IMMUNORECONSTITUTION IN SEVERE COMBINED IMMUNODEFICIENCY AFTER TRANSPLANTATION OF HLA-HAPLOIDENTICAL, T-CELL-DEPLETED BONE MARROW

761

significantly reduce blood-pressure in our patients. In addition, our patients, along with the rest of the local population, had been exposed to media suggestion that sodium restriction reduces blood pressure. Despite these pretrial biases, the results lead us to conclude, along with would

IMMUNORECONSTITUTION IN SEVERE COMBINED IMMUNODEFICIENCY AFTER TRANSPLANTATION OF

HLA-HAPLOIDENTICAL, T-CELL-DEPLETED BONE MARROW

others,5,6,17,18

that moderate sodium restriction has little effect on arterial pressure, and that it may cause pressure to fall in some, but to rise in others. Furthermore, potassium supplementation did not lower blood-pressure significantly. Although our results may be open to criticism on grounds of small patient numbers, brief duration of electrolyte modification, and modesty in the degree of sodium restriction, the same criticisms apply to most studies claiming significant blood-pressure changes. Our results from patients with mild essential hypertension cannot of course be extrapolated to all subgroups of hypertensives-for example, those with more severe hypertension, or the elderly. Such

patients may exhibit more uniform responses to manipulations of dietary electrolytes. Keeping in mind the dictum "first do not harm", we suggest that proponents of widespread sodium restriction or potassium supplementation demonstrate firstly, that the tiny overall reductions in blood-pressure are of benefit to hypertensive patients; secondly, that the increase in arterial pressure produced by such dietary modifications in a sizeable minority of essential hypertensives is not harmful; and thirdly, that such dietary manipulations are not in some unexpected way disadvantageous to a subgroup of the general population. We thank the special tests sisters, dietitians, nurses, catheter staff, Sister Collins and staff, endocrinology technicians, biochemistry department, and Mrs Natalie Purdue for their help, and the National Heart Foundation and the Medical Research Council of New Zealand for financial assistance.

Correspondence should be addressed to M. G. N., Department of Endocnnology, Princess Margaret Hospital, Cashmere Road, Christchurch 2, New Zealand. REFERENCES 1. 2.

Morgan T, Gillies A, Morgan G, Adam W, Wilson M, Carney S. Hypertension treated by salt restriction Lancet 1978, i 227-30. MacGregor GA, Markandu ND, Best FE, et al Double-blind randomised crossover trial of moderate sodium restriction in essential hypertension. Lancet 1982; i. 351-55.

O, Kijima T, Kikuchi K, et al. Studies on the hypotensive effect of high potassium intake in patients with essential hypertension. Clin Sci 1981, 61: 77s-80s. MacGregor GA, Smith SJ, Markandu ND, Banks RA, Sagnella GA. Moderate potassium supplementation in essential hypertension. Lancet 1982, ii 567-70. Longworth DL, Drayer JIM, Weber MA, Laragh JH. Divergent blood pressure responses during short-term sodium restriction in hypertension Clin Pharmacol Ther 1980, 27: 544-46. Watt GCM, Edwards C, Hart JT, Hart M, Walton P, Foy CJW. Dietary sodium restriction for mild hypertension in general practice. Br Med J 1983; 286: 432-36. Rose GA, Holland WW, Crowley EA. A sphygmomanometer for epidemiologists. Lancet 1964; i: 296-300. Millar-Craig MW, Hawes D, Whittington J. New system for recording ambulatory blood pressure in man Med Biol Comput 1978; 16: 727-31 Millar-Craig MW, Bishop CN, Raftery EB Circadian variation of blood pressure.

3. Iimura

4

5

6 7 8 9

Lancet

1978, i: 795-97

10. Mann S, Millar-Craig MW, Balasubramanian V, Cashman PMM, Raftery EB. Ambulant blood pressure: reproducibility and the assessment of interventions Clin Sci 1980; 59: 497-500 11Dunn PJ, Espiner EA. Outpatient screening tests for primary aldosteronism Aust NZ J

Med 1976, 6: 131-35. 12 Nicholls

MG, Espiner EA. A sensitive, rapid radio-immunoassay for angiotensin II. NZ Med J 1976; 83: 399-403. 13 Lun S, Espiner EA, Nicholls MG, Yandle TG A direct radioimmunoassay for aldosterone in plasma Clin Chem 1983; 29: 268-71. 14. Peuler JD, Johnson GA. Simultaneous single isotope radioenzymatic assays of plasma norepinephrine, epinephrine and dopamine. Life Sci 1977; 21: 625-36. 15 Cohen J Statistical power analysis for the behavioural sciences (revised ed). New York: Academic Press, 1977 16 Tobian L Human essential hypertension: implications of animal studies Ann Intern Med 1983, 98: 729-34. 17 Silman AJ, Locke C, Humpherson P Salt restriction and no drug treatment in mild to moderate hypertension Lancet 1982; i: 903-04.

