大剂量免疫抑制并自体外周血CD34～+细胞移植治疗重症/难治性自身免疫病的临床研究

【作者】 冷晓梅；

【导师】 唐福林；

【作者基本信息】 中国协和医科大学 ， 风湿病学， 2003， 博士

【摘要】 目的： 探讨大剂量免疫抑制治疗（HDIT）并自体外周血CD34+细胞移植治疗重症系统性红斑狼疮（SLE）和难治性类风湿关节炎（RA）的可行性、疗效及安全性。 方法： 自1999年起，对10例长期应用激素和免疫抑制剂不能缓解病情的重症SLE和1例应用4种以上慢作用抗风湿药物（DMARDs）不能控制病情活动的难治性RA患者进行大剂量免疫抑制并CD34+细胞移植（HSCT）治疗。入选病例均无严重的不可逆性内脏功能受损，无严重的药物过敏史，并于治疗前签署知情同意书。 1．HDIT+HSCT方案实施步骤： 1．1．患者状况评估：对入组的SLE患者的疾病活动程度行SLE-DAI评分，对RA患者的疾病活动程度行DAS28评分，并评估各脏器功能，同时排除结核、病毒等活动性感染。 1．2．干细胞动员、采集和分选：用环磷酰胺（CY）2g／m²和粒细胞集落刺激因子（G-CSF）5ug·kg^-1·d^-1行干细胞动员，动员成功后用血细胞分离机采集外周血单个核细胞（其中富含CD34+细胞）。应用ClinMACS细胞分选仪进行CD34+细胞分选。经处理完毕的采集物深低温冻存以备回输。 1．3．预处理方案：包括两种标准预处理方案，根据患者的具体情况选用： 一为CY+抗胸腺免疫球蛋白（ATG）：CY 200mg／kg，ATG 90mg／kg； 二是CY+全身照射（TBI）：CY200mg／kg，TBI 4 Gy。 1．4．造血干细胞回输：将造血干细胞于37℃水浴中快速复温，10～30分种内快速回输。 2．造血重建和免疫重建监测：造血重建定义为中性粒细胞连续3天＞1×10⁹／L，血小板计数连续3天＞20×10⁹／L。移植后每3个月应用流式细胞仪检测外周血淋巴细胞表型，以监测移植后免疫重建过程。同时比较接受HSCT的SLE患者的淋巴细胞表型与未行移植治疗的SLE活动患者和SLE平稳患者之间淋更多还原

【Abstract】 ObjectivesTo assess the feasibility, safety, and efficacy of intensive immunosuppression and autologous hemopoietic stem cell transplantation in severe systemic lupus erythematosus and refractory rheumatoid arthritis.MethodsTen patients with severe and persistent SLE despite use of prednisone and immunosupression agents and one patient with active, destructive, refractory RA entered the study. The eligible patients were with no severe non-reversible organ function impairment, no history of severe allergy to drugs. All patients provided written informed consent.1. Treatment protocols of HDIT+HSCT:1.1. Mobilization and leukapheresis of peripheral stem cell and selection of CD34⁺ cells: The mobilization regimen was CY 2 4 g/m² and G-CSF 5 μg·Kg^-1·d^-1. Peripheral mononuclear cells fraction in which stem cells were enriched was collected by use of the cytocentrifuge. Then a ClinMACS was used to select CD34⁺ cells.1.2.Conditioning regimen: We applied regimens of CY+ATG or CY+TBI. Total dose is CY 200 mg/kg , ATG 90 mg/kg and TBI 4 Gy.1.3. Infusion of CD34⁺ cells: CD34⁺ cells were reinfused intravenously within 10 to 30 minutes after defrostment.2. Monitoring of hematopoietic and immune reconstitution: ANC > 1.0 × 10⁹/L for consecutive 3 days, the first day of these 3 days is defined to the neutrophil recovering time. Platelet count > 20× 10⁹/L for consecutive 3 days, the third day of those 3 days is defined to the platelet recovering time. Detect the phenotype of the lymphocyte in the peripheral blood every three months after transplantation to monitor the immune reconstitution process. The difference of lymphocyte更多还原