Multicenter experience in hematopoietic stem cell transplantation for serious complications of common variable immunodeficiency Claudia Wehr, MD,a Andrew R. Gennery, MD,b Caroline Lindemans, MD, PhD,c Ansgar Schulz, MD,d Manfred Hoenig, MD,d Reinhard Marks, MD,e Mike Recher, MD,f Bernd Gruhn, MD,g Andreas Holbro, MD,h Ingmar Heijnen, PhD,i Deborah Meyer, BSc,j Goetz Grigoleit, MD,k Hermann Einsele, MD,k Ulrich Baumann, MD,l Thorsten Witte, MD,m Karl-Walter Sykora, MD,n Sigune Goldacker, MD,a Lorena Regairaz, MD,o Serap Aksoylar, MD,p € Omur Ardeniz, MD,q Marco Zecca, MD,r Przemyslaw Zdziarski, MD,s Isabelle Meyts, MD,t Susanne Matthes-Martin, MD,u Kohsuke Imai, MD,v Chikako Kamae, MD,w Adele Fielding, MD,x Suranjith Seneviratne, MD,y Nizar Mahlaoui, MD, MSc, € r, MD,j Peter D. Arkwright, MD,bb Joris van Montfrans, MD,cc € ngo MPH,z Mary A. Slatter, MD,aa Tayfun Gu dd Kathleen E. Sullivan, MD, PhD, Bodo Grimbacher, MD,a Andrew Cant, MD,b Hans-Hartmut Peter, MD,a Juergen Finke, MD,e H. Bobby Gaspar, MD,ee Klaus Warnatz, MD,a and Marta Rizzi, MD, PhD,a on behalf of the Inborn Errors Working Party of the European Society for Blood and Marrow Transplantation and the European Society for Immunodeficiency Freiburg, Ulm, Jena, W€ urzburg, and Hannover, Germany, Newcastle Upon Tyne, London, and Manchester, United Kingdom, Utrecht, The Netherlands, Basel and Zurich, Switzerland, Buenos Aires, Argentina, Bornova-Izmir an Izmir, Turkey, Pavia, Italy, Wroclaw, Poland, Leuven, Belgium, Vienna, Austria, Tokyo and Saitama, Japan, Paris, France, and Philadelphia, Pa Background: Common variable immunodeficiency (CVID) is usually well controlled with immunoglobulin substitution and immunomodulatory drugs. A subgroup of patients has a complicated disease course with high mortality. For these patients, investigation of more invasive, potentially curative treatments, such as allogeneic hematopoietic stem cell transplantation (HSCT), is warranted.

Objective: We sought to define the outcomes of HSCT for patients with CVID. Methods: Retrospective data were collected from 14 centers worldwide on patients with CVID receiving HSCT between 1993 and 2012. Results: Twenty-five patients with CVID, which was defined according to international criteria, aged 8 to 50 years at the time

From athe Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg and the University of Freiburg; bthe Department of Paediatric Immunology, Newcastle Upon Tyne Hospitals Foundation Trust; cthe Pediatric Blood and Bone Marrow Transplantation Program, UMC Utrecht; dthe Department of Pediatrics, University Medical Center Ulm; ethe Department of Hematology and Oncology, University Medical Center Freiburg; fthe Clinic for Primary Immunodeficiency, Medical Outpatient Clinic and Immunodeficiency Laboratory, Department of Biomedicine, University Hospital, Basel; gKlinik f€ ur Kinder- und Jugendmedizin, Universit€atsklinikum Jena, Friedrich-Schiller-Universit€at Jena; hthe Division of Hematology and Stem Cell Transplant Team, University Hospital Basel; iMedical Immunology, Laboratory Medicine, University Hospital Basel; jUniversity Children’s Hospital, Zurich; kthe Department of Hematology/Oncology, University Medical Center W€urzburg; lPaediatric Pulmonology, Allergy and Neonatology and mthe Clinic for Immunology and Rheumatology, Hannover Medical School; nthe Department of Pediatric Hematology and Oncology, University Hospital Hannover; oUnidad de Immunologıa, Hospital de Ni~nos Sor Marıa Ludovica La Plata, Buenos Aires; pthe Department of Pediatric Hematology & Oncology and BMT Center, Ege University, Bornova-Izmir; qthe Division of Allergy and Clinical Immunology, Ege University Medical Faculty, Izmir; rOncoematologia Pediatrica, Fondazione IRCCS Policlinico San Matteo, Pavia; sthe Lower Silesian Center for Cellular Transplantation, Wroclaw; tthe Department of Paediatrics, University Hospital Leuven; uSt Anna Kinderspital, Medical University, Vienna; vthe Department of Pediatrics, Tokyo Medical and Dental University; wthe Department of Pediatrics, National Defense Medical College, Saitama; xUniversity College London; y the Immunology Department, Royal Free London; zUnite d’Immuno-Hematologie et Rhumatologie Pediatrique, H^opital Necker-Enfants Malades, French National Reference Center for PIDs (CEREDIH), Stem Cell Transplantation for PIDs in Europe (SCETIDE) registry, Assistance Publique–H^opitaux de Paris; aathe Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne; bbUniversity of Manchester, Royal Manchester Children’s Hospital, Manchester; ccthe Pediatric Immunology and Infectious Disease, UMC Utrecht, Utrecht; ddthe Division of Allergy and Immunology, Children’s Hospital of Philadelphia; and eethe Center of Immunodeficiency, Molecular Immunology Unit, Institute of Child Health, London. Supported by the German Federal Ministry of Education and Research (BMBF 01 EO 0803). C.L. is supported by a clinical fellowship from the Dutch Cancer Society (2013-5883).

