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Introduction

High-dose immunosuppressive therapy (HDIT) with autologous hematopoietic stem cell transplantation (ASCT) is a promising approach to treatment of multiple sclerosis (MS) patients, since there are no effective treatment methods for this disease [4-7, 10]. HDCT+ASCT has been performed in more than 700 MS patients since 1995 all over the world. However, the patient selection criteria for HDIT +ASCT are still unclear and the proper selection of patients for transplantation remains the key issue [3, 9, 11]. In Russia more than 180 transplantations in MS patients were done within 10 years within a prospective Phase II multicenter trial coordinated by the Russian Cooperative Group for Cellular Therapy. The follow-up results of the patients who were enrolled in the Military Medical Academy (St. Petersburg) and Pirogov National Medical Surgical Center (Moscow) since 1999 are reported here. We focused on the efficacy of HDIT +ASCT in patients with different types and stages of MS. The patients underwent early, conventional, or salvage/late transplantation in accordance with the concept of HDIT +ASCT in MS [12, 13]. There are 3 strategies of HDIT +ASCT (Table 1). Early ASCT (in MS patients with EDSS 1.5–3.0) is performed soon after diagnosis in the case of primary refractory disease or poor prognosis. Conventional ASCT (EDSS 3.5–6.5) is performed in patients with secondary refractory disease. Salvage ASCT (EDSS 7.0–8.0) is an option in the case of high disease activity and rapid neurological deterioration in late stages of the disease.

Patients and Methods

132 MS patients were included in this study with a mean age of 33.0, and a male/female split of 58/74. The distribution according to the disease type was as follows: secondary progressive (SPMS): 57 patients, primary progressive (PPMS): 23, progressive-relapsing (PRMS): 9 and relapsing-remitting (RRMS): 43. 

Criteria for patient selection were: age between 18 and 55 years, diagnosis of multiple sclerosis verified by clinical and laboratory findings, EDSS score 1.5–8.0, normal mental status, and absence of severe concomitant diseases.  
The disease activity was determined either by magnetic resonance imaging scans displaying active lesions in the CNS (i.e., gadolinium-enhancing lesions, new or enlarging lesions on serial scans) or by clinical assessment showing rapid neurological deterioration, e.g., 0.5-point increase on the EDSS during the 6 months preceding enrollment. 

Table 1. Classification of HDIT +ASCT in MS patients

Type of transplantation	Pathogenetic goal	Overall goal	Timing
Early transplantation	To prevent the irreversible damage of the CNS by immunopathological process	To stop the disease progression and to prevent the patient’s disability	In early stages of the disease in cases of poor prognosis
Conventional transplantation	To prevent disease progression in a patient with neural damage and partial loss of function	To prevent the exacerbation of disability and to improve or stop the decline in patient’s QoL	In cases of refractory disease
Salvage transplantation	To stop disease progression in a patient with irreversible neural damage and a significant loss of function	To save a patient from complete disability and to improve severely declined patient QoL	In late stages of the disease in cases of rapid progression of patient disability

All three strategies of HDIT +ASCT were applied: 43 patients (32.7%) underwent early transplantation; 82 (62.0%), conventional transplantation; and 7 (5.3%) received salvage/late transplantation.

Neurological evaluation was performed at baseline, at discharge, at 3, 6, 9, and 12 months, and every 6 months thereafter; and MRI examinations at baseline, at 6, and 12 months, and at the end of follow-up.

According to the EBMT criteria of response, patients with steady EDSS scores representing halt of disease progression or with improved EDSS scores representing subsidence of inflammation in the CNS were regarded as responding to treatment. Clinical improvement was defined as a 0.5-point decrease in EDSS score as compared to the baseline. Progression was defined as an increase of at least 0.5 points. Both had to be confirmed after 6 months. Clinical relapse was defined as the appearance of new symptoms or worsening of old symptoms of at least 24-hour duration, in the absence of fever in a previously (4 weeks) stable patient.

A BEAM or BEAM-modified conditioning regimen was used.

Median EDSS at baseline was 4.5 (range 1.5-8.5). The mean follow-up duration was 21 months (range 6-120 months).

A separate group of patients was identified to whom consolidation therapy (Mitoxantrone) after HDIT +ASCT was administered. These were patients with a number of risk factors. 34 patients were enrolled in this group. The preliminary analysis of treatment outcomes in this group will be conducted by December 2009.

Results

Adverse events
No transplant-related deaths were reported; transplantation procedure was well tolerated by the patients. Mobilization was successful in all cases with a median number of 2.1 x10⁶/kg (range 1.5-5.5 x10⁶/kg) CD34+ cells collected; no major clinical adverse events were observed during this phase. Unmanipulated grafts were infused without complications. Engraftment was uneventful, and no signs of an engraftment syndrome were reported. Median days with PMN <0.5x10⁹ and Plt <50x10⁹ were 8 (range from 5 to 11) and 10 days (from 2 to 26), respectively.

Common adverse effects following the immunoablative regimen were thrombocytopenia (100%), neutropenia (100%), fatigue (100%), anemia (80%), alopecia (80%), neutropenic fever (51.6%), hepatic toxicity grade I and II (48.1%), transient neurological dysfunction (22.2%), and enteropathy (18.5%). Documented sepsis was registered in one patient. 

Clinical outcomes
Eighty-seven patients with a follow-up period of at least 9 months or longer were included in the clinical outcome analysis. All patients responded to the treatment. At 6 months post-transplant the following distribution of patients according to clinical response was observed: 46 patients (52.8%) achieved an objective improvement of neurological symptoms (defined as a 0.5 point decrease in the EDSS score as compared to the baseline and confirmed over 3 months), and 41 patients (47.2 %) had disease stabilization (steady EDSS level as compared to the baseline and confirmed over 3 months). At long-term follow-up the clinical response in 40 patients (50.6%) was classified as improvement; 34 patients (43.1%) remained stable. Two patients deteriorated to a worse score after 18 months of stabilization (SPMS and PPMS; conventional auto-HSCT), and one patient after 6 months of stabilization (SPMS, conventional auto-HSCT); 2 others progressed after 12 and 30 months of improvement (RRMS, early auto-HSCT and SPMM, conventional auto-HSCT, respectively). No active, new, or enlarging lesions were registered in patients without disease progression.

The analysis of clinical outcomes at long-term follow-up was performed separately for the groups after early, conventional, and salvage transplantation. Out of 24 patients who underwent early ASCT 14 patients (58.3%) improved, 9 patients (37.5) stabilized, and one patient (4.2%) progressed (after improvement). Out of 48 patients who underwent conventional ASCT 24 patients (50%) improved, 20 patients (42%) stabilized, and 4 (8%) progressed (3 after stabilization, and 1 after improvement). In the group of patients who underwent salvage ASCT 2 patients (29%) improved and 5 (71%) were stable during the follow-up.

Remarkably, nine patients improved dramatically (1.5 points by EDSS). Patients with different types of MS were observed in this group. As an illustration, in an SPMS patient with the baseline EDSS value of 6.0 we observed a 2.0 point decrease on the EDSS scale at 1 month post-transplant, an additional 1.5 point decrease at 6 months and stabilization with EDSS score of 1.5 at 18 months post-transplant. In another case, an RRMS patient with a baseline EDSS score of 4.5 experienced a decrease in EDSS to 2.0 at 1 month post-transplant with a further decrease to 1.0 at 3 months. The latter EDSS level remained stable throughout the entire follow-up period of 1.5 years. The PRMS patient with a baseline EDSS value of 6.0 improved at 3 months to EDSS of 4.5 and then showed further improvement at 30 months post-transplant to the EDSS score of 4.0. The EDSS score at the end of follow-up (6.5 years post-transplant) was 3.5. Finally, the PPMS patient with severe disease (EDSS score of 7.5) had a 1.5 point EDSS decrease and maintained this score during 3.5 years of follow-up.

Conclusions
- The results of our study demonstrate the benefits of HDIT +ASCT in patients with various types of MS. The transplantation procedure was well tolerated by patients, with no transplant-related deaths at all. All the patients included in the efficacy analysis responded to treatment. At long-term follow-up clinical response in terms of improvement or stabilization was registered in more than 90% of patients.

- The advantage of our study is that we included patients with different types of MS. In spite of some evidence that PPMS patients are less responsive to HDIT +ASCT as compared to both SPMS and RRMS, the information about the outcomes of HSCT in patients with various types of MS is limited. The results of our study confirm that transplantation is effective not only in SPMS and RRMS patients but in PPMS as well. Thus, patients with different types of MS might benefit from HDIT +ASCT.

- Another advantage of our study is the performance of early, conventional, or salvage transplantation, while most patients in the previous studies had late stages of MS. Our data supports the idea that HDIT +ASCT is more effective in young patients with early stages of rapidly progressing disease. In these patients, autoreactive T cells play a pivotal role in MS pathogenesis. HDIT ablates the patient's immune system and eradicates autoimmune T cells. It is followed by HSCT to restore the immune system, which is expected to become tolerant to autoantigens. Such "resetting" of the immune system is only effective at early stages of MS, particularly in relapsing-remitting MS. Later in the clinical course of the disease, processes of axonal degeneration prevail and the damage to CNS tissue is too significant to expect a neurological recovery after HDIT +ASCT. Indeed, failure of HDIT +ASCT to prevent progression of the disease when performed in the late stages has been demonstrated in both animal models [1] and in clinical studies [8, 2].

- The data obtained points to the feasibility of early, conventional, and salvage HDIT +ASCT in MS patients. Further studies should be done to investigate the clinical and patient-reported outcomes in MS patients receiving early, conventional, and salvage transplantation to better define treatment success. The concept of HDIT +ASCT in MS opens a new window of opportunity for treatment of this patient population.

References

1. Burt RK, et al. Effect of disease stage on clinical outcome after syngeneic bone marrow transplantation for relapsing experimental autoimmune encephalomyelitis. Blood. 1998;91:2609–2616.

2. Burt RK, et al. Autologous haematopoietic stem cell transplantation in multiple sclerosis: importance of disease stage on outcome [abstract]. Neurology. 2003;40:A150.

3. Comi G, et al. Guidelines for autologous blood and marrow stem cell transplantation in multiple sclerosis: a consensus report written on behalf of the European Group for Blood and Marrow Transplantation and the European Charcot Foundation. J Neurol. 2000;247:376-382.

4. Fassas A, et al. Peripheral blood stem cell transplantation in the treatment of progressive multiple sclerosis: first results of a pilot study. Bone Marrow Transplant. 1997;20:631-638.

5. Fassas A, et al. Autologous stem cell transplantation in progressive multiple sclerosisdan interim analysis of efficacy. J Clin Immunol. 2000;20:24-30. doi: 10.1023/A:1006686426090.

6. Fassas A, et al. Haematopoietic stem cell transplantation for multiple sclerosis. A retrospective multicenter study. J Neurol. 2002;249:1088-1097. doi: 10.1007/s00415-002-0800-7.

7. Fassas A, Nash R. Multiple sclerosis. Best Pract Res Clin Hematol. 2004;17:247-262. doi: 10.1016/j.beha.2004.04.005.

8. Nash RA, et al. High-dose immunosuppressive therapy and autologous peripheral blood stem cell transplantation for severe multiple sclerosis. Blood. 2003;102:2364-2372. doi: 10.1182/blood-2002-12-3908.

9. Saccardi R, et al. Autologous HSCT for severe progressive multiple sclerosis in a multicenter trial: impact on disease activity and quality of life. Blood. 2005;105:2601-2607. doi: 10.1182/blood-2004-08-3205.

10. Saccardi R, et al. Autoimmune Diseases Working Party of EBMT. Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database. Mult Scler. 2006;12:814-823.

11. Shevchenko Y, et al. Autologous hematopoietic stem cell transplantation in multiple sclerosis. Cellular Therapy and Transplantation (CTT). 2008;1:2. doi: 10.3205/ctt-2008-en-000025.01.

12. Shevchenko Y, Novik A, et al. Three strategies of high dose chemotherapy (HDCT)+autologous stem cell transplantation (ASCT) in autoimmune diseases. Bone Marrow Transplantation. 2004;33(1):346.

13. Shevchenko Y. et al. High-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation as a treatment option in multiple sclerosis. Experimental Hematology. 2008;36(8):922-928. doi: 10.1016/j.exphem.2008.03.001.

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Introduction

High-dose immunosuppressive therapy (HDIT) with autologous hematopoietic stem cell transplantation (ASCT) is a promising approach to treatment of multiple sclerosis (MS) patients, since there are no effective treatment methods for this disease [4-7, 10]. HDCT+ASCT has been performed in more than 700 MS patients since 1995 all over the world. However, the patient selection criteria for HDIT +ASCT are still unclear and the proper selection of patients for transplantation remains the key issue [3, 9, 11]. In Russia more than 180 transplantations in MS patients were done within 10 years within a prospective Phase II multicenter trial coordinated by the Russian Cooperative Group for Cellular Therapy. The follow-up results of the patients who were enrolled in the Military Medical Academy (St. Petersburg) and Pirogov National Medical Surgical Center (Moscow) since 1999 are reported here. We focused on the efficacy of HDIT +ASCT in patients with different types and stages of MS. The patients underwent early, conventional, or salvage/late transplantation in accordance with the concept of HDIT +ASCT in MS [12, 13]. There are 3 strategies of HDIT +ASCT (Table 1). Early ASCT (in MS patients with EDSS 1.5–3.0) is performed soon after diagnosis in the case of primary refractory disease or poor prognosis. Conventional ASCT (EDSS 3.5–6.5) is performed in patients with secondary refractory disease. Salvage ASCT (EDSS 7.0–8.0) is an option in the case of high disease activity and rapid neurological deterioration in late stages of the disease.

Patients and Methods

132 MS patients were included in this study with a mean age of 33.0, and a male/female split of 58/74. The distribution according to the disease type was as follows: secondary progressive (SPMS): 57 patients, primary progressive (PPMS): 23, progressive-relapsing (PRMS): 9 and relapsing-remitting (RRMS): 43. 

Criteria for patient selection were: age between 18 and 55 years, diagnosis of multiple sclerosis verified by clinical and laboratory findings, EDSS score 1.5–8.0, normal mental status, and absence of severe concomitant diseases.  
The disease activity was determined either by magnetic resonance imaging scans displaying active lesions in the CNS (i.e., gadolinium-enhancing lesions, new or enlarging lesions on serial scans) or by clinical assessment showing rapid neurological deterioration, e.g., 0.5-point increase on the EDSS during the 6 months preceding enrollment. 

Table 1. Classification of HDIT +ASCT in MS patients

Type of transplantation	Pathogenetic goal	Overall goal	Timing
Early transplantation	To prevent the irreversible damage of the CNS by immunopathological process	To stop the disease progression and to prevent the patient’s disability	In early stages of the disease in cases of poor prognosis
Conventional transplantation	To prevent disease progression in a patient with neural damage and partial loss of function	To prevent the exacerbation of disability and to improve or stop the decline in patient’s QoL	In cases of refractory disease
Salvage transplantation	To stop disease progression in a patient with irreversible neural damage and a significant loss of function	To save a patient from complete disability and to improve severely declined patient QoL	In late stages of the disease in cases of rapid progression of patient disability

All three strategies of HDIT +ASCT were applied: 43 patients (32.7%) underwent early transplantation; 82 (62.0%), conventional transplantation; and 7 (5.3%) received salvage/late transplantation.

Neurological evaluation was performed at baseline, at discharge, at 3, 6, 9, and 12 months, and every 6 months thereafter; and MRI examinations at baseline, at 6, and 12 months, and at the end of follow-up.

According to the EBMT criteria of response, patients with steady EDSS scores representing halt of disease progression or with improved EDSS scores representing subsidence of inflammation in the CNS were regarded as responding to treatment. Clinical improvement was defined as a 0.5-point decrease in EDSS score as compared to the baseline. Progression was defined as an increase of at least 0.5 points. Both had to be confirmed after 6 months. Clinical relapse was defined as the appearance of new symptoms or worsening of old symptoms of at least 24-hour duration, in the absence of fever in a previously (4 weeks) stable patient.

A BEAM or BEAM-modified conditioning regimen was used.

Median EDSS at baseline was 4.5 (range 1.5-8.5). The mean follow-up duration was 21 months (range 6-120 months).

A separate group of patients was identified to whom consolidation therapy (Mitoxantrone) after HDIT +ASCT was administered. These were patients with a number of risk factors. 34 patients were enrolled in this group. The preliminary analysis of treatment outcomes in this group will be conducted by December 2009.

Results

Adverse events
No transplant-related deaths were reported; transplantation procedure was well tolerated by the patients. Mobilization was successful in all cases with a median number of 2.1 x10⁶/kg (range 1.5-5.5 x10⁶/kg) CD34+ cells collected; no major clinical adverse events were observed during this phase. Unmanipulated grafts were infused without complications. Engraftment was uneventful, and no signs of an engraftment syndrome were reported. Median days with PMN <0.5x10⁹ and Plt <50x10⁹ were 8 (range from 5 to 11) and 10 days (from 2 to 26), respectively.

Common adverse effects following the immunoablative regimen were thrombocytopenia (100%), neutropenia (100%), fatigue (100%), anemia (80%), alopecia (80%), neutropenic fever (51.6%), hepatic toxicity grade I and II (48.1%), transient neurological dysfunction (22.2%), and enteropathy (18.5%). Documented sepsis was registered in one patient. 

Clinical outcomes
Eighty-seven patients with a follow-up period of at least 9 months or longer were included in the clinical outcome analysis. All patients responded to the treatment. At 6 months post-transplant the following distribution of patients according to clinical response was observed: 46 patients (52.8%) achieved an objective improvement of neurological symptoms (defined as a 0.5 point decrease in the EDSS score as compared to the baseline and confirmed over 3 months), and 41 patients (47.2 %) had disease stabilization (steady EDSS level as compared to the baseline and confirmed over 3 months). At long-term follow-up the clinical response in 40 patients (50.6%) was classified as improvement; 34 patients (43.1%) remained stable. Two patients deteriorated to a worse score after 18 months of stabilization (SPMS and PPMS; conventional auto-HSCT), and one patient after 6 months of stabilization (SPMS, conventional auto-HSCT); 2 others progressed after 12 and 30 months of improvement (RRMS, early auto-HSCT and SPMM, conventional auto-HSCT, respectively). No active, new, or enlarging lesions were registered in patients without disease progression.

The analysis of clinical outcomes at long-term follow-up was performed separately for the groups after early, conventional, and salvage transplantation. Out of 24 patients who underwent early ASCT 14 patients (58.3%) improved, 9 patients (37.5) stabilized, and one patient (4.2%) progressed (after improvement). Out of 48 patients who underwent conventional ASCT 24 patients (50%) improved, 20 patients (42%) stabilized, and 4 (8%) progressed (3 after stabilization, and 1 after improvement). In the group of patients who underwent salvage ASCT 2 patients (29%) improved and 5 (71%) were stable during the follow-up.

Remarkably, nine patients improved dramatically (1.5 points by EDSS). Patients with different types of MS were observed in this group. As an illustration, in an SPMS patient with the baseline EDSS value of 6.0 we observed a 2.0 point decrease on the EDSS scale at 1 month post-transplant, an additional 1.5 point decrease at 6 months and stabilization with EDSS score of 1.5 at 18 months post-transplant. In another case, an RRMS patient with a baseline EDSS score of 4.5 experienced a decrease in EDSS to 2.0 at 1 month post-transplant with a further decrease to 1.0 at 3 months. The latter EDSS level remained stable throughout the entire follow-up period of 1.5 years. The PRMS patient with a baseline EDSS value of 6.0 improved at 3 months to EDSS of 4.5 and then showed further improvement at 30 months post-transplant to the EDSS score of 4.0. The EDSS score at the end of follow-up (6.5 years post-transplant) was 3.5. Finally, the PPMS patient with severe disease (EDSS score of 7.5) had a 1.5 point EDSS decrease and maintained this score during 3.5 years of follow-up.

Conclusions
- The results of our study demonstrate the benefits of HDIT +ASCT in patients with various types of MS. The transplantation procedure was well tolerated by patients, with no transplant-related deaths at all. All the patients included in the efficacy analysis responded to treatment. At long-term follow-up clinical response in terms of improvement or stabilization was registered in more than 90% of patients.

- The advantage of our study is that we included patients with different types of MS. In spite of some evidence that PPMS patients are less responsive to HDIT +ASCT as compared to both SPMS and RRMS, the information about the outcomes of HSCT in patients with various types of MS is limited. The results of our study confirm that transplantation is effective not only in SPMS and RRMS patients but in PPMS as well. Thus, patients with different types of MS might benefit from HDIT +ASCT.

- Another advantage of our study is the performance of early, conventional, or salvage transplantation, while most patients in the previous studies had late stages of MS. Our data supports the idea that HDIT +ASCT is more effective in young patients with early stages of rapidly progressing disease. In these patients, autoreactive T cells play a pivotal role in MS pathogenesis. HDIT ablates the patient's immune system and eradicates autoimmune T cells. It is followed by HSCT to restore the immune system, which is expected to become tolerant to autoantigens. Such "resetting" of the immune system is only effective at early stages of MS, particularly in relapsing-remitting MS. Later in the clinical course of the disease, processes of axonal degeneration prevail and the damage to CNS tissue is too significant to expect a neurological recovery after HDIT +ASCT. Indeed, failure of HDIT +ASCT to prevent progression of the disease when performed in the late stages has been demonstrated in both animal models [1] and in clinical studies [8, 2].

- The data obtained points to the feasibility of early, conventional, and salvage HDIT +ASCT in MS patients. Further studies should be done to investigate the clinical and patient-reported outcomes in MS patients receiving early, conventional, and salvage transplantation to better define treatment success. The concept of HDIT +ASCT in MS opens a new window of opportunity for treatment of this patient population.

References

1. Burt RK, et al. Effect of disease stage on clinical outcome after syngeneic bone marrow transplantation for relapsing experimental autoimmune encephalomyelitis. Blood. 1998;91:2609–2616.

2. Burt RK, et al. Autologous haematopoietic stem cell transplantation in multiple sclerosis: importance of disease stage on outcome [abstract]. Neurology. 2003;40:A150.

3. Comi G, et al. Guidelines for autologous blood and marrow stem cell transplantation in multiple sclerosis: a consensus report written on behalf of the European Group for Blood and Marrow Transplantation and the European Charcot Foundation. J Neurol. 2000;247:376-382.

4. Fassas A, et al. Peripheral blood stem cell transplantation in the treatment of progressive multiple sclerosis: first results of a pilot study. Bone Marrow Transplant. 1997;20:631-638.

5. Fassas A, et al. Autologous stem cell transplantation in progressive multiple sclerosisdan interim analysis of efficacy. J Clin Immunol. 2000;20:24-30. doi: 10.1023/A:1006686426090.

6. Fassas A, et al. Haematopoietic stem cell transplantation for multiple sclerosis. A retrospective multicenter study. J Neurol. 2002;249:1088-1097. doi: 10.1007/s00415-002-0800-7.

7. Fassas A, Nash R. Multiple sclerosis. Best Pract Res Clin Hematol. 2004;17:247-262. doi: 10.1016/j.beha.2004.04.005.

8. Nash RA, et al. High-dose immunosuppressive therapy and autologous peripheral blood stem cell transplantation for severe multiple sclerosis. Blood. 2003;102:2364-2372. doi: 10.1182/blood-2002-12-3908.

9. Saccardi R, et al. Autologous HSCT for severe progressive multiple sclerosis in a multicenter trial: impact on disease activity and quality of life. Blood. 2005;105:2601-2607. doi: 10.1182/blood-2004-08-3205.

10. Saccardi R, et al. Autoimmune Diseases Working Party of EBMT. Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database. Mult Scler. 2006;12:814-823.

11. Shevchenko Y, et al. Autologous hematopoietic stem cell transplantation in multiple sclerosis. Cellular Therapy and Transplantation (CTT). 2008;1:2. doi: 10.3205/ctt-2008-en-000025.01.

12. Shevchenko Y, Novik A, et al. Three strategies of high dose chemotherapy (HDCT)+autologous stem cell transplantation (ASCT) in autoimmune diseases. Bone Marrow Transplantation. 2004;33(1):346.

13. Shevchenko Y. et al. High-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation as a treatment option in multiple sclerosis. Experimental Hematology. 2008;36(8):922-928. doi: 10.1016/j.exphem.2008.03.001.

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string(19) "2015-09-02 18:01:20" ["IBLOCK_ID"]=> string(1) "2" ["NAME"]=> string(12) "Авторы" ["ACTIVE"]=> string(1) "Y" ["SORT"]=> string(3) "500" ["CODE"]=> string(9) "AUTHOR_RU" ["DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } ["PROPERTY_TYPE"]=> string(1) "S" ["ROW_COUNT"]=> string(1) "1" ["COL_COUNT"]=> string(2) "30" ["LIST_TYPE"]=> string(1) "L" ["MULTIPLE"]=> string(1) "N" ["XML_ID"]=> string(2) "25" ["FILE_TYPE"]=> string(0) "" ["MULTIPLE_CNT"]=> string(1) "5" ["TMP_ID"]=> NULL ["LINK_IBLOCK_ID"]=> string(1) "0" ["WITH_DESCRIPTION"]=> string(1) "N" ["SEARCHABLE"]=> string(1) "N" ["FILTRABLE"]=> string(1) "N" ["IS_REQUIRED"]=> string(1) "N" ["VERSION"]=> string(1) "1" ["USER_TYPE"]=> string(4) "HTML" ["USER_TYPE_SETTINGS"]=> array(1) { ["height"]=> int(200) } ["HINT"]=> string(0) "" ["PROPERTY_VALUE_ID"]=> string(5) "18306" ["VALUE"]=> array(2) { ["TEXT"]=> string(422) "<p> <span lang="RU">Aндрей A. Новик¹, Алексей Н. Кузнецов^1,2, Владимир Я. Мельниченко¹, Денис А. Федоренко¹, Tатьяна И. Ионова³, Кира А. Курбатова³</span> </p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(316) "

Aндрей A. Новик¹, Алексей Н. Кузнецов^1,2, Владимир Я. Мельниченко¹, Денис А. Федоренко¹, Tатьяна И. Ионова³, Кира А. Курбатова³

" ["TYPE"]=> string(4) "HTML" } ["~DESCRIPTION"]=> string(0) "" ["~NAME"]=> string(12) "Авторы" ["~DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } } ["ORGANIZATION_RU"]=> array(36) { ["ID"]=> string(2) "26" ["TIMESTAMP_X"]=> string(19) "2015-09-02 18:01:20" ["IBLOCK_ID"]=> string(1) "2" ["NAME"]=> string(22) "Организации" ["ACTIVE"]=> string(1) "Y" ["SORT"]=> string(3) "500" ["CODE"]=> string(15) "ORGANIZATION_RU" ["DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } ["PROPERTY_TYPE"]=> string(1) "S" ["ROW_COUNT"]=> string(1) "1" ["COL_COUNT"]=> string(2) "30" ["LIST_TYPE"]=> string(1) "L" ["MULTIPLE"]=> string(1) "N" ["XML_ID"]=> string(2) "26" ["FILE_TYPE"]=> string(0) "" ["MULTIPLE_CNT"]=> string(1) "5" ["TMP_ID"]=> NULL ["LINK_IBLOCK_ID"]=> string(1) "0" ["WITH_DESCRIPTION"]=> string(1) "N" ["SEARCHABLE"]=> string(1) "N" ["FILTRABLE"]=> string(1) "N" ["IS_REQUIRED"]=> string(1) "N" ["VERSION"]=> string(1) "1" ["USER_TYPE"]=> string(4) "HTML" ["USER_TYPE_SETTINGS"]=> array(1) { ["height"]=> int(200) } ["HINT"]=> string(0) "" ["PROPERTY_VALUE_ID"]=> string(5) "18307" ["VALUE"]=> array(2) { ["TEXT"]=> string(1287) "<p class="bodytext">¹Национальный медико-хирургический центр им. Н.И. Пирогова, Москва, Россия; ²Институт усовершенствования врачей Национального медико-хирургического центра им. Н.И.Пирогова, Москва, Россия; ³Межнациональный центр исследования качества жизни, Санкт-Петербург, Россия<br /><br /><b>Контакт</b><br> А. А. Новик, Национальный медико-хирургический центр им.Н.И. Пирогова, ул. Нижняя Первомайская 70,  Москва, 105203, Россия<br> E-mail: <a href="javascript:linkTo_UnCryptMailto('qempxs.rgvxg48Dqemp2vy');">ncrtc04@<span style="display:none;">spam is bad</span>mail.ru</a>, <a href="javascript:linkTo_UnCryptMailto('qempxs.ruspgDcerhib2vy');">nqolc@<span style="display:none;">spam is bad</span>yandex.ru</a>  </p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(1105) "

¹Национальный медико-хирургический центр им. Н.И. Пирогова, Москва, Россия; ²Институт усовершенствования врачей Национального медико-хирургического центра им. Н.И.Пирогова, Москва, Россия; ³Межнациональный центр исследования качества жизни, Санкт-Петербург, Россия

Контакт
А. А. Новик, Национальный медико-хирургический центр им.Н.И. Пирогова, ул. Нижняя Первомайская 70,  Москва, 105203, Россия
E-mail: ncrtc04@spam is badmail.ru, nqolc@spam is badyandex.ru 

" ["TYPE"]=> string(4) "HTML" } ["~DESCRIPTION"]=> string(0) "" ["~NAME"]=> string(22) "Организации" ["~DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } } ["SUMMARY_RU"]=> array(36) { ["ID"]=> string(2) "27" ["TIMESTAMP_X"]=> string(19) "2015-09-02 18:01:20" ["IBLOCK_ID"]=> string(1) "2" ["NAME"]=> string(29) "Описание/Резюме" ["ACTIVE"]=> string(1) "Y" ["SORT"]=> string(3) "500" ["CODE"]=> string(10) "SUMMARY_RU" ["DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } ["PROPERTY_TYPE"]=> string(1) "S" ["ROW_COUNT"]=> string(1) "1" ["COL_COUNT"]=> string(2) "30" ["LIST_TYPE"]=> string(1) "L" ["MULTIPLE"]=> string(1) "N" ["XML_ID"]=> string(2) "27" ["FILE_TYPE"]=> string(0) "" ["MULTIPLE_CNT"]=> string(1) "5" ["TMP_ID"]=> NULL ["LINK_IBLOCK_ID"]=> string(1) "0" ["WITH_DESCRIPTION"]=> string(1) "N" ["SEARCHABLE"]=> string(1) "N" ["FILTRABLE"]=> string(1) "N" ["IS_REQUIRED"]=> string(1) "N" ["VERSION"]=> string(1) "1" ["USER_TYPE"]=> string(4) "HTML" ["USER_TYPE_SETTINGS"]=> array(1) { ["height"]=> int(200) } ["HINT"]=> string(0) "" ["PROPERTY_VALUE_ID"]=> string(5) "18308" ["VALUE"]=> array(2) { ["TEXT"]=> string(1567) "<p class="bodytext">Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области.<br /><br /><h3>Ключевые слова</h3> <p>рассеянный склероз, аутологичная трансплантация стволовых кроветворных клеток, отдаленные результаты лечения, ранняя трансплантация, этапная трансплантация, трансплантация спасения  </p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(1515) "

Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области.

Ключевые слова

рассеянный склероз, аутологичная трансплантация стволовых кроветворных клеток, отдаленные результаты лечения, ранняя трансплантация, этапная трансплантация, трансплантация спасения 

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Andrei A. Novik¹, Aleksey N. Kuznetsov¹, Vladimir Y. Melnichenko¹, Denis A. Fedorenko¹, Tatyana I. Ionova², Kira A. Kurbatova²

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¹Pirogov National Medical Surgical Center, Moscow, Russia; ²Multinational Center for Quality of Life Research, Saint Petersburg, Russia

Correspondence
Professor Tatyana I. Ionova, Multinational Center for Quality of Life Research, 1 Artilleriiskaya str., 191014 St. Petersburg, Russia
E-mail: tion16@spam is badmail.ru

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High-dose immunosuppressive therapy (HDIT) with autologous hematopoietic stem cell transplantation (ASCT) is a promising approach to the treatment of multiple sclerosis (MS) patients. The data obtained points to the feasibility of early, conventional, and salvage HDIT +ASCT in MS patients. Further studies should be done to investigate clinical and patient-reported outcomes in MS patients receiving early, conventional, and salvage transplantation to better define treatment success. The concept of HDIT +ASCT in MS opens a new window of opportunity for treatment of this patient population.

