Autologous hematopoietic SCT (HSCT) in combination with high-dose chemotherapy is one of the effective therapies for treating systemic autoimmune diseases, such as multiple sclerosis, systemic sclerosis, rheumatoid arthritis, systemic lupus erythematosus, or juvenile arthritis.1, 2 Still, after 15 years of clinical experience, the mechanisms that determine efficiency of HSCT treatment remain unexplained, hampering the rational development and optimization of this therapy. As more data are obtained confirming the efficiency and safety of this therapeutic approach, so too will the list of autoimmune diseases for which HSCT can be used expand.2, 3 One such candidate disease is ankylosing spondylitis (AS), an autoimmune disease characterized by chronic inflammation of the spine and sacroiliac joints. Although manifestations of AS can be quite severe, this disease is usually not life-threatening and HSCT is not used to treat it. One case was reported in which a lymphoma patient with active AS received an autologous HSCT.4 In this case, CR was observed for the entire 20-month follow-up period, demonstrating the potential of HSCT therapy for AS. However, the highly cytotoxic BEAM chemotherapy regimen used for lymphoma patients differs from that of modern HSCT protocols for treating autoimmune diseases, which use much milder immunoablative pre-transplant regimens. Here we report the first case of intentional treatment of AS with HSCT performed after immunoablative chemotherapy. Basing on the fate of T-cell clones tracked by quantitative next-generation sequencing (NGS) for 4 years before and for 2 years after the treatment, we suggest basic mechanisms that lead to the protective reconstitution of the immune system after HSCT.
The patient, HLA-B27-positive man born in 1963, was subjected to the high-dose chemotherapy (200 mg/kg of CY for 4 days) and autologous HSCT (2.4 × 106 kg body weight of CD34+ stem cells, no CD34+-positive selection was performed) with infusion of antithymocyte globulin for in vivo T-cell depletion. The procedure was performed in June 2009, in accordance with the European Group for Bone Marrow Transplantation (EBMT) protocol.1, 2 The patient was examined every 3–6 months after HSCT. The BASDAI, BASFI and BAS-G values decreased significantly and remained stably low for the entire 2-year follow-up period (Supplementary Figure S1 on the BMT website). The treatment resulted in the complete resolution of spine and hip pain symptoms. Since the HSCT, the patient has not taken any NSAIDs, disease-modifying antirheumatic drugs or anti-TNF-alpha therapy. During the follow-up period, there were several episodes of fever followed by aphthous stomatitis on the lips and mouth. These symptoms were efficiently suppressed by prompt oral administration of low-dose (800 mg/day) acyclovir, indicating that resistance to herpes virus infections was depressed after HSCT. Magnetic resonance imaging (MRI) of the spine and hips was performed 1 and 2 years after HSCT, and showed the absence of inflammatory lesions in the spine and only mild inflammation in the left hip (BM edema of the femoral head, Supplementary Figure S2 on the BMT website). However, no baseline MRI was available for comparison. X-ray of cervical and lumbar spine did not reveal bone proliferation. Overall, complete clinical remission was observed for the whole follow-up period, indicating that HSCT can be an effective treatment for AS in those cases where anti-TNF-alpha biologics efficiency is low. Blood count and flow cytometry analysis were performed at several time points during the 2 years of observation after HSCT. The total numbers of T, B and NK cells reached the pre-graft levels at 8 months post HSCT. Kinetics of the repopulation of the CD4 and CD8 T cells differed significantly, and both populations consisted of large percentages of activated effector-memory and effector T cells. Both the naïve T-cell pool and the CD4/CD8T-cell ratio partially recovered, indicating general reconstitution of the immune system to a healthy state (for details, see Supplementary Data S1 and Supplementary Table S1 on the BMT website).