Disclosure of potential conflict of interest: C. Wehr has received research and travel support from the German Federal Ministry of Education and Research. C. Lindemans has received research support from the Dutch Cancer Society (2013-5883). A. Schulz is employed by Medical Center Ulm. M. Recher has received research support from a Swiss National Science Foundation Professorship Grant (PP00P3_144863). U. Baumann has received research support from EURO-PADnet (FP7/2007-2011). K.-W. Sykora has received travel support from EUSA Pharma. S. Goldacker has received research support from Octapharma. A. Fielding has received consultancy fees from Amgen. S. Seneviratne is employed by the Royal Free Hospital, London. K. E. Sullivan has received consultancy fees from the Immune Deficiency Foundation, is employed by UpToDate, and has received research support from Baxter. B. Grimbacher has received research support from BMBF (01E01303 and 012X1306F) and the European Union (EU); is employed by UCL and UKL-FR; has received research support from BMBF (01E01303 and 012X1306F), the EU, and Helmholtz (DZIF 8000805-3); and has received lecture fees from CSL, Baxter, and Biotest. H.H. Peter has provided expert testimony for Pfizer and has received lecture fees. K. Warnatz has received lecture fees from Baxter, GlaxoSmithKline, CSL Behring, Pfizer, Biotest, Novartis Pharma, Stallergenes AG, Roche, Meridian HealthComms, Octapharma, and the American Academy of Allergy, Asthma & Immunology; has received payment for manuscript preparation from UCB Pharma; and has received payment for development of educational presentations from European Society for Immunodeficiency. M. Rizzi has received research support from Pfizer (Europe Aspire Award [10/2013-09/2014]) and Novartis (Stiftung f€ur Klinische Forschung Grant [11/201410-2016]). The rest of the authors declare that they have no relevant conflicts of interest. Received for publication January 13, 2014; revised November 18, 2014; accepted for publication November 19, 2014. Corresponding author: Marta Rizzi, MD, PhD, Center of Chronic Immunodeficiency, University Medical Center Freiburg, Engesserstrasse 4, 79108 Freiburg, Germany. E-mail: [email protected]. Or: Klaus Warnatz, MD, Center of Chronic Immunodeficiency, University Medical Center Freiburg, Breisacherstrasse 117, 79106 Freiburg, Germany. E-mail: [email protected]. 0091-6749/$36.00 Ó 2014 American Academy of Allergy, Asthma & Immunology http://dx.doi.org/10.1016/j.jaci.2014.11.029

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of transplantation were included in the study. The indication for HSCT was immunologic dysregulation in the majority of patients. The overall survival rate was 48%, and the survival rate for patients undergoing transplantation for lymphoma was 83%. The major causes of death were treatment-refractory graft-versus-host disease accompanied by poor immune reconstitution and infectious complications. Immunoglobulin substitution was stopped in 50% of surviving patients. In 92% of surviving patients, the condition constituting the indication for HSCT resolved. Conclusion: This multicenter study demonstrated that HSCT in patients with CVID was beneficial in most surviving patients; however, there was a high mortality associated with the procedure. Therefore this therapeutic approach should only be considered in carefully selected patients in whom there has been extensive characterization of the immunologic and/or genetic defect underlying the CVID diagnosis. Criteria for patient selection, refinement of the transplantation protocol, and timing are needed for an improved outcome. (J Allergy Clin Immunol 2014;nnn:nnn-nnn.) Key words: Common variable immunodeficiency, hypogammaglobulinemia, hematopoietic stem cell transplantation, immunologic reconstitution, immunoglobulin substitution/replacement, outcome, mortality, survival

