Hypomorphic RAG deficiency: impact of disease burden on survival and thymic recovery argues for early diagnosis and HSCT

Research output: Contribution to journalResearch articleContributedpeer-review

Contributors

  • Inborn Errors Working Party (IEWP) of the European Society for Immunodeficiencies (ESID) and European Society for Blood and Marrow Transplantation (EBMT) and the Primary Immune Deficiency Treatment Consortium (PIDTC) - (Author)
  • C. Schuetz - , Department of Paediatrics (First author)
  • J. Gerke - , Department of Paediatrics (Author)
  • Ludwig Maximilian University of Munich
  • University of South Florida
  • Johns Hopkins University
  • Great Ormond Street Hospital for Children NHS Trust
  • National Cancer Institute (NCI)
  • Children's Memorial Health Institute
  • University of Utah
  • Erciyes University
  • Pirogov Russian National Research Medical University
  • National Institutes of Health (NIH)
  • Leiden University
  • University of Oslo
  • University of California at Irvine
  • University of California at San Francisco
  • Newcastle University
  • University of Zurich
  • Children's Hospital of Philadelphia (CHOP)
  • University of Pennsylvania
  • IRCCS Istituto Giannina Gaslini - Genova
  • KU Leuven
  • Royal Free London NHS Foundation Trust
  • Vall d'Hebron Research Institute (VHIR)
  • Ministry of Health of the Republic of Belarus
  • University of Sydney
  • Great North Children's Hospital
  • Ulm University
  • Université Paris Cité
  • College de France
  • INSERM - Institut national de la santé et de la recherche médicale
  • Necker–Enfants Malades Hospital
  • Imagine Institute
  • Helmholtz Zentrum München - German Research Center for Environmental Health

Abstract

Patients with hypomorphic mutations in the RAG1 or RAG2 gene present with either Omenn syndrome or atypical combined immunodeficiency with a wide phenotypic range. Hematopoietic stem cell transplantation (HSCT) is potentially curative, but data are scarce. We report on a worldwide cohort of 60 patients with hypomorphic RAG variants who underwent HSCT, 78% of whom experienced infections (29% active at HSCT), 72% had autoimmunity, and 18% had granulomas pretransplant. These complications are frequently associated with organ damage. Eight individuals (13%) were diagnosed by newborn screening or family history. HSCT was performed at a median of 3.4 years (range 0.3-42.9 years) from matched unrelated donors, matched sibling or matched family donors, or mismatched donors in 48%, 22%, and 30% of the patients, respectively. Grafts were T-cell depleted in 15 cases (25%). Overall survival at 1 and 4 years was 77.5% and 67.5% (median follow-up of 39 months). Infection was the main cause of death. In univariable analysis, active infection, organ damage pre-HSCT, T-cell depletion of the graft, and transplant from a mismatched family donor were predictive of worse outcome, whereas organ damage and T-cell depletion remained significant in multivariable analysis (hazard ratio [HR] = 6.01, HR = 8.46, respectively). All patients diagnosed by newborn screening or family history survived. Cumulative incidences of acute and chronic graft-versus-host disease were 35% and 22%, respectively. Cumulative incidences of new-onset autoimmunity was 15%. Immune reconstitution, particularly recovery of naïve CD4+ T cells, was faster and more robust in patients transplanted before 3.5 years of age, and without organ damage. These findings support the indication for early transplantation.

Details

Original languageEnglish
Pages (from-to)713-724
Number of pages12
JournalBlood
Volume141
Issue number7
Publication statusPublished - 16 Feb 2023
Peer-reviewedYes

External IDs

PubMed 36279417
ORCID /0009-0003-6519-0482/work/146166633

Keywords

Keywords

  • Infant, Newborn, Humans, Tissue Donors, T-Lymphocytes, Hematopoietic Stem Cell Transplantation/adverse effects, Early Diagnosis, Cost of Illness, Graft vs Host Disease/diagnosis, Retrospective Studies, Unrelated Donors, Transplantation Conditioning

Library keywords