Keywords

multiple sclerosis, autologous stem cell transplantation, long-term clinical outcomes, early ASCT, conventional ASCT, salvage ASCT

" ["TYPE"]=> string(4) "HTML" } ["~DESCRIPTION"]=> string(0) "" ["~NAME"]=> string(21) "Description / Summary" ["~DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } } ["NAME_EN"]=> array(36) { ["ID"]=> string(2) "40" ["TIMESTAMP_X"]=> string(19) "2015-09-03 10:49:47" ["IBLOCK_ID"]=> string(1) "2" ["NAME"]=> string(4) "Name" ["ACTIVE"]=> string(1) "Y" ["SORT"]=> string(3) "500" ["CODE"]=> string(7) "NAME_EN" ["DEFAULT_VALUE"]=> string(0) "" ["PROPERTY_TYPE"]=> string(1) "S" ["ROW_COUNT"]=> string(1) "1" ["COL_COUNT"]=> string(2) "80" ["LIST_TYPE"]=> string(1) "L" ["MULTIPLE"]=> string(1) "N" ["XML_ID"]=> string(2) "40" ["FILE_TYPE"]=> string(0) "" ["MULTIPLE_CNT"]=> string(1) "5" ["TMP_ID"]=> NULL ["LINK_IBLOCK_ID"]=> string(1) "0" ["WITH_DESCRIPTION"]=> string(1) "N" ["SEARCHABLE"]=> string(1) "N" ["FILTRABLE"]=> string(1) "N" ["IS_REQUIRED"]=> string(1) "Y" ["VERSION"]=> string(1) "1" ["USER_TYPE"]=> NULL ["USER_TYPE_SETTINGS"]=> NULL ["HINT"]=> string(0) "" ["PROPERTY_VALUE_ID"]=> string(5) "18294" ["VALUE"]=> string(92) "Three strategies of autologous hematopoietic stem cell transplantation in multiple sclerosis" ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> string(92) "Three strategies of autologous hematopoietic stem cell transplantation in multiple sclerosis" ["~DESCRIPTION"]=> string(0) "" ["~NAME"]=> string(4) "Name" ["~DEFAULT_VALUE"]=> string(0) "" } ["FULL_TEXT_RU"]=> &array(36) { ["ID"]=> string(2) "42" ["TIMESTAMP_X"]=> string(19) "2015-09-07 20:29:18" ["IBLOCK_ID"]=> string(1) "2" ["NAME"]=> string(23) "Полный текст" ["ACTIVE"]=> string(1) "Y" ["SORT"]=> string(3) "500" ["CODE"]=> string(12) "FULL_TEXT_RU" ["DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } ["PROPERTY_TYPE"]=> string(1) "S" ["ROW_COUNT"]=> string(1) "1" ["COL_COUNT"]=> string(2) "30" ["LIST_TYPE"]=> string(1) "L" ["MULTIPLE"]=> string(1) "N" ["XML_ID"]=> string(2) "42" ["FILE_TYPE"]=> string(0) "" ["MULTIPLE_CNT"]=> string(1) "5" ["TMP_ID"]=> NULL ["LINK_IBLOCK_ID"]=> string(1) "0" ["WITH_DESCRIPTION"]=> string(1) "N" ["SEARCHABLE"]=> string(1) "N" ["FILTRABLE"]=> string(1) "N" ["IS_REQUIRED"]=> string(1) "N" ["VERSION"]=> string(1) "1" ["USER_TYPE"]=> string(4) "HTML" ["USER_TYPE_SETTINGS"]=> array(1) { ["height"]=> int(200) } ["HINT"]=> string(0) "" ["PROPERTY_VALUE_ID"]=> string(5) "18309" ["VALUE"]=> array(2) { ["TEXT"]=> string(17433) "<p class="bodytext"> Традиционные методы иммуномодулирующей и иммуносупрессивной терапии рассеянного склероза (РС) не позволяют достичь выраженного и длительного терапевтического эффекта [4-7, 10]. Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). В настоящее время в мире выполнено более 700 трансплантаций больным с различными формами РС. Безопасность и эффективность метода изучена в международных многоцентровых исследованиях. К нерешенным вопросам ВИСТ+ТСКК относятся следующие: показания, методы трансплантации, режимы кондиционирования, деплеция Т-лимфоцитов, фармакоэкономическое обоснование и др. [3, 9, 11].<br> <br> Разработана концепция ВИСТ+ТКСК при РС, включающая следующие положения: содержание метода, основные показания, методика проведения трансплантации, общий алгоритм, направления дальнейших исследований. Основные положения концепции подтверждены результатами проспективного многоцентрового исследования Российской кооперативной группы клеточной терапии изучения эффективности ВИСТ+ТКСК у больных различными формами РС. <br> <br> В рамках концепции выделено две принципиальные цели лечения больных РС. Первая из них патогенетическая – остановить прогрессирование заболевания и предотвратить появление новых очагов демиелинизации в ЦНС за счет воздействия на иммунопатологический процесс на различных уровнях. Вторая цель, основная или конечная, состоит в сохранении и, по возможности, в улучшении качества жизни больных. Данные положения основаны на теории принятия решений в клинической медицине, согласно которой в формализованном виде существует три возможных цели лечения больного: <br> <br> I – излечение с учетом качества жизни больного после выздоровления, <br> II – увеличение продолжительности жизни больного с учетом ее качества<br> III – улучшение качества жизни больного. <br> <br> При РС, хроническом неизлечимом заболевании, в большинстве случаев не снижающем продолжительность жизни больного, максимально возможное восстановление и сохранение параметров качества жизни  является приоритетной целью лечения. Вследствие этого, наряду с традиционными лабораторными и инструментальными тестами, описывающими изменения в течении патологического процесса на фоне терапии, к ключевым критериям эффективности лечения РС следует отнести и показатели качества жизни больного, отражающие сложный комплекс физических, психологических и социальных детерминант, свойственных конкретному индивидууму. <br> <br> Учитывая вышесказанное, в рамках концепции выделены 3 вида трансплантации, отличающиеся по целям и времени проведения операции [12, 13]<br> <br> <b>Ранняя трансплантация</b><br> 1. Патогенетическая цель – предупредить развитие необратимых изменений в ЦНС в результате иммунопатологического процесса.<br> 2. Основная цель – сохранить качество жизни больного, предотвратить формирование инвалидизации. <br> 3. Время проведения – в дебюте заболевания.<br> <br> <b>Этапная трансплантация</b><br> 4. Патогенетическая цель – остановить прогрессирование  заболевания на фоне  самоподдерживающегося иммунопатологического процесса, имеющихся очагов  необратимых изменений и частично утраченных функций, предупредить появление новых очагов поражения.<br> 5. Основная цель – улучшить качество жизни больного и сохранить его на максимально возможном уровне, предупредить углубление инвалидизации пациента.<br> 6. Время проведения – на различных этапах прогрессирования РС при выходе заболевания из-под контроля традиционных методов лечения.<br> <br> <b>Трансплантация спасения<br> </b>7. Патогенетическая цель – остановить прогрессирование заболевания на фоне большого количества очагов необратимых изменений  и существенно нарушенных функций, предупредить появление новых очагов поражения.<br> 8. Основная цель – сохранить качество жизни больного на максимально возможном уровне, предотвратить наступление критической инвалидизации.<br> 9. Время проведения – в далеко зашедшей стадии заболевания при высокой активности иммунопатологического процесса, быстром прогрессировании инвалидизации больного. </p> <p class="bodytext"> В данном докладе представлены результаты исследования безопасности и эффективности ВИСТ+ТКСК у 132 больных РС, которым  ВИСТ+ТКСК проведена в Военно-медицинской академии (Санкт-Петербург) и Национальном медико-хирургическом центре им. Н.И. Пирогова (Москва), начиная с 1999 года. В исследование включено 58 мужчин и 74 женщины; средний возраст – 33 года. У 57 пациентов была диагностирована вторично-прогрессирующая форма заболевания, у 23 – первично-прогрессирующая,  у 9 – прогрессирующе-рецидивирующая и у 43 – рецидивирующая ремитирующая.  Выделены три группы пациентов в зависимости от вида трансплантации: ранняя трансплантация проводилась при EDSS от 1,5 до 3,0; этапная трансплантация - при EDSS от 3,5 до 6,5; трансплантация спасения - при EDSS от 7,0 до 8,5. 83 пациентам была проведена этапная ВИСТ+ТКСК;  43 – ранняя трансплантация; 7 – трансплантация спасения. Для кондиционирования использовали режимы BEAM или mini-BEAM. Эффект ВИСТ+ТКСК оценивали по изменению степени инвалидизации больного и активности заболевания.<br> <br> Отдельно была выделена группа больных, которым проводили консолидирующую терапию (митоксантрон) после ВИСТ+ТКСК. В эту группу вошли пациенты, имеющие факторы риска. В настоящее время данная группа включает 34 пациента; анализ результатов лечения в этой группе будет проведен в декабре 2009г.<br> <br> При проведении ВИСТ+ТКСК не было летальных исходов, связанных с трансплантацией, а также тяжелых непрогнозируемых осложнений. У всех больных зарегистрирован ответ на лечение: у половины больных было зарегистрировано клиническое улучшение; у остальных – стабилизация состояния. По данным МРТ у всех больных имелось либо улучшение,  либо стабилизация процесса. В отдаленные сроки после ВИСТ+ТКСК (2 года и более) у подавляющего большинства больных (более 90%) наблюдали клиническое улучшение или стабилизацию заболевания. По данным магнитно-резонансной томографии отсутствие активности заболевания зарегистрировано у всех больных с клиническим улучшением или стабилизацией. Особого внимания заслуживает группа больных, которым проведена ранняя ВИСТ+ТКСК, и группа больных, у которых трансплантацию проводили с применением немиелоаблативных режимов кондиционирования. <br> <br> ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области. </p> <h3>Литература</h3> <p class="bodytext"> 1. <a href="http://bloodjournal.hematologylibrary.org/cgi/reprint/91/7/2609" title="Opens external link in new window" target="_blank" class="external-link-new-window"><u>Burt RK, et al. Effect of disease stage on clinical outcome after syngeneic bone marrow transplantation for relapsing experimental autoimmune encephalomyelitis. Blood. 1998;91:2609–2616</u></a><u>.</u> </p> <p class="bodytext"> 2. Burt RK, et al. Autologous haematopoietic stem cell transplantation in multiple sclerosis: importance of disease stage on outcome [abstract]. Neurology. 2003;40:A150. </p> <p class="bodytext"> 3. Comi G, et al. Guidelines for autologous blood and marrow stem cell transplantation in multiple sclerosis: a consensus report written on behalf of the European Group for Blood and Marrow Transplantation and the European Charcot Foundation. J Neurol. 2000;247:376-382. </p> <p class="bodytext"> 4. <a href="http://www.nature.com/bmt/journal/v20/n8/pdf/1700944a.pdf" title="Opens external link in new window" target="_blank" class="external-link-new-window"><u>Fassas A, et al. Peripheral blood stem cell transplantation in the treatment of progressive multiple sclerosis: first results of a pilot study. Bone Marrow Transplant. 1997;20:631-638</u></a><u>.</u> </p> <p class="bodytext"> 5. Fassas A, et al. Autologous stem cell transplantation in progressive multiple sclerosisdan interim analysis of efficacy. J Clin Immunol. 2000;20:24-30. doi: 10.1023/A:1006686426090. </p> <p class="bodytext"> 6. Fassas A, et al. Haematopoietic stem cell transplantation for multiple sclerosis. A retrospective multicenter study. J Neurol. 2002;249:1088-1097. doi: 10.1007/s00415-002-0800-7. </p> <p class="bodytext"> 7. Fassas A, Nash R. Multiple sclerosis. Best Pract Res Clin Hematol. 2004;17:247-262. doi: 10.1016/j.beha.2004.04.005. </p> <p class="bodytext"> 8. <a href="http://bloodjournal.hematologylibrary.org/cgi/content/full/102/7/2364" title="Opens external link in new window" target="_blank" class="external-link-new-window"><u>Nash RA, et al. High-dose immunosuppressive therapy and autologous peripheral blood stem cell transplantation for severe multiple sclerosis. Blood. 2003;102:2364-2372. doi: 10.1182/blood-2002-12-3908</u></a><u>.</u> </p> <p class="bodytext"> 9. <a href="http://bloodjournal.hematologylibrary.org/cgi/content/full/105/6/2601" title="Opens external link in new window" target="_blank" class="external-link-new-window"><u>Saccardi R, et al. Autologous HSCT for severe progressive multiple sclerosis in a multicenter trial: impact on disease activity and quality of life. Blood. 2005;105:2601-2607. doi: 10.1182/blood-2004-08-3205</u></a><u>.</u> </p> <p class="bodytext"> 10. Saccardi R, et al. Autoimmune Diseases Working Party of EBMT. Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database. Mult Scler. 2006;12:814-823. </p> <p class="bodytext"> 11. <a href="typo3/1-2-shevchenko-et-al-2008dec3.html" title="Opens external link in new window" class="external-link-new-window"><u>Shevchenko Y, et al. Autologous hematopoietic stem cell transplantation in multiple sclerosis. Cellular Therapy and Transplantation (CTT). 2008;1:2. doi: 10.3205/ctt-2008-en-000025.01</u></a>. </p> <p class="bodytext"> 12. Shevchenko Y, Novik A, et al. Three strategies of high dose chemotherapy (HDCT)+autologous stem cell transplantation (ASCT) in autoimmune diseases. Bone Marrow Transplantation. 2004;33(1):346. </p> <p class="bodytext"> 13. Shevchenko Y. et al. High-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation as a treatment option in multiple sclerosis. Experimental Hematology. 2008;36(8):922-928. doi: 10.1016/j.exphem.2008.03.001. </p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(16499) "

Традиционные методы иммуномодулирующей и иммуносупрессивной терапии рассеянного склероза (РС) не позволяют достичь выраженного и длительного терапевтического эффекта [4-7, 10]. Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). В настоящее время в мире выполнено более 700 трансплантаций больным с различными формами РС. Безопасность и эффективность метода изучена в международных многоцентровых исследованиях. К нерешенным вопросам ВИСТ+ТСКК относятся следующие: показания, методы трансплантации, режимы кондиционирования, деплеция Т-лимфоцитов, фармакоэкономическое обоснование и др. [3, 9, 11].

Разработана концепция ВИСТ+ТКСК при РС, включающая следующие положения: содержание метода, основные показания, методика проведения трансплантации, общий алгоритм, направления дальнейших исследований. Основные положения концепции подтверждены результатами проспективного многоцентрового исследования Российской кооперативной группы клеточной терапии изучения эффективности ВИСТ+ТКСК у больных различными формами РС. 

В рамках концепции выделено две принципиальные цели лечения больных РС. Первая из них патогенетическая – остановить прогрессирование заболевания и предотвратить появление новых очагов демиелинизации в ЦНС за счет воздействия на иммунопатологический процесс на различных уровнях. Вторая цель, основная или конечная, состоит в сохранении и, по возможности, в улучшении качества жизни больных. Данные положения основаны на теории принятия решений в клинической медицине, согласно которой в формализованном виде существует три возможных цели лечения больного: 

I – излечение с учетом качества жизни больного после выздоровления, 
II – увеличение продолжительности жизни больного с учетом ее качества
III – улучшение качества жизни больного. 

При РС, хроническом неизлечимом заболевании, в большинстве случаев не снижающем продолжительность жизни больного, максимально возможное восстановление и сохранение параметров качества жизни  является приоритетной целью лечения. Вследствие этого, наряду с традиционными лабораторными и инструментальными тестами, описывающими изменения в течении патологического процесса на фоне терапии, к ключевым критериям эффективности лечения РС следует отнести и показатели качества жизни больного, отражающие сложный комплекс физических, психологических и социальных детерминант, свойственных конкретному индивидууму. 

Учитывая вышесказанное, в рамках концепции выделены 3 вида трансплантации, отличающиеся по целям и времени проведения операции [12, 13]

Ранняя трансплантация
1. Патогенетическая цель – предупредить развитие необратимых изменений в ЦНС в результате иммунопатологического процесса.
2. Основная цель – сохранить качество жизни больного, предотвратить формирование инвалидизации. 
3. Время проведения – в дебюте заболевания.

Этапная трансплантация
4. Патогенетическая цель – остановить прогрессирование  заболевания на фоне  самоподдерживающегося иммунопатологического процесса, имеющихся очагов  необратимых изменений и частично утраченных функций, предупредить появление новых очагов поражения.
5. Основная цель – улучшить качество жизни больного и сохранить его на максимально возможном уровне, предупредить углубление инвалидизации пациента.
6. Время проведения – на различных этапах прогрессирования РС при выходе заболевания из-под контроля традиционных методов лечения.

Трансплантация спасения
7. Патогенетическая цель – остановить прогрессирование заболевания на фоне большого количества очагов необратимых изменений  и существенно нарушенных функций, предупредить появление новых очагов поражения.
8. Основная цель – сохранить качество жизни больного на максимально возможном уровне, предотвратить наступление критической инвалидизации.
9. Время проведения – в далеко зашедшей стадии заболевания при высокой активности иммунопатологического процесса, быстром прогрессировании инвалидизации больного.

В данном докладе представлены результаты исследования безопасности и эффективности ВИСТ+ТКСК у 132 больных РС, которым  ВИСТ+ТКСК проведена в Военно-медицинской академии (Санкт-Петербург) и Национальном медико-хирургическом центре им. Н.И. Пирогова (Москва), начиная с 1999 года. В исследование включено 58 мужчин и 74 женщины; средний возраст – 33 года. У 57 пациентов была диагностирована вторично-прогрессирующая форма заболевания, у 23 – первично-прогрессирующая,  у 9 – прогрессирующе-рецидивирующая и у 43 – рецидивирующая ремитирующая.  Выделены три группы пациентов в зависимости от вида трансплантации: ранняя трансплантация проводилась при EDSS от 1,5 до 3,0; этапная трансплантация - при EDSS от 3,5 до 6,5; трансплантация спасения - при EDSS от 7,0 до 8,5. 83 пациентам была проведена этапная ВИСТ+ТКСК;  43 – ранняя трансплантация; 7 – трансплантация спасения. Для кондиционирования использовали режимы BEAM или mini-BEAM. Эффект ВИСТ+ТКСК оценивали по изменению степени инвалидизации больного и активности заболевания.

Отдельно была выделена группа больных, которым проводили консолидирующую терапию (митоксантрон) после ВИСТ+ТКСК. В эту группу вошли пациенты, имеющие факторы риска. В настоящее время данная группа включает 34 пациента; анализ результатов лечения в этой группе будет проведен в декабре 2009г.

При проведении ВИСТ+ТКСК не было летальных исходов, связанных с трансплантацией, а также тяжелых непрогнозируемых осложнений. У всех больных зарегистрирован ответ на лечение: у половины больных было зарегистрировано клиническое улучшение; у остальных – стабилизация состояния. По данным МРТ у всех больных имелось либо улучшение,  либо стабилизация процесса. В отдаленные сроки после ВИСТ+ТКСК (2 года и более) у подавляющего большинства больных (более 90%) наблюдали клиническое улучшение или стабилизацию заболевания. По данным магнитно-резонансной томографии отсутствие активности заболевания зарегистрировано у всех больных с клиническим улучшением или стабилизацией. Особого внимания заслуживает группа больных, которым проведена ранняя ВИСТ+ТКСК, и группа больных, у которых трансплантацию проводили с применением немиелоаблативных режимов кондиционирования. 

ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области.

Литература

1. Burt RK, et al. Effect of disease stage on clinical outcome after syngeneic bone marrow transplantation for relapsing experimental autoimmune encephalomyelitis. Blood. 1998;91:2609–2616.

2. Burt RK, et al. Autologous haematopoietic stem cell transplantation in multiple sclerosis: importance of disease stage on outcome [abstract]. Neurology. 2003;40:A150.

3. Comi G, et al. Guidelines for autologous blood and marrow stem cell transplantation in multiple sclerosis: a consensus report written on behalf of the European Group for Blood and Marrow Transplantation and the European Charcot Foundation. J Neurol. 2000;247:376-382.

4. Fassas A, et al. Peripheral blood stem cell transplantation in the treatment of progressive multiple sclerosis: first results of a pilot study. Bone Marrow Transplant. 1997;20:631-638.

5. Fassas A, et al. Autologous stem cell transplantation in progressive multiple sclerosisdan interim analysis of efficacy. J Clin Immunol. 2000;20:24-30. doi: 10.1023/A:1006686426090.

6. Fassas A, et al. Haematopoietic stem cell transplantation for multiple sclerosis. A retrospective multicenter study. J Neurol. 2002;249:1088-1097. doi: 10.1007/s00415-002-0800-7.

7. Fassas A, Nash R. Multiple sclerosis. Best Pract Res Clin Hematol. 2004;17:247-262. doi: 10.1016/j.beha.2004.04.005.

8. Nash RA, et al. High-dose immunosuppressive therapy and autologous peripheral blood stem cell transplantation for severe multiple sclerosis. Blood. 2003;102:2364-2372. doi: 10.1182/blood-2002-12-3908.

9. Saccardi R, et al. Autologous HSCT for severe progressive multiple sclerosis in a multicenter trial: impact on disease activity and quality of life. Blood. 2005;105:2601-2607. doi: 10.1182/blood-2004-08-3205.

10. Saccardi R, et al. Autoimmune Diseases Working Party of EBMT. Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database. Mult Scler. 2006;12:814-823.

11. Shevchenko Y, et al. Autologous hematopoietic stem cell transplantation in multiple sclerosis. Cellular Therapy and Transplantation (CTT). 2008;1:2. doi: 10.3205/ctt-2008-en-000025.01.

12. Shevchenko Y, Novik A, et al. Three strategies of high dose chemotherapy (HDCT)+autologous stem cell transplantation (ASCT) in autoimmune diseases. Bone Marrow Transplantation. 2004;33(1):346.

13. Shevchenko Y. et al. High-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation as a treatment option in multiple sclerosis. Experimental Hematology. 2008;36(8):922-928. doi: 10.1016/j.exphem.2008.03.001.

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Novik¹, Aleksey N. Kuznetsov¹, Vladimir Y. Melnichenko¹, Denis A. Fedorenko¹, Tatyana I. Ionova², Kira A. Kurbatova²</p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(199) "

Andrei A. Novik¹, Aleksey N. Kuznetsov¹, Vladimir Y. Melnichenko¹, Denis A. Fedorenko¹, Tatyana I. Ionova², Kira A. Kurbatova²

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Andrei A. Novik¹, Aleksey N. Kuznetsov¹, Vladimir Y. Melnichenko¹, Denis A. Fedorenko¹, Tatyana I. Ionova², Kira A. Kurbatova²

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High-dose immunosuppressive therapy (HDIT) with autologous hematopoietic stem cell transplantation (ASCT) is a promising approach to the treatment of multiple sclerosis (MS) patients. The data obtained points to the feasibility of early, conventional, and salvage HDIT +ASCT in MS patients. Further studies should be done to investigate clinical and patient-reported outcomes in MS patients receiving early, conventional, and salvage transplantation to better define treatment success. The concept of HDIT +ASCT in MS opens a new window of opportunity for treatment of this patient population.

Keywords

multiple sclerosis, autologous stem cell transplantation, long-term clinical outcomes, early ASCT, conventional ASCT, salvage ASCT

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High-dose immunosuppressive therapy (HDIT) with autologous hematopoietic stem cell transplantation (ASCT) is a promising approach to the treatment of multiple sclerosis (MS) patients. The data obtained points to the feasibility of early, conventional, and salvage HDIT +ASCT in MS patients. Further studies should be done to investigate clinical and patient-reported outcomes in MS patients receiving early, conventional, and salvage transplantation to better define treatment success. The concept of HDIT +ASCT in MS opens a new window of opportunity for treatment of this patient population.

Keywords

multiple sclerosis, autologous stem cell transplantation, long-term clinical outcomes, early ASCT, conventional ASCT, salvage ASCT

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¹Pirogov National Medical Surgical Center, Moscow, Russia; ²Multinational Center for Quality of Life Research, Saint Petersburg, Russia

Correspondence
Professor Tatyana I. Ionova, Multinational Center for Quality of Life Research, 1 Artilleriiskaya str., 191014 St. Petersburg, Russia
E-mail: tion16@spam is badmail.ru

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¹Pirogov National Medical Surgical Center, Moscow, Russia; ²Multinational Center for Quality of Life Research, Saint Petersburg, Russia

Correspondence
Professor Tatyana I. Ionova, Multinational Center for Quality of Life Research, 1 Artilleriiskaya str., 191014 St. Petersburg, Russia
E-mail: tion16@spam is badmail.ru

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Aндрей A. Новик¹, Алексей Н. Кузнецов^1,2, Владимир Я. Мельниченко¹, Денис А. Федоренко¹, Tатьяна И. Ионова³, Кира А. Курбатова³

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ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области.<br /><br /><h3>Ключевые слова</h3> <p>рассеянный склероз, аутологичная трансплантация стволовых кроветворных клеток, отдаленные результаты лечения, ранняя трансплантация, этапная трансплантация, трансплантация спасения  </p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(1515) "

Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области.

Ключевые слова

рассеянный склероз, аутологичная трансплантация стволовых кроветворных клеток, отдаленные результаты лечения, ранняя трансплантация, этапная трансплантация, трансплантация спасения 

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Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области.

Ключевые слова

рассеянный склероз, аутологичная трансплантация стволовых кроветворных клеток, отдаленные результаты лечения, ранняя трансплантация, этапная трансплантация, трансплантация спасения 

" } ["ORGANIZATION_RU"]=> array(37) { ["ID"]=> string(2) "26" ["TIMESTAMP_X"]=> string(19) "2015-09-02 18:01:20" ["IBLOCK_ID"]=> string(1) "2" ["NAME"]=> string(22) "Организации" ["ACTIVE"]=> string(1) "Y" ["SORT"]=> string(3) "500" ["CODE"]=> string(15) "ORGANIZATION_RU" ["DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } ["PROPERTY_TYPE"]=> string(1) "S" ["ROW_COUNT"]=> string(1) "1" ["COL_COUNT"]=> string(2) "30" ["LIST_TYPE"]=> string(1) "L" ["MULTIPLE"]=> string(1) "N" ["XML_ID"]=> string(2) "26" ["FILE_TYPE"]=> string(0) "" ["MULTIPLE_CNT"]=> string(1) "5" ["TMP_ID"]=> NULL ["LINK_IBLOCK_ID"]=> string(1) "0" ["WITH_DESCRIPTION"]=> string(1) "N" ["SEARCHABLE"]=> string(1) "N" ["FILTRABLE"]=> string(1) "N" ["IS_REQUIRED"]=> string(1) "N" ["VERSION"]=> string(1) "1" ["USER_TYPE"]=> string(4) "HTML" ["USER_TYPE_SETTINGS"]=> array(1) { ["height"]=> int(200) } ["HINT"]=> string(0) "" ["PROPERTY_VALUE_ID"]=> string(5) "18307" ["VALUE"]=> array(2) { ["TEXT"]=> string(1287) "<p class="bodytext">¹Национальный медико-хирургический центр им. Н.И. Пирогова, Москва, Россия; ²Институт усовершенствования врачей Национального медико-хирургического центра им. Н.И.Пирогова, Москва, Россия; ³Межнациональный центр исследования качества жизни, Санкт-Петербург, Россия<br /><br /><b>Контакт</b><br> А. А. Новик, Национальный медико-хирургический центр им.Н.И. Пирогова, ул. Нижняя Первомайская 70,  Москва, 105203, Россия<br> E-mail: <a href="javascript:linkTo_UnCryptMailto('qempxs.rgvxg48Dqemp2vy');">ncrtc04@<span style="display:none;">spam is bad</span>mail.ru</a>, <a href="javascript:linkTo_UnCryptMailto('qempxs.ruspgDcerhib2vy');">nqolc@<span style="display:none;">spam is bad</span>yandex.ru</a>  </p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(1105) "

¹Национальный медико-хирургический центр им. Н.И. Пирогова, Москва, Россия; ²Институт усовершенствования врачей Национального медико-хирургического центра им. Н.И.Пирогова, Москва, Россия; ³Межнациональный центр исследования качества жизни, Санкт-Петербург, Россия

Контакт
А. А. Новик, Национальный медико-хирургический центр им.Н.И. Пирогова, ул. Нижняя Первомайская 70,  Москва, 105203, Россия
E-mail: ncrtc04@spam is badmail.ru, nqolc@spam is badyandex.ru 

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¹Национальный медико-хирургический центр им. Н.И. Пирогова, Москва, Россия; ²Институт усовершенствования врачей Национального медико-хирургического центра им. Н.И.Пирогова, Москва, Россия; ³Межнациональный центр исследования качества жизни, Санкт-Петербург, Россия

Контакт
А. А. Новик, Национальный медико-хирургический центр им.Н.И. Пирогова, ул. Нижняя Первомайская 70,  Москва, 105203, Россия
E-mail: ncrtc04@spam is badmail.ru, nqolc@spam is badyandex.ru 