Common variable immunodeficiency (CVID) is an immunologically and genetically heterogeneous condition characterized by hypogammaglobulinemia of at least 2 immunoglobulin isotypes.1 CVID can be either classified according to immunologic phenotype2-5 or molecular6,7 or clinical8-10 characteristics. Two subtypes can be broadly described on clinical grounds. Patients might have only infections and typically have a normal life expectancy. In contrast, patients with splenomegaly, granuloma, autoimmunity, enteropathy, liver, interstitial lung disease, or neoplasia have a compromised life expectancy.8,9,11-13 The severity of the clinical phenotype often correlates with aspects of T-cell deficiency.4,5,14,15 In fact, the French Study Group defined a subgroup of late-onset combined immunodeficiency within the CVID cohort.16 Hematopoietic stem cell transplantation (HSCT) is often used for patients with T-cell defects.17 The growing appreciation of the T-cell defect in patients with CVID16 and greater data suggesting a poor outcome in this subset13 have led to interest in HSCT for the treatment of CVID. HSCT has been used for individual patients with CVID with malignancy or suspected combined immunodeficiency18 with variable humoral immune reconstitution. Therefore to understand the indications and outcomes of HSCT in patients with CVID, we performed a retrospective multicenter study of 25 patients with an underlying diagnosis of CVID who underwent HSCT.

METHODS Inclusion criteria The study was approved by the Ethics committee of the Freiburg University Medical Center (no. 275/12), and all patients or their parents signed informed consent forms for data collection. Patients with a diagnosis of CVID who underwent transplantation for any indication were recruited through the SCETIDE database of the Inborn Errors Working Party of the European Society for Blood and Marrow Transplantation, European Society for Immunodeficiencies (ESID), and personal communication. Inclusion criteria

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Abbreviations used aGvHD: Acute graft-versus-host disease BM: Bone marrow cGvHD: Chronic graft-versus-host disease CMV: Cytomegalovirus CVID: Common variable immunodeficiency ESID: European Society for Immunodeficiencies GvHD: Graft-versus-host disease HCT-CI: Hematopoietic Cell Transplant-Comorbidity Index HSCT: Hematopoietic stem cell transplantation MAC: Myeloablative conditioning PID: Primary immunodeficiency RIC: Reduced-intensity conditioning

were HSCT for any indication and a diagnosis of CVID. Currently published definitions of CVID are controversial because they do not specify delineation from predominant T-cell deficiencies. We used a definition elaborated in an expert consensus process for the registration of patients with CVID in the ESID registry (www.esid.org): (1) susceptibility to infection or autoimmune manifestation or granulomatous disease or unexplained polyclonal lymphoproliferation, or affected family member with CVID; (2) reduction in IgG and IgA levels and (3) poor vaccination response or low switched memory B-cell numbers (0.4 g/L). Vaccination responses, which were available in 3 patients, were restored to protein antigens in all (3/3) patients and to polysaccharide antigens in 2 of 3 patients. Immunoglobulin treatment was stopped between days 130 and 1859 (331 6 302 days) after transplantation, partly influenced by posttransplantation immunosuppression in some cases. Follow-up in patients with ongoing immunoglobulin substitution ranged from 464 to 3202 days after HSCT (1711 6 1030 days). IgM levels in these patients were less than the detection limit in 3 of 6 patients and

between 0.22 and 0.4 g/L IgM in the other 3 patients. IgA levels during immunoglobulin substitution were less than or near the detection limit in 4 of 6 patients and normal in patients 004 (3.5 g/L) and 030 (0.98 g/L). In patient 004 withdrawal of immunoglobulin substitution failed because of infections. Available lymphocyte counts 1 year after transplantation from 9 of 12 long-time survivors showed normal natural killer cells in all patients, normal CD81 and CD191 cells in 5 of 9 patients, and CD41 cells in 3 of 9 patients. As expected, the ability to produce normal immunoglobulin serum levels positively correlated with peripheral B-cell numbers at last follow-up (Fig 4, B). All patients

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TABLE III. Time points and cause of death Patient no.

003 006 007 009 011 013 015 016 018 019 020 024 028

Days after HSCT

Cause of death

90 15 227 134 105 44 26 61 121 609 499 10 104

Alveolar hemorrhage caused by adenovirus, CMV, and EBV infection Gastrointestinal hemorrhage caused by CMV duodenitis Tetraparesis attributed to neurologic GvHD, recurrence of AML, and sepsis Brain stem encephalitis caused by adenovirus Disseminated aspergillosis and graft failure caused by GvHD and immunosuppression Systemic CMV infection, cerebral ischemia of unknown origin with bleeding, leading to increased intracranial pressure VOD Disseminated CMV and adenovirus infection, VOD Severe aGvHD and disseminated adenovirus infection Treatment-refractory cGvHD Treatment-refractory cGvHD Pseudomonas species sepsis in neutropenia aGVHD, poor immune reconstitution and pulmonary aspergillosis, CMV reactivation, and adenovirus infection

CMV, Cytomegalovirus; VOD, veno-occlusive disease.

