Nonmyeloablative hematopoietic stem cell transplantation for systemic lupus erythematosus.
BACKGROUND
Manifestations of systemic lupus erythematosus (SLE) may in most patients be ameliorated with medications that suppress the immune system. Nevertheless, there remains a subset of SLE patients for whom current strategies are insufficient to control disease.


OBJECTIVE
To assess the safety of intense immunosuppression and autologous hematopoietic stem cell support in patients with severe and treatment-refractory SLE.


METHODS
A single-arm trial of 50 patients with SLE refractory to standard immunosuppressive therapies and either organ- or life-threatening visceral involvement. Patients were enrolled from April 1997 through January 2005 in an autologous nonmyeloablative hematopoietic stem cell transplantation (HSCT) study at a single US medical center.


METHODS
Peripheral blood stem cells were mobilized with cyclophosphamide (2.0 g/m2) and granulocyte colony-stimulating factor (5 microg/kg per day), enriched ex vivo by CD34+ immunoselection, cryopreserved, and reinfused after treatment with cyclophosphamide (200 mg/kg) and equine antithymocyte globulin (90 mg/kg).


METHODS
The primary end point was survival, both overall and disease-free. Secondary end points included SLE Disease Activity Index (SLEDAI), serology (antinuclear antibody [ANA] and anti-double-stranded (ds) DNA), complement C3 and C4, and changes in renal and pulmonary organ function assessed before treatment and at 6 months, 12 months, and then yearly for 5 years.


RESULTS
Fifty patients were enrolled and underwent stem cell mobilization. Two patients died after mobilization, one from disseminated mucormycosis and another from active lupus after postponing the transplantation for 4 months. Forty-eight patients underwent nonmyeloablative HSCT. Treatment-related mortality was 2% (1/50). By intention to treat, treatment-related mortality was 4% (2/50). With a mean follow-up of 29 months (range, 6 months to 7.5 years) for patients undergoing HSCT, overall 5-year survival was 84%, and probability of disease-free survival at 5 years following HSCT was 50%. Secondary analysis demonstrated stabilization of renal function and significant improvement in SLEDAI score, ANA, anti-ds DNA, complement, and carbon monoxide diffusion lung capacity adjusted for hemoglobin.


CONCLUSIONS
In treatment-refractory SLE, autologous nonmyeloablative HSCT results in amelioration of disease activity, improvement in serologic markers, and either stabilization or reversal of organ dysfunction. These data are nonrandomized and thus preliminary, providing the foundation and justification for a definitive randomized trial. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT00271934.
Burt
Richard K
RK
Division of Immunotherapy, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill 60611, USA. rburt@northwestern.edu
Traynor
Ann
A
Statkute
Laisvyde
L
Barr
Walter G
WG
Rosa
Robert
R
Schroeder
James
J
Verda
Larissa
L
Krosnjar
Nela
N
Quigley
Kathleen
K
Yaung
Kimberly
K
Villa Bs
Marcello
M
Takahashi
Miyuki
M
Jovanovic
Borko
B
Oyama
Yu
Y
D000328:Adult; D019072:Antibiotic Prophylaxis; D003520:Cyclophosphamide / Q000627:therapeutic use*; D005260:Female; D019650:Hematopoietic Stem Cell Mobilization; D018380:Hematopoietic Stem Cell Transplantation / Q000379:methods; D006801:Humans; D008180:Lupus Erythematosus, Systemic / Q000276:immunology / Q000628:therapy*; D008297:Male; D019653:Myeloablative Agonists / Q000627:therapeutic use*; D012074:Remission Induction; D016879:Salvage Therapy; D016019:Survival Analysis; D019172:Transplantation Conditioning; D014182:Transplantation, Autologous
D019653:Myeloablative Agonists; D003520:Cyclophosphamide