Experimental basis of hematopoietic stem cell transplantation
for treatment of autoimmune diseases
D. W. van Bekkum
Crucell B.V., Leiden, The Netherlands
Abstract: Experiments with animal models of au-
toimmune disease provided the rational and stim-
ulus for the current, clinical studies of autologous
stem cell transplantation for the treatment of a
variety of severe, refractory, autoimmune dis-
eases. The discoveries that led to the recognition of
the key role of hematopoietic stem cells and the
successful treatment of autoimmune diseases with
bone marrow transplants are reviewed. The rele-
vance of spontaneous and induced autoimmune
disease models for the development of clinical
treatment regimens is discussed. Most of the inves-
tigations with autologous stem cell transplantation
have been performed with induced autoimmune
disorders: in rats with adjuvant arthritis and in rats
or mice with experimental, allergic encephalomy-
elitis, the current model for multiple sclerosis. The
main aspects of this translational research were the
conditioning regimens and the degree of T cell
depletion of the graft as determinants of remission
induction and the incidence of relapses. The
emerging recommendations are compared with the
outcome so far of the clinical studies. J. Leukoc.
Biol. 72: 609 – 620; 2002.
Key Words: transplants 䡠 bone marrow 䡠 arthritis 䡠 encephalomy-
elitis
INTRODUCTION
The pivotal role of the hematopoietic system in the develop-
ment of autoimmune diseases (AID) was first suggested more
than 30 years ago by Morton and Siegel [1] who described the
development of antinuclear antibodies in normal mice after the
transplantation of bone marrow (BM) from NZB mice. NZB is
an inbred strain of mice that spontaneously develop a syn-
drome resembling systemic lupus erythematosus (SLE). Adop-
tive transfer of the potential to develop AID as well as its
prevention with BM cells from resistant donors were subse-
quently demonstrated to hold for several other AID in experi-
mental animals.
The clinical literature contains sporadic case reports of the
transfer of AID and allergic disorders with donor BM to pa-
tients treated for leukemia or aplastic anemia. These include
thrombocytopenic purpura, thyroiditis, diabetes type I, celiac
disease, and myasthenia gravis [2]. After the discovery that
full-blown AID of experimental animals can be cured by allo-
geneic BM transplantation (BMT), the records of patients who
were long-term survivors of treatment with allogeneic BMT for
leukemia or aplastic anemia were searched for those with
coexisting AID at the time of transplantation. The search
revealed 21 patients suffering from rheumatoid arthritis (RA),
psoriasis, Crohn’s disease, ulcerative colitis, SLE, or insulin-
dependent diabetes type 1 (IDD1), all of whom experienced a
complete remission of their autoimmune disorder. The trans-
plant-associated risks of allogeneic BMT, however, precluded
its use in AID. It was only after our unexpected finding that
autologous BMT could also cure experimental AID that trans-
plantation of BM or peripheral blood stem cells (PBSC) were
introduced into the clinic as a treatment option for refractory
AID. Thus far, the results of these clinical studies, which
comprise several hundreds of patients, have established a
highly predictive value of the disease models that were used.
RELEVANCE OF ANIMAL MODELS FOR
HUMAN AID
For appraisal of the predictive value of experiments with AID
models, an analysis of the causes and nature of the human
diseases is needed. Many if not all of the human AID are T
cell-initiated or -mediated. In the majority, the presence of
autoantibodies in the serum of the affected subjects is now
considered an associated or epiphenomenon. The activation of
T lymphocytes against self-antigens may be induced by the
release of an excessive amount of tissue-specific antigens to
which the organism has not become tolerant during develop-
ment, as in the case of sympathetic ophthalmia. Although the
target antigens have been identified for many of the human
AID, the inducing agents are unknown for most, despite ex-
tensive epidemiological research. This failure suggests that
exposure to such antigens is ubiquitous and that affected
individuals must have an unusually high responsiveness—a
predisposition that is genetically determined. However, al-
though numerous reports describe the linkage of certain major
histocompatibility complex genes of the human leukocyte an-
tigen (HLA) and the D/DR regions with specific AID, the
linkages are far from absolute [3]. Also, concordance in
monozygotic twins is limited: in multiple sclerosis (MS), 20 –
Correspondence: D. W. van Bekkum, Crucell B.V., P.O. Box 2048 2301 CA,
Leiden, The Netherlands
Received February 5, 2002; revised May 1, 2002; accepted June 4, 2002.
Journal of Leukocyte Biology Volume 72, October 2002 609
30%; in Crohn’s disease, 44%; and in RA, 11% [4], indicating
that genetic and environmental factors are involved.
The animal models of AID are of two distinct categories: the
spontaneous (or hereditary) and the induced forms. In the first
category, the disease develops spontaneously in a large pro-
portion or in all of the individuals of a so-called autoimmune
strain of mice or rats. Well-known examples are the lupus-like
syndromes in several inbred mouse strains and diabetes in
NOD mice and BB rats.
The induced AID require immunization with certain anti-
gens to develop and do so only in selected inbred strains—the
susceptible ones or responders—and not in others—the resis-
tant or nonresponder strains. The best described models are
adjuvant arthritis (AA) in rats and experimental allergic en-
cephalitis (EAE), which can be induced in many species. The
latter is considered the most appropriate animal model for MS.
Susceptibility and resistance to inducible AID have been
shown to be genetically determined by cross-breeding experi-
ments.
A continuous subject of debate is the question of what type
of disease model is expected to best predict efficacy of new
therapeutic modalities in human AID. The induced models
appear to be the favored candidates, as they share a dual
ethiology with their human counterparts. However, some of the
spontaneous AID of animals have also been found to be
strongly influenced if not dependent on environmental factors,
such as microbes, food, and hormones. For instance, HLA-B27
transgenic rats do not develop the characteristic colitis and
arthritis when reared germ free [5]. In germ-free NZB mice, the
incidence and severity of renal lesions were much lower than in
conventional controls [6], but in MRL-lrp mice similar exper-
iments did not provide any evidence for a role of infectious
agents in the development of their lupus-like disease [7].
Exposure to a common rat virus, the Kilman rat virus, initiates
autoimmune IDD1 in some but not all rat strains that are
normally not susceptible to spontaneous diabetes [8, 9]. On the
other hand, elimination of environmental viruses by Caesarian
derivation of diabetes-prone BB rats increased the incidence
and rate of development of diabetes [10]. Other environmental
factors that have been identified in diabetes-prone rodents are
the diet and hormones. A semi-purified diet prevents diabetes
in BB rats [11], and a raised environmental temperature, which
decreases food intake, reduced the incidence of diabetes in
NOD mice [12]. Exposure to environmental stressors enhanced
the onset and increased the incidence of diabetes in BB rats
[13], and sex hormones influence the occurrence of insulinitis
and diabetes, sialitis, and dacryoadenitis in NOD mice [14].
Interestingly, in several instances, the microflora or hor-
mones was also found to modify the susceptibility to induction
of AID. F344 rats are resistant to induction of adjuvant arthritis
under conventional conditions but are highly responsive in the
germ-free state [15]. This was not the case for collagen-induced
arthritis (CIA), to which F344 rats are equally resistant under
both conditions. However, CIA was markedly enhanced in
germ-free (susceptible) DA rats as compared with conventional
ones [16]. In this context, it should be reminded that graft
versus host disease (GvHD), which has many pathological
features in common with SLE and autoimmune colitis, is
610 Journal of Leukocyte Biology Volume 72, October 2002
strongly influenced by the composition of the microflora in
experimental animals [17] and human patients [18].
The disease pattern of EAE is profoundly influenced by the
plasma level of corticosteroids. Nonresponsive PVG rats de-
velop severe and fatal EAE when they are adrenalectomized
prior to induction. Adrenalectomy of the responder Lewis rat
alters its usual pattern of acute remitting, nonrelapsing EAE
into nonremitting fatal disease [19]. The original reaction pat-
tern is restored by replacement therapy with corticosteroids.
Rats of the low-responder strain WAG have an incidence of
10% following immunization, which increases to 50% in adre-
nalectomized animals [20].
Another factor identified as influencing EAE development is
the presence of cyclophosphamide (CY)-sensitive suppressor
cells. Abrogation of the resistance of acridine orange rats [21]
and of BALB/c mice [22] to encephalitogenic immunizations
was obtained by pretreatment with low dose (20 mg/kg) CY.
The incidence of subclinical EAE as defined by histological
lesions in the central nervous system (CNS) of WAG rats
increased from 37% to 86% by pretreatment with a similarly
low dose of CY, but the incidence of clinical EAE remained
unaltered at 10% [21].
In view of these data, the differences between the sponta-
neous and the inducible animal models may well be gradual
rather than fundamental. In both cases, there is a genetic
disposition that allows activation of antiself immunity; in the
case of the spontaneous diseases, activation is by relatively
weak, ubiquitous antigens; in the case of the inducible AID, by
strong, specific antigens. Both mechanisms accommodate a
role for infectious microorganisms acting as the initiating stim-
ulus by providing antigens that resemble tissue targets (so-
called mimicry) or as regulators of the immune reactivity,
similar to adjuvants, hormones, and dietary factors. All these
determinants, genetic as well as environmental, have also been
implicated in the pathogenesis of human AID. The etiology of
human AID is undisputedly multifactorial. In almost all auto-
immune conditions, there is a familial tendency. Many AID are
induced by drugs: more than 70 different drugs have been
reported to induce SLE. Furthermore, many xenobiotics, e.g.,
food supplements, heavy metals, and environmental toxins,
have been linked to the development of SLE-like illnesses.
Although in many patients with AID, the causative agent
remains unknown, the low concordance in identical twins
seems to argue in favor of the induced disease models as being
more realistic tools for translational research.
ADJUVANT ARTHRITIS IN BUFFALO (BUF)
RATS
A large variety of antigens and immunization schedules were
known to induce various forms of inflammatory arthritis in
susceptible, experimental animals. Among the antigens are
complete Freund’s adjuvant (CFA), collagens, and streptococ-
cal cell-wall preparations. The most widely studied are the
Lewis rat and CFA, but in our hands, as in most other labo-
ratories, immunization of Lewis rats with adjuvant induced a
typically acute form of the disease of short duration, resulting
in resistance to reinduction after remission. We then studied a
http://www.jleukbio.org
variety of mouse, rat, and guinea pig strains using adjuvant and
collagen as inducing agents and compared the clinical picture
as well as the histopathology of the lesions. Our conclusion
from this extensive exploration was that AA in the BUF rat
strain provides the most resemblance to RA in humans. In the
BUF rat, a single, intracutaneous inoculation of Mycobacterium
tuberculosis in CFA causes a chronic, progressive type of
polyarthritis within 3– 4 weeks in over 80% of the animals. The
inflammation involves chiefly the distal extremities, as a
chronic, proliferative synovitis with pannus formation, destruc-
tion of cartilage and subchondral bone, vasculitis, pericapsular
fibrosis, and extensive, reactive bone formation. Clincally,
there is swelling and redness of the affected joints. During the
acute and the progressive, chronic stage, the inflamed joints
are reddish and painful. In some animals, the inflammation
recedes after 10 weeks at the earliest; in others, inflammation
continues for as long as 30 weeks, by which time the experi-
ments were usually terminated. Following extinction of the
inflammation, spontaneously or as a result of treatment, the
osseous deformities persist. Spontaneous remissions occur in
only 12% of the animals. Reimmunization at 15 weeks after
induction did not alter the clinical condition. Treatment with
cyclosporin A of rats during the acute phase causes partial
regression but the arthritis exacerbates and progresses again
after discontinuation of the drug.
EXPERIMENTAL AUTOIMMUNE
ENCEPHALOMYELITIS IN RODENTS
EAE is an inflammatory demyelating disease of the CNS that
can be induced in certain strains of rodents and in monkeys by
immunization with whole spinal cord or purified myelin pro-
teins and CFA. This review is limited to EAE in rodents. In the
Lewis rat, symptoms last for 5–7 days, followed by complete
recovery. Thereafter, the animals are resistant to reinduction.
The neurological symptoms of acute EAE are probably due to
a combination of reversible demyelination and edema caused
by the inflammation.
Relapsing EAE develops after a similar immunization in
SJL/J mice, in Biozzi mice, in BUF rats, and in Lewis rats, but
in the latter only if pretreated with low-dose cyclosporin A.
Relapses are characterized by one or more new episodes of
paralysis and paresis after the animals have recovered from the
first attack. Most of the animals recover after each subsequent
attack; some 10% of the BUF rats succumb during that period.
The spontaneous relapses are accompanied by more wide-
spread inflammation in the CNS and more pronounced demy-
elination. After 40 –50 days, relapses no longer develop spon-
taneously, but can be reinduced by another immunization.
Such induced relapses are likely due to activation of memory T
cells, as the latent period is 2– 6 days less than in the case of
primary immunization. It remains a matter of speculation how
to interpret spontaneous and induced relapses as models for
relapses that occur in MS patients. In all cases, the relapses are
associated with flare-up of the inflammatory processes in the
CNS at “old” sites or at new locations. As it is unknown what
causes relapse in MS, notably if it represents a nonspecific
activation or a re-exposure to the sensitizing antigen, it cannot
van Bekkum Stem cell transplants for autoimmune disease
be decided whether induced relapses in the animals have any
counterpart in the clinic. Nevertheless, I and others have recorded
the incidence of induced relapses after BMT, reasoning that it will
provide information on the presence of residual memory cells.
In the Biozzi mouse, immunization with spinal cord tissue
induces a chronic form of EAE, which eventually leads to more
extensive demyelination than is observed in the remitting
relapsing EAE of rats. EAE in Biozzi mice is therefore a better
model for studying the effects of therapeutic interventions on
chronic, persistent demyelating disease, which is mainly due to
the scars from previous inflammations.
AID AS DISEASES OF THE HEMATOPOIETIC
STEM CELLS
Having discussed the causes of AID, I will focus on the
immune system itself, which is instrumental in initiating and
maintaining the lesions of AID. Failure to abstain from or to
limit self-destruction is regarded as a defect of regulatory
immune mechanisms. The question is whether this occurs at
the level of the lymphoid cell population; for example, a
dysregulation resulting from an abnormal generation—too
much or not enough— of certain lymphocyte subpopulations
(effector or suppressor cells). Examples are the multiform,
autoimmune syndrome that develops in mice and Syrian ham-
sters following neonatal thymectomy [23] and the AID that are
induced by treatment with cyclosporin A of lethally irradiated
rats rescued with syngeneic BM grafts [24].
An alternative hypothesis is based on the finding that the
potential for developing spontaneous AID can be transferred by
BMT to lethally irradiated animals from a nonautoimmune
strain, and reversely, autoimmune-prone animals do not de-
velop the disease when grafted at an early age, before the
disease is manifest, with BM from a normal strain. This prop-
erty was discovered in NZB mice, which spontaneously de-
velop a lupus-like syndrome, by Morton and Siegel [1] who
postulated “that some defect. . .may exist in the NZB mouse at
the level of the hemopoietic stem cell.” Similar transfers were
demonstrated in several different spontaneous AID strains as
listed in Table 1. It also led to a re-emphasis, most strongly by
Ikehara et al. [30], of AID being stem cell diseases. However,
this conclusion is not fully justified as long as the transfers
have not been accomplished with highly purified stem cells.
For the time being, it seems appropriate to use the term “stem
cell-associated diseases.”
Regarding the inducible disease models, studies have been
performed with hematopoietic chimeras of resistant recipients
and susceptible donors and vice versa (Table 2). After chi-
merism had been established, these animals were immunized
with the appropriate antigen. Similar to the findings in the
spontaneous models, responsiveness is generally dictated by
the BM donor genotype.
Among the notable exceptions is CIA in DBA/1 mice. Ar-
thritis could not be induced in DBA/1 3 SWR chimeras,
which might be a result of the C5 deficiency of the recipients.
Surprisingly, the SWR 3 DBA/1 chimeras were susceptible.
In this particular case, the inherent potential to react against
611
 TABLE 1. Transfer (T) and Prevention (P) of Spontaneous AID by Allogeneic BMT between Autoimmune and Normal Rodent Strains