FIG 3. GvHD. A, Occurrence of mild (light blue), severe (indigo), or absent (dark blue) GvHD in the whole CVID cohort and outcome of patients with severe GvHD. B and C, GvHD according to donor type (P 5 .9694; Fig 3, B) and stem cell source (P 5 .603; Fig 3, C). Solid symbols, Patients with CVID without signs of cellular immunodeficiency; open symbols, patients with CVID with signs of cellular immunodeficiency. CB, Cord blood; mMUD, Mismatched unrelated donor; MRD, matched related donor; MUD, matched unrelated donor.

(n 5 4) with normal B-cell numbers before HSCT stopped immunoglobulin substitution after HSCT, whereas this was the case for only one third (2/6 patients) with low B-cell numbers. At last follow-up, all patients independent of immunoglobulin substitution exhibited 100% whole-blood donor chimerism. However, also among the patients still requiring immunoglobulin, 4 of 6 had 100% whole-blood donor chimerism: patient 004 had 97% whole-blood donor chimerism (lineage-specific donor chimerism not available), and patient 001 had a lineage-specific blood chimerism showing 100% donor chimerism in B cells with 89% donor chimerism within the T-cell compartment and without evidence for recurrence of his large granular lymphocytic leukemia. These data suggest that the incomplete functionality of the B-cell compartment was not due to residual host B-cell chimerism in the blood.

Outcome of indication for HSCT and PID-related complications in long-term survivors Among the long-term survivors, 11 (92%) of 12 patients had resolution of the condition constituting the primary indication of transplantation based on results of clinical evaluation and diagnostic tests (see Table E3 in this article’s Online Repository at www.jacionline.org). Interestingly, all identified PID-related complications resolved or improved after HSCT. Of note, of the 6 patients undergoing transplantation for lymphoma, 5 survived, and all were in complete remission at last follow-up (mean follow-up, 4 years and 2 months; range, 374-3285 days). DISCUSSION In a subgroup of patients with CVID, the disease can take a severe course and is associated with an increased mortality rate

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FIG 4. Reconstitution of the B-cell compartment. A, Percentage of patients withdrawn from immunoglobulin replacement (off Ig) over time. Ticks indicate last follow-up. B, B-cell numbers at last follow-up in patients still dependent on (on Ig subst.) and patients independent of (off Ig subst.) immunoglobulin substitution. Error bars show means 6 SEMs. The shaded area indicates normal range.

compared with that of the general population.8,13 Recently, HSCT has been reported in a few CVID cases to be a potentially curative treatment.18 This multicenter study was performed to provide clinicians caring for patients with CVID more robust information regarding outcome after HSCT. In our cohort the indications for HSCT were complications secondary to CVID, such as lymphoma or treatment-refractory immune dysregulation, which resolved or improved in all surviving patients. Many patients experienced years of complications before HSCT. Importantly, this study demonstrated resolution of the specific complication for which the HSCT was performed. The overall mortality of 52% is comparable with that reported for patients undergoing transplantation for complications of severe aplastic anemia,28-30 a patient cohort that has also undergone immunosuppressive pretreatment and might experience end-organ damage before proceeding to HSCT. Similarly, our cohort presented with high HCT-CI values, and we presume that HSCT was considered late in the disease course because CVID is not an established indication for transplantation. In fact, a trend of higher prevalence of liver, renal, lung, and granulomatous organ involvement before transplantation was found in deceased patients, indicating a more severe course of CVID disease compared with that seen in surviving patients. These data, although not statistically significant, are in line with findings for other transplantable immune deficiencies in which early HSCT before end-organ damage markedly improves