W. FRIEDRICH U. VETTER B. HEYMER Y. REISNER

S. F. GOLDMANN T. M. FLIEDNER H. H. PETER E. KLEIHAUER

Departments of Paediatrics, Transfusion Medicine, Clinical Physiology and Occupational Medicine, and Pathology, University of Ulm, West Germany; Department of Clinical Immunology and Transfusion Medicine, Medizinische Hochschule Hannover, West Germany; Department of Biophysics, Weizmann Institute of Science, Rehovot, Israel; and Department of Transplantation Immunology, Red Cross Blood Bank, Ulm

Immunological reconstitution by transplantation of HLA-haploidentical, paternal bone marrow was attempted in four infants with severe combined immunodeficiency who lacked HLA-identical donors. To prevent graft-versus-host disease, T lymphocytes were removed from the grafts by agglutination with soybean agglutinin and rosette formation with sheep red blood cells. None of the patients received conditioning treatment before transplantation. Normal, donor-derived cellular immune functions developed in all four patients within several months of transplantation. Threatening complications of graftversus-host reactions were not seen. All four patients remain in excellent health 12-15 months after discharge home, with persisting normal T-cell functions. Summary

Introduction BONE-MARROXX7 transplantation has emerged as a potential cure for infants with severe combined immunodeficiency1,2 but has been possible only when HLA-matched bone-marrow donors, usually siblings, are available. Several modifications of the transplantation process have been suggested for the prevention of graft-versus-host disease (GvHD), thus offering the possibility of carrying out bone-marrow transplantation across HLA barriers.3 One such modification is the inactivation or removal of T lymphocytes contaminating the marrow grafts, as successfully applied in animal models.4,5 Reisner et al have developed a technique to remove T cells from human bone-marrow grafts by lectin agglutination and rosette formation with sheep red blood cells.6 They successfully treated six patients with severe combined immunodeficiency by means of T-cell-depleted bone marrow from HLA-mismatched, related donors.’,8 Complications due to GvHD were completely prevented. However, engraftment and functional differentiation of lymphoid cells were difficult to achieve and several grafts or

18. 19. 20

Laragh JH, Pecker MS. Dietary sodium and essential hypertension: hopes, and truths. Ann Intern Med 1983, 98: 735-43. Swales JD. Dietary salt and hypertension. Lancet 1980, i. 1177-79 Tannen RL Effects of potassium on blood pressure control. Ann Intern

773-80. 21. Ibsen H, Leth

myths,

Med 1983,

98:

mild essential A, Hollnagel H, Renin-angiotensin system hypertension The functional significance of angiotensin II in untreated and thiazide-treated hypertensive patients Clin Sci Mol Med 1978, 55: 319s-21s 22. Leonetti G, Terzoli L, Sala C, Bianchini C, Sernesi L, Zanchetti A Relationship between the hypotensive and renin-stimulating actions of diuretic therapy in hypertensive patients Clin Sci Mol Med 1978, 55: 307s-09s 23. Agabiti Rosei E, Brown JJ, Cumming AMM, et al. Is the ’sodium index’ a useful way of expressing clinical plasma renm, angiotensin and aldosterone values? Clin Endocrinol 1978, 8: 141-47. 24. Nicholls MG, Kiowski W, Zweifler AJ, Julius S, Schork MA, Greenhouse J. Plasma norepinephrine variations with dietary sodium intake. Hypertension 1980; 2: 29-32. et

al.

some

m

762

pretransplant immunosuppressive

treatment

were

needed

before immunoreconstitution was finally achieved. We now report our findings in four children with severe combined immunodeficiency who had no HLA-identical siblings and were treated with paternal, lectin-separated bone marrow.