Disease AI strain Non-AI strain T and/or P Ref.

SLE-like syndromes (mice) NZB, (NZB⫻SJL/J)F1 (NZB⫻C57BL)F1 BALB/c, SJL/J, C57BL T 1

NZB BALB/c, B10.D2, C57BL, DBA/2 T/Pa 25–27
MRL/lpr C3H nu/nu P 28
MLR/lpr C57BLb T 29
(NZW⫻BXSB)F1 C3H, C57BL T 30
BXSB CBA P 31
Polyarthritis (mice) NZB/KN C57BL P 32
Insulin-dependent diabetes mellitus NOD NON, (NOD⫻NON)F1 T 33
(mice) NOD (NOD⫻B10)F1 T 34
NOD C57BL/6B10.BR/cd T/P 35
(rats) BB BB diabetes-resistant subline P 36
BB WF P 37
Motheaten syndrome (mice) me/me ⫹/⫹ T 38
Skin fibrosis (mice) tsk ⫹/⫹ T 39
Multisystem AID (rats) HLA-B27 transgenic Nontransgenic T/P 40
a
Partly purified stem cells were transplanted by one group of investigators [25]. b T cell-depleted BM cells and bone as a source of stromal cells were grafted.

collagen may be present in the so-called resistant donor strain
but masked by its C5 deficiency.
In the EAE group of experiments, those reported by Korn-
gold et al. [47] are contrasting with the other data. In their
paper, they demonstrate that the responses of the chimeras are
dictated by the recipient strain, similarly when the CNS anti-
gen used for induction was of BALB/c or B10.S origin. In
another publication of the same year, Lublin et al. [48] con-
firmed these results with the SJL-derived antigen, but immu-
nization with the B10.S antigen induced a high incidence of
clinical EAE in B10.S 3 SJL and SJL 3 B10.S chimeras. A
satisfactory explanation has not emerged so far.
TREATMENT OF FULLY DEVELOPED
EXPERIMENTAL AID WITH ALLOGENEIC BMT
In view of the transfer data described above, it was logical to
investigate if full-blown AID might be cured by BMT from
resistant animals. As this involves allogeneic donors, engraft-
ment requires ablation of the lymphohemopoietic system of the
recipient (to be designated as conditioning in analogy with the
treatment of leukemia). Successful treatment with allogeneic
BMT was first reported in 1985 by Ikehara et al. [53] in
MLR/lpr and BXSB mice with overt lupus-like disease and in
NOD mice with insulinitis [54]. Ikehara’s group continued to
publish similar therapeutic effects in other hereditary, autoim-
mune conditions (Table 3). Grafting of fetal thymus and fetal
bone fragments in addition to T cell-depleted allogeneic BM
improved the results [57], which was attributed to facilitation of
the engraftment of the BM stem cells. The problem with
allogeneic BMT in treating SLE-type syndromes is that mea-
sures have to be taken to prevent graft versus host reactions, as
these resemble some of the manifestations of SLE, notably
dermatitis and the liver lesions.
Treatment of induced AID with allogeneic BM has been
equally successful as in the case of the spontaneous syndromes
(Table 4). Complete lasting remissions and near absence of

TABLE 2. Transfer of Susceptibility (S) or Resistance (R) to Induction of AID by Allogeneic BMT

AID AI strains Non-AI strains Transfer of S and/or R Ref.