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outcomes.31 Considering the extended organ involvement in our cohort, patients receiving RIC had better survival. Both lower HSCT-CI values and use of RIC regimens might have contributed to the better survival observed in patients undergoing transplantation for lymphoma. In an attempt to stratify the heterogeneous cohort of patients with CVID, we divided them into those CVID with and without signs of cellular immunodeficiency. Recognition of these 2 groups might be relevant for the pathophysiology of the disease and could affect the design of future studies. Patients with CVID with signs of cellular immunodeficiency almost exclusively underwent transplantation for immune dysregulation and had higher HCT-CI values compared with patients with CVID without signs of cellular immunodeficiency. Despite the more favorable HCT-CI values in the latter group, mortality did not differ significantly between the 2 groups. This was most likely due to an unexpectedly high incidence and severity of GvHD in the CVID subgroup without signs of cellular immunodeficiency contributing to transplantation-related mortality. The high incidence of GvHD (64%) in our cohort can be attributed to limited GvHD prophylaxis, which was generally administered as single agent. Therefore intensification of GvHD prophylaxis should be considered for future patients. The high incidence and severity of GvHD in patients with CVID without signs of cellular immunodeficiency might suggest contributions from complications related to CVID. Given the role of increased TNF levels during the early phase of GvHD,32,33 increased serum TNF levels reported in patients with CVID34-36 might be one of these factors. Further prospective studies will be needed to dissect the susceptibility to GvHD in this subgroup of patients. Humoral immune reconstitution was achieved in 50% of longterm surviving patients. This is a surprisingly low number because leukocytes and platelets engrafted in the expected time frame,37 donor chimerism was complete in nearly all long-term survivors, and the frequency of boost transplantations was comparable with that in previous reports.31 Normally, in patients not affected by PIDs, B-cell recovery occurs within months38,39 and can take up to 2 years in children.40 In pretransplantation immunocompetent adults and children, the need for life-long immunoglobulin replacement after HSCT is a rare event. Delayed B-cell reconstitution has been reported in patients treated with rituximab after HSCT41 or in patients with GvHD42; however, we could not identify this association in our cohort (data not shown). Up to 35% of patients with CVID carry a partial block of B-cell development in the BM,14 and in vitro CVID-derived BM stroma cells showed altered cytokine profiles.43 Persisting humoral immunodeficiency in our cohort was associated with lower B-cell numbers, and therefore we speculate that in these patients the BM microenvironment might not be supportive of normal B-cell development. Detailed analysis of the B-cell phenotype and lineage-specific chimerism will be required to substantiate this hypothesis. Despite the limitations of a retrospective study, we conclude from the collected data that HSCT can be an effective curative therapy for CVID with secondary complications, but it is limited in its application by high mortality and susceptibility to severe GvHD. HSCT was beneficial in all surviving patients. Indeed, HSCT was safe and effective in patients with CVID with lymphoma and severe immune dysregulation. Patients uniformly resolved the complication that led to the HSCT. Although half of

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the surviving patients remained dependent on immunoglobulin replacement therapy, HSCT can change the course of CVID after HSCT by turning a patient with a complex form of CVID into an ‘‘infection-only’’ patient9,10 with better prognosis.13 Better clinical and laboratory risk stratification is required to guide patient selection and timing of HSCT because the current high treatment-related mortality remains a major challenge. The increased mortality is clearly multifactorial and might differ between patient subgroups; however, our data suggest that intensified GvHD prophylaxis and RIC strategies should be carefully considered. Furthermore, a major effort in functional and genetic characterization of patients with signs of immune dysregulation should be undertaken early during the disease to identify patients with hypomorphic forms of genetically defined PIDs for which the indication for HSCT may be established. Nevertheless, a substantial number of patients with complicated forms of CVID will remain genetically undefined, and HSCT is a reasonable therapeutic intervention for those with a severe course. Therefore the establishment of an ESID/European Society for Blood and Marrow Transplantation–based registry with prospectively defined clinical and immunologic assessments before and after HSCT will be of great value to better identify the risks and optimal strategies in HSCT. We thank Sam Doerken (CCI) for statistical advice, Virginie Courteille from the SCETIDE register for support in patients recruitment, Yoshiaki Shikama (Division of Infection, Immunology and Rheumatology, Kanagawa Children’s Medical Center), Akihisa Sawada (Osaka Medical Center and Research Institute for Maternal and Child Health) for patient care, and Thomas Vraetz (CCI) for critical reading of the manuscript.