Patients and Methods Methods Bone-marrow fractionation and transplantation.-600-800 ml bone marrow was obtained from each donor by multiple aspirations under general anaesthesia. T lymphocytes were removed from the bone-marrow cell suspensionsbby lectin agglutination with soybean agglutinin (Vector Laboratories, Burlingame, California) and rosetting with sheep red blood cells, both native and treated with neuraminidase (Vibrio cholerae, Behring Werke AG, Marburg, West Germany). Cells remaining at the end of the fractionation procedure (ie, non-agglutinable, non-rosettmg mononuclear bone-marrow cells) were resuspended in 0.9% saline containing 1% human albumin, at a concentration of 5-10x 106 cells per ml, and were infused intravenously. A mean of 0-87 x 108 nucleated cells per kg body weight were transplanted (range 0.2x108-1.8x108). The patients received no immunosuppressive or cytoreductive treatment before transplantation and no GvHD prophylaxis afterwards. Immunological analysis.-In-vitro lymphocyte stimulation with mitogens, antigens, and allogeneic cells in mixed lymphocyte cultures was carried out by standard microtitre plate assays, and proliferative responses were quantified by tritiated thymidine incorporation.9 Analysis of lymphocytes for sheep red blood cell receptors, surface and cytoplasmic immunoglobulins, and separation of sheep-red-blood-cell-rosetting mononuclear cells from non-rosetting cells were carried out as previously.10 Histocompatibility HLA A, B, C, and D testing was done by standard serological techniques.11 Assay for myeloid precursors.-CFU-C were assayed with human placental conditioned medium and Evaluation of GvHD.-We used the clinical criteria ofGlucksberg et al.13 Skin biopsy samples taken 14-96 days after bone-marrow transplantation were studied histologically for signs of GvHD.14,15

alpha-thioglycerol.l2

Patients Patient 1,

male infant, was diagnosed as having severe combined immunodeficiency at 5 months, when chronic enteritis and extensive candidiasis developed. The family history was negative. After bacterial decontamination he was placed in a sterile closed isolator. When 9 months old he was transplanted with T-celldepleted bone marrow from his HLA-haploidentical father. A week later, symptoms of generalised infection developed with high temperatures, abdominal distension, hepatosplenomegaly with raised liver enzymes, watery diarrhoea, and respiratory distress. Apart from rotavirus in stool samples, no causative agent was recovered. A maculopapular, faintly erythematous generalised rash appeared. Prednisolone, 2 mg/kg, was administered for clinically suspected graft-versus-host reaction (GvHR) but was withdrawn gradually 5 days later when the biopsy result, showing only mild inflammatory changes not characteristic of GvHR, was available. Despite many therapeutic attempts, the infant remained ill until about 8 weeks after transplantation, when he improved unexpectedly; the fever disappeared and bowel and liver functions returned to normal. At this time there was evidence of engraftment, with donor-type T lymphocytes in peripheral blood. Shortly . thereafter, a second T-cell-depleted graft from the same donor was given in an effort to accelerate immunological reconstitution. There were no further significant infectious or nutritional complications. 4 months after the first transplantation rotavirus was no longer detectable in stool samples. When immunological studies revealed normal T-cell functions, the child was removed from the sterile unit after selective bacterial recontamination and discharged home, aged 16 months. 2. -In Patient this infant male severe combined immunodeficiency was diagnosed shortly after delivery because of a a

positive family history. Nursing care was carried out in reverse isolation throughout the whole hospital stay and the child was breast-fed until 6 months old. At 3 months, a T-cell-depleted bonemarrow graft from the HLA-haploidentical father was given. 2 weeks later an erythematous dermatitis, initially confined to the face and upper trunk and then generalising, developed. Over several weeks the rash changed into a dry, scaling, mildly pruritic eczematous dermatitis. Repeated skin biopsies were not diagnostic of GvHR. Initial treatment consisted of topical steroids followed by vigorous lubrication over several months. All changes disappeared about 2 months later. At no time were liver or gastrointestinal abnormalities noted, but significant eosinophilia was present for almost 2 months. Donor-derived T lymphocytes appeared in the blood about 6 weeks after transplantation. When T-cell functions were repeatedly found to be normal, the patient was discharged home, aged 8 months. Patient 3, a female infant, was diagnosed as having severe combined immunodeficiency when 21/2 months old. Two siblings had died of the disorder. As well as chronic rotavirus enteritis and candidiasis the patient also had signs and symptoms of a general BCG infection. As a newborn, she had received routine BCG vaccination. Tuberculostatic treatment was initiated shortly after diagnosis. The infant was nursed in a sterile isolator and was transplanted with T-cell-depleted bone marrow from her HLAhaploidentical father when 7 months old. A faint, mildly pruritic dermatitis developed 4 weeks later, but subsided without treatment after several weeks. Mild eosinophilia was noted temporarily. 4 months after transplantation functions of newly developed, donorderived T cells were normal. At this time, skin testing with tuberculin became positive. The child was discharged home in good clinical condition and without signs of active BCG infection aged 14 months. Patient 4.-Two siblings of this male infant had died from complications of severe combined immunodeficiency. His mother was referred shortly before term, and after sterile delivery, the baby was immediately transferred into a sterile isolator. Immunological evaluation confirmed severe combined immunodeficiency. HLA typing showed the father to be phenotypically identical with his son. A T-cell-depleted bone-marrow graft was given when the child was 4 months old. He remained germ-free throughout the whole isolation. The clinical course was uneventful with the exception of a mild rash subsiding completely without treatment. 3 months after transplantation the child had normal T-cell functions and he was discharged in excellent condition aged 8 months. ,

