 1 in 50,000 and that of HTLV-II infection 1 in 100,000. No seroconverters have been found.

[Risk of disease transmission via donor blood in Denmark at the turn of the century]. / Risiko for smitte med donorblod i Danmark ved årtusindskiftet.

INTRODUCTION: Published results of donor blood screening in Denmark were used to calculate the risks of window phase donations. METHODS: The main parameter was the frequencies of a confirmed positive donation from regular donors per 100,000 donations are: 0.34, for HIV; 0.47 for hepatitis C virus; 0.53 for hepatitis B virus; and nil for HTLVI/II. The mean interdonation interval between donations from regular donors is six months year. Window phase duration were estimated to be 22 days for anti-HIV; 10 weeks for anti-HCV; and 56 days for HBsAg. Blood from candidate donors is not used in Denmark. Thus, the risk of a window phase donation equals the risk of a window phase donation in donations from regular donors. RESULTS: The risks of window phase donations in Denmark are: 1 in 2,000,000 for HIV; 1 in 500,000 for hepatitis C; 1 in 250,000 for hepatitis B; and immeasurably low for HTLVI/II. DISCUSSION: The measures taken nowadays to prevent infection from allogeneic blood transfusion have resulted in a risk reduction of HIV transmission by a factor 50 and of HCV transmission by a factor 400, compared with the risks prevailing in Denmark in the early 1980s. The present very low risk renders obsolete predeposited autologous blood solely on the indication to prevent infection. Zero risk of transmission of HIV and HCV might be approached by introducing NAT screening for these viruses.

[No development of HIV infection after transfusion with HIV-contaminated blood and postexposure antiviral prevention]. / Manglende udvikling af hiv-infektion efter transfusion med HIV-kontamineret blod og efterfølgende antiviral forebyggelse.

In the case reported here, transfusion or HIV RNA-positive HIV seronegative blood did not lead to infection of the recipient, probably because potent postexposure antiretroviral therapy was initiated promptly.

Flow cytometric assessment of lymphocyte subsets, lymphoid progenitors, and hematopoietic stem cells in allogeneic stem cell grafts.

Currently, bone marrow (BM), cord blood (CB), and G-CSF-mobilized peripheral blood progenitor cells (PBPCs) are the most commonly used sources for allogeneic stem cell transplantation (SCT). The aim of this study was to assess the yields and distribution of lymphocyte subsets, lymphocyte progenitors and hematopoietic stem cells (HSC) in each type of allograft by three-color flow cytometry. The yields of CD34(+)CD38(-) HSCs did not differ significantly between BM grafts (2.80 +/- 0.74 x 10(6)) and leukapheresis products (LPs) (1.82 +/- 0.64 x 10(6)), and were lowest in CB grafts (0.21 +/- 0.05 x 10(6)). For most lymphocyte subsets yields were lowest in CB grafts and significantly higher in LPs than in BM grafts. BM grafts, however, contained the highest yields of CD34(+)CD19(+)CD20(-) B cell progenitors and CD19(+)CD20(-) B cells. The relative frequencies of the naive CD45RA(+)CD45RO(-) phenotype among CD4(+) and CD8(high) T cells were highest in CB grafts (P < or = 0.001), and higher in LPs than in BM grafts (P < or = 0.02). The latter finding was in accordance with a preferential G-CSF mobilization of naive T cells relative to the total lymphocyte population (P < or = 0.014). CD3(+)CD8(low) and CD3(+)CD8(low)CD4(-) subsets, which facilitate engraftment in murine transplantation models, demonstrated a tendency towards lower frequencies among T cells in CB grafts and LPs compared to BM grafts. This observation coincided with a significantly reduced mobilization of subsets potentially enriched for facilitating cells as compared to the total lymphocyte population (P < or = 0.036). The CD34(+) compartment of CB grafts contained a significantly higher percentage (12.1%) of CD34(+)CD7(+)CD3(-) T cell progenitors than those of BM grafts (5.1%) and LPs (3.6%). In addition, CB lymphocytes contained the highest fraction of CD3(-)CD16/56(+) NK cells (P < or = 0.013) and almost no CD3(+)CD16/56(+) NKT cells (P < 0.001) compared to adult cell sources. In summary, LPs, CB allografts and BM allografts differ widely with respect to the cellular composition of their lymphocyte compartments, which is partially affected by a varying mobilization efficiency of G-CSF for distinct lymphocyte subsets.

Recruitment of CD34+ cells during large-volume leukapheresis.

Mobilized peripheral blood stem and progenitor cells (PBPCs) are increasingly used to restore hematopoiesis after myeloablative treatment. To obtain a sufficient number of CD34(+) cells, many studies have focused on the improvement of the collection technique during the leukapheresis procedure (LP), and so-called large-volume leukapheresis (LVL) procedures have been developed. Such procedures can be performed by extending the duration of the LP and/or by increasing the inlet flow rate. However, no previous studies have compared the efficiency of these procedures. In the present study, we compared the kinetics of PBPCs recruitment (including CD34(+) cell subsets), the PBPCs yield, and the collection efficiency as well as the overall feasibility of the procedures during a single LVL performed by standard (group I) (median 85 ml/min; range 50-97 ml/min) and high inlet flow rates (group II) (median 130 ml/min; range 110-150 ml/min). Seven patients with hematological malignancies were enrolled and allocated to each group. The patients' blood volumes (BV) were processed four times. The apheresis product (AP) was collected in four separate bags, which were changed every time one BV had been processed. The CD34(+) cell number and CD34(+) cell subsets were assessed in the four collection bags and in peripheral blood (PB) before every time one BV had been processed and after the leukapheresis. The CD34(+) cell yield exceeded the pre-apheresis CD34(+) cell number per ml BV in 6 out of 7 patients in group I and in 3 out of 7 patients in group II. In group II, the recruitment of CD34(+) cells from the bone marrow (BM) to PB starts in the second collection period--as early as 30-60 min after initiating the procedure. No exhaustion in the recruitment was observed in the two groups for at least 5 h during the leukapheresis, and all CD34(+) cell subsets were recruited at a steady rate. However, the collection efficiency in group II was only half of that in group I. In addition, we experienced many technical problems during the leukapheresis in group II. Thus, in 4 out of 7 patients in this group, it was not possible to perform the maximal inlet flow rate because of catheter problems. In conclusion, due to the technical problems associated with the high inlet flow rate procedure and the fact that the relative number of CD34(+) cells harvested and recruited during the leukapheresis was higher in group I than II and, also reflected an approximately two-fold higher collection efficiency, we recommend that LVL be performed by standard inlet flow rate.