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Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). В настоящее время в мире выполнено более 700 трансплантаций больным с различными формами РС. Безопасность и эффективность метода изучена в международных многоцентровых исследованиях. К нерешенным вопросам ВИСТ+ТСКК относятся следующие: показания, методы трансплантации, режимы кондиционирования, деплеция Т-лимфоцитов, фармакоэкономическое обоснование и др. [3, 9, 11].<br> <br> Разработана концепция ВИСТ+ТКСК при РС, включающая следующие положения: содержание метода, основные показания, методика проведения трансплантации, общий алгоритм, направления дальнейших исследований. Основные положения концепции подтверждены результатами проспективного многоцентрового исследования Российской кооперативной группы клеточной терапии изучения эффективности ВИСТ+ТКСК у больных различными формами РС. <br> <br> В рамках концепции выделено две принципиальные цели лечения больных РС. Первая из них патогенетическая – остановить прогрессирование заболевания и предотвратить появление новых очагов демиелинизации в ЦНС за счет воздействия на иммунопатологический процесс на различных уровнях. Вторая цель, основная или конечная, состоит в сохранении и, по возможности, в улучшении качества жизни больных. Данные положения основаны на теории принятия решений в клинической медицине, согласно которой в формализованном виде существует три возможных цели лечения больного: <br> <br> I – излечение с учетом качества жизни больного после выздоровления, <br> II – увеличение продолжительности жизни больного с учетом ее качества<br> III – улучшение качества жизни больного. <br> <br> При РС, хроническом неизлечимом заболевании, в большинстве случаев не снижающем продолжительность жизни больного, максимально возможное восстановление и сохранение параметров качества жизни  является приоритетной целью лечения. Вследствие этого, наряду с традиционными лабораторными и инструментальными тестами, описывающими изменения в течении патологического процесса на фоне терапии, к ключевым критериям эффективности лечения РС следует отнести и показатели качества жизни больного, отражающие сложный комплекс физических, психологических и социальных детерминант, свойственных конкретному индивидууму. <br> <br> Учитывая вышесказанное, в рамках концепции выделены 3 вида трансплантации, отличающиеся по целям и времени проведения операции [12, 13]<br> <br> <b>Ранняя трансплантация</b><br> 1. Патогенетическая цель – предупредить развитие необратимых изменений в ЦНС в результате иммунопатологического процесса.<br> 2. Основная цель – сохранить качество жизни больного, предотвратить формирование инвалидизации. <br> 3. Время проведения – в дебюте заболевания.<br> <br> <b>Этапная трансплантация</b><br> 4. Патогенетическая цель – остановить прогрессирование  заболевания на фоне  самоподдерживающегося иммунопатологического процесса, имеющихся очагов  необратимых изменений и частично утраченных функций, предупредить появление новых очагов поражения.<br> 5. Основная цель – улучшить качество жизни больного и сохранить его на максимально возможном уровне, предупредить углубление инвалидизации пациента.<br> 6. Время проведения – на различных этапах прогрессирования РС при выходе заболевания из-под контроля традиционных методов лечения.<br> <br> <b>Трансплантация спасения<br> </b>7. Патогенетическая цель – остановить прогрессирование заболевания на фоне большого количества очагов необратимых изменений  и существенно нарушенных функций, предупредить появление новых очагов поражения.<br> 8. Основная цель – сохранить качество жизни больного на максимально возможном уровне, предотвратить наступление критической инвалидизации.<br> 9. Время проведения – в далеко зашедшей стадии заболевания при высокой активности иммунопатологического процесса, быстром прогрессировании инвалидизации больного. </p> <p class="bodytext"> В данном докладе представлены результаты исследования безопасности и эффективности ВИСТ+ТКСК у 132 больных РС, которым  ВИСТ+ТКСК проведена в Военно-медицинской академии (Санкт-Петербург) и Национальном медико-хирургическом центре им. Н.И. Пирогова (Москва), начиная с 1999 года. В исследование включено 58 мужчин и 74 женщины; средний возраст – 33 года. У 57 пациентов была диагностирована вторично-прогрессирующая форма заболевания, у 23 – первично-прогрессирующая,  у 9 – прогрессирующе-рецидивирующая и у 43 – рецидивирующая ремитирующая.  Выделены три группы пациентов в зависимости от вида трансплантации: ранняя трансплантация проводилась при EDSS от 1,5 до 3,0; этапная трансплантация - при EDSS от 3,5 до 6,5; трансплантация спасения - при EDSS от 7,0 до 8,5. 83 пациентам была проведена этапная ВИСТ+ТКСК;  43 – ранняя трансплантация; 7 – трансплантация спасения. Для кондиционирования использовали режимы BEAM или mini-BEAM. Эффект ВИСТ+ТКСК оценивали по изменению степени инвалидизации больного и активности заболевания.<br> <br> Отдельно была выделена группа больных, которым проводили консолидирующую терапию (митоксантрон) после ВИСТ+ТКСК. В эту группу вошли пациенты, имеющие факторы риска. В настоящее время данная группа включает 34 пациента; анализ результатов лечения в этой группе будет проведен в декабре 2009г.<br> <br> При проведении ВИСТ+ТКСК не было летальных исходов, связанных с трансплантацией, а также тяжелых непрогнозируемых осложнений. У всех больных зарегистрирован ответ на лечение: у половины больных было зарегистрировано клиническое улучшение; у остальных – стабилизация состояния. По данным МРТ у всех больных имелось либо улучшение,  либо стабилизация процесса. В отдаленные сроки после ВИСТ+ТКСК (2 года и более) у подавляющего большинства больных (более 90%) наблюдали клиническое улучшение или стабилизацию заболевания. По данным магнитно-резонансной томографии отсутствие активности заболевания зарегистрировано у всех больных с клиническим улучшением или стабилизацией. Особого внимания заслуживает группа больных, которым проведена ранняя ВИСТ+ТКСК, и группа больных, у которых трансплантацию проводили с применением немиелоаблативных режимов кондиционирования. <br> <br> ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области. </p> <h3>Литература</h3> <p class="bodytext"> 1. <a href="http://bloodjournal.hematologylibrary.org/cgi/reprint/91/7/2609" title="Opens external link in new window" target="_blank" class="external-link-new-window"><u>Burt RK, et al. Effect of disease stage on clinical outcome after syngeneic bone marrow transplantation for relapsing experimental autoimmune encephalomyelitis. Blood. 1998;91:2609–2616</u></a><u>.</u> </p> <p class="bodytext"> 2. Burt RK, et al. Autologous haematopoietic stem cell transplantation in multiple sclerosis: importance of disease stage on outcome [abstract]. Neurology. 2003;40:A150. </p> <p class="bodytext"> 3. Comi G, et al. Guidelines for autologous blood and marrow stem cell transplantation in multiple sclerosis: a consensus report written on behalf of the European Group for Blood and Marrow Transplantation and the European Charcot Foundation. J Neurol. 2000;247:376-382. </p> <p class="bodytext"> 4. <a href="http://www.nature.com/bmt/journal/v20/n8/pdf/1700944a.pdf" title="Opens external link in new window" target="_blank" class="external-link-new-window"><u>Fassas A, et al. Peripheral blood stem cell transplantation in the treatment of progressive multiple sclerosis: first results of a pilot study. Bone Marrow Transplant. 1997;20:631-638</u></a><u>.</u> </p> <p class="bodytext"> 5. Fassas A, et al. Autologous stem cell transplantation in progressive multiple sclerosisdan interim analysis of efficacy. J Clin Immunol. 2000;20:24-30. doi: 10.1023/A:1006686426090. </p> <p class="bodytext"> 6. Fassas A, et al. Haematopoietic stem cell transplantation for multiple sclerosis. A retrospective multicenter study. J Neurol. 2002;249:1088-1097. doi: 10.1007/s00415-002-0800-7. </p> <p class="bodytext"> 7. Fassas A, Nash R. Multiple sclerosis. Best Pract Res Clin Hematol. 2004;17:247-262. doi: 10.1016/j.beha.2004.04.005. </p> <p class="bodytext"> 8. <a href="http://bloodjournal.hematologylibrary.org/cgi/content/full/102/7/2364" title="Opens external link in new window" target="_blank" class="external-link-new-window"><u>Nash RA, et al. High-dose immunosuppressive therapy and autologous peripheral blood stem cell transplantation for severe multiple sclerosis. Blood. 2003;102:2364-2372. doi: 10.1182/blood-2002-12-3908</u></a><u>.</u> </p> <p class="bodytext"> 9. <a href="http://bloodjournal.hematologylibrary.org/cgi/content/full/105/6/2601" title="Opens external link in new window" target="_blank" class="external-link-new-window"><u>Saccardi R, et al. Autologous HSCT for severe progressive multiple sclerosis in a multicenter trial: impact on disease activity and quality of life. Blood. 2005;105:2601-2607. doi: 10.1182/blood-2004-08-3205</u></a><u>.</u> </p> <p class="bodytext"> 10. Saccardi R, et al. Autoimmune Diseases Working Party of EBMT. Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database. Mult Scler. 2006;12:814-823. </p> <p class="bodytext"> 11. <a href="typo3/1-2-shevchenko-et-al-2008dec3.html" title="Opens external link in new window" class="external-link-new-window"><u>Shevchenko Y, et al. Autologous hematopoietic stem cell transplantation in multiple sclerosis. Cellular Therapy and Transplantation (CTT). 2008;1:2. doi: 10.3205/ctt-2008-en-000025.01</u></a>. </p> <p class="bodytext"> 12. Shevchenko Y, Novik A, et al. Three strategies of high dose chemotherapy (HDCT)+autologous stem cell transplantation (ASCT) in autoimmune diseases. Bone Marrow Transplantation. 2004;33(1):346. </p> <p class="bodytext"> 13. Shevchenko Y. et al. High-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation as a treatment option in multiple sclerosis. Experimental Hematology. 2008;36(8):922-928. doi: 10.1016/j.exphem.2008.03.001. </p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(16499) "

Традиционные методы иммуномодулирующей и иммуносупрессивной терапии рассеянного склероза (РС) не позволяют достичь выраженного и длительного терапевтического эффекта [4-7, 10]. Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). В настоящее время в мире выполнено более 700 трансплантаций больным с различными формами РС. Безопасность и эффективность метода изучена в международных многоцентровых исследованиях. К нерешенным вопросам ВИСТ+ТСКК относятся следующие: показания, методы трансплантации, режимы кондиционирования, деплеция Т-лимфоцитов, фармакоэкономическое обоснование и др. [3, 9, 11].

Разработана концепция ВИСТ+ТКСК при РС, включающая следующие положения: содержание метода, основные показания, методика проведения трансплантации, общий алгоритм, направления дальнейших исследований. Основные положения концепции подтверждены результатами проспективного многоцентрового исследования Российской кооперативной группы клеточной терапии изучения эффективности ВИСТ+ТКСК у больных различными формами РС. 

В рамках концепции выделено две принципиальные цели лечения больных РС. Первая из них патогенетическая – остановить прогрессирование заболевания и предотвратить появление новых очагов демиелинизации в ЦНС за счет воздействия на иммунопатологический процесс на различных уровнях. Вторая цель, основная или конечная, состоит в сохранении и, по возможности, в улучшении качества жизни больных. Данные положения основаны на теории принятия решений в клинической медицине, согласно которой в формализованном виде существует три возможных цели лечения больного: 

I – излечение с учетом качества жизни больного после выздоровления, 
II – увеличение продолжительности жизни больного с учетом ее качества
III – улучшение качества жизни больного. 

При РС, хроническом неизлечимом заболевании, в большинстве случаев не снижающем продолжительность жизни больного, максимально возможное восстановление и сохранение параметров качества жизни  является приоритетной целью лечения. Вследствие этого, наряду с традиционными лабораторными и инструментальными тестами, описывающими изменения в течении патологического процесса на фоне терапии, к ключевым критериям эффективности лечения РС следует отнести и показатели качества жизни больного, отражающие сложный комплекс физических, психологических и социальных детерминант, свойственных конкретному индивидууму. 

Учитывая вышесказанное, в рамках концепции выделены 3 вида трансплантации, отличающиеся по целям и времени проведения операции [12, 13]

Ранняя трансплантация
1. Патогенетическая цель – предупредить развитие необратимых изменений в ЦНС в результате иммунопатологического процесса.
2. Основная цель – сохранить качество жизни больного, предотвратить формирование инвалидизации. 
3. Время проведения – в дебюте заболевания.

Этапная трансплантация
4. Патогенетическая цель – остановить прогрессирование  заболевания на фоне  самоподдерживающегося иммунопатологического процесса, имеющихся очагов  необратимых изменений и частично утраченных функций, предупредить появление новых очагов поражения.
5. Основная цель – улучшить качество жизни больного и сохранить его на максимально возможном уровне, предупредить углубление инвалидизации пациента.
6. Время проведения – на различных этапах прогрессирования РС при выходе заболевания из-под контроля традиционных методов лечения.

Трансплантация спасения
7. Патогенетическая цель – остановить прогрессирование заболевания на фоне большого количества очагов необратимых изменений  и существенно нарушенных функций, предупредить появление новых очагов поражения.
8. Основная цель – сохранить качество жизни больного на максимально возможном уровне, предотвратить наступление критической инвалидизации.
9. Время проведения – в далеко зашедшей стадии заболевания при высокой активности иммунопатологического процесса, быстром прогрессировании инвалидизации больного.

В данном докладе представлены результаты исследования безопасности и эффективности ВИСТ+ТКСК у 132 больных РС, которым  ВИСТ+ТКСК проведена в Военно-медицинской академии (Санкт-Петербург) и Национальном медико-хирургическом центре им. Н.И. Пирогова (Москва), начиная с 1999 года. В исследование включено 58 мужчин и 74 женщины; средний возраст – 33 года. У 57 пациентов была диагностирована вторично-прогрессирующая форма заболевания, у 23 – первично-прогрессирующая,  у 9 – прогрессирующе-рецидивирующая и у 43 – рецидивирующая ремитирующая.  Выделены три группы пациентов в зависимости от вида трансплантации: ранняя трансплантация проводилась при EDSS от 1,5 до 3,0; этапная трансплантация - при EDSS от 3,5 до 6,5; трансплантация спасения - при EDSS от 7,0 до 8,5. 83 пациентам была проведена этапная ВИСТ+ТКСК;  43 – ранняя трансплантация; 7 – трансплантация спасения. Для кондиционирования использовали режимы BEAM или mini-BEAM. Эффект ВИСТ+ТКСК оценивали по изменению степени инвалидизации больного и активности заболевания.

Отдельно была выделена группа больных, которым проводили консолидирующую терапию (митоксантрон) после ВИСТ+ТКСК. В эту группу вошли пациенты, имеющие факторы риска. В настоящее время данная группа включает 34 пациента; анализ результатов лечения в этой группе будет проведен в декабре 2009г.

При проведении ВИСТ+ТКСК не было летальных исходов, связанных с трансплантацией, а также тяжелых непрогнозируемых осложнений. У всех больных зарегистрирован ответ на лечение: у половины больных было зарегистрировано клиническое улучшение; у остальных – стабилизация состояния. По данным МРТ у всех больных имелось либо улучшение,  либо стабилизация процесса. В отдаленные сроки после ВИСТ+ТКСК (2 года и более) у подавляющего большинства больных (более 90%) наблюдали клиническое улучшение или стабилизацию заболевания. По данным магнитно-резонансной томографии отсутствие активности заболевания зарегистрировано у всех больных с клиническим улучшением или стабилизацией. Особого внимания заслуживает группа больных, которым проведена ранняя ВИСТ+ТКСК, и группа больных, у которых трансплантацию проводили с применением немиелоаблативных режимов кондиционирования. 

ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области.

Литература

1. Burt RK, et al. Effect of disease stage on clinical outcome after syngeneic bone marrow transplantation for relapsing experimental autoimmune encephalomyelitis. Blood. 1998;91:2609–2616.

2. Burt RK, et al. Autologous haematopoietic stem cell transplantation in multiple sclerosis: importance of disease stage on outcome [abstract]. Neurology. 2003;40:A150.

3. Comi G, et al. Guidelines for autologous blood and marrow stem cell transplantation in multiple sclerosis: a consensus report written on behalf of the European Group for Blood and Marrow Transplantation and the European Charcot Foundation. J Neurol. 2000;247:376-382.

4. Fassas A, et al. Peripheral blood stem cell transplantation in the treatment of progressive multiple sclerosis: first results of a pilot study. Bone Marrow Transplant. 1997;20:631-638.

5. Fassas A, et al. Autologous stem cell transplantation in progressive multiple sclerosisdan interim analysis of efficacy. J Clin Immunol. 2000;20:24-30. doi: 10.1023/A:1006686426090.

6. Fassas A, et al. Haematopoietic stem cell transplantation for multiple sclerosis. A retrospective multicenter study. J Neurol. 2002;249:1088-1097. doi: 10.1007/s00415-002-0800-7.

7. Fassas A, Nash R. Multiple sclerosis. Best Pract Res Clin Hematol. 2004;17:247-262. doi: 10.1016/j.beha.2004.04.005.

8. Nash RA, et al. High-dose immunosuppressive therapy and autologous peripheral blood stem cell transplantation for severe multiple sclerosis. Blood. 2003;102:2364-2372. doi: 10.1182/blood-2002-12-3908.

9. Saccardi R, et al. Autologous HSCT for severe progressive multiple sclerosis in a multicenter trial: impact on disease activity and quality of life. Blood. 2005;105:2601-2607. doi: 10.1182/blood-2004-08-3205.

10. Saccardi R, et al. Autoimmune Diseases Working Party of EBMT. Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database. Mult Scler. 2006;12:814-823.

11. Shevchenko Y, et al. Autologous hematopoietic stem cell transplantation in multiple sclerosis. Cellular Therapy and Transplantation (CTT). 2008;1:2. doi: 10.3205/ctt-2008-en-000025.01.

12. Shevchenko Y, Novik A, et al. Three strategies of high dose chemotherapy (HDCT)+autologous stem cell transplantation (ASCT) in autoimmune diseases. Bone Marrow Transplantation. 2004;33(1):346.

13. Shevchenko Y. et al. High-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation as a treatment option in multiple sclerosis. Experimental Hematology. 2008;36(8):922-928. doi: 10.1016/j.exphem.2008.03.001.

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Традиционные методы иммуномодулирующей и иммуносупрессивной терапии рассеянного склероза (РС) не позволяют достичь выраженного и длительного терапевтического эффекта [4-7, 10]. Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). В настоящее время в мире выполнено более 700 трансплантаций больным с различными формами РС. Безопасность и эффективность метода изучена в международных многоцентровых исследованиях. К нерешенным вопросам ВИСТ+ТСКК относятся следующие: показания, методы трансплантации, режимы кондиционирования, деплеция Т-лимфоцитов, фармакоэкономическое обоснование и др. [3, 9, 11].

Разработана концепция ВИСТ+ТКСК при РС, включающая следующие положения: содержание метода, основные показания, методика проведения трансплантации, общий алгоритм, направления дальнейших исследований. Основные положения концепции подтверждены результатами проспективного многоцентрового исследования Российской кооперативной группы клеточной терапии изучения эффективности ВИСТ+ТКСК у больных различными формами РС. 

В рамках концепции выделено две принципиальные цели лечения больных РС. Первая из них патогенетическая – остановить прогрессирование заболевания и предотвратить появление новых очагов демиелинизации в ЦНС за счет воздействия на иммунопатологический процесс на различных уровнях. Вторая цель, основная или конечная, состоит в сохранении и, по возможности, в улучшении качества жизни больных. Данные положения основаны на теории принятия решений в клинической медицине, согласно которой в формализованном виде существует три возможных цели лечения больного: 

I – излечение с учетом качества жизни больного после выздоровления, 
II – увеличение продолжительности жизни больного с учетом ее качества
III – улучшение качества жизни больного. 

При РС, хроническом неизлечимом заболевании, в большинстве случаев не снижающем продолжительность жизни больного, максимально возможное восстановление и сохранение параметров качества жизни  является приоритетной целью лечения. Вследствие этого, наряду с традиционными лабораторными и инструментальными тестами, описывающими изменения в течении патологического процесса на фоне терапии, к ключевым критериям эффективности лечения РС следует отнести и показатели качества жизни больного, отражающие сложный комплекс физических, психологических и социальных детерминант, свойственных конкретному индивидууму. 

Учитывая вышесказанное, в рамках концепции выделены 3 вида трансплантации, отличающиеся по целям и времени проведения операции [12, 13]

Ранняя трансплантация
1. Патогенетическая цель – предупредить развитие необратимых изменений в ЦНС в результате иммунопатологического процесса.
2. Основная цель – сохранить качество жизни больного, предотвратить формирование инвалидизации. 
3. Время проведения – в дебюте заболевания.

Этапная трансплантация
4. Патогенетическая цель – остановить прогрессирование  заболевания на фоне  самоподдерживающегося иммунопатологического процесса, имеющихся очагов  необратимых изменений и частично утраченных функций, предупредить появление новых очагов поражения.
5. Основная цель – улучшить качество жизни больного и сохранить его на максимально возможном уровне, предупредить углубление инвалидизации пациента.
6. Время проведения – на различных этапах прогрессирования РС при выходе заболевания из-под контроля традиционных методов лечения.

Трансплантация спасения
7. Патогенетическая цель – остановить прогрессирование заболевания на фоне большого количества очагов необратимых изменений  и существенно нарушенных функций, предупредить появление новых очагов поражения.
8. Основная цель – сохранить качество жизни больного на максимально возможном уровне, предотвратить наступление критической инвалидизации.
9. Время проведения – в далеко зашедшей стадии заболевания при высокой активности иммунопатологического процесса, быстром прогрессировании инвалидизации больного.

В данном докладе представлены результаты исследования безопасности и эффективности ВИСТ+ТКСК у 132 больных РС, которым  ВИСТ+ТКСК проведена в Военно-медицинской академии (Санкт-Петербург) и Национальном медико-хирургическом центре им. Н.И. Пирогова (Москва), начиная с 1999 года. В исследование включено 58 мужчин и 74 женщины; средний возраст – 33 года. У 57 пациентов была диагностирована вторично-прогрессирующая форма заболевания, у 23 – первично-прогрессирующая,  у 9 – прогрессирующе-рецидивирующая и у 43 – рецидивирующая ремитирующая.  Выделены три группы пациентов в зависимости от вида трансплантации: ранняя трансплантация проводилась при EDSS от 1,5 до 3,0; этапная трансплантация - при EDSS от 3,5 до 6,5; трансплантация спасения - при EDSS от 7,0 до 8,5. 83 пациентам была проведена этапная ВИСТ+ТКСК;  43 – ранняя трансплантация; 7 – трансплантация спасения. Для кондиционирования использовали режимы BEAM или mini-BEAM. Эффект ВИСТ+ТКСК оценивали по изменению степени инвалидизации больного и активности заболевания.

Отдельно была выделена группа больных, которым проводили консолидирующую терапию (митоксантрон) после ВИСТ+ТКСК. В эту группу вошли пациенты, имеющие факторы риска. В настоящее время данная группа включает 34 пациента; анализ результатов лечения в этой группе будет проведен в декабре 2009г.

При проведении ВИСТ+ТКСК не было летальных исходов, связанных с трансплантацией, а также тяжелых непрогнозируемых осложнений. У всех больных зарегистрирован ответ на лечение: у половины больных было зарегистрировано клиническое улучшение; у остальных – стабилизация состояния. По данным МРТ у всех больных имелось либо улучшение,  либо стабилизация процесса. В отдаленные сроки после ВИСТ+ТКСК (2 года и более) у подавляющего большинства больных (более 90%) наблюдали клиническое улучшение или стабилизацию заболевания. По данным магнитно-резонансной томографии отсутствие активности заболевания зарегистрировано у всех больных с клиническим улучшением или стабилизацией. Особого внимания заслуживает группа больных, которым проведена ранняя ВИСТ+ТКСК, и группа больных, у которых трансплантацию проводили с применением немиелоаблативных режимов кондиционирования. 

ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области.

Литература

1. Burt RK, et al. Effect of disease stage on clinical outcome after syngeneic bone marrow transplantation for relapsing experimental autoimmune encephalomyelitis. Blood. 1998;91:2609–2616.

2. Burt RK, et al. Autologous haematopoietic stem cell transplantation in multiple sclerosis: importance of disease stage on outcome [abstract]. Neurology. 2003;40:A150.

3. Comi G, et al. Guidelines for autologous blood and marrow stem cell transplantation in multiple sclerosis: a consensus report written on behalf of the European Group for Blood and Marrow Transplantation and the European Charcot Foundation. J Neurol. 2000;247:376-382.

4. Fassas A, et al. Peripheral blood stem cell transplantation in the treatment of progressive multiple sclerosis: first results of a pilot study. Bone Marrow Transplant. 1997;20:631-638.

5. Fassas A, et al. Autologous stem cell transplantation in progressive multiple sclerosisdan interim analysis of efficacy. J Clin Immunol. 2000;20:24-30. doi: 10.1023/A:1006686426090.

6. Fassas A, et al. Haematopoietic stem cell transplantation for multiple sclerosis. A retrospective multicenter study. J Neurol. 2002;249:1088-1097. doi: 10.1007/s00415-002-0800-7.

7. Fassas A, Nash R. Multiple sclerosis. Best Pract Res Clin Hematol. 2004;17:247-262. doi: 10.1016/j.beha.2004.04.005.

8. Nash RA, et al. High-dose immunosuppressive therapy and autologous peripheral blood stem cell transplantation for severe multiple sclerosis. Blood. 2003;102:2364-2372. doi: 10.1182/blood-2002-12-3908.

9. Saccardi R, et al. Autologous HSCT for severe progressive multiple sclerosis in a multicenter trial: impact on disease activity and quality of life. Blood. 2005;105:2601-2607. doi: 10.1182/blood-2004-08-3205.

10. Saccardi R, et al. Autoimmune Diseases Working Party of EBMT. Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database. Mult Scler. 2006;12:814-823.

11. Shevchenko Y, et al. Autologous hematopoietic stem cell transplantation in multiple sclerosis. Cellular Therapy and Transplantation (CTT). 2008;1:2. doi: 10.3205/ctt-2008-en-000025.01.

12. Shevchenko Y, Novik A, et al. Three strategies of high dose chemotherapy (HDCT)+autologous stem cell transplantation (ASCT) in autoimmune diseases. Bone Marrow Transplantation. 2004;33(1):346.

13. Shevchenko Y. et al. High-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation as a treatment option in multiple sclerosis. Experimental Hematology. 2008;36(8):922-928. doi: 10.1016/j.exphem.2008.03.001.

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Introduction

Multiple sclerosis (MS) is a chronic immune-mediated disease of the central nervous system, producing multifocal neurological symptoms caused by nerve demyelination and progressive neurodegeneration. The pathological hallmark of MS is multiple demyelinated plaques (sharply defined areas of demyelination) in the white matter and widely distributed areas of degeneration [7, 10]. The core process in MS is inflammatory, with T cells and their mediators triggering myelin injury; additionally, oligodendrocyte/myelin damage is often mediated by autoantibody fixation with consequent complement activation. Therefore, multiple sclerosis is an autoimmune condition with a complex pathogenesis involving cellular and humoral immune response activation [3].

Presently in MS four types of neural tissue injury can be distinguished [9]. Two of them are caused by activation of cellular and humoral immune system compartments, and the others are characterized by degenerative changes in oligodendrocytes with primary or distal injury. These four types can occur at the different stages of MS. The present conception of MS pathogenesis encompasses two basic mechanisms – autoimmune inflammation and neurodegenerative changes [1, 11].

Multiple studies and clinical observations showed the progressive decrease of brain tissue total volume in MS [4, 12, 15, 16]. The beginning of the disease course is characterized by repeated episodes of inflammation with new contrast-accumulating T2 lesions revealed by MRI. However a considerable amount of recent data suggests the importance of degenerative changes at the earliest stages of the disease [4]. Today the pathogenesis of MS is considered to be a complex process with the inflammatory component being only a part of the general process.

Even small T2 lesions can be associated with general atrophy, though within the clinical course brain atrophy is not always associated with high EDSS scores. Recently much attention has been given to focal atrophy at different stages of MS [2, 5, 13, 14]. Apart from direct cell damage, the mechanism of inflammation can exert a protective effect. The immune cells recruited to the inflammatory foci produce growth factors, are able to delete myelin-associated molecules, and can have a suppressive phenotype. Therefore there are still some controversies in the inflammatory concept to be resolved.
 
Patients with MS receive treatment with Copaxone, Betaseron, Rebif-44, monoclonal antibodies, and cytostatics. In MS cases the most promising seems to be a complex therapy aimed at inflammatory process suppression and neuroprotection [6, 8].

The aim of our study was to investigate the role of autologous HSCT in treatment of patients with MS as a complex treatment.

The first autologous hematopoietic stem cell transplantation (auto-HSCT) was performed in 2001. According to protocol, the patients were divided into two groups based on the rate of disease progression. The patients with fast progression of MS belong to the first group. In this group we consider a salvage high-dose chemotherapy with fludarabine-melphalan conditioning regimen and auto-HSCT. The patients with a stable disease course were included into the second group and received BEAM as a conditioning regimen.

Inclusion criteria

• Definitive MS (McDonald, 2005)

• Relapsing-remitting MS; second progressive MS and aggressive MS with severe relapses.

• Age 18–55 yrs.

• Duration of MS ≥1 year

• EDSS 0–6.5

• MRI within the 30 days period before auto-SCT

• Standard therapy methods proven to be ineffective

• The increase of EDSS 1.5 (EDSS 3.0–5.0) or 1 (EDSS ≥5.5)

• 2 relapses in the last 24 months or 1 relapse in the last 12 months on standard therapy.

The follow-up period varied from 2 months to 8 years.

• Median age 34.5 (22–52) yrs

• Sex distribution: male: 11 patients, median age 31.7 (22– 41) yrs; female: 12 patients, median age 37 (26–52) yrs

• PPMS = 5 patients, SPMS = 12 patients, R-RMS = 6 patients

• Median period from debut of MS to auto-SCT: 6.8 yrs

• Median EDSS: 5.7 (1.5–7.5)ВЕАМ: 17 patients, Flu-Mel: 6 patients

• Median of neutropenia duration: 12.7 days (ВЕАМ: 12.6, Flu-Mel: 12.8 days).

To evaluate the therapy effects, clinical scales and immunological and radiological methods were used. We used the EDSS scale, MSFC clinical outcome measure, and a relapse evaluation test. The methods of immunological status evaluation included:

• detection of oligoclonal bands (OCB) in plasma and cerebrospinal fluid (CSF)

• light chain detection in plasma and CSF

• plasma and CSF T cell cytofluorometry (CD 3+CD19-; CD3+CD8+; CD3+CD4+; CD3+CD19+; CD3-CD19+; CD3-СD20+; CD3-CD(16+56); CD3+CD(16+56); CD3+HLA-DR+; CD3-HLA-DR+; CD3+HLA-DR-; CD4+CD25+; СВ19+СВ27+ phenotypes).

For CSN visualization the following MRI protocol was used:

• Routine protocol with contrast (Gd)

• T2 and T1 volume

• T1 and T2 lesion calculation

• Brain volume evaluation

Prior to auto-HSCT the patients received the following treatment: pulse therapy with steroids: 90%, beta-IFN: (Betaseron, Rebif, Avonex) 54%, mitoxantrone: 15%, Copaxone: 22%, intravenous IgG: 5%, no previous treatment: 5%.

Outcomes

Clinical symptoms evaluation: two end-points for EDSS assessment were established (day 0 and 12 months after auto-SCT). An evident therapy effect was observed in three patients, with decreases of EDSS scores from 6.5 to 1.5 in one patient, and from 5.5 to 4.5 in two patients. 10 patients (43.4%) remained with stable EDSS score values for 12 months after auto-SCT. 4 patients (17.3%) experienced disease progression (increase of EDSS). One patient died of sepsis.

MRI metrics examined included the number of Gd enhancing lesions, number of T2 lesions, total T2 lesion volume, and atrophy evaluation (decrease of total brain volume; changes in the third ventricle diameter; atrophy of corpus callosum). In the 18-month period after auto-SCT an increase in T2 lesion volumes was observed in 8% of cases, 20.4% of patients developed new T2 lesions, and 12% of patients had T1 contrast lesions. MRI signs of general brain atrophy were found in 95.6% of patients. We observed a certain discrepancy of MRI signs: while the volume of T2 lesions decreased and no signs of systemic inflammation were observed, the atrophic changes continued to progress. Judging by MRI metrics, auto-SCT can eliminate the inflammatory, but not the neurodegenerative component of MS.

Immunology: We performed cytofluorometry of serum and CSF immunocompetent cell populations, and evaluated the level of intrathecal IgG as a highly specific marker of MS. Cell population changes showed no definite pattern and are hard to interpret. No evident dynamics of intrathecal IgG level was observed.

After ASCT 91.1% patients had constant intratecal synthesis of OCB. Only in 1 patient we revealed no signs of OCB synthesis in CSF and plasma.  

Early post-transplant period complications: infectious complications: 84%; hemorrhagic complications: 54%; serum sickness: 44%; neurological complications: 30%.

Conclusions

Our results show the evident decrease of inflammatory changes and better disease control in MS patients treated with conventional chemotherapy or high-dose chemotherapy with auto-HSCT due to its immunosuppressive effect. However, more intensive therapy is associated with a higher complications rate and risk of mortality. There are some questions still unanswered. It is still to be determined whether the conventional regimens able to roll the disease course back to previous stages or more radical high-dose therapy lead to better long-term survival and disease control. Also still to be determined is the best time for high-dose therapeutic intervention.

On the whole, auto-HSCT is a promising method of MS treatment, but there are certain practical aspects to be developed:

• Indications for auto-SCT

• Conditioning regimen

• Stem cell source and transplant processing

• Complex methods of disease course evaluation (clinical, immunological, radiological, and morphological evaluation)

• Quality of life evaluation

• Role of mesenchymal stem cells and monoclonal antibodies in the treatment of multiple sclerosis.

References

1. Barnett MH, Prineas JW. Relapsing and remitting multiple sclerosis: pathology of the newly forming lesion. Ann Neurol. 2004;55:458-68. doi: 10.1002/ana.20016.

2. Benedict RH, Hussein S, Englert J, Dwyer MG, Abdelrahman N, Cox JL, et al. Cortical atrophy and personality in multiple sclerosis. Neuropsychology. 2008;22:432-41. doi: 10.1037/0894-4105.22.4.432.

3. Evdoshenko E, Maslyansky A, Zaslavsky L, Skoromets A, Ziuzgin I, Riabykina O, et al. Opportunities of anti B-cell therapy in multiple sclerosis. Medical Immunology. 2009;11:63-70.

4. Gauthier SA, Berger AM, Liptak Z, Duan Y, Egorova S, Buckle GJ, et al. Rate of brain atrophy in benign vs early multiple sclerosis. Arch Neurol. 2009;66:234-7.

5. Giorgio A, Battaglini M, Smith SM, De Stefano N. Brain atrophy assessment in multiple sclerosis: importance and limitations. Neuroimaging Clin N Am. 2008;18:675-86, xi. doi: 10.1016/j.nic.2008.06.007.

6. Hohlfeld R, Kerschensteiner M, Stadelmann C, Lassmann H, Wekerle H. The neuroprotective effect of inflammation: implications for the therapy of multiple sclerosis. J Neuroimmunol. 2000;107:161-6.

7. Kappos L, Radue EW, O'Connor P, Polman C, Hohlfeld R, Calabresi P, et al. A Placebo-Controlled Trial of Oral Fingolimod in Relapsing Multiple Sclerosis. N Engl J Med. 2010;362:387-401.

8. Kerschensteiner M, Hohlfeld R. Neurotrophic factors protect myelin from attack. Int MS J. 2003;10:2-4.

9. Lucchinetti CF, Parisi J, Bruck W. The pathology of multiple sclerosis. Neurol Clin. 2005;23:77-105,vi. doi: 10.1016/j.ncl.2004.09.002.

10. Montalban X, Sastre-Garriga J, Filippi M, Khaleeli Z, Tellez N, Vellinga MM, et al. Primary progressive multiple sclerosis diagnostic criteria: a reappraisal. Mult Scler. 2009;15:1459-65.

11. Morales Y, Parisi JE, Lucchinetti CF. The pathology of multiple sclerosis: evidence for heterogeneity. Adv Neurol. 2006;98:27-45.

12. Prakhova LN, Il'ves AG, Petrov AM, Kataeva GV, Pozdniakov AV, Totolian NA, et al. [Brain atrophy and neurological impairment in patients with multiple sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova. 2009;109:32-7.

13. Reich DS, Zackowski KM, Gordon-Lipkin EM, Smith SA, Chodkowski BA, Cutter GR, et al. Corticospinal tract abnormalities are associated with weakness in multiple sclerosis. AJNR Am J Neuroradiol. 2008;29:333-9. doi: 10.3174/ajnr.A0788.

14. Rovaris M, Judica E, Ceccarelli A, Ghezzi A, Martinelli V, Comi G, et al. A 3-year diffusion tensor MRI study of grey matter damage progression during the earliest clinical stage of MS. J Neurol. 2008;255:1209-14. doi: 10.1007/s00415-008-0877-8.