Results Before transplantation there was a complete lack ofB and T cell functions in all four patients (table I). Erythrocyte adenosone deaminase and purine nucleoside phosphorylase levels were normal (Prof W. H. Hitzig, UniversitatsKinderklinik, Zurich). There was no evidence of maternal lymphocytes acquired by intrauterine transfusion. In all cases the donors and recipients were HLA haploidentical (table II) and patient 4 and his donor were phenotypically identical (the parents of this infant were unrelated). The fractionation procedure resulted in a profound loss of nucleated bone-marrow cells (table III). However, comparative determinations of CFU-C activities in the original marrow samples and the final fractions revealed twenty to thirty fold higher activities in the latter, thus reflecting significant enrichment of stem cells. There was no evidence of residual T lymphocytes in final stem-cellenriched bone-marrow fractions-no cellular response to phytohaemagglutinin, concanavalin A, and allogeneic cells, as well as a complete lack of E-rosetting cells. The latter was always confirmed before the cells were infused into patients. Bacterial cultures, set up routinely from all grafts, remained ’ sterile. In all four patients, T lymphocytes appeared in the blood 6-8 weeks after transplantation. HLA typing then revealed

763 TABLE I-IMMUNE STATUS BEFORE BONE-MARROW TRANSPLANTATION

*Lowest levels before

TABLE IV—IMMUNE STATUS AFTER TRANSPLANTATION

y-globulin substitution. TABLE II-HLA TYPING

*All patients substituted tBlood group AB.

TABLE III-RESULTS OF BONE-MARROW FRACTIONATION

*Cells

not

agglutinating with soybean antigen

and E-rosette negative.

the presence of new, donor-derived antigens in patients 1 and 2. HLA typing showed that E-rosetting cells were of donor

origin, whereas non-rosetting cells showed only host antigens, indicating that non-T cells remained of host origin. In patient 3, whose donor was homozygous at the A, B, and C loci, the lack of markers of the patient’s second haplotype on the E-rosetting cells, but not on the non-E-rosetting cells, proved the donor origin of the T cells. T-cell functions, as determined by proliferative responses to mitogens, allogeneic cells, and bacterial antigens, were normal in all patients 4-7 months after transplantation (table IV). In addition, delayedtype skin reactions to candidin, and in patient 3 also to

with intravenous

y-globulin.

all cases, but little evidence of antibody synthesis. Low titres of isoagglutinins corresponding to the patients’ blood groups were noted in three patients. Patient 3 (blood group AB) had no isoagglutinins. After active immunisation of the patients with diphtheria toxoid, no specific antibody became detectable. Skin biopsies were carried out in all four patients at various stages of their post-transplantation rashes and the samples were examined histologically for evidence ofGvHR. In three patients only slight, non-specific inflammatory reactions were present. In patient 2, however, definite pathological lesions were seen-oedema and hyperaemia of the upper dermis, moderate infiltration of the dermis and epidermis by lymphocytes and neutrophils, and patchy spongiosis; necrosis of keratinocytes could not be detected. Macroscopic and histological skin changes disappeared completely in all four infants without prolonged use of steroids or other

immunosuppression. No significant difficulties have occurred since the patients were discharged. At regular follow-up growth and physical and mental development have been normal. None of the patients is receiving antibiotic prophylaxis. In all four small cervical lymph nodes have developed. Immunological evaluations continue to show normal T-cell functions, but up humoral immunity has remained incomplete in all four children and intravenous y-globulin substitution is to now

continuing. Discussion Our results

fully

confirm the

potential

of Reisner

et

al’s

be of

method6 for obtaining stem-cell-enriched bone-marrow cell

origin, while non-rosetting cells (B lymphocytes, monocytes) carried exclusively markers of the recipients (not evaluable in patient 4). Erythrocyte markers, which had been determined in the patients and the donors before bonemarrow transplantation, remained of host type (data not shown). There was clear evidence ofy-globulin production in

fractions completely free of T cells. T cells were completely removed in all experiments we did, indicating the high reproducibility and reliability of the method. In studies in man16-17 in which T-cell elimination was attempted by other means, extremely small numbers of residual T cells were able to cause severe, potentially lethal complications of GvHD.

