2. Background
Autoimmunity after HSCT is reported in several
conditions:
• Transfer of donor autoimmunity
• Altered immunity associated with chronic GVHD
• Appearance or new development of residual host
autoimmunity
Daikeler, Best Pract, 2007
3. Onset of secondary AD after
allo/auto HSCT: BM, PBSC
Adoptive transfer of autoimmune disease from donor to recipients
Autoimmune diseases Graft sources Reference
Psoriasis Syngeneic BM BJD, 1997
Psoriatic arthritis Sibling BM Rheumatology, 1999
Celiac disease Sibling BM BMT, 1997
Vitiligo Sibling BM JAAD, 2002
Type I diabetis mellitus Sibling BM Lancet, 1993
Autoimmune thyroiditis Sibling PBSC BMT, 1997 and 1999
Crohn’s disease PBSC Gut, 2003
Myasthenia gravis Unknown NEJM, 1983
Daikeler, Best Pract, 2007
4. Few case reports / small series autoimmune disease
Most of the AD reported are autoantibodies mediated and organ
specific, more rarely multisistemic
Autoimmune Cytopenias
Rheumatic Diseases : Barnabe Semin Arthritis Rheum 2008
* After autologous HSCT
Athritis SPA, RA, Infectious Polyarthritis CMV Koch 2000, Burns 1993
SLE Nephritis, Autoantibodies, APS Imamura 2002, Boghati 2007
Vasculitis Pulmonary Renal Syndrome Kingdon1994, Mc Cloy 1996, Seiden
1990
* After allogeneic HSCT
Arthritis Oligoarthrtitis, Psoriasic Arthritis Daikeler 1999, Snowden 1998
Vasculitis ANCA, microPAN, Jejunal vasculitis Shetti, 2002, Almoallim 2005,
Other AD reported after allo / auto HSCT (BM or PBSC)
for malignant and non malignant diseases
5. • No larger studies reporting the incidence of
autoimmune disease after HSCT
• Daikeler etal. recently showed 7% of incidence
of new AD in a cohort of patients with AD
transplanted with autologous HSC
6. * Increase in the use of cord blood as an alternative
source of adults HSC for allotransplant
* CB lymphocytes are immature
* Most of the CBT are HLA mismatched
= > High incidence of secondary AD after CBT?
Daikeler, Blood 2013
7. Aims and Methods
To identify the incidence and risk factors of
secondary autoimmune disease (AD) after CBT
Questionnaire to all EBMT centers
Status at last follow-up
Sec AD: Yes /No; Yes Cases No Control group = No sec AD
Specific questionnaire for sec AD
Analysis of 778 patients, 52 developed AD (n=52)
and the remaining who did not developed AD (n=726)
8. Diagnosis of AD after CBT :
n = 52 (41 AIC + 11 others)
Median time of onset :
191 days (27-4267)
Median time of onset :
377 days (70-1116)
• Type Autoimmune Disease after CBT:
AIHA 20
ITP 11
Evans Syndrome 9
Immune neutropenia 1
Thyroiditis 3
Glomerulonephritis 2
Graves disease 1
Psoriasis 1 , Psoriasis arthritis 1 2
Crohn‘s 1
Rheumatoid arthritis 1
Lupus 1
• Post transplant events at time of onset of AD:
aGvHD (n=3), c GvHD (n=6)
Preceding infections (n=10)
9. Patients characteristics, n=778
Pts
characteristics
AD pts (n=52) Non AD pts
(n=726)
P
Female sex 37% 44%
Age at HSCT 5 (0.2-45.3) yrs 16 (0.1-66.5) yrs <0.0001
Year of HSCT 2006 (1995-2008) 2006 (1992-2008) 0.05
Type of Donor Unrelated 96% 92% 0.25
Indication
for CBT
ALL 21% 31%
AML 10% 26%
MDS 8% 11%
AA 12% 8%
Severe Combined
Immune Deficiency
12% 7% Malignant vs non
malignant, <0.0001
CML 10% 5%
NHL 0 4%
Hemoglobinopathy 0 2%
Histiocytosis 4% 2%
Metabolic diseases 23% 2%
Others 2% 0%
10. Graft characteristics, n= 778
Pts characteristics AD pts
(N=52)
Non AD pts
(N=726)
P
Graft Single cord 85% 81% 0.48
Double cord 15% 19%
HLA
compatibility
5/6+6/6 66% 48% 0.02
Conditioning
RIC 82% 76% 0.32
TBI 18% 35% 0.013
Serotherapy 76% 78% 0.73
Recipient
CMV status
Positive 46% 60% 0.05
11. Cumulative incidence of AD after CBT, n= 778
Overall incidence Incidence by type of diagnosis
0 12 24 36 48 60
0.00.20.40.60.81.0
6(±1)% at 3 years
0 12 24 36 48 60
0.00.20.40.60.81.
14% non malignant disorders
5% malignant disorders
HR 1.85, p = 0.0001
12. Risks Factors for AD after CBT
Mutivariate Analysis
p HR 95%CI
Interval from diagnosis
to transplant > median 0.034 0.30 0.51 0.17
Malignant disease
versus others 0.0001 1.85 1.05 3.27
13. Overall Survival at 5 years
Secondary AD after CBT (as time dependent variable)
was not associated with overall survival (p=0.43)
OS: 50 ± 2%, n=778
Outcome of pts with new onset of AD (n=52):
40 Alive, 12 Dead>>> 6 patients died from AD (3 AIHA,
2 Evans syndrome, and 1 ITP);
4 patients died of TRM and 2 of relapse
14. Treatment of patients having developed an AD
Hematologic AD:
From the 40 patients with AIHA, ITP, or Evans syndrome, 7 received steroids only and
33 additional IST, mainly rituximab (RTX) and cyclosporine A (CSA).
Nineteen patients needed 2nd line treatment (mainly RTX) and 13 achieved CR or PR
5-year OS was 91% for patients who developed ITP, 59% for those with AIHA, and
67% for those with Evans syndrome
Non Hematologic AD:
• Two of the 3 patients with autoimmune thyroiditis (hypothyroidism) received
replacement therapy with thyroxin
• Psoriasis was treated with CSA and prednisone or topical tacrolimus
• Membranous glomerulonephritis with prednisone or CSA
• The patient with SLE responded to steroid and CSA treatment (CR)
• Ulcerative colitis was successfully treated with steroids and tacrolimus and RA
with prednisone and methotrexate
15. Occurence of autoimmune disease after CBT
does not seem different from other stem cell sources
In hematological malignancies the CI of developing AD was 4%
In non malignant diseases, 14%
The difference could be related to:
• Different diagnosis (autoimmune disease background of non
malignant disorders)
• Difference of pretransplant treatment
• Difference in type of conditioning regimen (non malignant disease
mainly non myeloablative)
Autoimmune Diseases: is it more frequent
after CB vs PBSC or BM transplantation??
16. Conclusion
• In our study the CI of development of AD after CBT
was 6%
• AIHA and ITP were observed most commonly and
earlier and therefore have to be considered as a
possible reason for unexplained cytopenia post
UCBT
• Comparative studies analyzing CBT versus BM and
PBSC are necessary to determine whether AD
disease is more frequent in CBT or in other types of
graft
