An attempt to personalize approaches to the treatment of patients with amyotrophic lateral sclerosis: analysis of immunological parameters of bone marrow cells and clonal hematopoiesis

Introduction. Recent advances in pathogenesis of neurodegenerative diseases have shown that inflammation is a key factor of progression. The levels of T cells, NK cells, monocytes and neutrophils are found to be increased in amyotrophic lateral sclerosis (ALS) patients and are associated with disease progression. The aim of the study was to evaluate the dynamics of immunological parameters of bone marrow cells and clonal hematopoiesis in patients with ALS. Material and methods. The ALS group included 10 patients (M/F 4/6). The mean age was 53.9±9.9 years (95 % CI, 28–47). Whole-exome sequencing and immunophenotyping of CD34+ subsets in bone marrow cells were performed before the start of therapy (point 1) and during the first 6 months of follow-up (point 2). The control group included 10 bone marrow donors, mean age was 39.5±8.5 years (CI 95 %, 46–66, p=0.007). CHIP was detected in 3 cases (30 %) before therapy. Results. The peripheral blood mononuclear cells (PBMCs) were collected after four-day G-CSF administration. The mean number of collected CD34+ cells was 184.5±121.5x106 (95 % CI, 126.0–444.8). Patients received fludarabine 25 mg/ m2 /day, on days 1 and 2. To induce hematopoietic stem cell proliferation the harvested cells were incubated with human placenta double-stranded DNA fragments (Panagen®) ex vivo. The obtained CD34+ cells were reinfused intravenously 48 hours post fludarabine. A significant increase in the number of CD34+CD13+ and CD34+CD123+ HSCs was detected after immunomodulatory therapy and reinfusion of transdifferentiated CD34+ HSCs. The level of CD34+CD44+ in bone marrow significantly decreased. Levels of CD34+CD7+, CD34+CD2+ and CD34+CD56+ showed a trend toward increased mean value and widened confidence intervals compared with the values before treatment, although they did not reach statistical significance. After therapy, two cases demonstrated absence of CHIP while, one case showed a decrease in the allelic variant frequency (VAF). During follow-up the mean ALSFRS-R score did not change (40±1 points (CI 95 %, 37.5–40) vs. 40±2 (CI 95 %, 38–42.5), p>0.05). Conclusion. Our study is the first attempt to characterize the subsets of bone marrow HSCs in ALS. Our results have clinical significance, although they are limited and preliminary. First, they demonstrate that bone marrow is one of the organs responding to immune-mediated neuroinflammation. Second, the issue of whether the abnormal immune response leading to neurodegeneration can be restarted and corrected is raised. Moreover, preliminary results indicate a possible link between CHIP and ALS and point the way to eliminating aberrant clones. 

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