15. Sanchez MP, Nieto A, Barroso J, Martin V, Hernandez MA. Brain atrophy as a marker of cognitive impairment in mildly disabling relapsing-remitting multiple sclerosis. Eur J Neurol. 2008;15:1091-9. doi: 10.1111/j.1468-1331.2008.02259.x.

16. Tao G, Datta S, He R, Nelson F, Wolinsky JS, Narayana PA. Deep gray matter atrophy in multiple sclerosis: a tensor based morphometry. J Neurol Sci. 2009;282:39-46. doi: 10.1016/j.jns.2008.12.035.

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Introduction

Multiple sclerosis (MS) is a chronic immune-mediated disease of the central nervous system, producing multifocal neurological symptoms caused by nerve demyelination and progressive neurodegeneration. The pathological hallmark of MS is multiple demyelinated plaques (sharply defined areas of demyelination) in the white matter and widely distributed areas of degeneration [7, 10]. The core process in MS is inflammatory, with T cells and their mediators triggering myelin injury; additionally, oligodendrocyte/myelin damage is often mediated by autoantibody fixation with consequent complement activation. Therefore, multiple sclerosis is an autoimmune condition with a complex pathogenesis involving cellular and humoral immune response activation [3].

Presently in MS four types of neural tissue injury can be distinguished [9]. Two of them are caused by activation of cellular and humoral immune system compartments, and the others are characterized by degenerative changes in oligodendrocytes with primary or distal injury. These four types can occur at the different stages of MS. The present conception of MS pathogenesis encompasses two basic mechanisms – autoimmune inflammation and neurodegenerative changes [1, 11].

Multiple studies and clinical observations showed the progressive decrease of brain tissue total volume in MS [4, 12, 15, 16]. The beginning of the disease course is characterized by repeated episodes of inflammation with new contrast-accumulating T2 lesions revealed by MRI. However a considerable amount of recent data suggests the importance of degenerative changes at the earliest stages of the disease [4]. Today the pathogenesis of MS is considered to be a complex process with the inflammatory component being only a part of the general process.

Even small T2 lesions can be associated with general atrophy, though within the clinical course brain atrophy is not always associated with high EDSS scores. Recently much attention has been given to focal atrophy at different stages of MS [2, 5, 13, 14]. Apart from direct cell damage, the mechanism of inflammation can exert a protective effect. The immune cells recruited to the inflammatory foci produce growth factors, are able to delete myelin-associated molecules, and can have a suppressive phenotype. Therefore there are still some controversies in the inflammatory concept to be resolved.
 
Patients with MS receive treatment with Copaxone, Betaseron, Rebif-44, monoclonal antibodies, and cytostatics. In MS cases the most promising seems to be a complex therapy aimed at inflammatory process suppression and neuroprotection [6, 8].

The aim of our study was to investigate the role of autologous HSCT in treatment of patients with MS as a complex treatment.

The first autologous hematopoietic stem cell transplantation (auto-HSCT) was performed in 2001. According to protocol, the patients were divided into two groups based on the rate of disease progression. The patients with fast progression of MS belong to the first group. In this group we consider a salvage high-dose chemotherapy with fludarabine-melphalan conditioning regimen and auto-HSCT. The patients with a stable disease course were included into the second group and received BEAM as a conditioning regimen.

Inclusion criteria

• Definitive MS (McDonald, 2005)

• Relapsing-remitting MS; second progressive MS and aggressive MS with severe relapses.

• Age 18–55 yrs.

• Duration of MS ≥1 year

• EDSS 0–6.5

• MRI within the 30 days period before auto-SCT

• Standard therapy methods proven to be ineffective

• The increase of EDSS 1.5 (EDSS 3.0–5.0) or 1 (EDSS ≥5.5)

• 2 relapses in the last 24 months or 1 relapse in the last 12 months on standard therapy.

The follow-up period varied from 2 months to 8 years.

• Median age 34.5 (22–52) yrs

• Sex distribution: male: 11 patients, median age 31.7 (22– 41) yrs; female: 12 patients, median age 37 (26–52) yrs

• PPMS = 5 patients, SPMS = 12 patients, R-RMS = 6 patients

• Median period from debut of MS to auto-SCT: 6.8 yrs

• Median EDSS: 5.7 (1.5–7.5)ВЕАМ: 17 patients, Flu-Mel: 6 patients

• Median of neutropenia duration: 12.7 days (ВЕАМ: 12.6, Flu-Mel: 12.8 days).

To evaluate the therapy effects, clinical scales and immunological and radiological methods were used. We used the EDSS scale, MSFC clinical outcome measure, and a relapse evaluation test. The methods of immunological status evaluation included:

• detection of oligoclonal bands (OCB) in plasma and cerebrospinal fluid (CSF)

• light chain detection in plasma and CSF

• plasma and CSF T cell cytofluorometry (CD 3+CD19-; CD3+CD8+; CD3+CD4+; CD3+CD19+; CD3-CD19+; CD3-СD20+; CD3-CD(16+56); CD3+CD(16+56); CD3+HLA-DR+; CD3-HLA-DR+; CD3+HLA-DR-; CD4+CD25+; СВ19+СВ27+ phenotypes).

For CSN visualization the following MRI protocol was used:

• Routine protocol with contrast (Gd)

• T2 and T1 volume

• T1 and T2 lesion calculation

• Brain volume evaluation

Prior to auto-HSCT the patients received the following treatment: pulse therapy with steroids: 90%, beta-IFN: (Betaseron, Rebif, Avonex) 54%, mitoxantrone: 15%, Copaxone: 22%, intravenous IgG: 5%, no previous treatment: 5%.

Outcomes

Clinical symptoms evaluation: two end-points for EDSS assessment were established (day 0 and 12 months after auto-SCT). An evident therapy effect was observed in three patients, with decreases of EDSS scores from 6.5 to 1.5 in one patient, and from 5.5 to 4.5 in two patients. 10 patients (43.4%) remained with stable EDSS score values for 12 months after auto-SCT. 4 patients (17.3%) experienced disease progression (increase of EDSS). One patient died of sepsis.

MRI metrics examined included the number of Gd enhancing lesions, number of T2 lesions, total T2 lesion volume, and atrophy evaluation (decrease of total brain volume; changes in the third ventricle diameter; atrophy of corpus callosum). In the 18-month period after auto-SCT an increase in T2 lesion volumes was observed in 8% of cases, 20.4% of patients developed new T2 lesions, and 12% of patients had T1 contrast lesions. MRI signs of general brain atrophy were found in 95.6% of patients. We observed a certain discrepancy of MRI signs: while the volume of T2 lesions decreased and no signs of systemic inflammation were observed, the atrophic changes continued to progress. Judging by MRI metrics, auto-SCT can eliminate the inflammatory, but not the neurodegenerative component of MS.

Immunology: We performed cytofluorometry of serum and CSF immunocompetent cell populations, and evaluated the level of intrathecal IgG as a highly specific marker of MS. Cell population changes showed no definite pattern and are hard to interpret. No evident dynamics of intrathecal IgG level was observed.

After ASCT 91.1% patients had constant intratecal synthesis of OCB. Only in 1 patient we revealed no signs of OCB synthesis in CSF and plasma.  

Early post-transplant period complications: infectious complications: 84%; hemorrhagic complications: 54%; serum sickness: 44%; neurological complications: 30%.

Conclusions

Our results show the evident decrease of inflammatory changes and better disease control in MS patients treated with conventional chemotherapy or high-dose chemotherapy with auto-HSCT due to its immunosuppressive effect. However, more intensive therapy is associated with a higher complications rate and risk of mortality. There are some questions still unanswered. It is still to be determined whether the conventional regimens able to roll the disease course back to previous stages or more radical high-dose therapy lead to better long-term survival and disease control. Also still to be determined is the best time for high-dose therapeutic intervention.

On the whole, auto-HSCT is a promising method of MS treatment, but there are certain practical aspects to be developed:

• Indications for auto-SCT

• Conditioning regimen

• Stem cell source and transplant processing

• Complex methods of disease course evaluation (clinical, immunological, radiological, and morphological evaluation)

• Quality of life evaluation

• Role of mesenchymal stem cells and monoclonal antibodies in the treatment of multiple sclerosis.

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Евдошенко, Людмила Ст. Зубаровская, Леонид Г. Заславский, Александр А. Скоромец, Сергей М. Алексеев, Юлия А. Станкевич, Наталья А. Тотолян, Борис В. Афанасьев</p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(307) "

Евгений П. Евдошенко, Людмила Ст. Зубаровская, Леонид Г. Заславский, Александр А. Скоромец, Сергей М. Алексеев, Юлия А. Станкевич, Наталья А. Тотолян, Борис В. Афанасьев

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В данной статье приводятся результаты наблюдения за 23 пациентами с рассеянным склерозом после проведенной аутологичной трансплантации стволовых кроветворных клеток. Обсуждаются риски высокодозной химиотерапии и ее преимущества перед другими методами терапии, а также оптимальный выбор режима кондиционирования и предикторов терапии. Результаты показывают прогрессирование заболевания у большинства пациентов после проведенной терапии через 12-18 месяцев.

Ключевые слова

аутологичная трансплантация стволовых кроветворных клеток (АТСК), рассеянный склероз

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Evgeny P. Evdoshenko¹, Lyudmila S. Zubarovskaya², Leonid G. Zaslavsky¹, Alexander A. Skoromets³, Sergey A. Alexeev⁴, Julia A. Stankevich⁴, Natalia A. Totolyan³, Boris V. Afanasyev²

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¹Leningrad Region Center for Multiple Sclerosis, Leningrad Region Clinical Hospital/ Chair of Neurology, Department of Neurology, St. Petersburg Pavlov State Medical University, St. Petersburg, Russia; ²Memorial R.M. Gorbacheva Institute of Children Hematology and Transplantation, St. Petersburg Pavlov State Medical University, St. Petersburg, Russia; ³Chair of Neurology, St. Petersburg Pavlov State Medical University, St. Petersburg, Russia; ⁴BMT Unit for adults, Memorial R.M. Gorbacheva Institute of Children Hematology and Transplantation, St. Petersburg Pavlov State Medical University, St. Petersburg, Russia

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The results of observing 23 patients with multiple sclerosis who received autologous hematopoietic stem cell transplantation are shown in this article. The risks of an auto-HSCT and its advantages compared with other therapy methods, and also an optimal choice for the therapy predictors are discussed. The results show progress of disease in most cases after 12-18 months.

Keywords

autologous hematopoietic stem cell transplantation (auto-HSCT), multiple sclerosis

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Evdoshenko¹, Lyudmila S. Zubarovskaya², Leonid G. Zaslavsky¹, Alexander A. Skoromets³, Sergey A. Alexeev⁴, Julia A. Stankevich⁴, Natalia A. Totolyan³, Boris V. Afanasyev²</p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(275) "

Evgeny P. Evdoshenko¹, Lyudmila S. Zubarovskaya², Leonid G. Zaslavsky¹, Alexander A. Skoromets³, Sergey A. Alexeev⁴, Julia A. Stankevich⁴, Natalia A. Totolyan³, Boris V. Afanasyev²

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Evgeny P. Evdoshenko¹, Lyudmila S. Zubarovskaya², Leonid G. Zaslavsky¹, Alexander A. Skoromets³, Sergey A. Alexeev⁴, Julia A. Stankevich⁴, Natalia A. Totolyan³, Boris V. Afanasyev²

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The results of observing 23 patients with multiple sclerosis who received autologous hematopoietic stem cell transplantation are shown in this article. The risks of an auto-HSCT and its advantages compared with other therapy methods, and also an optimal choice for the therapy predictors are discussed. The results show progress of disease in most cases after 12-18 months.

Keywords

autologous hematopoietic stem cell transplantation (auto-HSCT), multiple sclerosis

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The results of observing 23 patients with multiple sclerosis who received autologous hematopoietic stem cell transplantation are shown in this article. The risks of an auto-HSCT and its advantages compared with other therapy methods, and also an optimal choice for the therapy predictors are discussed. The results show progress of disease in most cases after 12-18 months.

Keywords

autologous hematopoietic stem cell transplantation (auto-HSCT), multiple sclerosis

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¹Leningrad Region Center for Multiple Sclerosis, Leningrad Region Clinical Hospital/ Chair of Neurology, Department of Neurology, St. Petersburg Pavlov State Medical University, St. Petersburg, Russia; ²Memorial R.M. Gorbacheva Institute of Children Hematology and Transplantation, St. Petersburg Pavlov State Medical University, St. Petersburg, Russia; ³Chair of Neurology, St. Petersburg Pavlov State Medical University, St. Petersburg, Russia; ⁴BMT Unit for adults, Memorial R.M. Gorbacheva Institute of Children Hematology and Transplantation, St. Petersburg Pavlov State Medical University, St. Petersburg, Russia

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¹Leningrad Region Center for Multiple Sclerosis, Leningrad Region Clinical Hospital/ Chair of Neurology, Department of Neurology, St. Petersburg Pavlov State Medical University, St. Petersburg, Russia; ²Memorial R.M. Gorbacheva Institute of Children Hematology and Transplantation, St. Petersburg Pavlov State Medical University, St. Petersburg, Russia; ³Chair of Neurology, St. Petersburg Pavlov State Medical University, St. Petersburg, Russia; ⁴BMT Unit for adults, Memorial R.M. Gorbacheva Institute of Children Hematology and Transplantation, St. Petersburg Pavlov State Medical University, St. Petersburg, Russia

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Евгений П. Евдошенко, Людмила Ст. Зубаровская, Леонид Г. Заславский, Александр А. Скоромец, Сергей М. Алексеев, Юлия А. Станкевич, Наталья А. Тотолян, Борис В. Афанасьев

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Евгений П. Евдошенко, Людмила Ст. Зубаровская, Леонид Г. Заславский, Александр А. Скоромец, Сергей М. Алексеев, Юлия А. Станкевич, Наталья А. Тотолян, Борис В. Афанасьев

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Evdoshenko" ["LINK_ELEMENT_VALUE"]=> bool(false) } ["SUMMARY_RU"]=> array(37) { ["ID"]=> string(2) "27" ["TIMESTAMP_X"]=> string(19) "2015-09-02 18:01:20" ["IBLOCK_ID"]=> string(1) "2" ["NAME"]=> string(29) "Описание/Резюме" ["ACTIVE"]=> string(1) "Y" ["SORT"]=> string(3) "500" ["CODE"]=> string(10) "SUMMARY_RU" ["DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } ["PROPERTY_TYPE"]=> string(1) "S" ["ROW_COUNT"]=> string(1) "1" ["COL_COUNT"]=> string(2) "30" ["LIST_TYPE"]=> string(1) "L" ["MULTIPLE"]=> string(1) "N" ["XML_ID"]=> string(2) "27" ["FILE_TYPE"]=> string(0) "" ["MULTIPLE_CNT"]=> string(1) "5" ["TMP_ID"]=> NULL ["LINK_IBLOCK_ID"]=> string(1) "0" ["WITH_DESCRIPTION"]=> string(1) "N" ["SEARCHABLE"]=> string(1) "N" ["FILTRABLE"]=> string(1) "N" ["IS_REQUIRED"]=> string(1) "N" ["VERSION"]=> string(1) "1" ["USER_TYPE"]=> string(4) "HTML" ["USER_TYPE_SETTINGS"]=> array(1) { ["height"]=> int(200) } ["HINT"]=> string(0) "" ["PROPERTY_VALUE_ID"]=> string(5) "18391" ["VALUE"]=> array(2) { ["TEXT"]=> string(1125) "<p class="bodytext">В данной статье приводятся результаты наблюдения за 23 пациентами с рассеянным склерозом после проведенной аутологичной трансплантации стволовых кроветворных клеток. Обсуждаются риски высокодозной химиотерапии и ее преимущества перед другими методами терапии, а также оптимальный выбор режима кондиционирования и предикторов терапии. Результаты показывают прогрессирование заболевания у большинства пациентов после проведенной терапии через 12-18 месяцев. </p> <h3>Ключевые слова</h3> <p> аутологичная трансплантация стволовых кроветворных клеток (АТСК), рассеянный склероз</p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(1079) "

В данной статье приводятся результаты наблюдения за 23 пациентами с рассеянным склерозом после проведенной аутологичной трансплантации стволовых кроветворных клеток. Обсуждаются риски высокодозной химиотерапии и ее преимущества перед другими методами терапии, а также оптимальный выбор режима кондиционирования и предикторов терапии. Результаты показывают прогрессирование заболевания у большинства пациентов после проведенной терапии через 12-18 месяцев.

Ключевые слова

аутологичная трансплантация стволовых кроветворных клеток (АТСК), рассеянный склероз

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В данной статье приводятся результаты наблюдения за 23 пациентами с рассеянным склерозом после проведенной аутологичной трансплантации стволовых кроветворных клеток. Обсуждаются риски высокодозной химиотерапии и ее преимущества перед другими методами терапии, а также оптимальный выбор режима кондиционирования и предикторов терапии. Результаты показывают прогрессирование заболевания у большинства пациентов после проведенной терапии через 12-18 месяцев.

Ключевые слова

аутологичная трансплантация стволовых кроветворных клеток (АТСК), рассеянный склероз

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Introduction

Multiple sclerosis (MS) is a major inflammatory and demyelinating disease of the central nervous system (CNS), associated with a broad spectrum of physical, psychological, and social impairments. MS patients suffer from a variety of symptoms such as fatigue, spasticity, problems with balance and coordination, visual impairment, bowel or bladder dysfunction, decreased cognitive function, etc., and these symptoms decrease their quality of life (QoL) [6, 11]. Most importantly, the level of impact of the wide range of health problems associated with MS needs to be understood in terms of patients’ own perceptions of those impacts and the degree to which they affect their lives [9, 4].

Currently there is no known cure for MS. Thus, the goal of treatment is to control symptoms and improve a patient’s quality of life. In order to evaluate the efficacy of treatment or rehabilitation of MS patients it is necessary to assess patients’ QoL and severity of symptoms [5, 10]. “Quality of life of a patient” is a new and important category in clinical medicine. To assess it in a proper way it is worthwhile to define it clearly.

There are many definitions of QoL at present. The one which is most relevant to clinical setting is as follows: “Quality of life is integral characteristics of a physical, psychological, and social functioning of an individual, based on his/her subjective perception” (A. Novik, T. Ionova, P. Kind, 1999).

This definition covers 3 major domains of an individual’s function:
(1) Physical well-being;
(2) Psychological well-being;
(3) Social well-being.

Importantly it implies self-assessment. Special tools have been developed to measure QOL and symptoms. QoL questionnaires and symptom assessment tools refer to patient-reported outcomes (PRO) [2, 1]. PRO is an umbrella term that is widely used at present. It covers a whole range of potential types of measurement, but is used specifically to refer to questionnaires completed by the patient. The most commonly used PRO measures assess QoL and symptoms.

There are several QoL measures which are used for evaluating QOL in MS. The most widespread are general QoL questionnaires: RAND Short Form-36 (SF-36), EQ-5D, and Sickness Impact Profile (SIP). MS-specific measures of QOL include the Functional Assessment of Multiple Sclerosis (FAMS), the Multiple Sclerosis Quality of Life-54 Instrument (MSQOL-54), and the Disability & Impact Profile (DIP).

As for symptom assessment tools it is worth mentioning the Comprehensive Symptom Profile-MS-22 Short Form (CSP-MS-22-SF). This instrument was developed in 2007 by the New Jersey Center for Quality of Life and Health Outcome Research (USA) and Multinational Center for QoL Research (Russia) [3]. The CSP-MS-22-SF aims to assess the severity of 22 symptoms that are common and most disturbing for MS patients. It consists of numerical analogous scales, scored from “0” (no symptom) to “10” (most expressed symptom). Applicability of CSP-MS-22-SF with the analysis of its psychometric properties was tested in the study which included more than 120 patients with different types of MS.

At present high-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation (ASCT) has been used with increasing frequency as a therapeutic option for MS patients. Both disease-free period and improvement of the patient’s quality of life (QoL) are recognized as important outcome parameters. With this in mind, evaluation of both clinical and patient-reported outcomes in MS patients after ASCT is worthwhile. A comprehensive analysis of PRO has not been available. Thus, we aimed to study PRO in MS patients after ASCT.

Patients and methods

101 patients with MS (secondary progressive: 41 patients, primary progressive: 21, progressive-relapsing: 5 and relapsing-remitting: 34) were included in this study (mean age 32.5, range: 17–54; male/female 42/59). BEAM or BEAM-modified conditioning was used. Median EDSS at baseline was 5.0 (range 1.5–8.5). The mean follow-up duration was 21 months (range 6–120 months).

QoL was assessed using RAND SF-36 and FAMS. RAND SF-36 is a general QoL measure which consists of 36 questions and contains 8 scales: physical functioning, role–physical functioning, bodily pain, general health, vitality, social functioning, role–emotional functioning, and mental health. The FAMS is disease specific to assess QoL in MS patients. It consists of 58 questions and contains 7 scales: mobility, symptoms, emotional well-being, general contentment, thinking and fatigue, family/social well-being, additional concerns. Symptom severity was assessed using CSP-MS-22-SF. Patients filled in the questionnaires at baseline, at discharge, at 3, 6, 9, and 12 months, and every 6 months thereafter.

QoL treatment response was classified as improvement, stabilization, or worsening. To determine QoL treatment response the Integral QoL Index (IQLI) was calculated for each patient using the method of Integral Profiles on the basis of SF-36 scales (A. Novik, T. Ionova, A. Kishtovich, 2005) [8].

Using IQLI the grade of QoL impairment was determined for each patient. According to the grades of QoL impairment, five groups of patients can be identified: with no QoL impairment, mild QoL impairment, moderate QoL impairment, severe QoL impairment, and critical QoL impairment [7].

No QoL impairment means that a patient has no QoL decrease from a population norm (PN), mild QoL impairment <25% decrease from a PN, moderate QoL impairment 25–50% decrease from a PN, severe QoL impairment 50–75% decrease from a PN, and critical QoL impairment >75% decrease from a PN.

Results

Quality of life parameters in MS patients after ASCT

Monitoring of QoL parameters using the MS specific QoL questionnaire FAMS was made. QoL parameters at discharge, 6 months post-transplant, and 12 months post-transplant as compared to base-line are presented on Fig. 1–3. As can be seen from the figures, quality of life parameters are lower at the baseline than after ASCT across the majority of FAMS scales. Statistically significant improvement at baseline was found for the following scales: emotional well-being (p<0.001), general contentment (p<0.05), family/social well-being (p<0.001), and additional concerns (p<0.001).

In 6 months after ASCT statistically significant improvement as compared to base-line was registered across all scales except family/social well-being and additional concerns: mobility (p<0.001), symptoms (p<0.001), emotional well-being (p<0.01), general contentment (p<0.01), thinking and fatigue (p<0.01), and additional concerns (p<0.001). In a year the post-transplant QoL parameters had further increased with statistically significant improvement across all scales (p<0.01) except family/social well-being.

Mean total FAMS score at base-line was 115.5 (SD 29.6). At discharge it improved to 121.1 (SD 29.8; p<0.05) with further improvement in 6 months (mean 130.6; SD 31.8; p<0.01), and in a year post-transplant (mean 134.8; SD 28.1; p<0.001).

Figure 1. Quality of life parameters of MS patients before ASCT and at discharge (FAMS questionnaire)

Figure 2. Quality of life parameters of MS patients before ASCT and 6 months after ASCT (FAMS questionnaire)

Figure 3. Quality of life parameters of MS patients before ASCT and 12 months after ASCT (FAMS questionnaire)

Further analysis included the comparison of QoL parameters of MS patients before and after ASCT as compared with the population norm. For these purposes QoL was measured using RAND SF-36. Quality of life profiles of MS patients at baseline and 6 months post-transplant as well as of the population norm are presented in Fig. 4.  As can be seen, the quality of life profile in MS patients before ASCT is characterized by compression and deformation as compared with the population norm. Quality of life parameters of MS patients before ASCT were significantly lower than of the population norm across all SF-36 scales. Six months after transplantation definite improvement of QoL parameters was registered, with statistically significant changes across all the scales (p<0.01) except pain and role–emotional functioning. The Mean Integral QoL Index increased dramatically as compared to base-line value (0.32 (SD 0.26) vs. 0.50 (SD 0.28); p< 0.01).

Figure 4. Quality of life profiles in MS patients before and 6 months after ASCT as compared with the population norm (SF-36 questionnaire) 
Note: PF = physical functioning, RPF = role–physical functioning, BP = bodily pain, GH = general health, V = vitality, SF = social functioning, REF = role–emotional functioning, MH = mental health.

Taking into account the patients’ heterogeneity in terms of their QoL the patients were stratified at baseline by the grades of QoL impairment. Five groups were identified according to the grades of QoL impairment: with no QoL impairment, mild QoL impairment, moderate QoL impairment, severe QoL impairment, and critical QoL impairment.

Distribution of patients according to the grades of QoL impairment before and 6 months after ASCT is shown in Table 1.

Table 1. Distribution of patients according to the grades of QoL impairment before ASCT and 6 months post-transplant (n=33)

QoL impairment grade	N, %
	Before ASCT	After ASCT
No QoL impairment	9 (27)	17 (52)
Mild QoL impairment	4 (13)	3 (9)
Moderate QoL impairment	1 (3)	4 (13)
Severe QoL impairment	10 (30)	7 (20)
Critical QoL impairment	9 (27)	2 (6

Changes in the distribution of patients according to the grades of QoL impairment took place after ASCT. The number of patients with no QoL impairment increased after transplantation, while the number of patients with critical QoL impairment decreased. Notably, ASCT resulted in a two-fold increase in the number of patients with QoL comparable to population norms: before transplantation 27% of patients had no QoL impairment, and 6 months after ASCT it was 52%. At the same time the number of patients with critical QoL impairment had experienced a triple decrease: at base-line 27% of patients had critical QoL impairment, and 6 months after ASCT it was only 6%.

Thus, ASCT is accompanied by an increase in the number of patients with no QoL impairment and a decrease in the number of patients with critical QoL impairment.

Symptoms in MS patients after ASCT

Symptom prevalence in MS patients before and after ASCT is presented in Fig. 5. Before transplantation MS patients experienced a wide range of symptoms. The most prevalent symptom was fatigue (83%). Of those who had fatigue about half of the patients reported it at moderate-to-severe level. The other frequent symptoms were toddling, heat sensitivity, psychological problems (anxiety and sadness) and numbness/tingling with their prevalence of 79%, 76%, 72%, and 70%, respectively. More than half of the patients reported these symptoms at the moderate-to-severe level. The majority of patients (60% on average) experienced such symptoms as movement disorders, coordination problems, urination dysfunction, and vision impairment.

In response to treatment, changes in symptom prevalence in MS patients were found. Positive changes in prevalence of the most frequent symptoms – fatigue, toddling, psychological problems (anxiety and sadness), numbness/tingling, movement disorders, coordination problems, urination dysfunction, and vision impairment – were observed 6 months after ASCT. The prevalence of the vast majority of moderate-to-severe symptoms after transplantation was lower than before treatment.

Figure 5. Symptom prevalence in MS patients before ASCT and 6 months post-transplant

Information about symptom severity in MS patients before and 6 months after ASCT is presented in Table 2. Before transplantation the most severe symptom was toddling followed by heat sensitivity, fatigue, movement disorders, and coordination disorders. In response to treatment, the severity of these symptoms decreased. As it is seen from the table the mean value of the severity of these symptoms 6 months after ASCT was lower than before treatment. The severity of other symptoms decreased as well.

Table 2. Symptom severity in MS patients before ASCT and 6 months post-transplant

Symptoms	Before ASCT	6 months after ASCT
		Mean (SD)	Meand (SD)
Toddling	5.3(4.1)	4.2(4.0)
Heat sensitivity	4.7(3.7)	4.5(3.8)
Fatigue	4.4(3.1)	3.5(3.0)
Movement disorders	3.9(3.8)	3.2(3.8)
Coordination disorders	3.7(3.8)	3.0(3.8)
Urination dysfunction	3.3(3.8)	1.9(2.8)
Numbness/tingling	3.3(3.3)	1.8(2.4)
Stool problems	3.2(3.6)	2.4(3.4)
Anxiety	3.0(2.9)	1.8(2.7)
Vision impairment	2.8(3.4)	1.9(3.1)
Sadness	2.8(3.0)	1.6(2.7)
Dizziness	2.3(2.9)	1.2(2.0)
Muscle cramps	2.1(3.0)	2.0(3.0)
Sexual dysfunction	2.0(3.7)	1.4(2.9)
Pain	1.5(2.2)	1.2(2.1)
Decreased concentration	1.3(1.9)	1.4(2.5)
Memory loss	1.1(2.0)	1.2(2.3)
Tremor	1.1(1.9)	0.9(2.0)
Chills	0.8(1.9)	1.3(2.7)
Speech disorders	0.7(1.9)	0.9(1.8)
Hearing disorders	0.5(1.7)	0.4(1.6)
Swallowing problems	0.4(0.8)	0.3(1.1)

QoL treatment response in MS patients after ASCT

QoL treatment response characterizes changes in physical, psychological, and social functioning of a patient after treatment. Three types of QoL treatment response after ASCT can be identified: improvement, stabilization, and worsening.

QoL treatment response was determined at different time-points after ASCT. Here we present the data on QoL treatment response at 6 months post-transplant (n=33). Three types of QoL treatment response were registered: improvement, stabilization, or worsening. QoL improvement or QoL stabilization was shown in the vast majority of patients. QoL improvement was achieved in 16 (48.5%) patients; and QoL stabilization in other 16 patients. QoL worsening was noticed in one patient only.

Thus, the vast majority of patients (97%) experienced either QoL improvement or QoL stabilization in 6 months after ASCT.

Conclusions

1. Physical, psychological and social functioning in MS patients is significantly deteriorated. The quality of life profile of these patients is characterized by compression and deformation. The majority of patients exhibit either severe or critical QoL impairment.

2. MS patients experience a wide range of disease-related symptoms. The most frequent symptoms – fatigue, toddling, heat sensitivity, psychological problems (anxiety and sadness), and numbness/tingling – are present in more than 70% of patients. About a half of the patients report these symptoms at the moderate-to-severe level.

3. ASCT in MS patients improves their physical, psychological and social function. The most definite improvement of quality of life takes place in a year after transplantation.

4. After ASCT the number of patients with no QoL impairment increases whereas the number of patients with critical QoL impairment decreases.

5. Quality of life treatment response (QoL improvement or QoL stabilization) was achieved in the vast majority of MS patients after ASCT.

6. ASCT is associated with decline of symptom prevalence and severity in MS patients.

References

1. Cella D, Yount S, Rothrock N, et al. The Patient-Reported Outcomes Measurement Information System (PROMIS). Med. Care. 2007;45(5):3-11. doi: 10.1097/01.mlr.0000258615.42478.55.

2. FDA Guidance for Industry: Patient-reported outcome measures: use in medical product development to support labeling claims. Bulletin of the Multinational Center of Quality of Life Research. 2006;7-8:153-154.

3. Fedorenko DA, Kishtovich AV, Ionova TI, Novik АА. Symptom assessment in patients with multiple sclerosis after hematopoietic stem cell transplantation. Bulletin of the Multinational Center of Quality of Life Research. 2008;11-12:157-158.

4. Hemmett L, Holmes J, Barnes M, Russe N. What drives quality of life in multiple sclerosis? Ass. Physic. 2004;QJM;Vol. 97(10):185-187. doi: 10.1093/qjmed/hch105.

5. Nortvedt MW, Riise T, Myhr KM, et al. Quality of life as a predictor for change in disability in MS. Neurology. 2000 Jul 12;55(1):51-4.

6. Nortvedt MW, Riise T, Myhr KM, et al. Quality of life in multiple sclerosis: measuring the disease effects more broadly. // Neurology. 1999;22(53):1098-1103.

7. Novik AA, Ionova TI. Guidelines of quality of life research in medicine. М: Olma Media Grupp, 2007.

8. Novik AA, Ionova TI, Kalyadina SA, Kishtovich AV. Conceptual and statistical models of stratification of the patients population according to the grades of quality of life impairement. Bulletin of the Multinational Center of Quality of Life Research. 2007;9-10:88-98.

9. Ramp M, Khan F, Misajon RA, Pallant JF. Rasch analysis of the Multiple Sclerosis Impact Scale (MSIS-29) Hlth Quality Life Outcomes. 2009;7:58. doi: 10.1186/1477-7525-7-58.

10. Rice GP, Oger J, Duquette P, et al. Treatment with interferon beta-1b improves quality of life in multiple sclerosis. // Can. J. Neurol. Sci. 1999;26(4):276-282.

11. The Canadian Burden of Illness Study Group. Burden of illness of multiple sclerosis: Part II: Quality of life. // Can. J. Neurol. Sci. 1998;25:31-38.