AA
(rats) Lewis F344 S/R 41
(rats) BUF WAG S/P 42
Streptococcal cell-wall arthritis
(rats) Lewis F344 S/R 41
Collagen-induced arthritis
(rats) WAG BUF S 20
(mice) DBA/1 SWR No transfera 43
EAE
(rats) (Lewis⫻BN)F1 BN S/Rb 44
(guinea pigs) strain 13, (2⫻13)F1 strain 2 S/R 45
(rats) Lewis Le-R S/R 46
(mice) SJL/J B10.S No transfer 47, 48
(mice) SJL/J B10.S S/R 49
(rats) BUF WAG S/R 50
(rats) (WAG⫻BUF)F1 WAG S/R 50
(rats) BUF BN.1B S/R 51
(mice) BUF, Lewis, SJL/J CB-17-scid/scid S 52
a
The SWR mouse is C5-deficient, and C5 seems to be required for the development of CIA. b T cell-depleted bone marrow.

612 Journal of Leukocyte Biology Volume 72, October 2002 http://www.jleukbio.org

 TABLE 3. Treatment of Fully Developed, Spontaneous AID with Allogeneic BMT

AI straina Normal donor strain Effect Ref.

NOD BALB/c nu/nu Resolution of insulinitis 54

B/W, BXSB BALB/c nu/nu Regression of glomerular damage 53, 55
Reduction in circulating immune
Complexes or complete cures
MLR/lpr BALB/c nu/nu Complete cures 53
MRL/lpr C57BL Complete resolution of glomerulonephritis, arthritis, and correction of immunological 56
abnormalities; stroma cell transplants required
old MRL/⫹ C57BLb Cure of pancreatitis and sialoadenitis, normalization of T and B cell functions 57
a b
Conditioning with lethal dose of TBI. T cell-depleted BM and fetal bone fragments and fetal thymus transplanted.

relapses were obtained in rats suffering from AA or EAE by
treatment in the acute phase of the disease. In AA, BMT is only
effective when there is active inflammation going on. When
treatment is given in the chronic phase, disease progression is
halted, but osseous deformations of the joints are not repaired.
BMT failed to induce remissions in mice with CIA; this may
also have been a result of the presence of irreversible joint
damage.
EAE in BUF rats is a remitting, relapsing disease that does
not develop into a chronic phase in contrast to EAE in Biozzi
mice. In the acute stage of EAE, i.e., at 20 days post-immu-
nization, Biozzi mice responded well to allogeneic BMT. All
animals went into complete remission, and only one mouse had
a mild relapse with full recovery. Without treatment, 80%
recover from the first attack. Of those, 76% suffer one or more
relapses and eventually recover or enter the chronic phase.
The chronic disease is characterized by extensive demyeli-
nation, axonal loss, and gliosis. The majority of the remitting
animals experience one or more relapses. Mice treated with
allogeneic BMT when chronically ill at day 108 post-immuni-
zation did not respond at all to allogeneic BMT. Apparently,
treatment with BMT effectively halts the inflammatory pro-
cesses but does not lead to repair of scar tissue in the nervous
tissue.
Overall, the results obtained with allogeneic BMT are im-
pressive, considering that the animals were quite sick when
treated and had almost no relapses. These findings stimulated
a search of the clinical records of long-term survivors of
allogeneic BMT for patients with coexisting AID at the time of
grafting. Twenty-one patients with a follow-up of 7–21 years
were discovered. All experienced complete remission of their
various AID and only one patient relapsed. These cases have
been reviewed by Marmont [61] and Nelson et al. [62].
Despite such strong evidence of its therapeutic potency,
allogeneic BMT has not been intentionally applied to the
treatment of severe AID so far, except for refractory, idiopathic,
aplastic anemia, where it is a long-established therapy, pri-
marily intended to replace the lost BM. The highly successful
treatment of this life-threatening AID with allogeneic BMT is
perhaps the most convincing argument for extending this mo-
dality to other AID. However, the considerable risk of trans-
plantation-associated mortality has precluded this.
The discovery that autologous BMT is equally effective as
allogeneic BMT in inducing complete remissions in rats with
AA an EAE cleared the way for clinical application, as autol-
ogous BMT is less risky. Among more than 500 patients
registered so far as having been treated with autologous stem
cells for severe refractory AID, the overall transplant-associ-
ated mortality was 9%, with significant variation between dis-
eases [63].
AUTOLOGOUS BMT
The use of autologous BM was by no means a rational approach
in view of the evidence that AID are hematopoietic stem
cell-associated diseases. Experiments using autologous grafts
were initiated after the unexpected finding that arthritic rats
responded just as well to treatment with syngeneic BM from
healthy donors as the ones grafted with allogeneic marrow.
Actually, the experiments with syngeneic BMT were included
because of the (mistaken) assumption that they would serve as
negative controls. Even more surprisingly, reimmunization of
the cured rats, at 24 h or at 28 days following the engraftment,
did not induce any relapses [58].
Curiosity made us investigate treatment with autologous BM.
Once more, against all expectations, autologous BM was just as
efficacious as syngeneic marrow from healthy animals and as
allogeneic marrow [64]. These results were confirmed with
grafts of real autologous BM, which was harvested from the

TABLE 4. Treatment of Fully Developed, Induced AID with Allogeneic BMT

Disease Responsive strain Resistant strain Effect Ref.

AAa (rats) BUF WAG Complete remission 58

CIAa (mice) DBA/1 BALB/c No remission; complete prevention of progression 59
EAEb (rats) BUF WAG and BN.1B Complete remission; few relapses 50, 51
EAEa (mice) Biozzi CBA Treated in acute phase: Complete remission; few relapses 60
Treated in chronic phase: No effect
a
Conditioning with lethal total body irradiation. b Conditioning with lethal total body irradiation or CY and busulfan.

