ABSTRACT
Autoimmune diseases (AID) such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and systemic sclerosis follow a chronic relapsing course causing considerable morbidity and mortality. Immune-mediated haematological disorders, such as immune thrombocytopenic purpura (ITP) and autoimmune haemolytic anaemia, usually respond to conventional immunosuppression but can sometimes prove resistant to such therapy. These diseases may be modified only by treatment with immunosuppressive agents whose toxicity limits the dose which may be given. Immunoablative therapy has been proposed as a means of achieving profound immunosuppression and durable remissions in such patients whose disease becomes refractory to conventional treatment. However, since this approach would also result in myeloablation, a means of stem-cell rescue must be simultaneously provided. Because of the higher mortality associated with allogeneic sibling donor stem-cell transplant, autologous peripheral blood stem-cell transplantation is the currently favoured procedure
for stem-cell rescue following immunoablative therapy. However, the ideal immunosuppressive protocol and the means and degree of T-cell depletion required to prevent relapse of the AID by autoreactive T-cells is yet to be determined. Additionally, the specific disease indications for this approach to treatment have not been formally clarified. For these reasons, a liaison group between the European Group for Blood and Marrow Transplant (EBMT) and European League Against Rheumatism (EULAR) has been established. It has already announced a written consensus report with preliminary recommendations, and provided a means of data reporting to evaluate new techniques and monitor clinical outcome in order to determine whether the benefits of this approach outweigh the potential risks of this powerful immunoablative and myeloablative treatment. It is as yet uncertain whether such a procedure can result in cure of the AID. A realistic aim may, instead, be good long-term control of the disease allowing, for example, corticosteroid independence or dose reduction.