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Introduction

Multiple sclerosis (MS) is a major inflammatory and demyelinating disease of the central nervous system (CNS), associated with a broad spectrum of physical, psychological, and social impairments. MS patients suffer from a variety of symptoms such as fatigue, spasticity, problems with balance and coordination, visual impairment, bowel or bladder dysfunction, decreased cognitive function, etc., and these symptoms decrease their quality of life (QoL) [6, 11]. Most importantly, the level of impact of the wide range of health problems associated with MS needs to be understood in terms of patients’ own perceptions of those impacts and the degree to which they affect their lives [9, 4].

Currently there is no known cure for MS. Thus, the goal of treatment is to control symptoms and improve a patient’s quality of life. In order to evaluate the efficacy of treatment or rehabilitation of MS patients it is necessary to assess patients’ QoL and severity of symptoms [5, 10]. “Quality of life of a patient” is a new and important category in clinical medicine. To assess it in a proper way it is worthwhile to define it clearly.

There are many definitions of QoL at present. The one which is most relevant to clinical setting is as follows: “Quality of life is integral characteristics of a physical, psychological, and social functioning of an individual, based on his/her subjective perception” (A. Novik, T. Ionova, P. Kind, 1999).

This definition covers 3 major domains of an individual’s function:
(1) Physical well-being;
(2) Psychological well-being;
(3) Social well-being.

Importantly it implies self-assessment. Special tools have been developed to measure QOL and symptoms. QoL questionnaires and symptom assessment tools refer to patient-reported outcomes (PRO) [2, 1]. PRO is an umbrella term that is widely used at present. It covers a whole range of potential types of measurement, but is used specifically to refer to questionnaires completed by the patient. The most commonly used PRO measures assess QoL and symptoms.

There are several QoL measures which are used for evaluating QOL in MS. The most widespread are general QoL questionnaires: RAND Short Form-36 (SF-36), EQ-5D, and Sickness Impact Profile (SIP). MS-specific measures of QOL include the Functional Assessment of Multiple Sclerosis (FAMS), the Multiple Sclerosis Quality of Life-54 Instrument (MSQOL-54), and the Disability & Impact Profile (DIP).

As for symptom assessment tools it is worth mentioning the Comprehensive Symptom Profile-MS-22 Short Form (CSP-MS-22-SF). This instrument was developed in 2007 by the New Jersey Center for Quality of Life and Health Outcome Research (USA) and Multinational Center for QoL Research (Russia) [3]. The CSP-MS-22-SF aims to assess the severity of 22 symptoms that are common and most disturbing for MS patients. It consists of numerical analogous scales, scored from “0” (no symptom) to “10” (most expressed symptom). Applicability of CSP-MS-22-SF with the analysis of its psychometric properties was tested in the study which included more than 120 patients with different types of MS.

At present high-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation (ASCT) has been used with increasing frequency as a therapeutic option for MS patients. Both disease-free period and improvement of the patient’s quality of life (QoL) are recognized as important outcome parameters. With this in mind, evaluation of both clinical and patient-reported outcomes in MS patients after ASCT is worthwhile. A comprehensive analysis of PRO has not been available. Thus, we aimed to study PRO in MS patients after ASCT.

Patients and methods

101 patients with MS (secondary progressive: 41 patients, primary progressive: 21, progressive-relapsing: 5 and relapsing-remitting: 34) were included in this study (mean age 32.5, range: 17–54; male/female 42/59). BEAM or BEAM-modified conditioning was used. Median EDSS at baseline was 5.0 (range 1.5–8.5). The mean follow-up duration was 21 months (range 6–120 months).

QoL was assessed using RAND SF-36 and FAMS. RAND SF-36 is a general QoL measure which consists of 36 questions and contains 8 scales: physical functioning, role–physical functioning, bodily pain, general health, vitality, social functioning, role–emotional functioning, and mental health. The FAMS is disease specific to assess QoL in MS patients. It consists of 58 questions and contains 7 scales: mobility, symptoms, emotional well-being, general contentment, thinking and fatigue, family/social well-being, additional concerns. Symptom severity was assessed using CSP-MS-22-SF. Patients filled in the questionnaires at baseline, at discharge, at 3, 6, 9, and 12 months, and every 6 months thereafter.

QoL treatment response was classified as improvement, stabilization, or worsening. To determine QoL treatment response the Integral QoL Index (IQLI) was calculated for each patient using the method of Integral Profiles on the basis of SF-36 scales (A. Novik, T. Ionova, A. Kishtovich, 2005) [8].

Using IQLI the grade of QoL impairment was determined for each patient. According to the grades of QoL impairment, five groups of patients can be identified: with no QoL impairment, mild QoL impairment, moderate QoL impairment, severe QoL impairment, and critical QoL impairment [7].

No QoL impairment means that a patient has no QoL decrease from a population norm (PN), mild QoL impairment <25% decrease from a PN, moderate QoL impairment 25–50% decrease from a PN, severe QoL impairment 50–75% decrease from a PN, and critical QoL impairment >75% decrease from a PN.

Results

Quality of life parameters in MS patients after ASCT

Monitoring of QoL parameters using the MS specific QoL questionnaire FAMS was made. QoL parameters at discharge, 6 months post-transplant, and 12 months post-transplant as compared to base-line are presented on Fig. 1–3. As can be seen from the figures, quality of life parameters are lower at the baseline than after ASCT across the majority of FAMS scales. Statistically significant improvement at baseline was found for the following scales: emotional well-being (p<0.001), general contentment (p<0.05), family/social well-being (p<0.001), and additional concerns (p<0.001).

In 6 months after ASCT statistically significant improvement as compared to base-line was registered across all scales except family/social well-being and additional concerns: mobility (p<0.001), symptoms (p<0.001), emotional well-being (p<0.01), general contentment (p<0.01), thinking and fatigue (p<0.01), and additional concerns (p<0.001). In a year the post-transplant QoL parameters had further increased with statistically significant improvement across all scales (p<0.01) except family/social well-being.

Mean total FAMS score at base-line was 115.5 (SD 29.6). At discharge it improved to 121.1 (SD 29.8; p<0.05) with further improvement in 6 months (mean 130.6; SD 31.8; p<0.01), and in a year post-transplant (mean 134.8; SD 28.1; p<0.001).

Figure 1. Quality of life parameters of MS patients before ASCT and at discharge (FAMS questionnaire)

Figure 2. Quality of life parameters of MS patients before ASCT and 6 months after ASCT (FAMS questionnaire)

Figure 3. Quality of life parameters of MS patients before ASCT and 12 months after ASCT (FAMS questionnaire)

Further analysis included the comparison of QoL parameters of MS patients before and after ASCT as compared with the population norm. For these purposes QoL was measured using RAND SF-36. Quality of life profiles of MS patients at baseline and 6 months post-transplant as well as of the population norm are presented in Fig. 4.  As can be seen, the quality of life profile in MS patients before ASCT is characterized by compression and deformation as compared with the population norm. Quality of life parameters of MS patients before ASCT were significantly lower than of the population norm across all SF-36 scales. Six months after transplantation definite improvement of QoL parameters was registered, with statistically significant changes across all the scales (p<0.01) except pain and role–emotional functioning. The Mean Integral QoL Index increased dramatically as compared to base-line value (0.32 (SD 0.26) vs. 0.50 (SD 0.28); p< 0.01).

Figure 4. Quality of life profiles in MS patients before and 6 months after ASCT as compared with the population norm (SF-36 questionnaire) 
Note: PF = physical functioning, RPF = role–physical functioning, BP = bodily pain, GH = general health, V = vitality, SF = social functioning, REF = role–emotional functioning, MH = mental health.

Taking into account the patients’ heterogeneity in terms of their QoL the patients were stratified at baseline by the grades of QoL impairment. Five groups were identified according to the grades of QoL impairment: with no QoL impairment, mild QoL impairment, moderate QoL impairment, severe QoL impairment, and critical QoL impairment.

Distribution of patients according to the grades of QoL impairment before and 6 months after ASCT is shown in Table 1.

Table 1. Distribution of patients according to the grades of QoL impairment before ASCT and 6 months post-transplant (n=33)

QoL impairment grade	N, %
	Before ASCT	After ASCT
No QoL impairment	9 (27)	17 (52)
Mild QoL impairment	4 (13)	3 (9)
Moderate QoL impairment	1 (3)	4 (13)
Severe QoL impairment	10 (30)	7 (20)
Critical QoL impairment	9 (27)	2 (6

Changes in the distribution of patients according to the grades of QoL impairment took place after ASCT. The number of patients with no QoL impairment increased after transplantation, while the number of patients with critical QoL impairment decreased. Notably, ASCT resulted in a two-fold increase in the number of patients with QoL comparable to population norms: before transplantation 27% of patients had no QoL impairment, and 6 months after ASCT it was 52%. At the same time the number of patients with critical QoL impairment had experienced a triple decrease: at base-line 27% of patients had critical QoL impairment, and 6 months after ASCT it was only 6%.

Thus, ASCT is accompanied by an increase in the number of patients with no QoL impairment and a decrease in the number of patients with critical QoL impairment.

Symptoms in MS patients after ASCT

Symptom prevalence in MS patients before and after ASCT is presented in Fig. 5. Before transplantation MS patients experienced a wide range of symptoms. The most prevalent symptom was fatigue (83%). Of those who had fatigue about half of the patients reported it at moderate-to-severe level. The other frequent symptoms were toddling, heat sensitivity, psychological problems (anxiety and sadness) and numbness/tingling with their prevalence of 79%, 76%, 72%, and 70%, respectively. More than half of the patients reported these symptoms at the moderate-to-severe level. The majority of patients (60% on average) experienced such symptoms as movement disorders, coordination problems, urination dysfunction, and vision impairment.

In response to treatment, changes in symptom prevalence in MS patients were found. Positive changes in prevalence of the most frequent symptoms – fatigue, toddling, psychological problems (anxiety and sadness), numbness/tingling, movement disorders, coordination problems, urination dysfunction, and vision impairment – were observed 6 months after ASCT. The prevalence of the vast majority of moderate-to-severe symptoms after transplantation was lower than before treatment.

Figure 5. Symptom prevalence in MS patients before ASCT and 6 months post-transplant

Information about symptom severity in MS patients before and 6 months after ASCT is presented in Table 2. Before transplantation the most severe symptom was toddling followed by heat sensitivity, fatigue, movement disorders, and coordination disorders. In response to treatment, the severity of these symptoms decreased. As it is seen from the table the mean value of the severity of these symptoms 6 months after ASCT was lower than before treatment. The severity of other symptoms decreased as well.

Table 2. Symptom severity in MS patients before ASCT and 6 months post-transplant

Symptoms	Before ASCT	6 months after ASCT
		Mean (SD)	Meand (SD)
Toddling	5.3(4.1)	4.2(4.0)
Heat sensitivity	4.7(3.7)	4.5(3.8)
Fatigue	4.4(3.1)	3.5(3.0)
Movement disorders	3.9(3.8)	3.2(3.8)
Coordination disorders	3.7(3.8)	3.0(3.8)
Urination dysfunction	3.3(3.8)	1.9(2.8)
Numbness/tingling	3.3(3.3)	1.8(2.4)
Stool problems	3.2(3.6)	2.4(3.4)
Anxiety	3.0(2.9)	1.8(2.7)
Vision impairment	2.8(3.4)	1.9(3.1)
Sadness	2.8(3.0)	1.6(2.7)
Dizziness	2.3(2.9)	1.2(2.0)
Muscle cramps	2.1(3.0)	2.0(3.0)
Sexual dysfunction	2.0(3.7)	1.4(2.9)
Pain	1.5(2.2)	1.2(2.1)
Decreased concentration	1.3(1.9)	1.4(2.5)
Memory loss	1.1(2.0)	1.2(2.3)
Tremor	1.1(1.9)	0.9(2.0)
Chills	0.8(1.9)	1.3(2.7)
Speech disorders	0.7(1.9)	0.9(1.8)
Hearing disorders	0.5(1.7)	0.4(1.6)
Swallowing problems	0.4(0.8)	0.3(1.1)

QoL treatment response in MS patients after ASCT

QoL treatment response characterizes changes in physical, psychological, and social functioning of a patient after treatment. Three types of QoL treatment response after ASCT can be identified: improvement, stabilization, and worsening.

QoL treatment response was determined at different time-points after ASCT. Here we present the data on QoL treatment response at 6 months post-transplant (n=33). Three types of QoL treatment response were registered: improvement, stabilization, or worsening. QoL improvement or QoL stabilization was shown in the vast majority of patients. QoL improvement was achieved in 16 (48.5%) patients; and QoL stabilization in other 16 patients. QoL worsening was noticed in one patient only.

Thus, the vast majority of patients (97%) experienced either QoL improvement or QoL stabilization in 6 months after ASCT.

Conclusions

1. Physical, psychological and social functioning in MS patients is significantly deteriorated. The quality of life profile of these patients is characterized by compression and deformation. The majority of patients exhibit either severe or critical QoL impairment.

2. MS patients experience a wide range of disease-related symptoms. The most frequent symptoms – fatigue, toddling, heat sensitivity, psychological problems (anxiety and sadness), and numbness/tingling – are present in more than 70% of patients. About a half of the patients report these symptoms at the moderate-to-severe level.

3. ASCT in MS patients improves their physical, psychological and social function. The most definite improvement of quality of life takes place in a year after transplantation.

4. After ASCT the number of patients with no QoL impairment increases whereas the number of patients with critical QoL impairment decreases.

5. Quality of life treatment response (QoL improvement or QoL stabilization) was achieved in the vast majority of MS patients after ASCT.

6. ASCT is associated with decline of symptom prevalence and severity in MS patients.

References

1. Cella D, Yount S, Rothrock N, et al. The Patient-Reported Outcomes Measurement Information System (PROMIS). Med. Care. 2007;45(5):3-11. doi: 10.1097/01.mlr.0000258615.42478.55.

2. FDA Guidance for Industry: Patient-reported outcome measures: use in medical product development to support labeling claims. Bulletin of the Multinational Center of Quality of Life Research. 2006;7-8:153-154.

3. Fedorenko DA, Kishtovich AV, Ionova TI, Novik АА. Symptom assessment in patients with multiple sclerosis after hematopoietic stem cell transplantation. Bulletin of the Multinational Center of Quality of Life Research. 2008;11-12:157-158.

4. Hemmett L, Holmes J, Barnes M, Russe N. What drives quality of life in multiple sclerosis? Ass. Physic. 2004;QJM;Vol. 97(10):185-187. doi: 10.1093/qjmed/hch105.

5. Nortvedt MW, Riise T, Myhr KM, et al. Quality of life as a predictor for change in disability in MS. Neurology. 2000 Jul 12;55(1):51-4.

6. Nortvedt MW, Riise T, Myhr KM, et al. Quality of life in multiple sclerosis: measuring the disease effects more broadly. // Neurology. 1999;22(53):1098-1103.

7. Novik AA, Ionova TI. Guidelines of quality of life research in medicine. М: Olma Media Grupp, 2007.

8. Novik AA, Ionova TI, Kalyadina SA, Kishtovich AV. Conceptual and statistical models of stratification of the patients population according to the grades of quality of life impairement. Bulletin of the Multinational Center of Quality of Life Research. 2007;9-10:88-98.

9. Ramp M, Khan F, Misajon RA, Pallant JF. Rasch analysis of the Multiple Sclerosis Impact Scale (MSIS-29) Hlth Quality Life Outcomes. 2009;7:58. doi: 10.1186/1477-7525-7-58.

10. Rice GP, Oger J, Duquette P, et al. Treatment with interferon beta-1b improves quality of life in multiple sclerosis. // Can. J. Neurol. Sci. 1999;26(4):276-282.

11. The Canadian Burden of Illness Study Group. Burden of illness of multiple sclerosis: Part II: Quality of life. // Can. J. Neurol. Sci. 1998;25:31-38.

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Ионова, Денис А. Федоренко, Никита Е. Мочкин, Кира А. Курбатова, Андрей А. Новик</p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(170) "

Татьяна И. Ионова, Денис А. Федоренко, Никита Е. Мочкин, Кира А. Курбатова, Андрей А. Новик

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Физическая, психологическая и социальная функции у больных рассеянным склерозом (РС) существеннно нарушены. Это находит отражение в значительном ухудшении качества жизни больных, и степень этого ухудшения вариирует от средней тяжести до критической. Среди большого количества патологических симптомов, сопровождающих течение РС, наиболее частыми, присутствующими у 70 % больных, являются слабость, трудности в ходьбе ("ковыляющая" походка), повышенная чувствительность к теплу, психологические проблемы (чувство тревоги и уныния), ощущение онемения или покалывания на  различных участках поверхности тела. Около половины больных с такими симптомами определяют их тяжесть от среднего уровня и выше. Аутологичная трансплантация стволовых клеток (АТСК) больным РС улучшает их физические, психологические и социальные функции. Наиболее отчётливо улучшение качества жизни проявляется в течение первого года после трансплантации. В частности, повышалось количество больных без нарушений показателей качества жизни, а также уменьшение количества больных, имевших до АТСК критическое снижение показателей качества жизни. Качество жизни в целом было улучшено в результате АТСК у подавляющего количества больных РС как за счёт сужения спектра патологических симптомов, так и уменьшения их тяжести.

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Tatyana I. Ionova¹, Denis A. Fedorenko², Nikita E. Mochkin², Kira A. Kurbatova¹, Andrey A. Novik²

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¹Multinational Center for Quality of Life Research, St. Petersburg, Russia; ²Department of Hematology and Cellular Therapy, Pirogov National Medical Surgical Center, Moscow, Russia

Correspondence
Tatyana I. Ionova, 195009, Finski per., 9, mailbox 57, St. Petersburg, Russia
Phone/Fax: +7 (812) 436-61-12, E-mail: qlife@spam is badrambler.ru

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Physical, psychological, and social function in MS patients is significantly deteriorated. Quality of life profile of the patients is characterized by compression and deformation. The majority of the patients exhibit either severe or critical QoL impairment. MS patients experience a wide range of disease-related symptoms; the most frequent symptoms are fatigue, toddling, heat sensitivity, psychological problems (anxiety and sadness), and numbness/tingling are present in more than 70% of patients. About half of all patients report these symptoms at the moderate-to-severe level. ASCT in MS patients improves their physical, psychological, and social function. The most definite improvement of quality of life takes place within a year of transplantation. After ASCT the number of patients with no QoL impairment increases and the number of patients with critical QoL impairment decreases. Quality of life treatment response was achieved in the vast majority of MS patients after ASCT. ASCT is associated with decline of symptom prevalence and severity in MS patients.

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Tatyana I. Ionova¹, Denis A. Fedorenko², Nikita E. Mochkin², Kira A. Kurbatova¹, Andrey A. Novik²

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Tatyana I. Ionova¹, Denis A. Fedorenko², Nikita E. Mochkin², Kira A. Kurbatova¹, Andrey A. Novik²

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Physical, psychological, and social function in MS patients is significantly deteriorated. Quality of life profile of the patients is characterized by compression and deformation. The majority of the patients exhibit either severe or critical QoL impairment. MS patients experience a wide range of disease-related symptoms; the most frequent symptoms are fatigue, toddling, heat sensitivity, psychological problems (anxiety and sadness), and numbness/tingling are present in more than 70% of patients. About half of all patients report these symptoms at the moderate-to-severe level. ASCT in MS patients improves their physical, psychological, and social function. The most definite improvement of quality of life takes place within a year of transplantation. After ASCT the number of patients with no QoL impairment increases and the number of patients with critical QoL impairment decreases. Quality of life treatment response was achieved in the vast majority of MS patients after ASCT. ASCT is associated with decline of symptom prevalence and severity in MS patients.

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Physical, psychological, and social function in MS patients is significantly deteriorated. Quality of life profile of the patients is characterized by compression and deformation. The majority of the patients exhibit either severe or critical QoL impairment. MS patients experience a wide range of disease-related symptoms; the most frequent symptoms are fatigue, toddling, heat sensitivity, psychological problems (anxiety and sadness), and numbness/tingling are present in more than 70% of patients. About half of all patients report these symptoms at the moderate-to-severe level. ASCT in MS patients improves their physical, psychological, and social function. The most definite improvement of quality of life takes place within a year of transplantation. After ASCT the number of patients with no QoL impairment increases and the number of patients with critical QoL impairment decreases. Quality of life treatment response was achieved in the vast majority of MS patients after ASCT. ASCT is associated with decline of symptom prevalence and severity in MS patients.

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¹Multinational Center for Quality of Life Research, St. Petersburg, Russia; ²Department of Hematology and Cellular Therapy, Pirogov National Medical Surgical Center, Moscow, Russia

Correspondence
Tatyana I. Ionova, 195009, Finski per., 9, mailbox 57, St. Petersburg, Russia
Phone/Fax: +7 (812) 436-61-12, E-mail: qlife@spam is badrambler.ru

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¹Multinational Center for Quality of Life Research, St. Petersburg, Russia; ²Department of Hematology and Cellular Therapy, Pirogov National Medical Surgical Center, Moscow, Russia

Correspondence
Tatyana I. Ionova, 195009, Finski per., 9, mailbox 57, St. Petersburg, Russia
Phone/Fax: +7 (812) 436-61-12, E-mail: qlife@spam is badrambler.ru

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Это находит отражение в значительном ухудшении качества жизни больных, и степень этого ухудшения вариирует от средней тяжести до критической. Среди большого количества патологических симптомов, сопровождающих течение РС, наиболее частыми, присутствующими у 70 % больных, являются слабость, трудности в ходьбе (&quot;ковыляющая&quot; походка), повышенная чувствительность к теплу, психологические проблемы (чувство тревоги и уныния), ощущение онемения или покалывания на  различных участках поверхности тела. Около половины больных с такими симптомами определяют их тяжесть от среднего уровня и выше. Аутологичная трансплантация стволовых клеток (АТСК) больным РС улучшает их физические, психологические и социальные функции. Наиболее отчётливо улучшение качества жизни проявляется в течение первого года после трансплантации. 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Физическая, психологическая и социальная функции у больных рассеянным склерозом (РС) существеннно нарушены. Это находит отражение в значительном ухудшении качества жизни больных, и степень этого ухудшения вариирует от средней тяжести до критической. Среди большого количества патологических симптомов, сопровождающих течение РС, наиболее частыми, присутствующими у 70 % больных, являются слабость, трудности в ходьбе ("ковыляющая" походка), повышенная чувствительность к теплу, психологические проблемы (чувство тревоги и уныния), ощущение онемения или покалывания на  различных участках поверхности тела. Около половины больных с такими симптомами определяют их тяжесть от среднего уровня и выше. Аутологичная трансплантация стволовых клеток (АТСК) больным РС улучшает их физические, психологические и социальные функции. Наиболее отчётливо улучшение качества жизни проявляется в течение первого года после трансплантации. В частности, повышалось количество больных без нарушений показателей качества жизни, а также уменьшение количества больных, имевших до АТСК критическое снижение показателей качества жизни. Качество жизни в целом было улучшено в результате АТСК у подавляющего количества больных РС как за счёт сужения спектра патологических симптомов, так и уменьшения их тяжести.

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Физическая, психологическая и социальная функции у больных рассеянным склерозом (РС) существеннно нарушены. Это находит отражение в значительном ухудшении качества жизни больных, и степень этого ухудшения вариирует от средней тяжести до критической. Среди большого количества патологических симптомов, сопровождающих течение РС, наиболее частыми, присутствующими у 70 % больных, являются слабость, трудности в ходьбе ("ковыляющая" походка), повышенная чувствительность к теплу, психологические проблемы (чувство тревоги и уныния), ощущение онемения или покалывания на  различных участках поверхности тела. Около половины больных с такими симптомами определяют их тяжесть от среднего уровня и выше. Аутологичная трансплантация стволовых клеток (АТСК) больным РС улучшает их физические, психологические и социальные функции. Наиболее отчётливо улучшение качества жизни проявляется в течение первого года после трансплантации. В частности, повышалось количество больных без нарушений показателей качества жизни, а также уменьшение количества больных, имевших до АТСК критическое снижение показателей качества жизни. Качество жизни в целом было улучшено в результате АТСК у подавляющего количества больных РС как за счёт сужения спектра патологических симптомов, так и уменьшения их тяжести.

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Introduction

Following injury to the nervous system, the activation of the immune system profoundly affects the ability of neurons to survive and to regenerate damaged axons. The role of immune response is controversial. It has long been established that immune cells in the CNS can cause or augment tissue injury. However, recent investigations show that immune cells and their factors can contribute to neuroprotection and neuroregeneration. This dual role of the immune system is determined by the type and duration of the immune response and the balance between destructive and protective factors that ultimately define the net result of the neuro-immune interaction [5].

The immune system operates via innate (antigen-independent) and adaptive (antigen-specific) immunity. Inflammatory responses during traumatic injury or different CNS diseases are dominated by cells of the innate immune system, most importantly resident microglia and blood-borne macrophages. After phagocytosing cellular debris, microglia/macrophages present antigens to lymphocytes, thereby activating the antigen-specific immune response [33]. 

Unlike most other systems, the central nervous system has a limited capacity for regeneration. While the inhibitory effects of proteoglycans and myelin on axonal growth have been well established, the role of neuroinflammation in regeneration failure remains highly controversial [6]. Several studies have demonstrated the beneficial effects of macrophages (Mφ) following injury [<23, 25, 27, 37]; however, others revealed that macrophages promoted injury [9, 19].

One of the possible explanations of these diverse macrophage effects could be connected with the differences between the macrophages used. Certainly, Mφ are remarkable for the heterogeneity and diverse biological activities [11]. There are at least two distinct functional Mφ subsets that are triggered in response to different stimuli: classical pro-inflammatory and nonclassical anti-inflammatory macrophages, also termed type 1 (M1) and type 2 (M2) macrophages. M1 are induced by IFN-γ, either alone or in concert with a microbial stimulus, possess high antigen-presented activity, and support Th1 response. These cells are involved in pro-inflammatory responses, mediate resistance to intracellular pathogens and anti-tumor resistance and are tissue destructive. In contrast, various forms of M2, generated in the presence IL-4 or IL-13, immune complexes, IL-10, etc., are not efficient at antigen presentation, suppress Th1 and/or favor Th2 response, and produce high levels of matrix-associated proteins. These cells are tolerogenic and generally oriented toward resistance to parasites, immunoregulation, tissue remodeling and repair, and tumor promotion [20, 10, 18]. It is important to note that macrophages can reversibly shift their functional phenotype in response to changes in their microenvironment. Sequential treatment of macrophages with multiple cytokines results in a progression through various functional phenotypes. That is, macrophages may progress from one functional phenotype to another [32, 21].

Recently, Kigerl et al has shown that in CNS injury rapidly induced M1 response than shift to M2 response. M1 were neurotoxic, whereas M2 promoted a regenerative growth response in adult sensory axons, even in the context of inhibitory substrates that dominated sites of CNS injury (e.g., proteoglycans and myelin). The authors concluded that switching macrophages toward an M2 phenotype could promote CNS repair while limiting secondary inflammatory-mediated injury [14]. Thus, boosting or modulating the immune response seems to be a promising strategy for successful CNS repair.

Since macrophages may be prospective candidates for cell therapy, the development of simple and reproducible technologies of M2-like macrophage generation seems to be a necessary step for the clinical application of this approach. For human monocytes GM-CSF treatment leads to the formation of Mφ1 macrophages with features of pro-inflammatory M1 cells, while the equivalent population following culture in M-CSF has been termed Mφ2 macrophages with features of M2 anti-inflammatory cells [34, 35]. In addition, macrophages that ingest apoptotic cells are shown to decrease pro-inflammatory and acquire anti-inflammatory properties [8]. Utilizing of M2-like macrophages in experimental models and clinical trail was successfully demonstrated by the Michel Schwartz group [27, 16]. Recently we developed a simple approach for generation of non-classical type2-like macrophages (Mφ3) in the presence of GM-CSF in serum-deficient conditions. The purpose of the current study was to compare the phenotype and functions of these Mφ3 with “standard” pro-inflammatory Mφ1 and anti-inflammatory Mφ2 subsets, generated in the presence of GM-CSF and M-CSF.

Materials and Methods

Isolation and generation of macrophages
Human blood samples were obtained from healthy donors with informed consent according to the policy approved by the local Ethical Committee. Human peripheral blood mononuclear cells (PBMCs) were obtained through density gradient centrifugation (Ficoll-Paque, Sigma-Aldrich) of heparinized whole blood samples. For monocyte separation PBMCs were plated at 3–5 x10⁶/ml in tissue culture dishes (TPP, Switzerland) in RPMI-1640 (Sigma-Aldrich) with 5% FCS (Biolot, Russia) for 18 h and then washed to remove non-adherent residual lymphocytes. The percentage of CD14-positive cells was demonstrated by flow cytometry analysis to be greater than 90–93% of the total cells recovered.

Classical type-1 macrophages (Mφ1) were generated by culturing adherent cells in six-well tissue plates (Nunclon, Denmark) in RPMI-1640 supplemented with 5% autologous plasma, 2% FCS, 0.05 mM 2-mercaptoethanol, 2 mM sodium pyruvate, 0.3 mg/ml L-glutamine (all reagents of Sigma-Aldrich), 1% nonessential amino acids, 100 μg/ml gentamycin and 50 ng/ml recombinant human GM-CSF (R&D Systems) at 37°C with 5% CO2 for 7 days. Non-classical type 2 macrophages (Mφ2) were obtained in identical culture conditions in complete RPMI-1640 supplemented with rhM-CSF (50 ng/ml; R&D Systems). Non-classical type 3 macrophages (Mφ3) were generated by incubation of monocytes in serum growth factors deficiency conditions. Specifically, adherent cells were cultured for 7 days in complete RPMI-1640 supplemented with 2% autologous plasma (without FCS) and 50 ng/ml rhGM-CSF. Polarized Mφ (Mφ1, -2, -3) were harvested by using EDTA in Hanks' balanced salt solution, washed and counted.

Flow cytometry analysis
For evaluation of the Mφ phenotype, cell suspensions were incubated for 20 min at 4°C with fluorescein isothiocyanate (FITC) or phycoerythrin (PE)-conjugated antibodies specific for human CD14, CD86, CD90, and HLA-DR or isotype controls. All monoclonal antibodies were obtained from BD Biosciences (USA). After incubation with antibodies, cells were washed with PBS containing 0.1% sodium azide (Sigma-Aldrich) and 0.1% bovine serum albumin, and were then analyzed with a FACSCalibur using CellQuest software (BD Biosciences).

T-cell proliferation assays
The antigen-presenting and allostimulatory activity of Mφ was determined by measuring T-cell proliferation in the mixed lymphocyte culture (MLC). Different types of Mφ were collected after generation and 1x10⁵ cells were then plated in RPMI-1640 supplemented with 0.3 mg/ml L-glutamine, 5 mM HEPES buffer, 100 μg/ml gentamycin and 10% inactivated donor serum (AB (IV) group), and added to 1x10⁶ allogeneic responder PBMCs. All cultures were carried out in triplicate in round-bottom 96-well tissue culture plates, in a final volume of 150 μl of RPMI complete medium. T-cell proliferation was assessed after 5 days by adding [³H]thymidine (1 μCi/well) for 18 h. Cells were then harvested and thymidine incorporation was measured in a liquid scintillation counter SL-30 (Intertechnic, France). The stimulatory capacity of Mφ in MLC was expressed by the stimulation index (SI) = cpm in MLC (PBMCs+Mφ) / cpm in control culture (PBMCs alone).

Cytokines, chemokines, and growth factor measurements
Culture supernatants of generated Mφ (Mφ1, -2, -3) were collected and stored at –80°C  prior to measurement. The concentration of secreted cytokines/chemokines was determined by using the Bio-Plex Protein Array System (kits and equipment of Bio-Rad, USA based on Luminex xMAP technology; sensitivity 2 pg/ml) in the case of TNF-α, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-12 (p70), IL-13, IL-17, G-CSF, IFN-γ, IL-8, MCP-1, and MIP-1β, and by using ELISAs from Diagnostic System Laboratories for insulin-like growth factor-I (IGF-I, sensitivity 0.01 ng/ml); from BioSource for basic fibroblast growth factor (FGF-basic, sensitivity 7 pg/ml); from R&D Systems for brain-derived neurotrophic factor (BDNF, sensitivity 20 pg/ml); from Invitrogen Corp. for vascular endothelial growth factor (VEGF, sensitivity 5 pg/ml); from Protein Contour (St-Petersburg, Russia) for erythropoietin (EPO, sensitivity 4 pg/ml) and epidermal growth factor (EGF, sensitivity 2 pg/ml); and from Vector-Best (Novosibirsk, Russia) for IL-18 (sensitivity 5 pg/ml).

Statistical analysis
Statistical analysis was performed using the STATISTICA software version 6.0 (StatSoft. Inc., USA). The Mann-Whitney non-parametric two-tailed U test was used to determine the significance of data, which are presented as median and inter-quartile range (IQR). Values of p < 0.05 were considered statistically significant.