van Bekkum Stem cell transplants for autoimmune disease 613

femur of arthritic recipients by a surgical procedure, followed
by total body irradiation (TBI) and intravenous return of their
own BM cells [64].
Subsequent studies with autologous stem cells were always
performed with BM harvested from animals with exactly the
same stage and severity of the disease as the recipients. The
marrow obtained in this way was termed pseudoautologous at
that time. By this procedure, unnecessary suffering of the very
sick animals from the surgical intervention needed for BM
collection is avoided. For each experiment, about 100 rats were
immunized, and when the disease was fully developed, each
animal was scored using a grading scale for the clinical symp-
toms. The animals were distributed over the various experi-
mental groups and the donor group of rats, assuring that the
average score of all groups was similar. Animals without symp-
toms (10 –20%) were always excluded. As the composition and
properties of pseudoautologous and autologous BM are identi-
cal, the term autologous is used for both throughout this review.
In contrast to the preclinical experiments with autologous
BMT, those with syngeneic transplants have little practical
significance, as identical twin donors are rarely available.
However, any difference in the results of treatment between
autologous and syngeneic cells is of great interest, as it may
shed light on the significance of activated T cells and memory
cells in the graft. As can be seen from Table 5, few published
data are available on syngeneic and autologous BMT in the
treatment of spontaneous AID. An early publication of Morton
and Siegel [27] contains an experiment with syngeneic BMT in
lethally irradiated 6-month-old (NZB⫻DBA/2) F1 mice. At
that time, 45% of the recipients were positive for antinuclear
antibodies. This proportion did not decline after the treatment,
in contrast to the near complete disappearance after allogeneic
BMT. The study did not contain a description of the clinical
condition of the mice. The second publication [40] concerns
the failure to cure HLA-B27 transgenic rats with syngeneic
BMT, as contrasted with the successes with allogeneic BM in
the same model. Good and Ikehara [70] may have investigated
syngeneic and autologous BMT in the course of their extensive
studies on the treatment of spontaneous, immune disorders, as
they stated, “Our preclinical studies do not support autologous
TABLE 5. Treatment of Fully Developed, Spontaneous, and Induced AID with Syngeneic or Autologous BMT
AID (strain) BM origin (conditioning)
Spontaneous AID
(NZB⫻DBA/2)F1 (mice) Syngeneic (TBI)
HLA-B27 (rats) Syngeneic (TBI)
Induced AID
EAMG (Lewis) Autologous
(rats) (CY⫹TBI)
AA (BUF) Syngeneic (TBI)
(rats) Autologous (TBI)
CIA (DBA/1) Syngeneic (TBI)
(mice)
EAE (BUF) Syngeneic (TBI)
(rats) Autologous (TBI)
EAE (SJL/J) (mice) Syngeneic (CY)
EAE (Biozzi) Syngeneic
(mice) Acute phase
614 Journal of Leukocyte Biology Volume 72, October 2002
or syngeneic BMT for treatment of mice, which may already
have developed systemic autoimmune disease.” However, de-
tails of such experiments have not been published.
It is the opinion of this reviewer that there is room for a more
exhaustive confirmation of these negative results, as there are
indications that some of the SLE-like syndromes in mice may
respond favorably to high dose immunomyeloablation and au-
tologous BMT.
Karussis et al. [71] treated MLR/lpr mice, aged 9 –10 weeks,
with high-dose CY or 9 gray (Gy) TBI followed by syngeneic
BMT. These mice remained disease-free for at least 36 weeks,
and untreated controls began to die at week 16. Unfortunately,
it is not stated whether the recipients were already sick at the
time of transplantation nor were the age and disease status of
the BM donors reported.
Loor et al. [72] reviewed several reports of complete and
lasting remissions in mice with spontaneous lupus-like dis-
eases after treatment with sublethal TBI. Furthermore, long-
term treatment with relatively high dose CY (100 mg/kg weekly
for 16 weeks) prolonged survival of sick MRL/lpr mice, caused
reversal of adenopathy, and prevented the development of
arthritis and glomerulonephritis [73]. In the latter study, the
follow-up was only 6 weeks after the last administration of the
drug, which is not long enough. Nevertheless, sublethal TBI
and high dose CY cause massive destruction of the lymphatic
and hematopoietic cells followed by endogenous repopulation
from primitive precursors. That process closely resembles the
repopulation following lethal TBI and autologous BMT.
Much more exhaustive investigations were performed with
autologous and syngeneic BMT in rodents suffering from in-
duced AID. Excellent therapeutic effects were seen in all
studies except for the one with CIA mice. Failure of these mice
to enter complete remission was also observed after allogeneic
BMT as discussed before.
The studies performed by Karussis et al. [69, 74] on EAE
induced in SJL mice are of particular interest, as they also
treated the mice before the appearance of clinical disease with
high dose CY (300 mg/kg) and syngeneic BM. The induction
schedule consisted of two immunizations, 1 week apart. The
latent interval between the first immunization and appearance
Effect Ref.
None 27
None 40
Reduction of a-AChR titer 65
Elimination of memory response
Complete remission 58
Complete remission 64, 66
No remission
Prevention of progression 59
Complete remission 67
Complete remission 68
Complete remission 69
Complete remission 60
http://www.jleukbio.org
of symptoms was between 14 and 18 days. When treated at day TABLE 6. Incidence of Relapses after Treatment of Experimental
6 after the first immunization, the development of the disease AID with BMT Following High-Dose Conditioning
was completely prevented, and the mice became resistant to
rechallenge with the encephalitogenic agent. However, treat- Spontaneous Induced
Disease Remission relapses relapses Ref.
ment at day 9 after the first immunization was not preventive;
it only delayed the onset of paralysis by about 1 week. The AA ratsa
authors’ interpretation is that shortly after the second inocula- Syngeneic 100% 0% 0% 58
tion, the population of autoreactive and memory lymphocytes is Autologous 100% 0% 6% 66
Allogeneic 100% 0% Not done
at a maximum and cannot be sufficiently reduced by the EAE miceb
conditioning with CY. Yet this explanation is difficult to rec- Syngeneic 100% 7% 25% 69
oncile with the finding that the same regimen was highly EAE ratsc
effective when applied 3 days after the appearance of clinical Syngeneic 100% 29% 44% 67
disease. Autologous 100% 30% 72% 68
Allogeneic 100% 5% 11% 50, 51
In addition to the results with treatment of spontaneous and EAMG ratsd
induced AID, as collected in Table 5, we should mention the Autologous 100%d Does not applyd 11%d 65
treatment of adoptively transferred EAE with syngeneic BM by
Conditioning: TBI 9 Gy; CY; TBI 10 Gy; CY ⫹ TBI 6 Gy. In this
a b c d
Burt et al. [75]. This is a relapsing form of EAE that can be
disease model, the criterion for remission is a decrease of the antiacetylcholine
evoked in SJL/J mice with lymph node cells from sensitized, receptor titer. The equivalent of relapse is a secondary antibody response
syngeneic donors. The cells are stimulated in vitro with the following reimmunization.
disease-initiating peptide, proteolipid protein 139 –151 prior to
transfer. These mice were treated at the peak of the acute phase
of the disease at 14 days after transfer or at day 74 during the tioning. Even the addition of large numbers of autologous
chronic phase with a lethal dose of TBI or with TBI and spleen cells or lymphocytes from the lymph nodes or from the
cyclophospamide followed by rescue with syngeneic BM. peripheral blood did not adversely influence the responses nor
Treatment in the early phase caused a significant clinical and did it evoke relapses [66]. So far, this cannot be explained but
histological improvement, but there was no effect of treatment it seems to be in line with our failure to passively transfer AA
of the chronically ill animals. This is reminiscent of the lack of in BUF rats with lymphoid cells.
responses of chronically ill Biozzi mice to treatment with Rats with EAE respond to autologous BMT with a rapid
allogeneic BM and supports the rule that BMT cannot repair regression of the neurological symptoms, but one or more
scar lesions. spontaneous relapses occur in 30% of the animals [68]. When
syngeneic BM instead of autologous BM is used for rescue, the
spontaneous relapse rate is the same, suggesting that these
EXPERIMENTAL DATA OF TRANSLATIONAL relapses are initiated by autoreactive cells that have survived
SIGNIFICANCE the conditioning. This is in accordance with our finding that T
cell depletion of autologous or syngeneic BM grafts, which
reduced the T cells to 0.1%, did not diminish the spontaneous
Most of the detailed information concerning conditioning and relapse rate. Rat BM contains 2–3% T lymphocytes. In these
transplantation regimens for autologous BMT was obtained experiments, the number of T lymphocytes (5⫻105) that was
with two models of induced AID, namely AA and EAE, in BUF returned with the unmanipulated BM was in the same range as
rats. The two models have a lot in common regarding the the estimated number of residual T lymphocytes (106), which
responses to treatment, but there are also considerable differ- explains the futility of T cell depletion in this situation. This
ences. In trying to translate the results into the clinic, one can does not imply that the number of T lymphocytes returned with
choose to adhere strictly to each specific model, e.g., use the the stem cells is irrelevant. On the contrary, the addition of
results of the AA model only for RA and SLE treatment autologous spleen cells containing 3 ⫻ 107 T lymphocytes to
strategies and the results obtained with EAE, only for MS. Of the BM graft, which raises the proportion of T cells to over
course, this approach suffers from the restrictions imposed by 50%, causes the spontaneous relapse rate to rise to 93%. (For
the imperfections of each model. Another way to apply the comparison, unmanipulated human BM grafts may contain
results is to select the conditions from each model that seem to 20 –30% of T cells and human PBSC, up to 50%.) These
be most favorable to the outcome and translate these into the findings contrast sharply with those in arthritic animals re-
clinical protocols until shown otherwise. ferred to above where addition of autologous T cells had no
Detailed results of autologous BMT in AA and influence whatsoever.
EAE This illustrates the dilemma of the translator: is T cell
depletion to be recommended for clinical transplants or only
After high dose TBI (9 –10 Gy), autologous BMT causes remis- for the treatment of patients with MS? As will be explained
sions of both diseases in all animals. In AA, 70% are complete later, the decision in this case can be made on more pragmatic
responders, and 30% are partial responders. Spontaneous re- grounds.
lapses or exacerbations are extremely rare; also relapses are Interestingly, the spontaneous relapse incidence in EAE was
hardly ever inducible (Table 6). In this disease model, the only 5% following allogeneic BMT as compared with 30% after
outcome seems to be dominated by the intensity of the condi- autologous and syngeneic BMT [50, 51]. The difference is