Clinical implications: HSCT in patients with CVID might improve PID-related complications and cure hypogammaglobulinemia but is associated with high mortality and high GvHD incidence. Cure of this chronic disease is possible, but patient selection and transplant refinement are critical. REFERENCES 1. Al-Herz W, Bousfiha A, Casanova JL, Chatila T, Conley ME, Cunningham-Rundles C, et al. Primary immunodeficiency diseases: an update on the classification from the international union of immunological societies expert committee for primary immunodeficiency. Front Immunol 2014;5:162. 2. Wehr C, Kivioja T, Schmitt C, Ferry B, Witte T, Eren E, et al. The EUROclass trial: defining subgroups in common variable immunodeficiency. Blood 2008;111:77-85. 3. Piqueras B, Lavenu-Bombled C, Galicier L, Bergeron-van der Cruyssen F, Mouthon L, Chevret S, et al. Common variable immunodeficiency patient classification based on impaired B cell memory differentiation correlates with clinical aspects. J Clin Immunol 2003;23:385-400. 4. Giovannetti A, Pierdominici M, Mazzetta F, Marziali M, Renzi C, Mileo AM, et al. Unravelling the complexity of t cell abnormalities in common variable immunodeficiency. J Immunol 2007;178:3932-43. 5. Moratto D, Gulino AV, Fontana S, Mori L, Pirovano S, Soresina A, et al. Combined decrease of defined B and T cell subsets in a group of common variable immunodeficiency patients. Clin Immunol 2006;121:203-14. 6. Driessen GJ, van Zelm MC, van Hagen PM, Hartwig NG, Trip M, Warris A, et al. B-cell replication history and somatic hypermutation status identify distinct pathophysiologic backgrounds in common variable immunodeficiency. Blood 2011;118:6814-23. 7. Kamae C, Nakagawa N, Sato H, Honma K, Mitsuiki N, Ohara O, et al. Common variable immunodeficiency classification by quantifying T-cell receptor and immunoglobulin k-deleting recombination excision circles. J Allergy Clin Immunol 2013;131:1437-40.e5. 8. Chapel H, Lucas M, Lee M, Bjorkander J, Webster D, Grimbacher B, et al. Common variable immunodeficiency disorders: division into distinct clinical phenotypes. Blood 2008;112:277-86.

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38.

39. 40.

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43.

HLA-identical relatives in patients with hematologic cancers. N Engl J Med 2001;344:175-81. Cavazzana-Calvo M, Andre-Schmutz I, Dal Cortivo L, Neven B, Hacein-BeyAbina S, Fischer A. Immune reconstitution after haematopoietic stem cell transplantation: obstacles and anticipated progress. Curr Opin Immunol 2009; 21:544-8. Geddes M, Storek J. Immune reconstitution following hematopoietic stem-cell transplantation. Best Pract Res Clin Haematol 2007;20:329-48. Avanzini MA, Locatelli F, Dos Santos C, Maccario R, Lenta E, Oliveri M, et al. B lymphocyte reconstitution after hematopoietic stem cell transplantation: functional immaturity and slow recovery of memory CD271 B cells. Exp Hematol 2005;33: 480-6. Petropoulou AD, Porcher R, de Latour RP, Xhaard A, Weisdorf D, Ribaud P, et al. Increased infection rate after preemptive rituximab treatment for Epstein-Barr Virus reactivation after allogeneic hematopoietic stem-cell transplantation. Transplant J 2012;94:879-83. Glauzy S, Soret J, Fournier I, Douay C, Moins-Teisserenc H, Peffault de Latour R, et al. Impact of acute and chronic graft-vs-host disease on human B-cell generation and replication. Blood 2014;124:2459-62. Isgro A, Marziali M, Mezzaroma I, Luzi G, Mazzone AM, Guazzi V, et al. Bone marrow clonogenic capability, cytokine production, and thymic output in patients with common variable immunodeficiency. J Immunol 2005;174: 5074-81.

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REFERENCE E1. Comans-Bitter WM, de Groot R, van den Beemd R, Neijens HJ, Hop WC, Groeneveld K, et al. Immunophenotyping of blood lymphocytes in childhood. Reference values for lymphocyte subpopulations. J Pediatr 1997;130:388-93.

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FIG E1. GvHD, comorbidity index, and mortality. A-C, HCT-CI stratified for survival, GvHD, and donor type. HCT-CI: dark gray, high risk of transplant-related mortality; light gray, intermediate risk of transplant-related mortality; and white, low risk of transplant-related mortality. D, Karnofsky index before transplantation (Tx) in deceased versus surviving patients. E and F, Survival curve of patients with CVID after HSCT stratified according to year of transplantation (before and from 2000 onward; Fig E1, E) and according to pediatric _18 years) status (Fig E1, F). The number (age at transplantation of patients in each group is indicated in parentheses. G and H, Occurrence and outcome of GvHD stratified according to absent (dark blue), mild (light blue), and severe (indigo) GvHD in patients with CVID without cellular immunodeficiency (Fig E1, G) and in patients with CVID with signs of cellular immunodeficiency (Fig E1, H).