Results

Characterization of generated Mφ
We generated three distinct Mφ subsets in vitro from peripheral blood monocytes and performed a series of parallel comparisons between them. As a first step, we measured cell yield and their phenotype. The number of Mφ1 and Mφ2 obtained from 1x10⁶ PBMCs was 3.35x10⁴ (IQR 2.2–7.4x10⁴) and 2.50x10⁴ (IQR 1.4–4.5x10⁴), whereas Mφ3 yield was significantly higher – 5.0x10⁴ (IQR 3.3– 0.4x10⁴, p_U<0.01), indicating that a low serum condition increased the quantity of macrophages generated in the presence of GM-CSF. 

After 7 days of culture, the majority of Mφ1, Mφ2, and Mφ3 were adherent cells with a classical “fried egg” morphology (data not shown) that expressed CD14 on their cell surface (Table 1). A small number of adherent cells had a stretched, spindle-like morphology (fibroblast-like cells). The average number of these cells in Mφ1 (n=8) and Mφ2 (n=8) populations was similar and constituted 25% (IQR 22–45 and 16.5–33.5%, respectively), and was slightly higher (Median 32.5%, IQR 17–43%, n=6) in the Mφ3 subset. However, the expression of CD90 antigen (a typical marker for a fibroblasts and mesenchymal stem cells) in all Mφ populations was low and the percentage of CD90+ cells did not exceed 2–3%. 

Table 1. Phenotype Mφ1, Mφ2 and Mφ3 subsets

Percentage of positive cell
Marker	Mφ1		Mφ2		Mφ3
	Median (IQR)	N	Median (IQR)	N	Median (IQR)	N
CD14	78 (70–84)	17	87 (78–91)	9	82 (67–92)	25
HLA-DR	97 (91–98)	21	96 (96–98)	9	87 (73–97)	17
CD86	37 (23–53)	18	27 (15–39)	13	23 (11–58)	17
CD90	2.5 (0–5.0)	10	2.0 (0–5.0)	13	3 (0.6–5.0)	8

All three Mφ populations strongly expressed the HLA-DR antigen, though the percentage of HLA-DR positive cells in the Mφ3 cultures was lower than in the Mφ1 and Mφ2. All types of monocyte-derived macrophages also expressed the CD86 antigen. The mean number of СD86+ cells in Mφ2 and Mφ3 was lower than in Mφ1, though not significantly.

The ability of Mφ to induce T-cell proliferation
The revealed differences of HLA-DR and CD86 expression in distinct Mφ populations could influence their antigen-presenting function. To determine whether Mφ1, Mφ2, and Mφ3 differed quantitatively in their capacity to present antigen, we tested and compared their ability to induce an allogeneic T-cell response. For this purpose distinct Mφ subsets derived from the same donor were cocultured with allogeneic PBMCs over a period of 5 days, and the T-cell proliferation was determined (Table 2). Analysis of [³H]thymidine incorporation revealed a strong proliferative response in PBMCs cocultured with Mφ1, whereas weak proliferation could be observed in PBMCs cocultured with Mφ2 or Mφ3. Remarkably, the T-cell stimulatory capacity of Mφ3 expressed by the stimulation index (SI) was significantly lower than that of Mφ1 and Mφ2.

Table 2. The stimulatory effect of Mφ1, Mφ2 and Mφ3 subsets on allogeneic T-cell proliferation

Culture		Mφ1 (n=24)	Mφ2 (n=24)	Mφ3 (n=24)
PBMCs alone	Median	330	140	370
	IQR	105–720	105–410	70–1300
PBMCs + Mφ (10:1)	Median	7380	3130 **	2070 ** #
	IQR	3500–13220	1600–3680	330–3230
Stimulation index	Median	19.6	14.8	3.4 ** ##
	IQR	14.9–74.5	6.2–35.3	1.4–13.7
Mφ (1x105 cells) were cultured with 1x106 allogeneic PBMCs over 5 days. 3[H]-thymidine (1 µCi/well) was added 18 h before harvesting to measure T-cell proliferation (cpm).  The stimulation index is expressed in calculated units (cpm in MLC (PBMCs+Mφ) / cpm in control culture (PBMCs alone).  ** pU < 0.01 vs Mφ1; # pU < 0.05 and ## pU < 0.01 vs Mφ2.

Generated Mφ differ in cytokine and chemokine production
To further characterize the secretory profile of generated Mφ subsets, we measured the production of Th1/pro-inflammatory (IFN-γ, IL-2, IL-1β, TNF-α, IL-12, IL-17, IL-18, IL-6) and Th2/anti-inflammatory cytokines (IL-4, IL-10, IL-13). Cytokine levels were measured in supernatants of 7-day cultures of Mφ1, Mφ2 and Mφ3. Mφ1 spontaneously produced considerable levels of IL-1β, IL-6, TNF-α, IFN- γ, IL-4, and IL-17 (Table 3). This finding confirms the pro-inflammatory nature of Mφ1 and their capacity for T-cell activation. Mφ2 were characterized by lower secretory activity for some of these cytokines, though the differences were significant only for IL-4 and IL-18. In contrast, Mφ3 displayed remarkably decreased basal levels of pro-inflammatory cytokines (IL-1β, TNF-α, IL-6, IL-18), Th1-cytokines (IFN-γ, IL-2), and IL-4. Mφ3 also differed from Mφ1 by a 2-fold lower IL-12 production and more pronounced production of IL-10, though not significantly. In addition to cytokines, we measured the levels of various inflammatory chemokines in the supernatants of unstimulated macrophages. Generated Mφ constitutively produced high levels of IL-8, MCP-1, and MIP-1β. Mφ1 and Mφ2 demonstrated similar levels in their production. In contrast, secretion of neutrophil-attracting IL-8 and monocyte-attracting MCP-1 by Mφ3 was significantly lower than by Mφ1 and Mφ2. However, the production of T-cell attracting MIP-1β by Mφ3 did not differ from that by Mφ1 and Mφ2. Together, these data confirm the pro-inflammatory nature of Mφ1 and significantly less pro-inflammatory activity of Mφ3.

Table 3. Cytokine/chemokine concentrations secreted by Mφ1, Mφ2, and Mφ3

Cytokines& chemokines (pg/ml)	Mφ1 (n=10) Median	IQR	Mφ2(n=10)   Median	IQR	Mφ3 (n=24) Median	IQR
IFN-γ	872	734–995	839	539–1010	626 * ↓	440–830
IL-2	154	115–154	115	70–155	72 *↓	47–115
IL-1β	405	246–670	313	150–790	195 * # ↓	68–290
TNF-α	175	124–282	148	55–224	99 * ↓	51–156
IL-12	28	20–29	19	7–25	14	3–33
IL-17	308	245–483	257	177–448	214	112–427
IL-18	33	29–51	27 * ↓	16.5–31.2	19 * ↓	15.7–35.8
IL-6	21340	13430–27340	20350	8380–25060	10900 * ↓	4110–21770
IL-4	215	198–246	119  ** ↓	79–141	106 ** ↓	53–190
IL-10	5	2–10	2	2–2	15	2–60
IL-13	78	37–113	48	37–78	78	42–112
IL-8	90380	74280–93340	67400	57940–94430	44320 ** ## ↓	29150–59000
MCP-1	11140	5680–14000	11910	4160–17660	3345 ** ## ↓	1100–4460
MIP-1β	1 960	1250–5590	1 560	930–2700	2220	790–7620
* pU < 0.05 and ** pU < 0.01 vs Mφ1; # pU < 0.05 and ## pU < 0.01 vs Mφ2.

Production of growth factors by generated Mφ
All three types of unstimulated macrophages secreted detectable concentrations of erythropoietin, G-CSF, FGF-basic, BDNF, and IGF-1 (Table 4). Mφ1 and Mφ2 produced analogous levels of these growth factors, although there was a strong tendency to higher production of EPO by Mφ2. Despite the decreased production of pro-inflammatory cytokines, Mφ3 secreted concentrations of G-CSF, EPO, FGF-basic and EGF comparable with Mφ2, though significantly lower concentration of BDNF. But the most prominent difference was revealed for the production of IGF-1, which was much higher in Mφ3 in comparison with Mφ1 and Mφ2 cultures. Concerning VEGF, its detectable concentrations in 7-day cultures were determined only in a quarter of tested donors. Among these cultures VEGF was predominantly produced by Mφ2, and especially by Mφ-3, but not Mφ1.

Table 4. Growth factors production by Mφ1, Mφ2 and Mφ3

Growth factors (pg/ml)	Mφ1 (n=10) Median	IQR	Mφ2 (n=10) Median	IQR	Mφ3 (n=24) Median	IQR
G-CSF	670	505–1610	730	315–2310	430	180–1050
EPO	19.2	1.7–36.9	46.5	33.8–81.1	34.9	21.5–56.5
FGF-basic	104	57–124	150	87–180	109	45–126
EGF	207	148–331	283	245–420	138	38–310
BDNF	392	187–705	438	215–739	131 * # ↓	78–235
IGF-1	322	170–8560	152	116–459	8310 * ## ↑	520–9500
VEGF (n=6)	5.0	5.0–97	92.8 * ↑	59.2–298	422.4 * # ↑	107.7–524.7
* pU < 0.05 and ** pU < 0.01 vs Mφ1; # pU < 0.05 and ## pU < 0.01 vs Mφ2. Wilcoxon matched non-parametric paris test was used to determine the significance of VEGF.

Discussion

Over the last decade, there has been an increasing interest in the role of the inflammatory reaction in CNS injury. Moreover, this interest has focused on the dominant cell type observed during inflammation, the macrophage. However, in the CNS the contribution of these cells to the healing process remains questionable [6].

The contradictory data regarding the contribution of Mφ to CNS recovery could be explained by diverse macrophage activities, many of which appear to be oppositional in nature. The destructive potential of macrophages in CNS pathology may be caused by pro-inflammatory activity, whereas their regenerative capacity may be linked with anti-inflammatory features [12].

In the search for macrophages with potential regenerative activity we developed a simple method for the generation of macrophages in growth factor deficient conditions and analyzed the phenotype and functional activity of these macrophages, termed Mφ3, with pro-inflammatory Mφ1 and anti-inflammatory Mφ2. We speculated that the deficiency of growth factors in low serum conditions may be one of the key factors capable of activating regenerative properties of macrophages. Particularly, low serum conditions during macrophage cultivation could stimulate deprivation-induced apoptosis of culturing cells (including admixture of non-adherent cells), and the ingestion of apoptotic cells may change the functional activity of macrophages toward an anti-inflammatory phenotype.

The received data demonstrated that low serum conditions did not influence the efficacy of Mφ3 generation. Moreover, the yield of Mφ3 significantly exceeded the number of Mφ1 and Mφ2. These data are correspondent with Plesner's study, who showed an enhanced yield of M-CSF treated macrophages in cultures with 1% fetal calf serum [22].

According to study of Verreck et al, anti-inflammatory Mφ2 have a lower expression of HLA-DR and CD86 molecules after LPS stimulation, though unstimulated macrophages expressed similar levels of these molecules [34]. We have shown that as compared to Mφ1 and Mφ2, Mφ3 cultures contained lower numbers of HLA-DR and CD86-positive cells. These differences, though not statistically significant, were important for the association with the decreased capacity of Mφ3 to stimulate allogeneic T cell proliferation. Type-2 anti-inflammatory macrophages are known to have a lower ability to stimulate T-cell proliferation in MLC [11]. This is in agreement with our data, and pointed to the lower allostimulatory activity of Mφ2 in comparison with Mφ1. Notably, Mφ3 virtually failed to stimulate lymphocyte proliferation in MLC. The medium value of the Mφ3 stimulation index was more than 6-fold lower than that of Mφ1. This fact strongly suggests that generated Mφ3 are not immunogenic and in this respect resemble anti-inflammatory M2 macrophages.

To further evaluate the pro- and anti-inflammatory activity of generated macrophages we compared their capacity to spontaneous production of Th1/pro- and Th2/anti-inflammatory cytokines. In contrast to Mφ1, Mφ3 produced significantly (2-fold) lower concentrations of pro-inflammatory (IL-1β, TNF-α, IL-6, IL-18) and Th1/Th2-cytokines (IFN-γ, IL-2, IL-4). Mφ3 supernatants also contained 2-fold lower concentrations of IL-12 and higher levels of IL-10, though these differences were not statistically significant.

Gordon and coworkers [11] have described alternatively activated macrophages after treatment with IL-4 or IL-13, which produce IL-10 without microbial stimulation. At the same time the study of Verreck demonstrated that unlike alternatively activated Mφ, M-CSF polarized Mφ2 failed to release IL-10 without activation, but effectively secreted IL-10 after mycobacterial activation. However, activated Mφ-2 produced no or relatively low levels of IL-12, IL-1β, IL-6, TNF-α [34]. We also did not reveal any significant concentrations of IL-10 in the supernatants of unstimulated Mφ2. In contrast to Mφ-2, Mφ-3 spontaneously produced IL-10 and displayed significantly less pro-inflammatory phenotype (as compare with Mφ1) without any additional stimulation.

Our results are also in agreement with findings suggesting a high ability of M-CSF polarized Mφ2 to secrete pro-inflammatory chemokines [35]. Mφ3 were also shown to secrete MIP-1β levels comparable with Mφ1 and Mφ2, but lower levels of IL-8 and MCP-1. This indicated that unlike Mφ1 and Mφ2 subsets, Mφ3 has less capacity to attract neutrophils and monocytes and therefore is less effective in supporting inflammation, whereas they could recruit effector Th1 cells and modify their functions.

One possible mechanism underlying the beneficial role of macrophages in CNS repair is connected with their capacity to produce a wide range of growth factors that can promote neuroprotection and regeneration [30, 17, 6]. The comparative analysis of some growth factors in the supernatants of generated macrophages revealed that all three Mφ subsets spontaneously produced detectable levels of EPO, G-CSF, IGF-1, FGF-basic, EGF, and BDNF. Mφ3 secreted concentrations of G-CSF, FGF-basic and EGF similar to Mφ1 and Mφ2, EPO comparable with Mφ2, and a lower level of BDNF, but more than 25-fold higher level of IGF-1. As for VEGF, this growth factor, identified only in quarter of patients, was produced by both Mφ2 and Mφ3, but not Mφ-1 and was significantly higher in Mφ3- than in Mφ2 cultures.

Production of classical neurotrophic factors including CNTF, IGF, HGF, PDGF, NGF, BDNF, GDNF, and NT-3 by macrophages have been shown in numerous studies [3, 7, 13]. Evaluation of two of these factors (BDNF and IGF-1) in cultures of distinct macrophage subtypes in our study supported previous data and demonstrated comparable production of these factors by inflammatory Mφ1 and anti-inflammatory Mφ2. Moreover we have shown for the first time that in spite of a lower level of BDNF, Mφ3 were characterized with exclusively high secretion of IGF-1.

IGF-1 is a potent neurotrophic factor. Its pleiotropic effects range from classical trophic actions on neurons such as housekeeping or anti-apoptotic/pro-survival effects to modulation of brain-barrier permeability, neuronal excitability, or new neuron formation. IGF-1 is also known to significantly improve axon growth and remyelination [2, 4]. The finding that IGF-1 is secreted abundantly by Mφ3 may point toward an important potential role for these macrophages in neuroprotection and regeneration.

In addition to neurotrophic factors, generated macrophages produced significant levels of VEGF. Detection of VEGF (in 7-day macrophage supernatants) only in part of the tested donors could be connected with an earlier peak of VEGF production. Nevertheless, in detectable cases VEGF was predominantly produced by both Mφ2 and Mφ3. VEGF has direct neuroprotective effects on motoneurons, induces neurogenesis and angiogenesis and its reduced levels cause neurodegeneration in part by impairing neural tissue perfusion [31, 38].

Other factors, such as EPO, G-CSF, FGF-β, and EGF, produced by Mφ-3 and Mφ1/Mφ2 subsets could also underlay the neuro-regenerative macrophage potential. Erythropoietin functions as a tissue-protective cytokine in addition to its crucial hormonal role in red cell production. This cytokine promotes both neuroprotection and neuroregeneration in various models of CNS injury and disease and is considered to be a promising candidate as neuroprotective agent [29,15]. G-CSF appears to have anti-apoptotic effect and stimulate differentiation of adult neural stem cells [26]. EGF is a motility factor for microglial cells and is shown to enhance the differentiation, maturation and survival of a variety of neurons in the central nervous system [36]. FGF-basic promotes the survival and neurite growth of brain neurons in vitro and in vivo, suggesting that it functions as a neurotrophic factor. In addition FGF acutely modulates synaptic transmission in the hippocampus, suggesting that it has a role similar to a neurotransmitter or neuromodulator [1].

Several groups have confirmed the therapeutic potential of activated microglia and monocyte derived macrophages in the injured spinal cord [3, 23-25]. The success of these pre-clinical models prompted a Phase I clinical trial that was completed without any adverse effects. Implantation of macrophages preincubated with dermis was well tolerated. Of the eight patients with complete spinal cord injury, three recovered clinically significant neurological motor and sensory function [16].

Recent study of this group showed that augmenting the naive monocyte pool by either adoptive transfer or CNS-specific vaccination resulted in a higher number of spontaneously recruited cells and improved recovery. Notably, the enhancement of motor functions was associated with anti-inflammatory activity of infiltrating macrophages, mediated by interleukin 10 [28].

In this aspect, the Mφ3 subset described in our study is characterized by low pro-inflammatory/immunogenic properties and high regenerative potential and therefore may represent new candidates for cell therapy in CNS injuries.

Acknowledgements

The authors declare no competing interests.

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Introduction

Following injury to the nervous system, the activation of the immune system profoundly affects the ability of neurons to survive and to regenerate damaged axons. The role of immune response is controversial. It has long been established that immune cells in the CNS can cause or augment tissue injury. However, recent investigations show that immune cells and their factors can contribute to neuroprotection and neuroregeneration. This dual role of the immune system is determined by the type and duration of the immune response and the balance between destructive and protective factors that ultimately define the net result of the neuro-immune interaction [5].

The immune system operates via innate (antigen-independent) and adaptive (antigen-specific) immunity. Inflammatory responses during traumatic injury or different CNS diseases are dominated by cells of the innate immune system, most importantly resident microglia and blood-borne macrophages. After phagocytosing cellular debris, microglia/macrophages present antigens to lymphocytes, thereby activating the antigen-specific immune response [33]. 

Unlike most other systems, the central nervous system has a limited capacity for regeneration. While the inhibitory effects of proteoglycans and myelin on axonal growth have been well established, the role of neuroinflammation in regeneration failure remains highly controversial [6]. Several studies have demonstrated the beneficial effects of macrophages (Mφ) following injury [<23, 25, 27, 37]; however, others revealed that macrophages promoted injury [9, 19].

One of the possible explanations of these diverse macrophage effects could be connected with the differences between the macrophages used. Certainly, Mφ are remarkable for the heterogeneity and diverse biological activities [11]. There are at least two distinct functional Mφ subsets that are triggered in response to different stimuli: classical pro-inflammatory and nonclassical anti-inflammatory macrophages, also termed type 1 (M1) and type 2 (M2) macrophages. M1 are induced by IFN-γ, either alone or in concert with a microbial stimulus, possess high antigen-presented activity, and support Th1 response. These cells are involved in pro-inflammatory responses, mediate resistance to intracellular pathogens and anti-tumor resistance and are tissue destructive. In contrast, various forms of M2, generated in the presence IL-4 or IL-13, immune complexes, IL-10, etc., are not efficient at antigen presentation, suppress Th1 and/or favor Th2 response, and produce high levels of matrix-associated proteins. These cells are tolerogenic and generally oriented toward resistance to parasites, immunoregulation, tissue remodeling and repair, and tumor promotion [20, 10, 18]. It is important to note that macrophages can reversibly shift their functional phenotype in response to changes in their microenvironment. Sequential treatment of macrophages with multiple cytokines results in a progression through various functional phenotypes. That is, macrophages may progress from one functional phenotype to another [32, 21].

Recently, Kigerl et al has shown that in CNS injury rapidly induced M1 response than shift to M2 response. M1 were neurotoxic, whereas M2 promoted a regenerative growth response in adult sensory axons, even in the context of inhibitory substrates that dominated sites of CNS injury (e.g., proteoglycans and myelin). The authors concluded that switching macrophages toward an M2 phenotype could promote CNS repair while limiting secondary inflammatory-mediated injury [14]. Thus, boosting or modulating the immune response seems to be a promising strategy for successful CNS repair.

Since macrophages may be prospective candidates for cell therapy, the development of simple and reproducible technologies of M2-like macrophage generation seems to be a necessary step for the clinical application of this approach. For human monocytes GM-CSF treatment leads to the formation of Mφ1 macrophages with features of pro-inflammatory M1 cells, while the equivalent population following culture in M-CSF has been termed Mφ2 macrophages with features of M2 anti-inflammatory cells [34, 35]. In addition, macrophages that ingest apoptotic cells are shown to decrease pro-inflammatory and acquire anti-inflammatory properties [8]. Utilizing of M2-like macrophages in experimental models and clinical trail was successfully demonstrated by the Michel Schwartz group [27, 16]. Recently we developed a simple approach for generation of non-classical type2-like macrophages (Mφ3) in the presence of GM-CSF in serum-deficient conditions. The purpose of the current study was to compare the phenotype and functions of these Mφ3 with “standard” pro-inflammatory Mφ1 and anti-inflammatory Mφ2 subsets, generated in the presence of GM-CSF and M-CSF.

Materials and Methods

Isolation and generation of macrophages
Human blood samples were obtained from healthy donors with informed consent according to the policy approved by the local Ethical Committee. Human peripheral blood mononuclear cells (PBMCs) were obtained through density gradient centrifugation (Ficoll-Paque, Sigma-Aldrich) of heparinized whole blood samples. For monocyte separation PBMCs were plated at 3–5 x10⁶/ml in tissue culture dishes (TPP, Switzerland) in RPMI-1640 (Sigma-Aldrich) with 5% FCS (Biolot, Russia) for 18 h and then washed to remove non-adherent residual lymphocytes. The percentage of CD14-positive cells was demonstrated by flow cytometry analysis to be greater than 90–93% of the total cells recovered.

Classical type-1 macrophages (Mφ1) were generated by culturing adherent cells in six-well tissue plates (Nunclon, Denmark) in RPMI-1640 supplemented with 5% autologous plasma, 2% FCS, 0.05 mM 2-mercaptoethanol, 2 mM sodium pyruvate, 0.3 mg/ml L-glutamine (all reagents of Sigma-Aldrich), 1% nonessential amino acids, 100 μg/ml gentamycin and 50 ng/ml recombinant human GM-CSF (R&D Systems) at 37°C with 5% CO2 for 7 days. Non-classical type 2 macrophages (Mφ2) were obtained in identical culture conditions in complete RPMI-1640 supplemented with rhM-CSF (50 ng/ml; R&D Systems). Non-classical type 3 macrophages (Mφ3) were generated by incubation of monocytes in serum growth factors deficiency conditions. Specifically, adherent cells were cultured for 7 days in complete RPMI-1640 supplemented with 2% autologous plasma (without FCS) and 50 ng/ml rhGM-CSF. Polarized Mφ (Mφ1, -2, -3) were harvested by using EDTA in Hanks' balanced salt solution, washed and counted.

Flow cytometry analysis
For evaluation of the Mφ phenotype, cell suspensions were incubated for 20 min at 4°C with fluorescein isothiocyanate (FITC) or phycoerythrin (PE)-conjugated antibodies specific for human CD14, CD86, CD90, and HLA-DR or isotype controls. All monoclonal antibodies were obtained from BD Biosciences (USA). After incubation with antibodies, cells were washed with PBS containing 0.1% sodium azide (Sigma-Aldrich) and 0.1% bovine serum albumin, and were then analyzed with a FACSCalibur using CellQuest software (BD Biosciences).

T-cell proliferation assays
The antigen-presenting and allostimulatory activity of Mφ was determined by measuring T-cell proliferation in the mixed lymphocyte culture (MLC). Different types of Mφ were collected after generation and 1x10⁵ cells were then plated in RPMI-1640 supplemented with 0.3 mg/ml L-glutamine, 5 mM HEPES buffer, 100 μg/ml gentamycin and 10% inactivated donor serum (AB (IV) group), and added to 1x10⁶ allogeneic responder PBMCs. All cultures were carried out in triplicate in round-bottom 96-well tissue culture plates, in a final volume of 150 μl of RPMI complete medium. T-cell proliferation was assessed after 5 days by adding [³H]thymidine (1 μCi/well) for 18 h. Cells were then harvested and thymidine incorporation was measured in a liquid scintillation counter SL-30 (Intertechnic, France). The stimulatory capacity of Mφ in MLC was expressed by the stimulation index (SI) = cpm in MLC (PBMCs+Mφ) / cpm in control culture (PBMCs alone).

Cytokines, chemokines, and growth factor measurements
Culture supernatants of generated Mφ (Mφ1, -2, -3) were collected and stored at –80°C  prior to measurement. The concentration of secreted cytokines/chemokines was determined by using the Bio-Plex Protein Array System (kits and equipment of Bio-Rad, USA based on Luminex xMAP technology; sensitivity 2 pg/ml) in the case of TNF-α, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-12 (p70), IL-13, IL-17, G-CSF, IFN-γ, IL-8, MCP-1, and MIP-1β, and by using ELISAs from Diagnostic System Laboratories for insulin-like growth factor-I (IGF-I, sensitivity 0.01 ng/ml); from BioSource for basic fibroblast growth factor (FGF-basic, sensitivity 7 pg/ml); from R&D Systems for brain-derived neurotrophic factor (BDNF, sensitivity 20 pg/ml); from Invitrogen Corp. for vascular endothelial growth factor (VEGF, sensitivity 5 pg/ml); from Protein Contour (St-Petersburg, Russia) for erythropoietin (EPO, sensitivity 4 pg/ml) and epidermal growth factor (EGF, sensitivity 2 pg/ml); and from Vector-Best (Novosibirsk, Russia) for IL-18 (sensitivity 5 pg/ml).

Statistical analysis
Statistical analysis was performed using the STATISTICA software version 6.0 (StatSoft. Inc., USA). The Mann-Whitney non-parametric two-tailed U test was used to determine the significance of data, which are presented as median and inter-quartile range (IQR). Values of p < 0.05 were considered statistically significant.

Results

Characterization of generated Mφ
We generated three distinct Mφ subsets in vitro from peripheral blood monocytes and performed a series of parallel comparisons between them. As a first step, we measured cell yield and their phenotype. The number of Mφ1 and Mφ2 obtained from 1x10⁶ PBMCs was 3.35x10⁴ (IQR 2.2–7.4x10⁴) and 2.50x10⁴ (IQR 1.4–4.5x10⁴), whereas Mφ3 yield was significantly higher – 5.0x10⁴ (IQR 3.3– 0.4x10⁴, p_U<0.01), indicating that a low serum condition increased the quantity of macrophages generated in the presence of GM-CSF. 

After 7 days of culture, the majority of Mφ1, Mφ2, and Mφ3 were adherent cells with a classical “fried egg” morphology (data not shown) that expressed CD14 on their cell surface (Table 1). A small number of adherent cells had a stretched, spindle-like morphology (fibroblast-like cells). The average number of these cells in Mφ1 (n=8) and Mφ2 (n=8) populations was similar and constituted 25% (IQR 22–45 and 16.5–33.5%, respectively), and was slightly higher (Median 32.5%, IQR 17–43%, n=6) in the Mφ3 subset. However, the expression of CD90 antigen (a typical marker for a fibroblasts and mesenchymal stem cells) in all Mφ populations was low and the percentage of CD90+ cells did not exceed 2–3%. 

Table 1. Phenotype Mφ1, Mφ2 and Mφ3 subsets

Percentage of positive cell
Marker	Mφ1		Mφ2		Mφ3
	Median (IQR)	N	Median (IQR)	N	Median (IQR)	N
CD14	78 (70–84)	17	87 (78–91)	9	82 (67–92)	25
HLA-DR	97 (91–98)	21	96 (96–98)	9	87 (73–97)	17
CD86	37 (23–53)	18	27 (15–39)	13	23 (11–58)	17
CD90	2.5 (0–5.0)	10	2.0 (0–5.0)	13	3 (0.6–5.0)	8

All three Mφ populations strongly expressed the HLA-DR antigen, though the percentage of HLA-DR positive cells in the Mφ3 cultures was lower than in the Mφ1 and Mφ2. All types of monocyte-derived macrophages also expressed the CD86 antigen. The mean number of СD86+ cells in Mφ2 and Mφ3 was lower than in Mφ1, though not significantly.

The ability of Mφ to induce T-cell proliferation
The revealed differences of HLA-DR and CD86 expression in distinct Mφ populations could influence their antigen-presenting function. To determine whether Mφ1, Mφ2, and Mφ3 differed quantitatively in their capacity to present antigen, we tested and compared their ability to induce an allogeneic T-cell response. For this purpose distinct Mφ subsets derived from the same donor were cocultured with allogeneic PBMCs over a period of 5 days, and the T-cell proliferation was determined (Table 2). Analysis of [³H]thymidine incorporation revealed a strong proliferative response in PBMCs cocultured with Mφ1, whereas weak proliferation could be observed in PBMCs cocultured with Mφ2 or Mφ3. Remarkably, the T-cell stimulatory capacity of Mφ3 expressed by the stimulation index (SI) was significantly lower than that of Mφ1 and Mφ2.

Table 2. The stimulatory effect of Mφ1, Mφ2 and Mφ3 subsets on allogeneic T-cell proliferation

Culture		Mφ1 (n=24)	Mφ2 (n=24)	Mφ3 (n=24)
PBMCs alone	Median	330	140	370
	IQR	105–720	105–410	70–1300
PBMCs + Mφ (10:1)	Median	7380	3130 **	2070 ** #
	IQR	3500–13220	1600–3680	330–3230
Stimulation index	Median	19.6	14.8	3.4 ** ##
	IQR	14.9–74.5	6.2–35.3	1.4–13.7
Mφ (1x105 cells) were cultured with 1x106 allogeneic PBMCs over 5 days. 3[H]-thymidine (1 µCi/well) was added 18 h before harvesting to measure T-cell proliferation (cpm).  The stimulation index is expressed in calculated units (cpm in MLC (PBMCs+Mφ) / cpm in control culture (PBMCs alone).  ** pU < 0.01 vs Mφ1; # pU < 0.05 and ## pU < 0.01 vs Mφ2.

Generated Mφ differ in cytokine and chemokine production
To further characterize the secretory profile of generated Mφ subsets, we measured the production of Th1/pro-inflammatory (IFN-γ, IL-2, IL-1β, TNF-α, IL-12, IL-17, IL-18, IL-6) and Th2/anti-inflammatory cytokines (IL-4, IL-10, IL-13). Cytokine levels were measured in supernatants of 7-day cultures of Mφ1, Mφ2 and Mφ3. Mφ1 spontaneously produced considerable levels of IL-1β, IL-6, TNF-α, IFN- γ, IL-4, and IL-17 (Table 3). This finding confirms the pro-inflammatory nature of Mφ1 and their capacity for T-cell activation. Mφ2 were characterized by lower secretory activity for some of these cytokines, though the differences were significant only for IL-4 and IL-18. In contrast, Mφ3 displayed remarkably decreased basal levels of pro-inflammatory cytokines (IL-1β, TNF-α, IL-6, IL-18), Th1-cytokines (IFN-γ, IL-2), and IL-4. Mφ3 also differed from Mφ1 by a 2-fold lower IL-12 production and more pronounced production of IL-10, though not significantly. In addition to cytokines, we measured the levels of various inflammatory chemokines in the supernatants of unstimulated macrophages. Generated Mφ constitutively produced high levels of IL-8, MCP-1, and MIP-1β. Mφ1 and Mφ2 demonstrated similar levels in their production. In contrast, secretion of neutrophil-attracting IL-8 and monocyte-attracting MCP-1 by Mφ3 was significantly lower than by Mφ1 and Mφ2. However, the production of T-cell attracting MIP-1β by Mφ3 did not differ from that by Mφ1 and Mφ2. Together, these data confirm the pro-inflammatory nature of Mφ1 and significantly less pro-inflammatory activity of Mφ3.

Table 3. Cytokine/chemokine concentrations secreted by Mφ1, Mφ2, and Mφ3

Cytokines& chemokines (pg/ml)	Mφ1 (n=10) Median	IQR	Mφ2(n=10)   Median	IQR	Mφ3 (n=24) Median	IQR
IFN-γ	872	734–995	839	539–1010	626 * ↓	440–830
IL-2	154	115–154	115	70–155	72 *↓	47–115
IL-1β	405	246–670	313	150–790	195 * # ↓	68–290
TNF-α	175	124–282	148	55–224	99 * ↓	51–156
IL-12	28	20–29	19	7–25	14	3–33
IL-17	308	245–483	257	177–448	214	112–427
IL-18	33	29–51	27 * ↓	16.5–31.2	19 * ↓	15.7–35.8
IL-6	21340	13430–27340	20350	8380–25060	10900 * ↓	4110–21770
IL-4	215	198–246	119  ** ↓	79–141	106 ** ↓	53–190
IL-10	5	2–10	2	2–2	15	2–60
IL-13	78	37–113	48	37–78	78	42–112
IL-8	90380	74280–93340	67400	57940–94430	44320 ** ## ↓	29150–59000
MCP-1	11140	5680–14000	11910	4160–17660	3345 ** ## ↓	1100–4460
MIP-1β	1 960	1250–5590	1 560	930–2700	2220	790–7620
* pU < 0.05 and ** pU < 0.01 vs Mφ1; # pU < 0.05 and ## pU < 0.01 vs Mφ2.