van Bekkum Stem cell transplants for autoimmune disease 615

ascribed to a graft-versus-autoimmunity reaction by which
residual, autoreactive cells of the recipient are eliminated, a
term introduced by A. M. Marmont in reference to the well-
known graft-versus-leukemia effect of allogeneic BM grafts.
The analogy with the treatment of leukemia may be extended
further by proposing that the treatment of severe AID should
also aim at eradication of as many autoreactive cells as possi-
ble by conditioning and in case of autologous BM, by ex vivo
purging of the graft prior to reinfusion.
The conditioning regimen
In both models, the best results have been obtained with the
strongest lymphomyeloablative regimens, e.g., the highest tol-
erated dose of 9 –10 Gy of TBI [66, 68]. Partial body irradiation
of the affected tissues only (the CNS in the case of EAE or the
legs and tail in the case of AA) or shielding of those parts while
irradiating the rest of the body resulted, at best, in a limited,
temporary remission [58, 67]. Fractionated irradiation was
investigated in the AA model [66] and proved to be as effective
as single dose TBI, provided the total dose was properly
adjusted upward. In AA and EAE, CY alone or busulfan (BU)
alone at highest tolerated doses was less effective than high
dose TBI, and the combined regimen of CY and BU was
equally effective. The combination of a lower dose of TBI (4 Gy
or 7 Gy) with a lower dose of CY (2⫻60 mg/kg) was also as
effective as the highest dose of TBI. In experimental autoim-
mune myasthenia gravis (EAMG), conditioning with CY alone
was inadequate, and a moderate dose of TBI had to be added
to get complete responses [65]. Notable features of high dose
CY as the sole conditioning agent in AA were not only the
lower rate of complete remissions, but also the substantial
incidence (36%) of spontaneous exacerbations. In contrast,
among 155 AA animals treated with high-dose TBI or the
combination regimens, only one relapse occurred.
So far, conditioning of more than 70 patients with severe RA
has consisted of high dose CY, either as the sole agent or
combined with anti-thymocyte globulin (ATG). Although the
majority of the patients went into complete or partial remission,
approximately two-thirds relapsed, usually within 1 year [63].
It seems fair to conclude that the equivocal results with exper-
imental arthritis have predicted this outcome. The main reason
for the rheumatologists not to adopt the combination of CY and
moderate dose TBI, which is clearly superior in AA and EAE,
has been fear of higher toxicity and mortality. By drawing once
more on the analogy with the treatment of leukemia, the relapse
rate can only be reduced by intensifying the conditioning. The
cost of the latter is more toxicity, unless target cell specificity
can be improved upon.
The most likely candidate target cells in overt AID are
activated T lymphocytes and memory T lymphocytes. The
characteristics of these cell types are still poorly defined.
Yet, there are some indications for differences in target
specificity between radiation and CY. In treating rats suffering
from EAMG, Pestronk et al. [65] showed CY to be less effective
than TBI in eliminating immunological memory. In this case,
the cells involved were most likely B memory cells, but T
memory cells (in this case against M. tuberculosis) were also
reported to be CY-resistant [76].
616 Journal of Leukocyte Biology Volume 72, October 2002
In addition, there is clinical evidence that CY as a single
agent is inadequate for ablation of memory T cells. In nonsen-
sitized patients with aplastic anemia, the allograft failure rate
is low after conditioning with high dose CY alone. However, in
patients sensitized by multiple blood transfusions, most allo-
grafts are rejected, and more intensive conditioning with a
combination of TBI and CY is required to prevent take failure.
Presently, there is not enough information regarding the num-
bers and drug sensitivity of memory lymphocytes in patients
with advanced AID and how the size of these cell populations
varies between patients.
We did not study fractionated TBI in EAE for two reasons.
First, fractionation does not produce different effects from
single dose TBI, provided the total dose is adjusted for the
fractionation effect. Secondly, I did not anticipate the use of
TBI in MS patients, as irradiation induced an acute exacerba-
tion of the neurological symptoms in rats with EAE. This
reaction recedes after 24 h, but was fatal in a small proportion
of cases. It occurred even after a dose as low as 1.5 Gy.
However, such adverse effects were not encountered so far in
MS patients after treatment with high dose TBI and CY for
conditioning [77].
ATG is used as part of the conditioning regimen in several
clinical protocols of autologous BMT for severe AID [78] and
juvenile idiopathic arthritis [79]. ATG was shown to protect
against allogeneic GvHD in mice and monkeys even when
administered before the BM [80, 81]. If used for the condition-
ing in AID patients, it is recommended that the last dose be
injected at least 24 h or less before the stem cell reinfusion. It
may then act on residual lymphocytes in the recipient as well
as on lymphocytes that are introduced with the graft [81].
Unfortunately, we could not evaluate the merits of ATG and
its optimal application in conditioning for experimental AID,
as the ant-rat ATG preparations available to us cross- reacted
with hematopoietic stem cells. There remains an urgent need
for more research on specific T lymphocytolytic agents to be
applied in conditioning.
Postulated mechamisms of autologous stem cell
transplantation and clinical relevance
The satisfactory, therapeutic results obtained with high dose
lympomyeloablative conditioning regimens discussed above
are easily understood if inflammatory AID are regarded as
being initiated and maintained by activated T cells. Treatment
of SLE and various connective tissue AID with moderate doses
of cytoreductive drugs such as CY and methotrexate was al-
ready known to be effective in many cases so that the improved
results with a higher dose is no surprise. The currently used
conditioning for severe RA with 200 mg/kg CY has resulted in
roughly 50% complete remissions and a high relapse rate.
Apparently, this dose is not completely myeloablative, as it was
associated with rapid hematological recovery when used with-
out stem cell rescue for treatment of severe AID [82]. In the
latter study comprising 25 patients, the complete remission
rate was also 50%, which suggests that the short-term re-
sponses at least are determined by the intensity of the condi-
tioning and not by the cellular composition of the autografts.
Many clinical teams engaged in autologous BMT for AID so
far prefer the use of CY alone or combined with anti-lympho-
http://www.jleukbio.org
cyte globulin (ALG). TBI is avoided mainly because of its
several delayed side effects, e.g., the development of excess
tumors, cataracts, and, in children, inhibition of skeletal
growth. Yet, as pointed out in a recent review [83], the alky-
lating drug CY is also carcinogenic [84, 85], as is prolonged
immunosuppressive treatment [86]. Prolonged conventional
treatment with high dose corticosteroids is known to cause
growth inhibition and cataract, but a moderate dose of 4 Gy
TBI does not have these sequels.
The experience with animal models indicates that there is
room for improvement by intensifying the conditioning, but of
course that would require hematological support with autolo-
gous stem cells unless more specific lymphocytolytic agents
could be introduced. One promising drug is fludarabine. It was
recently used successfully (120 mg/m2 over 4 days) in place of
TBI in combination with CY and ATG for conditioning six
transfusion-dependent patients with severe aplastic anemia for
grafting of allogeneic BM [87, 88]. There were no take failures,
and all patients achieved full donor chimerism. In Cynomolgus
monkeys, fludarabine (250 mg/m2 over 5 days) induced T- and
B-cell lymphopenia and prolonged the survival of allogeneic
skin grafts in naive and presensitized animals [89]. The drug
schedule used caused transient neutropenia as the only side
effect. Treatment of patients with refractory, severe RA with
pulsed fludarabine induced a reduction of naive and memory
CD4⫹ T cells [90]. High dose fludarabine (300 mg/m2 in two
courses of 5 days) was used in combination with ALG followed
by autologous stem cells in a pilot study for treating patients
with various severe AID [91]. This regimen was not toxic, and
the immediate responses resembled those after treatment with
CY plus ATG, but follow-up was not long enough for other
conclusions. There is certainly a strong need for sorting out, in
the appropriate, established animal models, the advantages
this drug has to offer and how it can be applied best.
The induction of remission and persistent
tolerance
How are the excellent, curative results with autologous BM in
experimental animals and the encouraging experience with
many patients with various severe AID to be explained?
The most favored hypothesis is that the reconstitution of the
immune system from a few stem cells represents a recapitula-
tion of ontogenesis, which entails the acquisition of self-toler-
ance. Burt et al. [92] provided evidence for such a mechanism.
They found persistence of T lymphocytes that react with frag-
ments 68 – 82 of myelin basic protein (MBP) in the spinal cord
of Lewis rats in spontaneous, clinical remission from acute
