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. 2005 Apr 13;64(10):1397–1405. doi: 10.1136/ard.2004.033332

Outcome of intensive immunosuppression and autologous stem cell transplantation in patients with severe rheumatoid arthritis is associated with the composition of synovial T cell infiltration

R Verburg 1, R Flierman 1, J Sont 1, F Ponchel 1, L van Dreunen 1, E Levarht 1, M Welling 1, R Toes 1, J Isaacs 1, J M van Laar 1
PMCID: PMC1755245  PMID: 15829573

Abstract

Objective: To determine clinical and immunological correlates of high dose chemotherapy (HDC) + autologous stem cell transplantation (ASCT) in patients with severe rheumatoid arthritis (RA), refractory to conventional treatment.

Methods: Serial samples of peripheral blood and synovial tissue were obtained from seven patients with RA treated with HDC and autologous peripheral blood grafts enriched for CD34+ cells. Disease activity was assessed with the Disease Activity Score (DAS), serum concentrations of C reactive protein (CRP), and human immunoglobulin (HIg) scans, and the extent of immunoablation was determined by immunophenotyping of peripheral blood mononuclear cells, and immunohistochemistry and double immunofluorescence of synovium.

Results: Clinical responders (n = 5) had a larger number of cells at baseline expressing CD3, CD4, CD27, CD45RA, CD45RB, and CD45RO in synovium (p<0.05), higher activity on HIg scans (p = 0.08), and a trend towards higher concentrations of CRP in serum than non-responders (n = 2). Subsequent remissions and relapses in responders paralleled reduction and re-expression, respectively, of T cell markers. A relatively increased expression of CD45RB and CD45RO on synovial CD3+ T cells was seen after HDC + ASCT. No correlations were found between DAS and changes in B cells or macrophage infiltration or synoviocytes.

Conclusions: HDC + ASCT results in profound but incomplete immunoablation of both the memory and naïve T cell compartment, which is associated with longlasting clinical responses in most patients. The findings provide strong circumstantial evidence for a role of T cells in established RA, and demonstrate a role for the synovium in post-transplantation T cell reconstitution.

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Figure 1.

Figure 1

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 Synovial tissue taken from patient No 2 (table 1) before and 3 months after HDC + ASCT. Infiltration with numerous lymphocytes and plasma cells before stem cell transplantation, which were almost absent after the transplantation.

Figure 2.

Figure 2

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 Immunohistochemically stained synovial tissue in a responder with CD3, CD27, CD45RA, and CD45RO, before and 3 months after HDC + ASCT.

Figure 3.

Figure 3

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 Semiquantitative infiltration scores before, 3 months after, and 1 year after HDC + ASCT of responders and non-responders for CD3, CD4, CD27, CD45RA, CD45RB, and CD45RO. *p<0.05, significant baseline difference between responders and non-responders; **p<0.05, significant decrease at 3 months after transplantation in responders CD45RA and CD27.

Figure 4.

Figure 4

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 Co-expression of CD3 and CD45RO in RA synovial tissue before transplantation in a responder. CD3 (FITC = green) and CD45RO (TRITC = red) were detected using immunofluorescence techniques. (A) Rheumatoid synovial tissue showing CD3+ cell infiltrate. (B) Rheumatoid synovial tissue showing CD45RO+ cell infiltrate. (C) Double positive cells as depicted by yellow and orange, showing numerous double positive and only a few CD45RO single positive cells (red).

Figure 6.

Figure 6

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 The mean number of CD45RA, CD45RB, and CD45RO expressed as a percentage of CD3+cells. (A) Immunofluorescence double staining of peripheral blood mononuclear cells with CD3 plus CD45RA, CD45RB, or CD45RO in the five responders at screening and at 1, 3, 6, 9, and 12 months after HDC + ASCT. Results expressed as the percentage of CD3 cells expressing the CD45R isoform. (B) Immunofluorescence double staining of synovial cells with CD3 plus CD45RA, CD45RB, or CD45RO in the five responders at screening and 3 and 12 months after HDC + ASCT. Results expressed as the percentage of CD3 cells expressing the CD45R isoform.

Figure 5.

Figure 5

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 Absolute cell count in peripheral blood mononuclear cells in the five responders for CD3, CD4, and CD8. Absolute cell numbers were calculated by multiplying absolute lymphocyte count (106/l (SEM)) by the percentage of each subset determined by flow cytometry after isolation of peripheral blood mononuclear cells by density gradient centrifugation.

Selected References

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