Production of growth factors by generated Mφ
All three types of unstimulated macrophages secreted detectable concentrations of erythropoietin, G-CSF, FGF-basic, BDNF, and IGF-1 (Table 4). Mφ1 and Mφ2 produced analogous levels of these growth factors, although there was a strong tendency to higher production of EPO by Mφ2. Despite the decreased production of pro-inflammatory cytokines, Mφ3 secreted concentrations of G-CSF, EPO, FGF-basic and EGF comparable with Mφ2, though significantly lower concentration of BDNF. But the most prominent difference was revealed for the production of IGF-1, which was much higher in Mφ3 in comparison with Mφ1 and Mφ2 cultures. Concerning VEGF, its detectable concentrations in 7-day cultures were determined only in a quarter of tested donors. Among these cultures VEGF was predominantly produced by Mφ2, and especially by Mφ-3, but not Mφ1.

Table 4. Growth factors production by Mφ1, Mφ2 and Mφ3

Growth factors (pg/ml)	Mφ1 (n=10) Median	IQR	Mφ2 (n=10) Median	IQR	Mφ3 (n=24) Median	IQR
G-CSF	670	505–1610	730	315–2310	430	180–1050
EPO	19.2	1.7–36.9	46.5	33.8–81.1	34.9	21.5–56.5
FGF-basic	104	57–124	150	87–180	109	45–126
EGF	207	148–331	283	245–420	138	38–310
BDNF	392	187–705	438	215–739	131 * # ↓	78–235
IGF-1	322	170–8560	152	116–459	8310 * ## ↑	520–9500
VEGF (n=6)	5.0	5.0–97	92.8 * ↑	59.2–298	422.4 * # ↑	107.7–524.7
* pU < 0.05 and ** pU < 0.01 vs Mφ1; # pU < 0.05 and ## pU < 0.01 vs Mφ2. Wilcoxon matched non-parametric paris test was used to determine the significance of VEGF.

Discussion

Over the last decade, there has been an increasing interest in the role of the inflammatory reaction in CNS injury. Moreover, this interest has focused on the dominant cell type observed during inflammation, the macrophage. However, in the CNS the contribution of these cells to the healing process remains questionable [6].

The contradictory data regarding the contribution of Mφ to CNS recovery could be explained by diverse macrophage activities, many of which appear to be oppositional in nature. The destructive potential of macrophages in CNS pathology may be caused by pro-inflammatory activity, whereas their regenerative capacity may be linked with anti-inflammatory features [12].

In the search for macrophages with potential regenerative activity we developed a simple method for the generation of macrophages in growth factor deficient conditions and analyzed the phenotype and functional activity of these macrophages, termed Mφ3, with pro-inflammatory Mφ1 and anti-inflammatory Mφ2. We speculated that the deficiency of growth factors in low serum conditions may be one of the key factors capable of activating regenerative properties of macrophages. Particularly, low serum conditions during macrophage cultivation could stimulate deprivation-induced apoptosis of culturing cells (including admixture of non-adherent cells), and the ingestion of apoptotic cells may change the functional activity of macrophages toward an anti-inflammatory phenotype.

The received data demonstrated that low serum conditions did not influence the efficacy of Mφ3 generation. Moreover, the yield of Mφ3 significantly exceeded the number of Mφ1 and Mφ2. These data are correspondent with Plesner's study, who showed an enhanced yield of M-CSF treated macrophages in cultures with 1% fetal calf serum [22].

According to study of Verreck et al, anti-inflammatory Mφ2 have a lower expression of HLA-DR and CD86 molecules after LPS stimulation, though unstimulated macrophages expressed similar levels of these molecules [34]. We have shown that as compared to Mφ1 and Mφ2, Mφ3 cultures contained lower numbers of HLA-DR and CD86-positive cells. These differences, though not statistically significant, were important for the association with the decreased capacity of Mφ3 to stimulate allogeneic T cell proliferation. Type-2 anti-inflammatory macrophages are known to have a lower ability to stimulate T-cell proliferation in MLC [11]. This is in agreement with our data, and pointed to the lower allostimulatory activity of Mφ2 in comparison with Mφ1. Notably, Mφ3 virtually failed to stimulate lymphocyte proliferation in MLC. The medium value of the Mφ3 stimulation index was more than 6-fold lower than that of Mφ1. This fact strongly suggests that generated Mφ3 are not immunogenic and in this respect resemble anti-inflammatory M2 macrophages.

To further evaluate the pro- and anti-inflammatory activity of generated macrophages we compared their capacity to spontaneous production of Th1/pro- and Th2/anti-inflammatory cytokines. In contrast to Mφ1, Mφ3 produced significantly (2-fold) lower concentrations of pro-inflammatory (IL-1β, TNF-α, IL-6, IL-18) and Th1/Th2-cytokines (IFN-γ, IL-2, IL-4). Mφ3 supernatants also contained 2-fold lower concentrations of IL-12 and higher levels of IL-10, though these differences were not statistically significant.

Gordon and coworkers [11] have described alternatively activated macrophages after treatment with IL-4 or IL-13, which produce IL-10 without microbial stimulation. At the same time the study of Verreck demonstrated that unlike alternatively activated Mφ, M-CSF polarized Mφ2 failed to release IL-10 without activation, but effectively secreted IL-10 after mycobacterial activation. However, activated Mφ-2 produced no or relatively low levels of IL-12, IL-1β, IL-6, TNF-α [34]. We also did not reveal any significant concentrations of IL-10 in the supernatants of unstimulated Mφ2. In contrast to Mφ-2, Mφ-3 spontaneously produced IL-10 and displayed significantly less pro-inflammatory phenotype (as compare with Mφ1) without any additional stimulation.

Our results are also in agreement with findings suggesting a high ability of M-CSF polarized Mφ2 to secrete pro-inflammatory chemokines [35]. Mφ3 were also shown to secrete MIP-1β levels comparable with Mφ1 and Mφ2, but lower levels of IL-8 and MCP-1. This indicated that unlike Mφ1 and Mφ2 subsets, Mφ3 has less capacity to attract neutrophils and monocytes and therefore is less effective in supporting inflammation, whereas they could recruit effector Th1 cells and modify their functions.

One possible mechanism underlying the beneficial role of macrophages in CNS repair is connected with their capacity to produce a wide range of growth factors that can promote neuroprotection and regeneration [30, 17, 6]. The comparative analysis of some growth factors in the supernatants of generated macrophages revealed that all three Mφ subsets spontaneously produced detectable levels of EPO, G-CSF, IGF-1, FGF-basic, EGF, and BDNF. Mφ3 secreted concentrations of G-CSF, FGF-basic and EGF similar to Mφ1 and Mφ2, EPO comparable with Mφ2, and a lower level of BDNF, but more than 25-fold higher level of IGF-1. As for VEGF, this growth factor, identified only in quarter of patients, was produced by both Mφ2 and Mφ3, but not Mφ-1 and was significantly higher in Mφ3- than in Mφ2 cultures.

Production of classical neurotrophic factors including CNTF, IGF, HGF, PDGF, NGF, BDNF, GDNF, and NT-3 by macrophages have been shown in numerous studies [3, 7, 13]. Evaluation of two of these factors (BDNF and IGF-1) in cultures of distinct macrophage subtypes in our study supported previous data and demonstrated comparable production of these factors by inflammatory Mφ1 and anti-inflammatory Mφ2. Moreover we have shown for the first time that in spite of a lower level of BDNF, Mφ3 were characterized with exclusively high secretion of IGF-1.

IGF-1 is a potent neurotrophic factor. Its pleiotropic effects range from classical trophic actions on neurons such as housekeeping or anti-apoptotic/pro-survival effects to modulation of brain-barrier permeability, neuronal excitability, or new neuron formation. IGF-1 is also known to significantly improve axon growth and remyelination [2, 4]. The finding that IGF-1 is secreted abundantly by Mφ3 may point toward an important potential role for these macrophages in neuroprotection and regeneration.

In addition to neurotrophic factors, generated macrophages produced significant levels of VEGF. Detection of VEGF (in 7-day macrophage supernatants) only in part of the tested donors could be connected with an earlier peak of VEGF production. Nevertheless, in detectable cases VEGF was predominantly produced by both Mφ2 and Mφ3. VEGF has direct neuroprotective effects on motoneurons, induces neurogenesis and angiogenesis and its reduced levels cause neurodegeneration in part by impairing neural tissue perfusion [31, 38].

Other factors, such as EPO, G-CSF, FGF-β, and EGF, produced by Mφ-3 and Mφ1/Mφ2 subsets could also underlay the neuro-regenerative macrophage potential. Erythropoietin functions as a tissue-protective cytokine in addition to its crucial hormonal role in red cell production. This cytokine promotes both neuroprotection and neuroregeneration in various models of CNS injury and disease and is considered to be a promising candidate as neuroprotective agent [29,15]. G-CSF appears to have anti-apoptotic effect and stimulate differentiation of adult neural stem cells [26]. EGF is a motility factor for microglial cells and is shown to enhance the differentiation, maturation and survival of a variety of neurons in the central nervous system [36]. FGF-basic promotes the survival and neurite growth of brain neurons in vitro and in vivo, suggesting that it functions as a neurotrophic factor. In addition FGF acutely modulates synaptic transmission in the hippocampus, suggesting that it has a role similar to a neurotransmitter or neuromodulator [1].

Several groups have confirmed the therapeutic potential of activated microglia and monocyte derived macrophages in the injured spinal cord [3, 23-25]. The success of these pre-clinical models prompted a Phase I clinical trial that was completed without any adverse effects. Implantation of macrophages preincubated with dermis was well tolerated. Of the eight patients with complete spinal cord injury, three recovered clinically significant neurological motor and sensory function [16].

Recent study of this group showed that augmenting the naive monocyte pool by either adoptive transfer or CNS-specific vaccination resulted in a higher number of spontaneously recruited cells and improved recovery. Notably, the enhancement of motor functions was associated with anti-inflammatory activity of infiltrating macrophages, mediated by interleukin 10 [28].

In this aspect, the Mφ3 subset described in our study is characterized by low pro-inflammatory/immunogenic properties and high regenerative potential and therefore may represent new candidates for cell therapy in CNS injuries.

Acknowledgements

The authors declare no competing interests.

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["TMP_ID"]=> NULL ["LINK_IBLOCK_ID"]=> string(1) "0" ["WITH_DESCRIPTION"]=> string(1) "N" ["SEARCHABLE"]=> string(1) "N" ["FILTRABLE"]=> string(1) "N" ["IS_REQUIRED"]=> string(1) "N" ["VERSION"]=> string(1) "1" ["USER_TYPE"]=> string(4) "HTML" ["USER_TYPE_SETTINGS"]=> array(1) { ["height"]=> int(200) } ["HINT"]=> string(0) "" ["PROPERTY_VALUE_ID"]=> string(5) "18503" ["VALUE"]=> array(2) { ["TEXT"]=> string(229) "<p>Елена Р. Черных, Екатерина Я. Шевела, Людмила В. Сахно, Марина А. Тихонова, Ярослав Л. Петровский, Александр А. Останин</p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(217) "

Елена Р. Черных, Екатерина Я. Шевела, Людмила В. Сахно, Марина А. Тихонова, Ярослав Л. Петровский, Александр А. Останин

" ["TYPE"]=> string(4) "HTML" } ["~DESCRIPTION"]=> string(0) "" ["~NAME"]=> string(12) "Авторы" ["~DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } } ["ORGANIZATION_RU"]=> array(36) { ["ID"]=> string(2) "26" ["TIMESTAMP_X"]=> string(19) "2015-09-02 18:01:20" ["IBLOCK_ID"]=> string(1) "2" ["NAME"]=> string(22) "Организации" ["ACTIVE"]=> string(1) "Y" ["SORT"]=> string(3) "500" ["CODE"]=> string(15) "ORGANIZATION_RU" ["DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } ["PROPERTY_TYPE"]=> string(1) "S" ["ROW_COUNT"]=> string(1) "1" ["COL_COUNT"]=> string(2) "30" ["LIST_TYPE"]=> string(1) "L" ["MULTIPLE"]=> string(1) "N" ["XML_ID"]=> string(2) "26" ["FILE_TYPE"]=> string(0) "" ["MULTIPLE_CNT"]=> string(1) "5" ["TMP_ID"]=> NULL ["LINK_IBLOCK_ID"]=> string(1) "0" ["WITH_DESCRIPTION"]=> string(1) "N" ["SEARCHABLE"]=> string(1) "N" ["FILTRABLE"]=> string(1) "N" ["IS_REQUIRED"]=> string(1) "N" ["VERSION"]=> string(1) "1" ["USER_TYPE"]=> string(4) "HTML" ["USER_TYPE_SETTINGS"]=> array(1) { ["height"]=> int(200) } ["HINT"]=> string(0) "" ["PROPERTY_VALUE_ID"]=> NULL ["VALUE"]=> string(0) "" ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> string(0) "" ["~DESCRIPTION"]=> string(0) "" ["~NAME"]=> string(22) "Организации" ["~DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } } ["SUMMARY_RU"]=> array(36) { ["ID"]=> string(2) "27" ["TIMESTAMP_X"]=> string(19) "2015-09-02 18:01:20" ["IBLOCK_ID"]=> string(1) "2" ["NAME"]=> string(29) "Описание/Резюме" ["ACTIVE"]=> string(1) "Y" ["SORT"]=> string(3) "500" ["CODE"]=> string(10) "SUMMARY_RU" ["DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } ["PROPERTY_TYPE"]=> string(1) "S" ["ROW_COUNT"]=> string(1) "1" ["COL_COUNT"]=> string(2) "30" ["LIST_TYPE"]=> string(1) "L" ["MULTIPLE"]=> string(1) "N" ["XML_ID"]=> string(2) "27" ["FILE_TYPE"]=> string(0) "" ["MULTIPLE_CNT"]=> string(1) "5" ["TMP_ID"]=> NULL ["LINK_IBLOCK_ID"]=> string(1) "0" ["WITH_DESCRIPTION"]=> string(1) "N" ["SEARCHABLE"]=> string(1) "N" ["FILTRABLE"]=> string(1) "N" ["IS_REQUIRED"]=> string(1) "N" ["VERSION"]=> string(1) "1" ["USER_TYPE"]=> string(4) "HTML" ["USER_TYPE_SETTINGS"]=> array(1) { ["height"]=> int(200) } ["HINT"]=> string(0) "" ["PROPERTY_VALUE_ID"]=> string(5) "18504" ["VALUE"]=> array(2) { ["TEXT"]=> string(3773) "<p class="bodytext">Регуляция иммунного ответа представляется перспективной стратегией в области восстановления повреждений центральной нервной системы (ЦНС). При этом важная роль в качестве кандидатов для клеточной терапии отводится макрофагам. Используя культуральные условия с низким содержанием сыворотки, мы разработали протокол генерации противовоспалительных, М2-подобных, макрофагов из моноцитов периферической крови и сравнили эти клетки (обозначенные как М3) со «стандартными» провоспалительными (Mφ1) и противовоспалительными (Mφ2) макрофагами, генерированными, соответственно, в присутствии GM-CSF и M-CSF. <br /><br />Основное внимание было прежде всего сосредоточено на способности макрофагов стимулировать пролиферацию Т-клеток, а также продукцию макрофагами различных цитокинов, хемокинов и ростовых факторов. Дефицит сывороточных факторов не сказывался негативным образом на количестве генерированных макрофагов. Напротив, наибольший выход клеток наблюдался в культурах M3. По своим свойствам M3 макрофаги больше походили на Mφ2, чем на Mφ1. Так, в отличие от Mφ1, макрофаги Mφ2 и, особенно, M3 отличались относительно низким уровнем экспрессии CD86 и не стимулировали пролиферативный ответ Т-клеток. В противоположность провоспалительным Mφ1 нестимулированные M3 продуцировали гораздо меньшие уровни провоспалительных (IL-1β, TNF-α, IL-6, IL-18, IL-12) и Th1/Th2 цитокинов (IFN-γ, IL-2, IL-4), вместе с тем  - более высокий уровень IL-10. Более того, концентрации IL-1β и провоспалительных хемокинов IL-8 и MCP-1 в супернатантах M3 были снижены не только по сравнению с Mφ1, но также и с Mφ2 культурами. Подобно Mφ1 и Mφ2, М3 обладали способностью продуцировать нейротрофические (BDNF, IGF-1), ангиогенные (VEGF) и другие ростовые факторы с нейропротективной и регенераторной активностью (EPO, G-CSF, FGF-basic, EGF). При этом уровень продукции IGF-1 макрофагами 3-его типа превышал секрецию этого фактора Mφ1 и Mφ2 более чем в 25 раз. <br /><br />Суммируя полученные данные, можно заключить, что генерируемые M3 клетки  представляют M2-подобные макрофаги с высоким регенераторным потенциалом. </p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(3727) "

Регуляция иммунного ответа представляется перспективной стратегией в области восстановления повреждений центральной нервной системы (ЦНС). При этом важная роль в качестве кандидатов для клеточной терапии отводится макрофагам. Используя культуральные условия с низким содержанием сыворотки, мы разработали протокол генерации противовоспалительных, М2-подобных, макрофагов из моноцитов периферической крови и сравнили эти клетки (обозначенные как М3) со «стандартными» провоспалительными (Mφ1) и противовоспалительными (Mφ2) макрофагами, генерированными, соответственно, в присутствии GM-CSF и M-CSF.

Основное внимание было прежде всего сосредоточено на способности макрофагов стимулировать пролиферацию Т-клеток, а также продукцию макрофагами различных цитокинов, хемокинов и ростовых факторов. Дефицит сывороточных факторов не сказывался негативным образом на количестве генерированных макрофагов. Напротив, наибольший выход клеток наблюдался в культурах M3. По своим свойствам M3 макрофаги больше походили на Mφ2, чем на Mφ1. Так, в отличие от Mφ1, макрофаги Mφ2 и, особенно, M3 отличались относительно низким уровнем экспрессии CD86 и не стимулировали пролиферативный ответ Т-клеток. В противоположность провоспалительным Mφ1 нестимулированные M3 продуцировали гораздо меньшие уровни провоспалительных (IL-1β, TNF-α, IL-6, IL-18, IL-12) и Th1/Th2 цитокинов (IFN-γ, IL-2, IL-4), вместе с тем  - более высокий уровень IL-10. Более того, концентрации IL-1β и провоспалительных хемокинов IL-8 и MCP-1 в супернатантах M3 были снижены не только по сравнению с Mφ1, но также и с Mφ2 культурами. Подобно Mφ1 и Mφ2, М3 обладали способностью продуцировать нейротрофические (BDNF, IGF-1), ангиогенные (VEGF) и другие ростовые факторы с нейропротективной и регенераторной активностью (EPO, G-CSF, FGF-basic, EGF). При этом уровень продукции IGF-1 макрофагами 3-его типа превышал секрецию этого фактора Mφ1 и Mφ2 более чем в 25 раз.

Суммируя полученные данные, можно заключить, что генерируемые M3 клетки  представляют M2-подобные макрофаги с высоким регенераторным потенциалом.

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Elena R. Chernykh, Ekaterina Ya. Shevela, Ludmila V. Sakhno, Marina A. Tikhonova, Yaroslav L. Petrovsky, Alexander A. Ostanin

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Laboratory of Cellular Immunotherapy, Institute of Clinical Immunology of Russian Academy of Medical Sciences, Siberian Branch, Novosibirsk, Russia

Correspondence
Elena Chernykh, Laboratory of Cellular Immunotherapy, Institute of Clinical Immunology RAMS SB, Yadrintsevskaya str., 14, Novosibirsk, 630099, Russia
Phone: +7(383)2360329; Fax: +7(383)2227028; E-mail: ct_lab@spam is badmail.ru

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Regulation of the immune response seems to be a promising strategy for a successful central nervous system (CNS) repair, and macrophages are considered to be prospective candidates for cell therapy. Using low serum conditions we generated human anti-inflammatory M2-like macrophages from peripheral blood monocytes and compared these cells (termed Mφ3) with “standard” pro-inflammatory Mφ1 and anti-inflammatory Mφ2, generated in the presence of GM-CSF and M-CSF. We focused primarily on the differences in T-cell stimulatory activity and production of various cytokines, chemokines, and growth factors. Low serum conditions had no negative impact on macrophage yield, the largest of which was for Mφ3. We showed that Mφ3 more closely resembled Mφ2 than Mφ1. Mφ2 and particularly Mφ3, but not Mφ1 expressed relatively low levels of CD86 and failed to stimulate T-cell proliferation. 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Chernykh, Ekaterina Ya. Shevela, Ludmila V. Sakhno, Marina A. Tikhonova, Yaroslav L. Petrovsky, Alexander A. Ostanin</p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(132) "

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Elena R. Chernykh, Ekaterina Ya. Shevela, Ludmila V. Sakhno, Marina A. Tikhonova, Yaroslav L. Petrovsky, Alexander A. Ostanin

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Regulation of the immune response seems to be a promising strategy for a successful central nervous system (CNS) repair, and macrophages are considered to be prospective candidates for cell therapy. Using low serum conditions we generated human anti-inflammatory M2-like macrophages from peripheral blood monocytes and compared these cells (termed Mφ3) with “standard” pro-inflammatory Mφ1 and anti-inflammatory Mφ2, generated in the presence of GM-CSF and M-CSF. We focused primarily on the differences in T-cell stimulatory activity and production of various cytokines, chemokines, and growth factors. Low serum conditions had no negative impact on macrophage yield, the largest of which was for Mφ3. We showed that Mφ3 more closely resembled Mφ2 than Mφ1. Mφ2 and particularly Mφ3, but not Mφ1 expressed relatively low levels of CD86 and failed to stimulate T-cell proliferation. In contrast to pro-inflammatory Mφ1, unstimulated Mφ3 produced significantly lower levels of pro-inflammatory cytokines (IL-1β, TNF-α, IL-6, IL-18, IL-12) and Th1/Th2-cytokines (IFN-γ, IL-2, IL-4) coupled with a higher IL-10 level. Moreover, concentrations of IL-1β and pro-inflammatory chemokines IL-8 and MCP-1 in Mφ-3 supernatants were lower not only when compared to Mφ1, but also to Mφ2 cultures. Like Mφ1 and Mφ2, Mφ3 was capable of producing neurotrophic- (BDNF, IGF-1), angiogenic- (VEGF), and other growth factors (EPO, G-CSF, FGF-basic, EGF) with neuroprotective and regenerative activity. In fact, IGF-1 production by Mφ-3 exceeds secretion of this factor by Mφ-1 and Mφ-2 by more than 25 fold. Thus, generated Mφ-3 represented M2-like macrophages with high regenerative potential." ["TYPE"]=> string(4) "HTML" } ["~DESCRIPTION"]=> string(0) "" ["~NAME"]=> string(21) "Description / Summary" ["~DEFAULT_VALUE"]=> array(2) { ["TEXT"]=> string(0) "" ["TYPE"]=> string(4) "HTML" } ["DISPLAY_VALUE"]=> string(1725) "

Regulation of the immune response seems to be a promising strategy for a successful central nervous system (CNS) repair, and macrophages are considered to be prospective candidates for cell therapy. Using low serum conditions we generated human anti-inflammatory M2-like macrophages from peripheral blood monocytes and compared these cells (termed Mφ3) with “standard” pro-inflammatory Mφ1 and anti-inflammatory Mφ2, generated in the presence of GM-CSF and M-CSF. We focused primarily on the differences in T-cell stimulatory activity and production of various cytokines, chemokines, and growth factors. Low serum conditions had no negative impact on macrophage yield, the largest of which was for Mφ3. We showed that Mφ3 more closely resembled Mφ2 than Mφ1. Mφ2 and particularly Mφ3, but not Mφ1 expressed relatively low levels of CD86 and failed to stimulate T-cell proliferation. 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Laboratory of Cellular Immunotherapy, Institute of Clinical Immunology of Russian Academy of Medical Sciences, Siberian Branch, Novosibirsk, Russia

Correspondence
Elena Chernykh, Laboratory of Cellular Immunotherapy, Institute of Clinical Immunology RAMS SB, Yadrintsevskaya str., 14, Novosibirsk, 630099, Russia
Phone: +7(383)2360329; Fax: +7(383)2227028; E-mail: ct_lab@spam is badmail.ru

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Laboratory of Cellular Immunotherapy, Institute of Clinical Immunology of Russian Academy of Medical Sciences, Siberian Branch, Novosibirsk, Russia

Correspondence
Elena Chernykh, Laboratory of Cellular Immunotherapy, Institute of Clinical Immunology RAMS SB, Yadrintsevskaya str., 14, Novosibirsk, 630099, Russia
Phone: +7(383)2360329; Fax: +7(383)2227028; E-mail: ct_lab@spam is badmail.ru

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Елена Р. Черных, Екатерина Я. Шевела, Людмила В. Сахно, Марина А. Тихонова, Ярослав Л. Петровский, Александр А. Останин

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повреждений центральной нервной системы (ЦНС). При этом важная роль в качестве кандидатов для клеточной терапии отводится макрофагам. Используя культуральные условия с низким содержанием сыворотки, мы разработали протокол генерации противовоспалительных, М2-подобных, макрофагов из моноцитов периферической крови и сравнили эти клетки (обозначенные как М3) со «стандартными» провоспалительными (Mφ1) и противовоспалительными (Mφ2) макрофагами, генерированными, соответственно, в присутствии GM-CSF и M-CSF. <br /><br />Основное внимание было прежде всего сосредоточено на способности макрофагов стимулировать пролиферацию Т-клеток, а также продукцию макрофагами различных цитокинов, хемокинов и ростовых факторов. Дефицит сывороточных факторов не сказывался негативным образом на количестве генерированных макрофагов. Напротив, наибольший выход клеток наблюдался в культурах M3. По своим свойствам M3 макрофаги больше походили на Mφ2, чем на Mφ1. Так, в отличие от Mφ1, макрофаги Mφ2 и, особенно, M3 отличались относительно низким уровнем экспрессии CD86 и не стимулировали пролиферативный ответ Т-клеток. В противоположность провоспалительным Mφ1 нестимулированные M3 продуцировали гораздо меньшие уровни провоспалительных (IL-1β, TNF-α, IL-6, IL-18, IL-12) и Th1/Th2 цитокинов (IFN-γ, IL-2, IL-4), вместе с тем  - более высокий уровень IL-10. Более того, концентрации IL-1β и провоспалительных хемокинов IL-8 и MCP-1 в супернатантах M3 были снижены не только по сравнению с Mφ1, но также и с Mφ2 культурами. Подобно Mφ1 и Mφ2, М3 обладали способностью продуцировать нейротрофические (BDNF, IGF-1), ангиогенные (VEGF) и другие ростовые факторы с нейропротективной и регенераторной активностью (EPO, G-CSF, FGF-basic, EGF). При этом уровень продукции IGF-1 макрофагами 3-его типа превышал секрецию этого фактора Mφ1 и Mφ2 более чем в 25 раз. <br /><br />Суммируя полученные данные, можно заключить, что генерируемые M3 клетки  представляют M2-подобные макрофаги с высоким регенераторным потенциалом. </p>" ["TYPE"]=> string(4) "HTML" } ["DESCRIPTION"]=> string(0) "" ["VALUE_ENUM"]=> NULL ["VALUE_XML_ID"]=> NULL ["VALUE_SORT"]=> NULL ["~VALUE"]=> array(2) { ["TEXT"]=> string(3727) "

Регуляция иммунного ответа представляется перспективной стратегией в области восстановления повреждений центральной нервной системы (ЦНС). При этом важная роль в качестве кандидатов для клеточной терапии отводится макрофагам. Используя культуральные условия с низким содержанием сыворотки, мы разработали протокол генерации противовоспалительных, М2-подобных, макрофагов из моноцитов периферической крови и сравнили эти клетки (обозначенные как М3) со «стандартными» провоспалительными (Mφ1) и противовоспалительными (Mφ2) макрофагами, генерированными, соответственно, в присутствии GM-CSF и M-CSF.

Основное внимание было прежде всего сосредоточено на способности макрофагов стимулировать пролиферацию Т-клеток, а также продукцию макрофагами различных цитокинов, хемокинов и ростовых факторов. Дефицит сывороточных факторов не сказывался негативным образом на количестве генерированных макрофагов. Напротив, наибольший выход клеток наблюдался в культурах M3. По своим свойствам M3 макрофаги больше походили на Mφ2, чем на Mφ1. Так, в отличие от Mφ1, макрофаги Mφ2 и, особенно, M3 отличались относительно низким уровнем экспрессии CD86 и не стимулировали пролиферативный ответ Т-клеток. В противоположность провоспалительным Mφ1 нестимулированные M3 продуцировали гораздо меньшие уровни провоспалительных (IL-1β, TNF-α, IL-6, IL-18, IL-12) и Th1/Th2 цитокинов (IFN-γ, IL-2, IL-4), вместе с тем  - более высокий уровень IL-10. Более того, концентрации IL-1β и провоспалительных хемокинов IL-8 и MCP-1 в супернатантах M3 были снижены не только по сравнению с Mφ1, но также и с Mφ2 культурами. Подобно Mφ1 и Mφ2, М3 обладали способностью продуцировать нейротрофические (BDNF, IGF-1), ангиогенные (VEGF) и другие ростовые факторы с нейропротективной и регенераторной активностью (EPO, G-CSF, FGF-basic, EGF). При этом уровень продукции IGF-1 макрофагами 3-его типа превышал секрецию этого фактора Mφ1 и Mφ2 более чем в 25 раз.

Суммируя полученные данные, можно заключить, что генерируемые M3 клетки  представляют M2-подобные макрофаги с высоким регенераторным потенциалом.

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Регуляция иммунного ответа представляется перспективной стратегией в области восстановления повреждений центральной нервной системы (ЦНС). При этом важная роль в качестве кандидатов для клеточной терапии отводится макрофагам. Используя культуральные условия с низким содержанием сыворотки, мы разработали протокол генерации противовоспалительных, М2-подобных, макрофагов из моноцитов периферической крови и сравнили эти клетки (обозначенные как М3) со «стандартными» провоспалительными (Mφ1) и противовоспалительными (Mφ2) макрофагами, генерированными, соответственно, в присутствии GM-CSF и M-CSF.

Основное внимание было прежде всего сосредоточено на способности макрофагов стимулировать пролиферацию Т-клеток, а также продукцию макрофагами различных цитокинов, хемокинов и ростовых факторов. Дефицит сывороточных факторов не сказывался негативным образом на количестве генерированных макрофагов. Напротив, наибольший выход клеток наблюдался в культурах M3. По своим свойствам M3 макрофаги больше походили на Mφ2, чем на Mφ1. Так, в отличие от Mφ1, макрофаги Mφ2 и, особенно, M3 отличались относительно низким уровнем экспрессии CD86 и не стимулировали пролиферативный ответ Т-клеток. В противоположность провоспалительным Mφ1 нестимулированные M3 продуцировали гораздо меньшие уровни провоспалительных (IL-1β, TNF-α, IL-6, IL-18, IL-12) и Th1/Th2 цитокинов (IFN-γ, IL-2, IL-4), вместе с тем  - более высокий уровень IL-10. Более того, концентрации IL-1β и провоспалительных хемокинов IL-8 и MCP-1 в супернатантах M3 были снижены не только по сравнению с Mφ1, но также и с Mφ2 культурами. Подобно Mφ1 и Mφ2, М3 обладали способностью продуцировать нейротрофические (BDNF, IGF-1), ангиогенные (VEGF) и другие ростовые факторы с нейропротективной и регенераторной активностью (EPO, G-CSF, FGF-basic, EGF). При этом уровень продукции IGF-1 макрофагами 3-его типа превышал секрецию этого фактора Mφ1 и Mφ2 более чем в 25 раз.

Суммируя полученные данные, можно заключить, что генерируемые M3 клетки  представляют M2-подобные макрофаги с высоким регенераторным потенциалом.

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E-mail: <a href="javascript:linkTo_UnCryptMailto('qempxs.rgvxg48Dqemp2vy');">ncrtc04@<span style="display:none;">spam is bad</span>mail.ru</a>, <a href="javascript:linkTo_UnCryptMailto('qempxs.ruspgDcerhib2vy');">nqolc@<span style="display:none;">spam is bad</span>yandex.ru</a> 
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Контакт
 А. А. Новик, Национальный медико-хирургический центр им.Н.И. Пирогова, ул. Нижняя Первомайская 70,  Москва, 105203, Россия

E-mail: ncrtc04@spam is badmail.ru, nqolc@spam is badyandex.ru 

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                    [TEXT] => <p class="bodytext">Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области.<br /><br /><h3>Ключевые слова</h3>
<p>рассеянный склероз, аутологичная трансплантация стволовых кроветворных клеток, отдаленные результаты лечения, ранняя трансплантация, этапная трансплантация, трансплантация спасения 
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Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области.