Age Age at at Age at Patient diagnosis onset HSCT no. (y) (y) (y)

T-cell number before HSCT

CVID without signs of cellular ID 001 37 37 40 12

T-cell proliferation before HSCT

Infections

LN SPL

GRA

LUNG

N

N

URTI, pneumonia

1

1

38

N

NA

URTI, pneumonia

0

1

44

N

NA

URTI, pneumonias

1

1 Lung

Granuloma

N

URTI, cellulitis

1

1 Lung

Granulomata

NA N

URTI URTI

0 1

1 3

URTI, pneumonia, meningitis

1

0

Bronchiectasis fibrosis

003

28

005

42

28

48

007 009

40 32

35 24

50 45

616/mL (normal, >700 mL) N N

011

4

3

18

N

N

018

6

8

N, normal g/d T cells

NA

URTI

1

1

LIP, bronchiectasis

019

12

12

17

N

NA

URTI, pneumonias

1

1 Lung spleen

Granuloma

020

12

10

16

N, normal g/d and naive T cells

N

URTI

1

1 Lung spleen LIP LN kidney

021

6

7

14

N

N

0

1

026

13

13

16

NA

0

0 GI tract

028

11

1

13

Pneumonia, recurrent Giardia lamblia infection, rec. pos. CMV PCR

1

1 Kidney lung

030

17

758/mL, (normal, >800 mL) under steroids 756/mL, (normal, >800 mL) under tacrolimus, steroids, normal g/d and naive T cells NA

URTI, rec. localized HSV infection URTI

NA

URTI, pneumonias, severe VZV 13

2

0

NA

URTI, aspergillosis (high-dose steroid)

1

4 Liver lung

CVID with signs of cellular ID 004 5 30

N

AI

LIV

Malignancy

Comments

LGL leukemia Angioimmunoblastic T-cell lymphoma Sarcoid-like lesions, esophageal varices Lymphocytic colitis

NLH (duodenum) Sprue-like enteropathy, NLH (ileum, colon), chronic HP infection Sprue-like enteropathy, atrophic gastritis, eosinophilic duodenitis

ITP AIHA

AION

EBV associated DLBCL

Vitiligo ITP AIHA

NRH

AML Extranodal MZL, transformation into high-grade lymphoma

AIN

Loss of B cells over time Homozygous TACI mutant C104R

NLH

ITP

ITP AIHA AIN

Bronchiectasis

Enteropathy (no biopsy specimen available) Crohn disease

GLILD

Nonspecific chronic inflammation (duodenum, colon)

ITP AIHA

No mutation in IFN-gR1 IL-12Rb, WASP, IL-2Rg No mutation in IFN-gR1 IL-12Rb, WASP, IL-2Rg

Granulomatous hepatitis

Pancreatitis

Chronic ‘‘transaminitis’’

Compound heterozygous TACI mutant: C104R, A181E

DLBCL (EBV2), EBV associated LPD of the lung Granuloma, fibrosis Sclerosing cholangitis

ITP

NGS no mutation found

Granulomata

(Continued)

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26

21

AIC

Bronchiectasis mild fibrosis

002

N

GI

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TABLE E1. Clinical characteristics of patients

Age Age at at Age at Patient diagnosis onset HSCT no. (y) (y) (y)

T-cell number before HSCT

T-cell proliferation before HSCT

006*

29

22

46

589 mL, (normal, >700 mL)

NA

008

6

2

21

N

NA

013

7

6

12

N

N

014

7

1 mo

18

N

015

9

2

14

N

016

13

1

24

023

6

1

14

590 mL, (normal, >700 mL) N

024

12

2

17

027

6

029

7

17

1

19

462/mL (normal, >700 mL) 487/mL, (normal, >700 mL) under tacrolimus, steroids 215/mL, (normal, >700/mL) under steroids

Infections

LN SPL

GRA

LUNG

URTI, pneumonia, atypical mycobacterial infection, CMV colitis URTI, pulmonary aspergillosis (neutropenia) URTI, CMV colitis

1

1 Lung

Bronchiectasis COP, mild fibrosis

1

1

LIP, COP

1

1

LIP

Reduced under URTI, pneumonias, immune CMV colitis, suppression positive EBV PCR

1

1

Bronchiectasis

0

0

0

1 Liver lung

LIP, bronchiectasis Tiny granuloma, bronchiectasis Bronchiectasis

NA N

URTI, cellulitis, candida esophagitis URTI, oral candidiasis

NA

URTI, pneumonia, 1 recurrent HSV infections

1

NA

URTI, hemorrhagic VZV

0

0

N

URTI, chronic norovirus and parechovirus diarrhea

1

1

N

URTI, bacterial meningitis

0

0

GI

AIC

AI

CMV colitis

LIV

CMV hepatitis, esophageal varices

Malignancy

Comments

Bilateral, invasive ductal carcinoma of the breasts

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TABLE E1. (Continued)

AIN and pure white cell aplasia Unspecific colitis responsive to AZA and low-fiber diet, CMV colitis Sprue-like enteropathy, ulcerative colitis