EAE but not in rats that had been treated with high dose TBI
and syngeneic BM to induce remission. Karussis et al. [69]
claimed induction of tolerance in EAE mice after treatment
with a 30% lethal dose of CY and rescue with syngeneic T
cell-depleted BM [69]. The induction of EAE and rechallenge
were with mouse spinal cord homogenate in CFA. They mea-
sured the proliferation response of lymphocytes obtained from
lymph nodes to the antigens guinea pig MBP (GMBP) and
tuberculin-purified protein derivative (PPD). The responses to
GMBP were weak or negative before and after rechallenge in
the treated animals as well as in the controls. The stimulation
index with PPD increased from 8 before to 46 after rechallenge
van Bekkum Stem cell transplants for autoimmune disease
in the controls and from 2.3 to 3.8 in the treated group. It is
doubtful if this can be regarded as evidence for tolerance. The
spontaneous relapse rate was low in the treated group (one
relapse in 15 mice) as compared with 21 relapses in 15
controls. Two out of eight mice suffered a relapse after rechal-
lenge as compared with nine out of nine controls.
Apart from our ignorance about the details of tolerance at the
cellular level, there is a clear tendency from the data in
animals that suboptimal conditioning results in less complete
responses (as in AA), more spontaneous relapses (as in EAE),
and more induced relapses (as in AA and in EAE). Further-
more, following optimal conditioning, the induced relapse rate
is higher with autologous or syngeneic stem cell grafts than
with allogeneic transplants (Table 6).
The causes of the different responses of AA and EAE to
BMT remain subject to speculation. One attractive hypothesis
is that if the genes determining susceptibility are weakly
expressed, the resulting state of tolerance may not be broken
easily. This may be the case in AA, where disease could not be
reinduced after complete remission was obtained with autolo-
gous BMT. On the other hand, in EAE rats, relapses could be
induced in a high proportion of animals after autologous BMT.
At the extreme end of the range is the HLA-B27 transgenic rat
that cannot even be brought into remission with syngeneic stem
cells. These animals bear up to 150 copies of the B27 gene,
which assumedly makes them respond to a large variety of
environmental antigenic stimuli with autoimmune reactions,
thereby precluding the development of autotolerance.
RECOMMENDATIONS
Intensive conditioning, such as can be achieved best with high
dose TBI, is expected to give the best therapeutic results,
presumably because it kills off the most T lymphocytes.
Clearly, high priority should be given to a search for agents
with a clinically effective, therapeutic window between lym-
photoxicity and myelotoxicity and with sufficient penetration
into inflamed tissues such as as spinal cord, brain, and joints.
Treatment with such agents would leave the stem cell popula-
tion intact, but whether tolerance would also develop under
these conditions remains to be seen.
It stands to reason that reinfusing any numbers of T lym-
phocytes that would add substantially to the residual popula-
tion should be avoided. A BM graft for an adult patient may
contain as many as 4 ⫻ 109 and a mobilized peripheral blood
cell graft, up to 2 ⫻ 1010 T lymphocytes as compared with an
estimated 3 ⫻ 108 residual T lymphocytes. That estimate is
based on conditioning regimes equivalent to 9 Gy TBI (single
dose), which causes roughly a 3 log kill of lymphocytes. The
total T cell population in an adult is taken as 3 ⫻ 1011. In view
of the uncertainties of these estimates and in analogy with the
policy of maximal purging of tumor cells in autologous BM
grafts used for the treatment of leukemia, it was recommended
to T cell-deplete the autograft as completely as current tech-
niques allow. This strategy was supported by the relapse of all
of the first five patients who received unmanipulated, autolo-
gous BM or mobilized peripheral blood cells [93]. The maxi-
mum number of reinfused T cells was recommended to be less
617
than 105 per kg [94], requiring between 3 and 4 log depletion
for BM and mobilized peripheral blood cells, respectively. In
practice, 106 T cells/kg seems more realistic as a maximum;
this number being well below the estimates of residual T cells.
However, it is unknown which subpopulations of T lympho-
cytes are crucially involved in the development of relapses and
what their radio- and chemosensitivity are.
Rescue with highly purified CD34⫹ stem cells is likely to
cause an extended period of severe immunosuppression with
increased risks of infections and lymphoproliferative malignan-
cies. Several cases of fatal “activated macrophage syndrome”
have occurred recently in children following treatment for
juvenile chronic arthritis with highly purified autologous stem
cells. It should be noted that the CD34⫹ cell selection tech-
niques that are currently used also effectively remove B cells,
natural killer cells, and macrophages, which may be unneces-
sary and possibly harmful. That has been the rationale for some
clinical teams to change to purging methods that specifically
deplete T lymphocytes only.
Finally, there is the option of using allogeneic stem cells,
which in the EAE rat minimizes relapses and also showed a
presumed graft-versus-autoimmune effect. Considering the
higher risks of transplantation-associated mortality of alloge-
neic BMT, its exploration should be postponed until it becomes
clear from the ongoing studies with autologous stem cells,
which patients might benefit from allogeneic grafts. The most
threatening side effect of allogeneic BMT is graft-versus-host
disease, which represents an antiself immune reaction par
excellence. Therefore, one risks replacing one severe disease
with another. The use of allogeneic stem cells should specifi-
cally be discouraged in the treatment of SLE, systemic sclero-
sis, and related syndromes, as certain lesions induced by the
graft-versus-host reactions, especially the ones associated with
chronic GvHD, will be very hard to differentiate from lesions
from a relapse of the original AID.
REFERENCES
1. Morton, J. I., Siegel, B. V. (1974) Transplantation of autoimmune poten-
tial. I. Development of antinuclear antibodies in H-2 histocompatible
recipients of bone marrow from New Zealand Black mice. Proc. Natl.
Acad. Sci. USA 71, 2162–2165.
2. Marmont, A. M. (1994) Immune ablation followed by allogeneic or autol-
ogous bone marrow transplantation: a new treatment for severe autoim-
mune diseases? Stem Cells 12, 125–135.
3. Charon, D. (1990) Molecular basis for human leukocyte antigen class II
associations. Adv. Immunol. 48, 107–159.
4. Silman, A. J., MacGregor, A. J., Thomson, W., Holligan, S., Carthy, D.,
Farhan, A., Ollier, W. E. (1993) Twin concordance rates for rheumatoid
arthritis: results from a nationwide study. Br. J. Rheumatol. 32, 903–907.
5. Taurog, J. D., Richardson, J. A., Croft, J. T., Simmons, W. A., Zhou, M.,
Fernandez-Sueiro, J. L., Balish, E., Hammer, R. E. (1994) The germfree
state prevents development of gut and joint inflammatory disease in
HLA-B27 transgenic rats. J. Exp. Med. 180, 2359 –2364.
6. Unnik, K. (1975) Comparative study of NZB mice under germfree and
controlled conditions. J. Rheumatol. 2, 36 – 44.
7. Maldonado, M. A., Kakkanaiah, V., MacDonald, G. C., Chen, F., Reap,
E. A., Balish, E., Farkas, W. R., Jennette, J. C., Madaio, M. P., Kotzin,
B. L., Cohen, P. L., Eisenberg, R. A. (1999) The role of environmental
antigens in the spontaneous development of autoimmunity in MRL-lpr
mice. J. Immunol. 162, 6322– 6330.
8. Thomas, V. A., Woda, B. A., Handler, E. S., Greiner, D. L., Mordes, J. P.,
Rossini, A. A. (1991) Altered expression of diabetes in BB/Wor rats by
exposure to viral pathogens. Diabetes 40, 255–258.
618 Journal of Leukocyte Biology Volume 72, October 2002
9. Ellerman, K. E., Richards, C. A., Guberski, D. L., Shek, W. R., Like, A. A.
(1996) Kilham rat triggers T-cell-dependent autoimmune diabetes in
multiple strains of rat. Diabetes 45, 557–562.
10. Like, A. A., Guberski, D. L., Butler, L. (1991) Influence of environmental
viral agents on frequency and tempo of diabetes mellitus in BB/Wor rats.
Diabetes 40, 259 –262.
11. Wang, G. S., Gruber, H., Smyth, P., Pulido, O., Rosenberg, L., Duguid,
W., Scott, F. W. (2000) Hydrolysed casein diet protects BB rats from
developing diabetes by promoting islet neogenesis. J. Autoimmun. 15,
407– 416.
12. Williams, A. J., Krug, J., Lampeter, E. F., Mansfield, K., Beales, P. E.,
Signore, A., Gale, E. A., Pozzilli, P. (1990) Raised temperature reduces
the incidence of diabetes in the NOD mouse. Diabetologia 33, 635– 637.
13. Carter, W. R., Herrman, J., Stokes, K., Cox, D. J. (1987) Promotion of
diabetes onset by stress in the BB rat. Diabetologia 30, 674 – 675.
14. Hunger, R. E., Carnaud, C., Vogt, I., Mueller, C. (1998) Male gonadal
environment paradoxically promotes dacryoadenitis in nonobese diabetic
mice. J. Clin. Investig. 101, 1300 –1309.
15. Kohashi, O., Kuwata, J., Umehara, K., Uemura, F., Takahashi, T., Ozawa,
A. (1979) Susceptibility to adjuvant-induced arthritis among germfree,
specific- pathogen-free, and conventional rats. Infect. Immun. 26, 791–
794.
16. Breban, M. A., Moreau, M. C., Fournier, C., Ducluzeau, R., Kahn, M. F.
(1993) Influence of the bacterial flora on collagen-induced arthritis in
susceptible and resistant strains of rats. Clin. Exp. Rheumatol. 11, 61– 64.
17. van Bekkum, D. W., Knaan, S. (1977) Role of bacterial microflora in