Ключевые слова
рассеянный склероз, аутологичная трансплантация стволовых кроветворных клеток, отдаленные результаты лечения, ранняя трансплантация, этапная трансплантация, трансплантация спасения 

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Andrei A. Novik1, Aleksey N. Kuznetsov1, Vladimir Y. Melnichenko1, Denis A. Fedorenko1, Tatyana I. Ionova2, Kira A. Kurbatova2
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                    [TEXT] => <p class="bodytext"><sup>1</sup>Pirogov National Medical Surgical Center, Moscow, Russia; <sup>2</sup>Multinational Center for Quality of Life Research, Saint Petersburg, Russia
</p><br>
<p class="bodytext"><b>Correspondence</b><br> Professor Tatyana I. Ionova, Multinational Center for Quality of Life Research, 1 Artilleriiskaya str., 191014 St. Petersburg, Russia <br>
E-mail: <a href="javascript:linkTo_UnCryptMailto('qempxs.xmsr5:Dqemp2vy');">tion16@<span style="display:none;">spam is bad</span>mail.ru</a>
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1Pirogov National Medical Surgical Center, Moscow, Russia; 2Multinational Center for Quality of Life Research, Saint Petersburg, Russia


Correspondence
 Professor Tatyana I. Ionova, Multinational Center for Quality of Life Research, 1 Artilleriiskaya str., 191014 St. Petersburg, Russia 

E-mail: tion16@spam is badmail.ru

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                    [TEXT] => <p class="bodytext">High-dose immunosuppressive therapy (HDIT) with autologous hematopoietic stem cell transplantation (ASCT) is a promising approach to the treatment of multiple sclerosis (MS) patients. The data obtained points to the feasibility of early, conventional, and salvage HDIT +ASCT in MS patients. Further studies should be done to investigate clinical and patient-reported outcomes in MS patients receiving early, conventional, and salvage transplantation to better define treatment success. The concept of HDIT +ASCT in MS opens a new window of opportunity for treatment of this patient population.</p>
<h3>Keywords</h3><p>multiple sclerosis, autologous stem cell transplantation, long-term clinical outcomes, early ASCT, conventional ASCT, salvage ASCT
</p>
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High-dose immunosuppressive therapy (HDIT) with autologous hematopoietic stem cell transplantation (ASCT) is a promising approach to the treatment of multiple sclerosis (MS) patients. The data obtained points to the feasibility of early, conventional, and salvage HDIT +ASCT in MS patients. Further studies should be done to investigate clinical and patient-reported outcomes in MS patients receiving early, conventional, and salvage transplantation to better define treatment success. The concept of HDIT +ASCT in MS opens a new window of opportunity for treatment of this patient population.
Keywords
multiple sclerosis, autologous stem cell transplantation, long-term clinical outcomes, early ASCT, conventional ASCT, salvage ASCT

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	 Традиционные методы иммуномодулирующей и иммуносупрессивной терапии рассеянного склероза (РС) не позволяют достичь выраженного и длительного терапевтического эффекта [4-7, 10]. Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). В настоящее время в мире выполнено более 700 трансплантаций больным с различными формами РС. Безопасность и эффективность метода изучена в международных многоцентровых исследованиях. К нерешенным вопросам ВИСТ+ТСКК относятся следующие: показания, методы трансплантации, режимы кондиционирования, деплеция Т-лимфоцитов, фармакоэкономическое обоснование и др. [3, 9, 11].<br>
 <br>
	 Разработана концепция ВИСТ+ТКСК при РС, включающая следующие положения: содержание метода, основные показания, методика проведения трансплантации, общий алгоритм, направления дальнейших исследований. Основные положения концепции подтверждены результатами проспективного многоцентрового исследования Российской кооперативной группы клеточной терапии изучения эффективности ВИСТ+ТКСК у больных различными формами РС. <br>
 <br>
	 В рамках концепции выделено две принципиальные цели лечения больных РС. Первая из них патогенетическая – остановить прогрессирование заболевания и предотвратить появление новых очагов демиелинизации в ЦНС за счет воздействия на иммунопатологический процесс на различных уровнях. Вторая цель, основная или конечная, состоит в сохранении и, по возможности, в улучшении качества жизни больных. Данные положения основаны на теории принятия решений в клинической медицине, согласно которой в формализованном виде существует три возможных цели лечения больного: <br>
 <br>
	 I – излечение с учетом качества жизни больного после выздоровления, <br>
	 II – увеличение продолжительности жизни больного с учетом ее качества<br>
	 III – улучшение качества жизни больного. <br>
 <br>
	 При РС, хроническом неизлечимом заболевании, в большинстве случаев не снижающем продолжительность жизни больного, максимально возможное восстановление и сохранение параметров качества жизни  является приоритетной целью лечения. Вследствие этого, наряду с традиционными лабораторными и инструментальными тестами, описывающими изменения в течении патологического процесса на фоне терапии, к ключевым критериям эффективности лечения РС следует отнести и показатели качества жизни больного, отражающие сложный комплекс физических, психологических и социальных детерминант, свойственных конкретному индивидууму. <br>
 <br>
	 Учитывая вышесказанное, в рамках концепции выделены 3 вида трансплантации, отличающиеся по целям и времени проведения операции [12, 13]<br>
 <br>
 <b>Ранняя трансплантация</b><br>
	 1. Патогенетическая цель – предупредить развитие необратимых изменений в ЦНС в результате иммунопатологического процесса.<br>
	 2. Основная цель – сохранить качество жизни больного, предотвратить формирование инвалидизации. <br>
	 3. Время проведения – в дебюте заболевания.<br>
 <br>
 <b>Этапная трансплантация</b><br>
	 4. Патогенетическая цель – остановить прогрессирование  заболевания на фоне  самоподдерживающегося иммунопатологического процесса, имеющихся очагов  необратимых изменений и частично утраченных функций, предупредить появление новых очагов поражения.<br>
	 5. Основная цель – улучшить качество жизни больного и сохранить его на максимально возможном уровне, предупредить углубление инвалидизации пациента.<br>
	 6. Время проведения – на различных этапах прогрессирования РС при выходе заболевания из-под контроля традиционных методов лечения.<br>
 <br>
 <b>Трансплантация спасения<br>
 </b>7. Патогенетическая цель – остановить прогрессирование заболевания на фоне большого количества очагов необратимых изменений  и существенно нарушенных функций, предупредить появление новых очагов поражения.<br>
	 8. Основная цель – сохранить качество жизни больного на максимально возможном уровне, предотвратить наступление критической инвалидизации.<br>
	 9. Время проведения – в далеко зашедшей стадии заболевания при высокой активности иммунопатологического процесса, быстром прогрессировании инвалидизации больного.
</p>
<p class="bodytext">
	 В данном докладе представлены результаты исследования безопасности и эффективности ВИСТ+ТКСК у 132 больных РС, которым  ВИСТ+ТКСК проведена в Военно-медицинской академии (Санкт-Петербург) и Национальном медико-хирургическом центре им. Н.И. Пирогова (Москва), начиная с 1999 года. В исследование включено 58 мужчин и 74 женщины; средний возраст – 33 года. У 57 пациентов была диагностирована вторично-прогрессирующая форма заболевания, у 23 – первично-прогрессирующая,  у 9 – прогрессирующе-рецидивирующая и у 43 – рецидивирующая ремитирующая.  Выделены три группы пациентов в зависимости от вида трансплантации: ранняя трансплантация проводилась при EDSS от 1,5 до 3,0; этапная трансплантация - при EDSS от 3,5 до 6,5; трансплантация спасения - при EDSS от 7,0 до 8,5. 83 пациентам была проведена этапная ВИСТ+ТКСК;  43 – ранняя трансплантация; 7 – трансплантация спасения. Для кондиционирования использовали режимы BEAM или mini-BEAM. Эффект ВИСТ+ТКСК оценивали по изменению степени инвалидизации больного и активности заболевания.<br>
 <br>
	 Отдельно была выделена группа больных, которым проводили консолидирующую терапию (митоксантрон) после ВИСТ+ТКСК. В эту группу вошли пациенты, имеющие факторы риска. В настоящее время данная группа включает 34 пациента; анализ результатов лечения в этой группе будет проведен в декабре 2009г.<br>
 <br>
	 При проведении ВИСТ+ТКСК не было летальных исходов, связанных с трансплантацией, а также тяжелых непрогнозируемых осложнений. У всех больных зарегистрирован ответ на лечение: у половины больных было зарегистрировано клиническое улучшение; у остальных – стабилизация состояния. По данным МРТ у всех больных имелось либо улучшение,  либо стабилизация процесса. В отдаленные сроки после ВИСТ+ТКСК (2 года и более) у подавляющего большинства больных (более 90%) наблюдали клиническое улучшение или стабилизацию заболевания. По данным магнитно-резонансной томографии отсутствие активности заболевания зарегистрировано у всех больных с клиническим улучшением или стабилизацией. Особого внимания заслуживает группа больных, которым проведена ранняя ВИСТ+ТКСК, и группа больных, у которых трансплантацию проводили с применением немиелоаблативных режимов кондиционирования. <br>
 <br>
	 ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области.
</p>
<h3>Литература</h3>
<p class="bodytext">
	 1. <a href="http://bloodjournal.hematologylibrary.org/cgi/reprint/91/7/2609" title="Opens external link in new window" target="_blank" class="external-link-new-window"><u>Burt RK, et al. Effect of disease stage on clinical outcome after syngeneic bone marrow transplantation for relapsing experimental autoimmune encephalomyelitis. Blood. 1998;91:2609–2616</u></a><u>.</u>
</p>
<p class="bodytext">
	 2. Burt RK, et al. Autologous haematopoietic stem cell transplantation in multiple sclerosis: importance of disease stage on outcome [abstract]. Neurology. 2003;40:A150.
</p>
<p class="bodytext">
	 3. Comi G, et al. Guidelines for autologous blood and marrow stem cell transplantation in multiple sclerosis: a consensus report written on behalf of the European Group for Blood and Marrow Transplantation and the European Charcot Foundation. J Neurol. 2000;247:376-382.
</p>
<p class="bodytext">
	 4. <a href="http://www.nature.com/bmt/journal/v20/n8/pdf/1700944a.pdf" title="Opens external link in new window" target="_blank" class="external-link-new-window"><u>Fassas A, et al. Peripheral blood stem cell transplantation in the treatment of progressive multiple sclerosis: first results of a pilot study. Bone Marrow Transplant. 1997;20:631-638</u></a><u>.</u>
</p>
<p class="bodytext">
	 5. Fassas A, et al. Autologous stem cell transplantation in progressive multiple sclerosisdan interim analysis of efficacy. J Clin Immunol. 2000;20:24-30. doi: 10.1023/A:1006686426090.
</p>
<p class="bodytext">
	 6. Fassas A, et al. Haematopoietic stem cell transplantation for multiple sclerosis. A retrospective multicenter study. J Neurol. 2002;249:1088-1097. doi: 10.1007/s00415-002-0800-7.
</p>
<p class="bodytext">
	 7. Fassas A, Nash R. Multiple sclerosis. Best Pract Res Clin Hematol. 2004;17:247-262. doi: 10.1016/j.beha.2004.04.005.
</p>
<p class="bodytext">
	 8. <a href="http://bloodjournal.hematologylibrary.org/cgi/content/full/102/7/2364" title="Opens external link in new window" target="_blank" class="external-link-new-window"><u>Nash RA, et al. High-dose immunosuppressive therapy and autologous peripheral blood stem cell transplantation for severe multiple sclerosis. Blood. 2003;102:2364-2372. doi: 10.1182/blood-2002-12-3908</u></a><u>.</u>
</p>
<p class="bodytext">
	 9. <a href="http://bloodjournal.hematologylibrary.org/cgi/content/full/105/6/2601" title="Opens external link in new window" target="_blank" class="external-link-new-window"><u>Saccardi R, et al. Autologous HSCT for severe progressive multiple sclerosis in a multicenter trial: impact on disease activity and quality of life. Blood. 2005;105:2601-2607. doi: 10.1182/blood-2004-08-3205</u></a><u>.</u>
</p>
<p class="bodytext">
	 10. Saccardi R, et al. Autoimmune Diseases Working Party of EBMT. Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database. Mult Scler. 2006;12:814-823.
</p>
<p class="bodytext">
	 11. <a href="typo3/1-2-shevchenko-et-al-2008dec3.html" title="Opens external link in new window" class="external-link-new-window"><u>Shevchenko Y, et al. Autologous hematopoietic stem cell transplantation in multiple sclerosis. Cellular Therapy and Transplantation (CTT). 2008;1:2. doi: 10.3205/ctt-2008-en-000025.01</u></a>.
</p>
<p class="bodytext">
	 12. Shevchenko Y, Novik A, et al. Three strategies of high dose chemotherapy (HDCT)+autologous stem cell transplantation (ASCT) in autoimmune diseases. Bone Marrow Transplantation. 2004;33(1):346.
</p>
<p class="bodytext">
	 13. Shevchenko Y. et al. High-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation as a treatment option in multiple sclerosis. Experimental Hematology. 2008;36(8):922-928. doi: 10.1016/j.exphem.2008.03.001.
</p>
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	 Традиционные методы иммуномодулирующей и иммуносупрессивной терапии рассеянного склероза (РС) не позволяют достичь выраженного и длительного терапевтического эффекта [4-7, 10]. Одним из новых перспективных подходов к лечению РС является высокодозная иммуносупрессивная терапия с трансплантацией кроветворных стволовых клеток (ВИСТ+ТКСК). В настоящее время в мире выполнено более 700 трансплантаций больным с различными формами РС. Безопасность и эффективность метода изучена в международных многоцентровых исследованиях. К нерешенным вопросам ВИСТ+ТСКК относятся следующие: показания, методы трансплантации, режимы кондиционирования, деплеция Т-лимфоцитов, фармакоэкономическое обоснование и др. [3, 9, 11].

 

	 Разработана концепция ВИСТ+ТКСК при РС, включающая следующие положения: содержание метода, основные показания, методика проведения трансплантации, общий алгоритм, направления дальнейших исследований. Основные положения концепции подтверждены результатами проспективного многоцентрового исследования Российской кооперативной группы клеточной терапии изучения эффективности ВИСТ+ТКСК у больных различными формами РС. 

 

	 В рамках концепции выделено две принципиальные цели лечения больных РС. Первая из них патогенетическая – остановить прогрессирование заболевания и предотвратить появление новых очагов демиелинизации в ЦНС за счет воздействия на иммунопатологический процесс на различных уровнях. Вторая цель, основная или конечная, состоит в сохранении и, по возможности, в улучшении качества жизни больных. Данные положения основаны на теории принятия решений в клинической медицине, согласно которой в формализованном виде существует три возможных цели лечения больного: 

 

	 I – излечение с учетом качества жизни больного после выздоровления, 

	 II – увеличение продолжительности жизни больного с учетом ее качества

	 III – улучшение качества жизни больного. 

 

	 При РС, хроническом неизлечимом заболевании, в большинстве случаев не снижающем продолжительность жизни больного, максимально возможное восстановление и сохранение параметров качества жизни  является приоритетной целью лечения. Вследствие этого, наряду с традиционными лабораторными и инструментальными тестами, описывающими изменения в течении патологического процесса на фоне терапии, к ключевым критериям эффективности лечения РС следует отнести и показатели качества жизни больного, отражающие сложный комплекс физических, психологических и социальных детерминант, свойственных конкретному индивидууму. 

 

	 Учитывая вышесказанное, в рамках концепции выделены 3 вида трансплантации, отличающиеся по целям и времени проведения операции [12, 13]

 

 Ранняя трансплантация

	 1. Патогенетическая цель – предупредить развитие необратимых изменений в ЦНС в результате иммунопатологического процесса.

	 2. Основная цель – сохранить качество жизни больного, предотвратить формирование инвалидизации. 

	 3. Время проведения – в дебюте заболевания.

 

 Этапная трансплантация

	 4. Патогенетическая цель – остановить прогрессирование  заболевания на фоне  самоподдерживающегося иммунопатологического процесса, имеющихся очагов  необратимых изменений и частично утраченных функций, предупредить появление новых очагов поражения.

	 5. Основная цель – улучшить качество жизни больного и сохранить его на максимально возможном уровне, предупредить углубление инвалидизации пациента.

	 6. Время проведения – на различных этапах прогрессирования РС при выходе заболевания из-под контроля традиционных методов лечения.

 

 Трансплантация спасения

 7. Патогенетическая цель – остановить прогрессирование заболевания на фоне большого количества очагов необратимых изменений  и существенно нарушенных функций, предупредить появление новых очагов поражения.

	 8. Основная цель – сохранить качество жизни больного на максимально возможном уровне, предотвратить наступление критической инвалидизации.

	 9. Время проведения – в далеко зашедшей стадии заболевания при высокой активности иммунопатологического процесса, быстром прогрессировании инвалидизации больного.


	 В данном докладе представлены результаты исследования безопасности и эффективности ВИСТ+ТКСК у 132 больных РС, которым  ВИСТ+ТКСК проведена в Военно-медицинской академии (Санкт-Петербург) и Национальном медико-хирургическом центре им. Н.И. Пирогова (Москва), начиная с 1999 года. В исследование включено 58 мужчин и 74 женщины; средний возраст – 33 года. У 57 пациентов была диагностирована вторично-прогрессирующая форма заболевания, у 23 – первично-прогрессирующая,  у 9 – прогрессирующе-рецидивирующая и у 43 – рецидивирующая ремитирующая.  Выделены три группы пациентов в зависимости от вида трансплантации: ранняя трансплантация проводилась при EDSS от 1,5 до 3,0; этапная трансплантация - при EDSS от 3,5 до 6,5; трансплантация спасения - при EDSS от 7,0 до 8,5. 83 пациентам была проведена этапная ВИСТ+ТКСК;  43 – ранняя трансплантация; 7 – трансплантация спасения. Для кондиционирования использовали режимы BEAM или mini-BEAM. Эффект ВИСТ+ТКСК оценивали по изменению степени инвалидизации больного и активности заболевания.

 

	 Отдельно была выделена группа больных, которым проводили консолидирующую терапию (митоксантрон) после ВИСТ+ТКСК. В эту группу вошли пациенты, имеющие факторы риска. В настоящее время данная группа включает 34 пациента; анализ результатов лечения в этой группе будет проведен в декабре 2009г.

 

	 При проведении ВИСТ+ТКСК не было летальных исходов, связанных с трансплантацией, а также тяжелых непрогнозируемых осложнений. У всех больных зарегистрирован ответ на лечение: у половины больных было зарегистрировано клиническое улучшение; у остальных – стабилизация состояния. По данным МРТ у всех больных имелось либо улучшение,  либо стабилизация процесса. В отдаленные сроки после ВИСТ+ТКСК (2 года и более) у подавляющего большинства больных (более 90%) наблюдали клиническое улучшение или стабилизацию заболевания. По данным магнитно-резонансной томографии отсутствие активности заболевания зарегистрировано у всех больных с клиническим улучшением или стабилизацией. Особого внимания заслуживает группа больных, которым проведена ранняя ВИСТ+ТКСК, и группа больных, у которых трансплантацию проводили с применением немиелоаблативных режимов кондиционирования. 

 

	 ВИСТ+ТКСК является эффективным методом лечения больных с различными формами РС. Целесообразно выделение следующих стратегий ВИСТ+ТКСК: ранняя трансплантация, этапная трансплантация и трансплантация спасения. Концепция ВИСТ+ТКСК открывает большие возможности для интеграции специалистов, занимающихся разработкой новых методов лечения РС, определяя основные направления дальнейших клинических исследований в данной области.

Литература

	 1. Burt RK, et al. Effect of disease stage on clinical outcome after syngeneic bone marrow transplantation for relapsing experimental autoimmune encephalomyelitis. Blood. 1998;91:2609–2616.


	 2. Burt RK, et al. Autologous haematopoietic stem cell transplantation in multiple sclerosis: importance of disease stage on outcome [abstract]. Neurology. 2003;40:A150.


	 3. Comi G, et al. Guidelines for autologous blood and marrow stem cell transplantation in multiple sclerosis: a consensus report written on behalf of the European Group for Blood and Marrow Transplantation and the European Charcot Foundation. J Neurol. 2000;247:376-382.


	 4. Fassas A, et al. Peripheral blood stem cell transplantation in the treatment of progressive multiple sclerosis: first results of a pilot study. Bone Marrow Transplant. 1997;20:631-638.


	 5. Fassas A, et al. Autologous stem cell transplantation in progressive multiple sclerosisdan interim analysis of efficacy. J Clin Immunol. 2000;20:24-30. doi: 10.1023/A:1006686426090.


	 6. Fassas A, et al. Haematopoietic stem cell transplantation for multiple sclerosis. A retrospective multicenter study. J Neurol. 2002;249:1088-1097. doi: 10.1007/s00415-002-0800-7.


	 7. Fassas A, Nash R. Multiple sclerosis. Best Pract Res Clin Hematol. 2004;17:247-262. doi: 10.1016/j.beha.2004.04.005.


	 8. Nash RA, et al. High-dose immunosuppressive therapy and autologous peripheral blood stem cell transplantation for severe multiple sclerosis. Blood. 2003;102:2364-2372. doi: 10.1182/blood-2002-12-3908.


	 9. Saccardi R, et al. Autologous HSCT for severe progressive multiple sclerosis in a multicenter trial: impact on disease activity and quality of life. Blood. 2005;105:2601-2607. doi: 10.1182/blood-2004-08-3205.


	 10. Saccardi R, et al. Autoimmune Diseases Working Party of EBMT. Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database. Mult Scler. 2006;12:814-823.


	 11. Shevchenko Y, et al. Autologous hematopoietic stem cell transplantation in multiple sclerosis. Cellular Therapy and Transplantation (CTT). 2008;1:2. doi: 10.3205/ctt-2008-en-000025.01.


	 12. Shevchenko Y, Novik A, et al. Three strategies of high dose chemotherapy (HDCT)+autologous stem cell transplantation (ASCT) in autoimmune diseases. Bone Marrow Transplantation. 2004;33(1):346.


	 13. Shevchenko Y. et al. High-dose immunosuppressive therapy with autologous hematopoietic stem cell transplantation as a treatment option in multiple sclerosis. Experimental Hematology. 2008;36(8):922-928. doi: 10.1016/j.exphem.2008.03.001.

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                    [TEXT] => <p class="bodytext">В данной статье приводятся результаты наблюдения за 23 пациентами с рассеянным склерозом после проведенной аутологичной трансплантации стволовых кроветворных клеток. Обсуждаются риски высокодозной химиотерапии и ее преимущества перед другими методами терапии, а также оптимальный выбор режима кондиционирования и предикторов терапии. Результаты показывают прогрессирование заболевания у большинства пациентов после проведенной терапии через 12-18 месяцев. </p>
<h3>Ключевые слова</h3>
<p> аутологичная трансплантация стволовых кроветворных клеток (АТСК), рассеянный склероз</p>
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В данной статье приводятся результаты наблюдения за 23 пациентами с рассеянным склерозом после проведенной аутологичной трансплантации стволовых кроветворных клеток. Обсуждаются риски высокодозной химиотерапии и ее преимущества перед другими методами терапии, а также оптимальный выбор режима кондиционирования и предикторов терапии. Результаты показывают прогрессирование заболевания у большинства пациентов после проведенной терапии через 12-18 месяцев. 
Ключевые слова
 аутологичная трансплантация стволовых кроветворных клеток (АТСК), рассеянный склероз
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                    [TEXT] => <p class="bodytext">The results of observing 23 patients with multiple sclerosis who received autologous hematopoietic stem cell transplantation are shown in this article. The risks of an auto-HSCT and its advantages compared with other therapy methods, and also an optimal choice for the therapy predictors are discussed. The results show progress of disease in most cases after 12-18 months. 
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<h3>Keywords </h3>
<p>autologous hematopoietic stem cell transplantation (auto-HSCT), multiple sclerosis </p>
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Keywords 
autologous hematopoietic stem cell transplantation (auto-HSCT), multiple sclerosis 
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<p class="bodytext"><b>Correspondence</b><br> Tatyana I. Ionova, 195009, Finski per., 9, mailbox 57, St. Petersburg, Russia<br>Phone/Fax: +7 (812) 436-61-12, E-mail: <a href="javascript:linkTo_UnCryptMailto('qempxs.upmjiDveqfpiv2vy');">qlife@<span style="display:none;">spam is bad</span>rambler.ru</a> 
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1Multinational Center for Quality of Life Research, St. Petersburg, Russia; 2Department of Hematology and Cellular Therapy, Pirogov National Medical Surgical Center, Moscow, Russia


Correspondence
 Tatyana I. Ionova, 195009, Finski per., 9, mailbox 57, St. Petersburg, Russia
Phone/Fax: +7 (812) 436-61-12, E-mail: qlife@spam is badrambler.ru 

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                    [TEXT] => <p class="bodytext">Регуляция иммунного ответа представляется перспективной стратегией в области восстановления повреждений центральной нервной системы (ЦНС). При этом важная роль в качестве кандидатов для клеточной терапии отводится макрофагам. Используя культуральные условия с низким содержанием сыворотки, мы разработали протокол генерации противовоспалительных, М2-подобных, макрофагов из моноцитов периферической крови и сравнили эти клетки (обозначенные как М3) со «стандартными» провоспалительными (Mφ1) и противовоспалительными (Mφ2) макрофагами, генерированными, соответственно, в присутствии GM-CSF и M-CSF. <br /><br />Основное внимание было прежде всего сосредоточено на способности макрофагов стимулировать пролиферацию Т-клеток, а также продукцию макрофагами различных цитокинов, хемокинов и ростовых факторов. Дефицит сывороточных факторов не сказывался негативным образом на количестве генерированных макрофагов. Напротив, наибольший выход клеток наблюдался в культурах M3. По своим свойствам M3 макрофаги больше походили на Mφ2, чем на Mφ1. Так, в отличие от Mφ1, макрофаги Mφ2 и, особенно, M3 отличались относительно низким уровнем экспрессии CD86 и не стимулировали пролиферативный ответ Т-клеток. В противоположность провоспалительным Mφ1 нестимулированные M3 продуцировали гораздо меньшие уровни провоспалительных (IL-1β, TNF-α, IL-6, IL-18, IL-12) и Th1/Th2 цитокинов (IFN-γ, IL-2, IL-4), вместе с тем  - более высокий уровень IL-10. Более того, концентрации IL-1β и провоспалительных хемокинов IL-8 и MCP-1 в супернатантах M3 были снижены не только по сравнению с Mφ1, но также и с Mφ2 культурами. Подобно Mφ1 и Mφ2, М3 обладали способностью продуцировать нейротрофические (BDNF, IGF-1), ангиогенные (VEGF) и другие ростовые факторы с нейропротективной и регенераторной активностью (EPO, G-CSF, FGF-basic, EGF). При этом уровень продукции IGF-1 макрофагами 3-его типа превышал секрецию этого фактора Mφ1 и Mφ2 более чем в 25 раз. <br /><br />Суммируя полученные данные, можно заключить, что генерируемые M3 клетки  представляют M2-подобные макрофаги с высоким регенераторным потенциалом.
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Регуляция иммунного ответа представляется перспективной стратегией в области восстановления повреждений центральной нервной системы (ЦНС). При этом важная роль в качестве кандидатов для клеточной терапии отводится макрофагам. Используя культуральные условия с низким содержанием сыворотки, мы разработали протокол генерации противовоспалительных, М2-подобных, макрофагов из моноцитов периферической крови и сравнили эти клетки (обозначенные как М3) со «стандартными» провоспалительными (Mφ1) и противовоспалительными (Mφ2) макрофагами, генерированными, соответственно, в присутствии GM-CSF и M-CSF. 

Основное внимание было прежде всего сосредоточено на способности макрофагов стимулировать пролиферацию Т-клеток, а также продукцию макрофагами различных цитокинов, хемокинов и ростовых факторов. Дефицит сывороточных факторов не сказывался негативным образом на количестве генерированных макрофагов. Напротив, наибольший выход клеток наблюдался в культурах M3. По своим свойствам M3 макрофаги больше походили на Mφ2, чем на Mφ1. Так, в отличие от Mφ1, макрофаги Mφ2 и, особенно, M3 отличались относительно низким уровнем экспрессии CD86 и не стимулировали пролиферативный ответ Т-клеток. В противоположность провоспалительным Mφ1 нестимулированные M3 продуцировали гораздо меньшие уровни провоспалительных (IL-1β, TNF-α, IL-6, IL-18, IL-12) и Th1/Th2 цитокинов (IFN-γ, IL-2, IL-4), вместе с тем  - более высокий уровень IL-10. Более того, концентрации IL-1β и провоспалительных хемокинов IL-8 и MCP-1 в супернатантах M3 были снижены не только по сравнению с Mφ1, но также и с Mφ2 культурами. Подобно Mφ1 и Mφ2, М3 обладали способностью продуцировать нейротрофические (BDNF, IGF-1), ангиогенные (VEGF) и другие ростовые факторы с нейропротективной и регенераторной активностью (EPO, G-CSF, FGF-basic, EGF). При этом уровень продукции IGF-1 макрофагами 3-его типа превышал секрецию этого фактора Mφ1 и Mφ2 более чем в 25 раз. 

Суммируя полученные данные, можно заключить, что генерируемые M3 клетки  представляют M2-подобные макрофаги с высоким регенераторным потенциалом.

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Elena R. Chernykh, Ekaterina Ya. Shevela, Ludmila V. Sakhno, Marina A. Tikhonova, Yaroslav L. Petrovsky, Alexander A. Ostanin
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                    [TEXT] => <p class="bodytext">Laboratory of Cellular Immunotherapy, Institute of Clinical Immunology of Russian Academy of Medical Sciences, Siberian Branch, Novosibirsk, Russia 
</p><br>
<p class="bodytext"><b>Correspondence</b><br> Elena Chernykh, Laboratory of Cellular Immunotherapy, Institute of Clinical Immunology RAMS SB, Yadrintsevskaya str., 14, Novosibirsk, 630099, Russia
<br>Phone: +7(383)2360329; Fax: +7(383)2227028; E-mail: <a href="javascript:linkTo_UnCryptMailto('qempxs.gx_pefDqemp2vy');">ct_lab@<span style="display:none;">spam is bad</span>mail.ru</a>
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Laboratory of Cellular Immunotherapy, Institute of Clinical Immunology of Russian Academy of Medical Sciences, Siberian Branch, Novosibirsk, Russia 


Correspondence
 Elena Chernykh, Laboratory of Cellular Immunotherapy, Institute of Clinical Immunology RAMS SB, Yadrintsevskaya str., 14, Novosibirsk, 630099, Russia

Phone: +7(383)2360329; Fax: +7(383)2227028; E-mail: ct_lab@spam is badmail.ru

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                    [TEXT] => <p class="bodytext">Regulation of the immune response seems to be a promising strategy for a successful central nervous system (CNS) repair, and macrophages are considered to be prospective candidates for cell therapy. Using low serum conditions we generated human anti-inflammatory M2-like macrophages from peripheral blood monocytes and compared these cells (termed Mφ3) with “standard” pro-inflammatory Mφ1 and anti-inflammatory Mφ2, generated in the presence of GM-CSF and M-CSF. We focused primarily on the differences in T-cell stimulatory activity and production of various cytokines, chemokines, and growth factors. Low serum conditions had no negative impact on macrophage yield, the largest of which was for Mφ3. We showed that Mφ3 more closely resembled Mφ2 than Mφ1. Mφ2 and particularly Mφ3, but not Mφ1 expressed relatively low levels of CD86 and failed to stimulate T-cell proliferation. In contrast to pro-inflammatory Mφ1, unstimulated Mφ3 produced significantly lower levels of pro-inflammatory cytokines (IL-1β, TNF-α, IL-6, IL-18, IL-12) and Th1/Th2-cytokines (IFN-γ, IL-2, IL-4) coupled with a higher IL-10 level. Moreover, concentrations of IL-1β and pro-inflammatory chemokines IL-8 and MCP-1 in Mφ-3 supernatants were lower not only when compared to Mφ1, but also to Mφ2 cultures. Like Mφ1 and Mφ2, Mφ3 was capable of producing neurotrophic- (BDNF, IGF-1), angiogenic- (VEGF), and other growth factors (EPO, G-CSF, FGF-basic, EGF) with neuroprotective and regenerative activity. In fact, IGF-1 production by Mφ-3 exceeds secretion of this factor by Mφ-1 and Mφ-2 by more than 25 fold. Thus, generated Mφ-3 represented M2-like macrophages with high regenerative potential.
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