tuberculin, could be elicited. All T cells continued donor

to

764

’

Reinherz et al observed severe GvHD in a patient with severe combined immunodeficiency transplanted with HLAhaploidentical marrow treated with a complement-binding, T-cell-specific monoclonal antibody (T12), and containing less than 0.1% residual T cells.17 These findings mean that extreme caution must be used in HLA-mismatched bonemarrow transplantation and that the removal of even trace amounts of T lymphocytes needs to be guaranteed, unless additional prophylactic measures against GvHD are added. Reisner et al’s method appears to meet this requirement. Large-scale bone-marrow fractionation procedures must take into account a potential loss of stem cells. Our experience confirms that of Reisner et al,6 that in most cases the majority of stem cells, as measured by CFU-C activity, can be recovered. In one experiment, however, only 15% of the total activity present in the original bone-marrow preparation was recovered. We are exploring further technical modifications in order to avoid unpredictable losses of stem cells. None of the skin biopsy samples obtained sequentially in the patients, during the time they had rashes, showed unequivocal histological evidence ofGvHR. There were no signs of liver or gastrointestinal disease in patients 2, 3, and 4; in patient 1, liver and intestinal dysfunction developed shortly after transplantation but disappeared completely after engraftment. The fact that these changes disappeared completely and without significant immunosuppressive therapy in all four patients appears to rule out the classical aggressor lymphocyte reactions that follow HLAmismatched bone-marrow transplantation; these have severe, usually fatal, courses.’ Nevertheless, the transient clinical and histological changes may represent manifestations of mitigated alloreactions of newly formed donor lymphocytes against cells of the host. Our results contrast with those of others’ who achieved stable engraftment in transplanted severe combined immunodeficiency patients only after two or three grafts; those results may indicate a relative resistance in some patients with severe combined immunodeficiency to the engraftment of HLA-non-identical lymphocytes.17 The observed failure ofB-cell engraftment and maturation in our patients might reflect a similar phenomenon. Clearly, better understanding of the various mechanisms delaying or preventing immunological reconstitution after HLAmismatched bone-marrow transplantation is needed to develop appropriate measures to enhance engraftment of HLA-mismatched bone marrow. We thank the nursing staff of the bone marrow transplantation unit for excellent care of the patients; Dr J. Beck, Universitats-Kinderklimk Erlangen, Prof H. J. Rohwedder, Kinderklinik Flensburg, and Dr H. von Voss, Kinderklinik Dusseldorf-Kaiswerwerth, for referring patients; Renate Weitmann, Marlene Fischer, Maria Fischer, and Esther Ruber for technical help; and Rita Kley for secretarial help. This work was supported by the

Deutsche

should be addressed to W. F., Universitats-Kinderklinik, Prittwitzstrasse 43, D-7900 Ulm, West Germany.

2.

3 4

5. 6

ANNE TARN KATE M. SPENCER BETTY M. DEAN J. LISTER G. F. BOTTAZZO

Department of Immunogenetics and Immunology, St Bartholomew’s and Middlesex

REFERENCES Kenny AB, Hitzig WH Bone marrow transplantation for severe combined immunodeficiency. Eur J Paediatr 1979; 131: 155-77. Pahwa R, Pahwa S, O’Reilly RO, Good RA. Treatment of the immunodeficiency disease—progress toward replacement therapy emphasizing cellular and macromolecular engineering Springer Semin Immunopathol 1978; 1: 355-404. Editorial Preventing graft-versus-host disease. Lancet 1980; ii: 1343-44. Muller-Buchholz W, Wottge HU, Muller-Hermelink HK Bone marrow transplantation in rats across strong histocompatibility barriers by selective elimination of lymphoid cells in donor marrow Transplant Proc 1976, 8: 537-41. Von Boehmer H, Spreut J, Nabholz M. Tolerance to histocompatibility determinants in tetraparental bone marrow chimeras J Exp Med 1975; 141: 322-34 Reisner Y, Kapoor N, Kirkpatrick D, et al Transplantation for acute leukaemia with HLA-A and B non-identical parental marrow cells fractionated with soybean agglutinin and sheep red blood cells Lancet 1981, ii: 327-31.