development of intestinal lesions from graft-versus-host reaction. J. Natl.
Cancer Inst. 58, 787–790.
18. Heidt, P. J., Vossen, J. M. (1992) Experimental and clinical gnotobiotics:
influence of the microflora on graft-versus-host disease after allogeneic
bone marrow transplantation. J. Med. 23, 161–173.
19. Mason, D., MacPhee, I., Antoni, F. (1990) The role of the neuroendocrine
system in determining genetic susceptibility to experimental allergic
encephalomyelitis in the rat. Immunology 70, 1–5.
20. van Gelder, M., Kinwel-Bohre, E. P., Mulder, A. H., van Bekkum, D.
(1996) Both bone marrow- and non-bone marrow-associated factors deter-
mine susceptibility to experimental autoimmune encephalomyelitis of
BUF and WAG rats. Cell. Immunol. 168, 39 – 48.
21. Mostarica-Stojkovic, M., Petrovic, M., Lukic, M. L. (1982) Resistance to
the induction of EAE in AO rats: its prevention by the pre-treatment with
cyclophosphamide or low dose of irradiation. Clin. Exp. Immunol. 50,
311–317.
22. Lando, Z., Teitelbaum, D., Arnon, R. (1980) Induction of experimental
allergic encephalomyelitis in genetically resistant strains of mice. Nature
287, 551–552.
23. de Vries, M. J., van Putten, L. M., Balner, H., van Bekkum, D. W. (1964)
Lésions suggérant une réactivité autoimmune chez des souris atteintes de
la “runt disease” après thymectomie nèonatale. Rev. Fr. Etud. Clin. Biol.
9, 381–397.
24. Bos, G. M., Majoor, G. D., Van Breda Vriesman, P. J. (1989) Perturbation
of T-cell differentiation in lethally irradiated rats reconstituted with syn-
geneic bone marrow and treated with cyclosporin-A. Thymus 14, 155–161.
25. Sardina, E. E., Sugiura, K., Ikehara, S., Good, R. A. (1991) Transplanta-
tion of wheat germ agglutinin-positive hematopoietic cells to prevent or
induce systemic autoimmune disease. Proc. Natl. Acad. Sci. USA 88,
3218 –3222.
26. de Heer, D. H., Edgington, T. S. (1977) Evidence for a B lymphocyte
defect underlying the anti-X anti-erythrocyte autoantibody response of
NZB mice. J. Immunol. 118, 1858 –1863.
27. Morton, J. I., Siegel, B. V. (1979) Transplantation of autoimmune poten-
tial. IV. Reversal of the NZB autoimmune syndrome by bone marrow
transplantation. Transplantation 27, 133–134.
28. Ikehara, S., Inaba, M., Ishida, T., Ogata, H., Hisha, H., Yasumizu, R.,
Oyaizu, N., Sugiura, K., Toki, J., Takao, F., Than, S., Kawamura, M.,
Nishioka, N., Nagata, N., Good, R. A. (1991) Rationale for transplantation
of both allogeneic bone marrow and stromal cells in the treatment of
autoimmune diseases. In New Strategies in Bone Marrow Transplantation:
UCLA Symposia on Molecular and Cellular Biology, New Series, vol. 137
(R. E. Champlin, R. P. Gale, eds.), New York, NY, Wiley-Liss, 251.
29. Miyashima, S., Nagata, N., Nakagawa, T., Hosaka, N., Takeuchi, K.,
Ogawa, R., Ikehara, S. (1996) Prevention of lpr-graft-versus-host disease
and transfer of autoimmune diseases in normal C57BL/6 mice by trans-
plantation of bone marrow cells plus bones (stromal cells) from MRL/lpr
mice. J. Immunol. 156, 79 – 84.
30. Ikehara, S., Kawamura, M., Takao, F., Inaba, M., Yasumizu, R., Than, S.,
Hisha, H., Sugiura, K., Koide, Y., Yoshida, T. O., et al. (1990) Organ-
specific and systemic autoimmune diseases originate from defects in
hematopoietic stem cells. Proc. Natl. Acad. Sci. USA 87, 8341– 8344.
http://www.jleukbio.org
31. Himeno, K., Good, R. A. (1988) Marrow transplantation from tolerant
donors to treat and prevent autoimmune diseases in BXSB mice. Proc.
Natl. Acad. Sci. USA 85, 2235–2239.
32. Nakagawa, T., Nagata, N., Hosaka, N., Ogawa, R., Nakamura, K., Ikehara,
S. (1993) Prevention of autoimmune inflammatory polyarthritis in male
New Zealand black/KN mice by transplantation of bone marrow cells plus
bone (stromal cells). Arthritis Rheum. 36, 263–268.
33. Serreze, D. V., Leiter, E. H., Worthen, S. M., Shultz, L. D. (1988) NOD
marrow stem cells adoptively transfer diabetes to resistant (NOD ⫻
NON)F1 mice. Diabetes 37, 252–255.
34. Wicker, L. S., Miller, B. J., Chai, A., Terada, M., Mullen, Y. (1988)
Expression of genetically determined diabetes and insulitis in the non-
obese diabetic (NOD) mouse at the level of bone marrow-derived cells.
Transfer of diabetes and insulitis to nondiabetic (NOD ⫻ B10) F1 mice
with bone marrow cells from NOD mice. J. Exp. Med. 167, 1801–1810.
35. LaFace, D. M., Peck, A. B. (1989) Reciprocal allogeneic bone marrow
transplantation between NOD mice and diabetes-nonsusceptible mice
associated with transfer and prevention of autoimmune diabetes. Diabetes
38, 894 –901.
36. Naji, A., Silvers, W. K., Kimura, H., Anderson, A. O., Barker, C. F. (1983)
Influence of islet and bone marrow transplantation on the diabetes and
immunodeficiency of BB rats. Metabolism 32, 62– 68.
37. Scott, J., Engelhard, V. H., Benjamin, D. C. (1987) Bone marrow irradi-
ation chimeras in the BB rat: evidence suggesting two defects leading to
diabetes and lymphopoenia. Diabetologia 30, 774 –781.
38. Kuntz, L., Montecino-Rodriguez, E., Jachez, B., Roman, D., Loor, F.
(1991) Adoptive transfer of viable motheaten pathology in sublethally
irradiated beige recipient mice. Immunology 73, 356 –362.
39. Walker, M. A., Harley, R. A., DeLustro, F. A., LeRoy, E. C. (1989)
Adoptive transfer of tsk skin fibrosis to ⫹/⫹ recipients by tsk bone
marrow and spleen cells. Proc. Soc. Exp. Biol. Med. 192, 196 –200.
40. Breban, M., Hammer, R. E., Richardson, J. A., Taurog, J. D. (1993)
Transfer of the inflammatory disease of HLA-B27 transgenic rats by bone
marrow engraftment. J. Exp. Med. 178, 1607–1616.
41. van Bruggen, M. C., van den Broek, M. F., van den Berg, W. B. (1991)
Streptococcal cell wall-induced arthritis and adjuvant arthritis in F344 3
Lewis and in Lewis 3 F344 bone marrow chimeras. Cell. Immunol. 136,
278 –290.
42. van Bekkum, D. W. (1997) Autologous stem cell therapy for treatment of
autoimmune diseases. In Autologous Marrow and Blood Transplantation:
Proceedings of the Eigth International Symposium on Autologous Bone
Marrow Transplantaion, Arlington, Texas (K. A. Dicke, A. Keating, eds.),
Charlottesville, VA, Carden Jennings, 645– 662.
43. Fujita, M., Mishima, M., Iwabuchi, K., Katsume, C., Gotohda, T., Oga-
sawara, K., Mizuno, Y., Good, R. A., Onoe, K. (1989) A study on type II
collagen-induced arthritis in allogeneic bone marrow chimaeras. Immu-
nology 66, 422– 427.
44. Singer, D. E., Moore, M. J., Williams, R. M. (1981) EAE in rat bone
marrow chimeras: analysis of the cellular mechanism of BN resistance.
J. Immunol. 126, 1553–1557.
45. Ben-Nun, A., Otmy, H., Cohen, I. R. (1981) Genetic control of autoim-
mune encephalomyelitis and recognition of the critical nonapeptide moi-
ety of myelin basic protein in guinea pigs are exerted through interaction
of lymphocytes and macrophages. Eur. J. Immunol. 11, 311–316.
46. Pelfrey, C. M., Waxman, F. J., Whitacre, C. C. (1989) Genetic resistance
in experimental autoimmune encephalomyelitis. I. Analysis of the mech-
anism of LeR resistance using radiation chimeras. Cell. Immunol. 122,
504 –516.
47. Korngold, R., Feldman, A., Rorke, L. B., Lublin, F. D., Doherty, P. C.
(1986) Acute experimental allergic encephalomyelitis in radiation bone
marrow chimeras between high and low susceptible strains of mice.
Immunogenetics 24, 309 –315.
48. Lublin, F. D., Knobler, R. L., Doherty, P. C., Korngold, R. (1986)
Relapsing experimental allergic encephalomyelitis in radiation bone mar-
row chimeras between high and low susceptible strains of mice. Clin. Exp.
Immunol. 66, 491– 496.
49. Binder, T. A., Greiner, D. L., Grunnet, M., Goldschneider, I. (1993)
Relative susceptibility of SJL/J and B10.S mice to experimental allergic
encephalomyelitis (EAE) is determined by the ability of prethymic cells in
bone marrow to develop into EAE effector T cells. J. Neuroimmunol. 42,
23–32.
50. van Gelder, M., van Bekkum, D. W. (1995) Treatment of relapsing
experimental autoimmune encephalomyelitis in rats with allogeneic bone
marrow transplantation from a resistant strain. Bone Marrow Transplant.
16, 343–351.
51. van Gelder, M., Mulder, A. H., van Bekkum, D. W. (1996) Treatment of
relapsing experimental autoimmune encephalomyelitis with largely MHC-
van Bekkum Stem cell transplants for autoimmune disease
matched allogeneic bone marrow transplantation. Transplantation 62,
810 – 818.
52. Jones, R. E., Bourdette, D. N., Whitham, R. H., Offner, H., Vandenbark,
A. A. (1993) Induction of experimental autoimmune encephalomyelitis in
severe combined immunodeficient mice reconstituted with allogeneic or
xenogeneic hematopoietic cells. J. Immunol. 150, 4620 – 4629.
53. Ikehara, S., Good, R. A., Nakamura, T., Sekita, K., Inoue, S., Oo, M. M.,
Muso, E., Ogawa, K., Hamashima, Y. (1985) Rationale for bone marrow
transplantation in the treatment of autoimmune diseases. Proc. Natl. Acad.
Sci. USA 82, 2483–2487.
54. Ikehara, S., Ohtsuki, H., Good, R. A., Asamoto, H., Nakamura, T., Sekita,
K., Muso, E., Tochino, Y., Ida, T., Kuzuya, H. (1985) Prevention of type
I diabetes in nonobese diabetic mice by allogenic bone marrow transplan-
tation. Proc. Natl. Acad. Sci. USA 82, 7743–7747.
55. Ikehara, S., Yasumizu, R., Inaba, M., Izui, S., Hayakawa, K., Sekita, K.,
Toki, J., Sugiura, K., Iwai, H., Nakamura, T., et al. (1989) Long-term
observations of autoimmune-prone mice treated for autoimmune disease
by allogeneic bone marrow transplantation. Proc. Natl. Acad. Sci. USA 86,
3306 –3310.
56. Ishida, T., Inaba, M., Hisha, H., Sugiura, K., Adachi, Y., Nagata, N.,
Ogawa, R., Good, R. A., Ikehara, S. (1994) Requirement of donor-derived
stromal cells in the bone marrow for successful allogeneic bone marrow