Agranulocytosis, AIHA, ITP

Pancreatitis

Unspecific hepatitis

Seronegative polyarthritis, sicca syndrome, thyroiditis

EBV associated, localized (gut), monomorphic lymphoproliferation

Recurrent Candida species esophagitis ITP

Granuloma

Chronic unspecific hepatitis

Hodgkin lymphoma (nodular sclerosis type)

Optic neuritis

Steroid-responsive enteropathy

Interstitial lung disease, bronchiectasis

Autoimmune enteropathy

ITP, AIHA, AIN

Thyroiditis

CD40 deficiency excluded

CVID with signs of cellular immunodeficiency defined patients fulfilling the inclusion criteria for CVID but with opportunistic infection or infections in their history or unusual low T-cell numbers with normal T-cell proliferation. Lymphadenopathy and splenomegaly values were as follows: 0, absent; 1, present at transplantation; 2, resolved before transplantation; 3, unknown; 4, splenectomized. ADA, Adenosine deaminase deficiency; AI, autoimmune phenomena other than cytopenia; AIC, autoimmune cytopenia; AIHA, autoimmune hemolytic anemia; AIN, autoimmune neutropenia; AION, anterior ischemic optic neuropathy; AZA, azathioprine; CMV, cytomegalovirus; COP, chronic organizing pneumonia; CRMO, chronic nonbacterial osteomyelitis; DLBCL, diffuse large B-cell lymphoma; GI, enteropathy; GLILD, granulomatous-lymphocytic interstitial lung disease; GRA, granulomatous inflammation; ID, immunodeficiency; ITP, idiopathic thrombocytopenic purpura; LGL, large granular lymphocyte; LIP, lymphocytic interstitial pneumonitis; LIV, liver involvement; LN, lymphadenopathy; LPD, lymphoproliferative disease; LUNG, lung involvement; MZL, marginal zone lymphoma; N, normal T-cell number or T-cell proliferation (age-adjusted reference values, according to Comans-Bitter et alE1); NA, not available; NGS, next-generation sequencing; NLH, nodular lymphoid hyperplasia; NRH, nodular regenerative hyperplasia; PNP, purine nucleoside phosphorylase deficiency; RAG, recombination-activating gene; SPL, splenomegaly; TACI, TNF receptor superfamily, member 13B; URTI, upper respiratory tract infection; WAS, Wiskott-Aldrich syndrome. *Longstanding CVID with typical infection profile and normal lymphocyte counts before first opportunistic infection and decrease of lymphocyte counts. J ALLERGY CLIN IMMUNOL nnn 2014

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TABLE E2. Additional reported (severe) adverse events (complementing Table III) Adverse event

Infections

Frequency

13/25 (52%)

VOD Drug-induced organ toxicity Malignancy

2/25 (8%) 5/25 (20%) 2/25 (8%)

Others

2/25 (8%)

Specification

AV, CMV, EBV, BK virus, HHV-6, Aspergillus species Renal, liver, CNS PTLD, squamous cell carcinoma of the lower lip Seizures caused by hypoglycemia, mucositis grade III-IV

AV, Adenovirus; CMV, cytomegalovirus; CNS, central nervous system; HHV-6, human herpesvirus 6; PTLD, posttransplantation lymphoproliferative disease; VOD, veno-occlusive disease.

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TABLE E3. Outcome of indication for HSCT and PID-related complications in long-term survivors Long-term survivors

Resolution Partial resolution No resolution Unknown

IND

LYM

SPL

LN

GRA

LUNG

GI

AIC

AI

LIV

11/12 (92%) 1/12 (8%)

5/5 (100%)

4/6 (67%) 2/6 (33%)

5/7 (71%)

1/3 (33%) 2/3 (67%)

2/5 (40%) 2/5 (40%)

4/5 (80%)

2/4 (50%) 1/4 (25%) 1/4 (25%)

2/3 (67%)

1/2 (50%) 1/2 (50%)

2/7 (29%)

1/5 (20%) 1/5 (20%)

1/3 (33%)

In this table only long-term survivors (n 5 12) were incorporated. Among these, only patients displaying the PID-related complication before transplantation were mentioned in the respective column. For example, 6 long-term survivors had splenomegaly before transplantation, which resolved in 4 cases after HSCT. A single subject can be included in several columns depending on how many complications he or she had. AI, Autoimmunity other than cytopenia; AIC, autoimmune cytopenia; GI, enteropathy; GRA, granulomata; IND, condition/disease for which HSCT was indicated; LIV, liver involvement; LN, lymphadenopathy; LUNG, lung involvement excluding bronchiectasis; LYM, lymphoma; SPL, splenomegaly.