Hospitals and King Edward

VII Hospital, Windsor

Complement-fixing islet-cell antibodies (CF-ICA) were found in 20 out of 685 unaffected first-degree relatives of children with type 1 diabetes. During a 5-year follow-up, 7 of the 20 became

Summary

diabetic,

1 continued to show the antibodies without any

abnormality of glucose tolerance, and 12 subjects lost them without the disease developing. Although CF-ICA are useful as a marker of active insulitis they should not at present be used to define subjects who might benefit from preventive immunosuppression. Introduction of type 1 (insulin-dependent) diabetes depends on both genetic and environmental factors. The best known genetic factor is the linkage of the disease with HLA haplotypes. This knowledge prompted the setting up of a family study in 1978. Within families of type 1 diabetics there will be a group of HLA-identical siblings who, having both haplotypes in common with the proband, will themselves be susceptible to the disease. We hoped that a prospective study of these predisposed individuals would clarify the events leading up to the onset of diabetes. Almost all newly diagnosed type 1 diabetic children have islet-cell antibody (ICA) in the blood at diagnosis; but in 70% of these ICA will have disappeared after 5 years. Complement-fixing variants of ICA (CF-ICA) seem to be more specific markers of islet-cell damage, probably because some of them react exclusively with beta cells. Diabetes developed in 7 first-degree relatives within this family study. All had at least one HLA haplotype in common with the proband; all had islet-cell antibodies before diagnosis and all but 1 had CF-ICA.2 THE

7.

8.

9.

10

Forschungsgememschaft.

Correspondence

1

FLUCTUATING ISLET-CELL AUTOIMMUNITY IN UNAFFECTED RELATIVES OF PATIENTS WITH INSULIN-DEPENDENT DIABETES

occurrence

O’Reilly RJ, Kapoor N, Kirkpatrick D, et al. Transplantation for severe combined immunodeficiency using histoincompatible parental marrow fractionated by soybean agglutinin and sheep red blood cells experience in six consecutive cases Transplant Proc 1983; 15: 1431-35. Reisner Y, Kapoor N, Kirkpatrick D, et al Transplantation for severe combined immunodeficiency with HLA-A, B, D, DR incompatible parental marrow cells fractionated by soybean agglutinin and sheep red cells. Blood 1983, 61: 341-48 Niethammer D, Goldmann SF, Haas RJ, et al. Bone marrow transplantation for severe combined immunodeficiency with the HLA-A incompatible, but MLC-identical mother as donor Transplant Proc 1976; 8: 623-28 Friedrich W, O’Reilly RJ, Koziner B, Gebhard DR, Good RA T-lymphocyte reconstitution in recipients of bone marrow transplants with and without GvHD imbalances of T-cell subpopulations having unique regulatory and cognitive functions. Blood 1982; 59: 696-701. PI, Bernoco D, Park MS, Ozturk G, Iwaky Y Microdroplet testing of HLAA, B, C and D antigens Am J Clin Pathol 1978, 64: 103-20 Schlunk T, Ruber E, Schleyer M. Survival of human bone marrow progenitor cells after freezing improved detection in the colony-formation assay Cryobiology 1981, 18: 111-18 Glucksberg HR, Storb R, Fefer A, et al. Clinical manifestations of graft-versus host disease in human recipients of marrow from HLA-matched sibling donors Transplantation 1974, 18: 295-304. Slavin RE, Woodruff JM. The pathology ofbone marrow transplantation Pathol Ann 1974, 9: 291-344. Woodruff JM, Hansen JA, Good RA, Santos GW, Slavin RE The pathology ofgraftversus-host reaction (GvHR) in adults receiving bone marrow transplants Transplant Proc 1976, 8: 675-81. Hayward AR, Murphy J, Githens J, Troup G, Ambroso D Failure of apan-reactive anti-T-cell antibody, OKT 3, to prevent graft versus host disease in severe combined immunodeficiency.J Pediatr 1982, 100: 665-68 Reinherz E, Geha R, Rappoport JM, et al. Reconstitution after transplantation with T-lymphocyte-depleted HLA haplotype-mismatched bone marrow for severe combined immunodeficiency. Proc Natl Acad Sci USA 1982, 79: 6047-51

11 Terasaki 12

13.

14 15

16.

17