transplantation. Complete prevention of recurrence of autoimmune dis-
eases in MRL/MP-Ipr/Ipr mice by transplantation of bone marrow plus
bones (stromal cells) from the same donor. J. Immunol. 152, 3119 –3127.
57. Hosaka, N., Nose, M., Kyogoku, M., Nagata, N., Miyashima, S., Good,
R. A., Ikehara, S. (1996) Thymus transplantation, a critical factor for
correction of autoimmune disease in aging MRL/⫹ mice. Proc. Natl. Acad.
Sci. USA 93, 8558 – 8562.
58. van Bekkum, D. W., Bohre, E. P., Houben, P. F., Knaan-Shanzer, S.
(1989) Regression of adjuvant-induced arthritis in rats following bone
marrow transplantation. Proc. Natl. Acad. Sci. USA 86, 10090 –10094.
59. Kamiya, M., Sohen, S., Yamane, T., Tanaka, S. (1993) Effective treatment
of mice with type II collagen induced arthritis with lethal irradiation and
bone marrow transplantation. J. Rheumatol. 20, 225–230.
60. Van Gelder, M. (1995) Bone Marrow Transplantation for Treatment of
Experimental Autoimmune Encephalomyelitis in Rats. Prospects for Ther-
apy of Severe Multiple Sclerosis, 1–163, Rijks Universiteit Leiden, Leiden,
Ph.D. thesis.
61. Marmont, A. M. (2001) Immunoablation followed or not by hematopoietic
stem cells as an intense therapy for severe autoimmune diseases. New
perspectives, new problems. Haematologica 86, 337–345.
62. Nelson, J. L., Torrez, R., Louie, F. M., Choe, O. S., Storb, R., Sullivan,
K. M. (1997) Pre-existing autoimmune disease in patients with long-term
survival after allogeneic bone marrow transplantation. J. Rheumatol.
Suppl. 48, 23–29.
63. Tyndall, A. (2001) Autologous hematopoietic stem cell transplantation for
severe autoimmune disease with special reference to rheumatoid arthritis.
J. Rheumatol. Suppl. 64, 5–7.
64. Knaan-Shanzer, S., Houben, P., Kinwel-Bohre, E. P., van Bekkum, D. W.
(1991) Remission induction of adjuvant arthritis in rats by total body
irradiation and autologous bone marrow transplantation. Bone Marrow
Transplant. 8, 333–338.
65. Pestronk, A., Drachman, D. B., Teoh, R., Adams, R. N. (1983) Combined
short-term immunotherapy for experimental autoimmune myasthenia gra-
vis. Ann. Neurol. 14, 235–241.
66. van Bekkum, D. W. (2000) Conditioning regimens for the treatment of
experimental arthritis with autologous bone marrow transplantation. Bone
Marrow Transplant. 25, 357–364.
67. van Gelder, M., Kinwel-Bohre, E. P., van Bekkum, D. W. (1993) Treat-
ment of experimental allergic encephalomyelitis in rats with total body
irradiation and syngeneic BMT. Bone Marrow Transplant. 11, 233–241.
68. van Gelder, M., van Bekkum, D. W. (1996) Effective treatment of relaps-
ing experimental autoimmune encephalomyelitis with pseudoautologous
bone marrow transplantation. Bone Marrow Transplant. 18, 1029 –1034.
69. Karussis, D. M., Slavin, S., Ben-Nun, A., Ovadia, H., Vourka-Karussis, U.,
Lehmann, D., Mizrachi-Kol, R., Abramsky, O. (1992) Chronic-relapsing
experimental autoimmune encephalomyelitis (CR-EAE): treatment and
induction of tolerance, with high dose cyclophosphamide followed by
syngeneic bone marrow transplantation. J. Neuroimmunol. 39, 201–210.
70. Good, R. A., Ikehara, S. (1997) Preclinical investigations that subserve
efforts to employ bone marrow transplantation for rheumatoid or autoim-
mune diseases. J. Rheumatol. Suppl. 48, 5–12.
71. Karussis, D. M., Vourka-Karussis, U., Lehmann, D., Abramsky, O., Ben-
Nun, A., Slavin, S. (1995) Immunomodulation of autoimmunity in MRL/lpr
mice with syngeneic bone marrow transplantation (SBMT). Clin. Exp.
Immunol. 100, 111–117.
619
72. Loor, F., Jachez, B., Montecino-Rodriguez, E., Klein, A. S., Kuntz, L.,
Pflumio, F., Fonteneau, P., Illinger, D. (1988) Radiation therapy of spon-
taneous autoimmunity: a review of mouse models. Int. J. Radiat. Biol.
Relat. Stud. Phys. Chem. Med. 53, 119 –136.
73. Smith, H. R., Chused, T. M., Steinberg, A. D. (1984) Cyclophosphamide-
induced changes in the MRL-lpr/lpr mouse: effects upon cellular compo-
sition, immune function, and disease. Clin. Immunol. Immunopathol. 30,
51– 61.
74. Karussis, D. M., Slavin, S., Lehmann, D., Mizrachi-Koll, R., Abramsky,
O., Ben-Nun, A. (1992) Prevention of experimental autoimmune enceph-
alomyelitis and induction of tolerance with acute immunosuppression
followed by syngeneic bone marrow transplantation. J. Immunol. 148,
1693–1698.
75. Burt, R. K., Padilla, J., Begolka, W. S., Canto, M. C., Miller, S. D. (1998)
Effect of disease stage on clinical outcome after syngeneic bone marrow
transplantation for relapsing experimental autoimmune encephalomyelitis.
Blood 91, 2609 –2616.
76. Orme, I. M. (1988) Characteristics and specificity of acquired immuno-
logic memory to Mycobacterium tuberculosis infection. J. Immunol. 140,
3589 –3593.
77. Burt, R. K., Traynor, A. E., Pope, R., Schroeder, J., Cohen, B., Karlin,
K. H., Lobeck, L., Goolsby, C., Rowlings, P., Davis, F. A., Stefoski, D.,
Terry, C., Keever-Taylor, C., Rosen, S., Vesole, D., Fishman, M., Brush,
M., Mujias, S., Villa, M., Burns, W. H. (1998) Treatment of autoimmune
disease by intense immunosuppressive conditioning and autologous he-
matopoietic stem cell transplantation. Blood 92, 3505–3514.
78. Fassas, A., Anagnostopoulos, A., Kazis, A., Kapinas, K., Sakellari, I.,
Kimiskidis, V., Tsompanakou, A. (1997) Peripheral blood stem cell trans-
plantation in the treatment of progressive multiple sclerosis: first results of
a pilot study. Bone Marrow Transplant. 20, 631– 638.
79. Wulffraat, N. M., Sanders, L. A., Kuis, W. (2000) Autologous hemopoietic
stem-cell transplantation for children with refractory autoimmune disease.
Curr. Rheumatol. Rep. 2, 316 –323.
80. van Bekkum, D. W. (1970) Mitigation of acute secundary disease by
treatment of the recipient with antilymphocyte serum before grafting of
hemopoietic cells. Exp. Hematol. 20, 3– 4.
81. van Bekkum, D. W., Balner, H., Dicke, K. A., van den Berg, F. G.,
Prinsen, G. H., Hollander, C. F. (1972) The effect of pretreatment of
allogeneic bone marrow graft recipients with antilymphocytic serum on the
acute graft-versus-host reaction in monkeys. Transplantation 13, 400 –
407.
82. Brodsky, R. A. (1999) Immunoabblative treatment of autoimmune diseases
without stem cell transplantation suppor. In Symposium on Autoimmune
Disease, Immunoablation and Stem Cells: Towards Y2K, 28th Annual
Meeting ISEH, Monte Carlo.
83. van Bekkum, D. W. (1999) Effectiveness and risks of total body irradiation
for conditioning in the treatment of autoimmune disease with autologous
bone marrow transplantation. Rheumatology (Oxford) 38, 757–761.
620 Journal of Leukocyte Biology Volume 72, October 2002
84. Zurcher, C., Varekamp, A. E., Solleveld, H. A., Durham, S. K., De Vries,
A. J., Hagenbeek, A. (1987) Late effects of cyclophosphamide and total
body irradiation as a conditioning regimen for bone marrow transplanta-
tion in rats (a preliminary report). Int. J. Radiat. Biol. Relat. Stud. Phys.
Chem. Med. 51, 1059 –1068.
85. Radis, C. D., Kahl, L. E., Baker, G. L., Wasko, M. C., Cash, J. M.,
Gallatin, A., Stolzer, B. L., Agarwal, A. K., Medsger Jr., T. A., Kwoh, C. K.
(1995) Effects of cyclophosphamide on the development of malignancy
and on long-term survival of patients with rheumatoid arthritis. A 20-year
followup study. Arthritis Rheum. 38, 1120 –1127.
86. Dantal, J., Hourmant, M., Cantarovich, D., Giral, M., Blancho, G., Dreno,
B., Soulillou, J. P. (1998) Effect of long-term immunosuppression in
kidney-graft recipients on cancer incidence: randomised comparison of
two cyclosporin regimens. Lancet 351, 623– 628.
87. Chan, K. W., Li, C. K., Worth, L. L., Chik, K. W., Jeha, S., Shing, M. K.,
Yuen, P. M. (2001) A fludarabine-based conditioning regimen for severe
aplastic anemia. Bone Marrow Transplant. 27, 125–128.
88. Nishio, M., Nakao, S., Endo, T., Fujimoto, K., Takashima, H., Sakai, T.,
Bacigalupo, A., Koike, T., Sawada, K. (2001) Successful non-myeloabla-
tive stem cell transplantation for a heavily transfused woman with severe
aplastic anemia complicated by heart failure. Bone Marrow Transplant.
28, 783–785.
89. Goodman, E. R., Fiedor, P. S., Fein, S., Athan, E., Hardy, M. A. (1996)
Fludarabine phosphate: a DNA synthesis inhibitor with potent immuno-
suppressive activity and minimal clinical toxicity. Am. Surg. 62, 435–
442.
90. Davis Jr., J. C., Fessler, B. J., Tassiulas, I. O., McInnes, I. B., Yarboro,
C. H., Pillemer, S., Wilder, R., Fleisher, T. A., Klippel, J. H., Boumpas,
D. T. (1998) High dose versus low dose fludarabine in the treatment of
patients with severe refractory rheumatoid arthritis. J. Rheumatol. 25,
1694 –1704.
91. Rabusin, M., Andolina, M., Maximova, N., Lepore, L., Parco, S., Tuveri,
G., Jankovic, G. (2000) Immunoablation followed by autologous hemato-
poietic stem cell infusion for the treatment of severe autoimmune disease.
Haematologica 85, 81– 85.
92. Burt, R. K., Burns, W., Ruvolo, P., Fischer, A., Shiao, C., Guimaraes, A.,
Barrett, J., Hess, A. (1995) Syngeneic bone marrow transplantation elim-
inates V beta 8.2 T lymphocytes from the spinal cord of Lewis rats with
experimental allergic encephalomyelitis. J. Neurosci. Res. 41, 526 –531.
93. Euler, H. H., Marmont, A. M., Bacigalupo, A., Fastenrath, S., Dreger, P.,
Hoffknecht, M., Zander, A. R., Schalke, B., Hahn, U., Haas, R., Schmitz,
N. (1996) Early recurrence or persistence of autoimmune diseases after
unmanipulated autologous stem cell transplantation. Blood 88, 3621–
3625.
94. Tyndall, A., Grathwol, A. (1997) Concensus statement on blood and
stemcell transplantation in autoimmune disease. Br. J. Rheumatol. 36,
90 –92.
http://www.jleukbio.org