Quantitative analysis of TCR V beta repertoires by NGS 5 was performed for the blood samples obtained at several time points: 48 months before, 2 weeks before, 4 months after, 10 months after and 25 months after the HSCT. This deep sequencing analysis revealed that the prevalence of major T-cell clones that were stably abundant for the previous 4 years declined after HSCT, yielding to other clones that expanded and demonstrated remarkable stability for the 2 years after HSCT (Figure 1). The abundance of clones that were most prominent before HSCT decreased up to 400-fold, whereas all new major T-cell clones arose from those that previously had been much lower in abundance (from 5- to 300-fold growth). Furthermore, the clone carrying TCR V beta CDR3 CASSVALGLNYEQYF, of unknown specificity, which constituted 2% of all T cells and ∼50% of all perforin-producing T cells in the patient's blood before HSCT,6 decreased fivefold, while the much less abundant anti-CMV clone carrying TCR V beta CDR3 CASSLAPGATNEKLFF 5, 7, 8 increased 10-fold and remained stably abundant after HSCT. No functional T-cell cytokine assays were performed and, therefore, we do not have information concerning the specific features of other T-cell clones.
Why autologous HSCT is effective for treating autoimmune diseases remains unexplained. As proposed earlier 9 and as we demonstrated recently,5 many T cells survive the ablation procedure. We believe that this survival of large numbers of T cells provides an important salvation effect for immunoablated patients for at least two reasons: (1) the survival of memory T-cell clones (to provide resistance to emerging infections), and (2) the survival of a considerable portion of the naïve T-cell repertoire. Further homeostatic proliferation of these cells apparently replenishes the naïve T-cell pool, which is particularly important for older patients whose thymus activity is minimal, as in the case described here. Several studies have demonstrated that CD34+ selection of the graft does not increase the effectiveness of HSCT for treating autoimmune diseases2, 10, 11 but increases the risk of secondary autoimmune diseases12 and infectious complications,13, 14, 15, 16 especially for heavily pretreated patients.17 Thus, we believe that the effectiveness of HSCT for treating autoimmune diseases is not the result of the complete elimination of autoimmune cells,5, 9, 18 and elimination of all immune cells, which would require both CD34+ selection and increased doses of cytotoxic chemotherapy,19 should not be the aim of HSCT protocols. At the same time, the ‘complex reprogramming’ of the immune system after HSCT that results in the suppression of the autoimmune process remains vaguely defined. This lack of understanding of the basic processes that underlie HSCT efficacy hampers the rational optimization of therapeutic approaches for treating autoimmune diseases. It has been hypothesized that competition with the rapid expansion of viral-specific T-cell clones limits the potential for re-expansion of self-antigen-specific clones after HSCT.20 Our data support this concept, indicating that after HSCT an irreversible ‘switch’ in the abundance of the dominant clones occurs. It has been reported that chronically activated T-cell clones are characterized by shortened telomeres and survive in a balance between senescence and stimulation that increases telomerase activity.21, 22 After HSCT, massive depletion forces T cells to proliferate actively in an attempt to replenish the homeostatic balance.23, 24 Thus, it can be presumed that the exhausted T-cell clones that drove chronic autoimmune inflammation fail to proliferate efficiently after HSCT and yield to the expansion of the ‘second echelon’ of recruited T-cell clones that arise to fight insurgent viral infections and that hopefully do not include autoimmune specificities. This course of events corresponds well with the present concepts of function and senescence of adaptive immunity and with our long-term quantitative data on the fate of major T-cell clones after HSCT. Further studies are required and should be performed using a cohort of HSCT-treated autoimmune patients and quantitative NGS of TCR repertoires, accompanied by telomere length characterization and wide identification of TCR specificities.
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We are grateful to Professor Poddubnyy DA for the valuable suggestions and comments on the manuscript. This work was supported by the Molecular and Cell Biology program RAS, Russian Science Support Foundation, Basic Research for Medicine RAS, Russian Foundation for Basic Research (10-04-01771-à, 11-04-12042-ofi-m) and Russian Federation President Grant for young scientists (MK-575.2011.4).
The authors declare no conflict of interest.
Supplementary Information accompanies the paper on Bone Marrow Transplantation website
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Britanova, O., Bochkova, A., Staroverov, D. et al. First autologous hematopoietic SCT for ankylosing spondylitis: a case report and clues to understanding the therapy. Bone Marrow Transplant 47, 1479–1481 (2012) doi:10.1038/bmt.2012.44
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