A 22-year-old woman presented with an 8-year history of a slow-growing mass involving the buttocks and right leg.

She had received a diagnosis of neurofibromatosis type 1 (NF-1) at the age of 18 years, when she had presented with axillary freckling, a family history of NF-1, caf au lait macules, and scoliosis. A physical examination at the current presentation revealed hypertrophy of the right leg and an irregular pendulous mass with overlying hyperpigmentation and hypertrichosis involving the right trunk, right buttock, and right leg (Panels A and B). Lisch nodules were seen on ophthalmologic examination. Histopathological examination showed spindle cells arranged in short fascicles that infiltrated the dermis and underlying soft tissues a finding that was suggestive of a massive softtissue neurofibroma. The patient underwent surgical debulking to alleviate the pain and improve the cosmetic appearance. Massive soft-tissue neurofibroma is an uncommon type of neurofibroma and is usually found only in patients with NF-1. Massive soft-tissue neurofibroma involving hypertrophy of the limb termed elephantiasis neuromatosa is a rare clinical presentation.
Thiele et al. (Jan. 31 issue)1 analyze donor exposures in recipients of pooled platelet concentrates as compared with apheresis platelets. They estimated a 44% increase in total exposures with pooled platelet concentrates instead of a 300 to 500% increase with only platelet exposures. Their assumption that the patient's risk of one donor exposure is equivalent for all blood products is incorrect in cases of bacterial contamination and reactions associated with the plasma. Furthermore, they assumed that the efficacy of apheresis platelets is equivalent to that of pooled platelet concentrates. The Platelet Dose Study (PLADO) investigators found a higher 4-hour platelet-count increment with apheresis platelets than with pooled platelet concentrates (P=0.002), and the 24-hour platelet increment was higher with apheresis platelets at all doses (P=0.015).2 The Trial to Reduce Alloimmunization to Platelets (TRAP) showed similar results.3 We calculated a 229% higher total donor exposure in the TRAP groups of patients who received pooled platelet concentrates than in the patients who received apheresis platelets; this increase was 109% when

adjusted to 4 units of platelets per pooled platelet concentrate (Table 1TABLE 1

Patient

Donor Exposures in the TRAP Study.). The results of the PLADO and TRAP studies are consistent with the

recovery of autologous platelets from whole blood4 and apheresis platelets5 (only apheresis platelets met the criteria of the Food and Drug Administration). Therefore, total donor exposures are higher with pooled platelet concentrates than with apheresis platelets. For some sequelae, the incremental clinical risk may approach the incremental platelet exposures. Larry J. Dumont, Ph.D. Zbigniew M. Szczepiorkowski, M.D., Ph.D. Geisel School of Medicine at Dartmouth, Lebanon, NH

larry.j.dumont@hitchcock.org
Dr. Dumont reports receiving consulting fees from Advanced Cell Technology; contract research support from Advanced Preservation Technologies, Haemonetics, Hemerus, and Terumo BCT; and consulting fees and contract research support from Fenwal (Fresenius Kabi) and New Health Sciences. Dr.

Szczepiorkowski reports receiving research support from Advanced Preservation Technologies, Haemonetics, Hemerus, New Health Sciences, and Terumo BCT; and research support and consulting fees from Fenwal (Fresenius Kabi). No other potential conflict of interest relevant to this letter was reported.
5 References Author/Editor Response

Dumont and Szczepiorkowski compared donor exposures between recipients of pooled platelet concentrates and apheresis platelets in the TRAP study. However, this study did not include plasma transfusions. Moreover, they compared a 100% supply of apheresis platelets with a 100% supply of pooled platelet concentrates. However, many countries use both pooled platelet concentrates (the standard product) and apheresis platelets (e.g., for antigen-matched platelet concentrates, cytomegalovirus-negative platelet concentrates, and shortages of pooled platelet concentrates). In our study, at Greifswald University Hospital, 11% of transfused platelets were apheresis platelets; at Hamilton Health Sciences, 35% of transfused platelets were apheresis platelets. Because the TRAP study did not include plasma transfusions and compared a 100% supply of apheresis platelets with a 100% supply of pooled platelet concentrates, the relative increase in donor exposures would be lower than the 109% calculated by Dumont and Szczepiorkowski. Although the risk of bacterial contamination might be higher in platelet-rich, plasma-derived pooled platelet concentrates that are used in the United States, this is not true of buffy coatderived pooled platelet concentrates that are used in Europe and Canada.1 Plasma-reduced pooled platelet concentrates further reduce the risk of plasma-related adverse effects.2Although platelet increments are higher after transfusion of apheresis platelets, it is unclear whether the magnitude of the platelet count increment is clinically relevant. The PLADO investigators indicate that this magnitude has no major effect on prevention of clinical bleeding. Hence, it remains uncertain whether there is any difference in adverse effects or clinical benefit between apheresis platelets and pooled platelet concentrates, especially when pooled platelet concentrates are prepared by the buffy-coat method. Thomas Thiele, M.D. Greifswald University Hospital, Greifswald, Germany Nancy Heddle, M.Sc. McMaster University, Hamilton, ON, Canada Andreas Greinacher, M.D. Greifswald University Hospital, Greifswald, Germany

greinach@uni-greifswald.de
Since publication of their let We previously reported results of our study of combined kidney and bone marrow transplantation without maintenance immunosuppression. We extended the study to include five additional patients. Here we report longer follow-up of the initial five patients and observations made after 3 years in the later cohort ( Table

1TABLE 1

Patient Characteristics and Results of Laboratory Tests.). Both trials were

sponsored by the Immune Tolerance Network and are currently closed to further enrollment.

The first five patients received the previously described conditioning regimen (regimen 1): cyclophosphamide, thymic irradiation, anti-CD2 monoclonal antibody, and an 8-to-14-month course of a calcineurin inhibitor.1 After irreversible acute humoral rejection was observed in Patient 3, who was retrospectively found to have preformed antidonor HLA class I antibodies, the regimen was modified to include two doses of rituximab before transplantation (regimen 2). Since low levels of donor-specific antibodies developed in Patients 4 and 5, the regimen was further modified to include two additional doses of rituximab (regimen 3). Patient 1 remained well, without rejection for more than 10 years. Patient 2 also remained rejection-free for more than 9 years, although mycophenolate mofetil was added after 7 years because of recurrence of his original disease, membranoproliferative glomerulonephritis. Kidney-allograft function remained stable for more than 7 years in Patient 4, but mycophenolate mofetil was initiated, since chronic humoral rejection was diagnosed at 5 years. Patient 5 remained rejection-free for 6 years, despite the development of low levels of donor-specific antibodies after discontinuation of immunosuppression. His most recent biopsy specimen at 6.8 years, however, showed minor transplant glomerulopathy (C4d-negative), which could indicate the incipient onset of chronic rejection. Patients 6, 7, and 9 received regimen 3 and successfully discontinued immunosuppression. Their condition remained stable, without evidence of rejection or donor-specific antibodies, for 3 to 4 years. Patient 8 resumed dialysis after losing kidney function due to thrombotic microangiopathy 6 months after transplantation. Immunosuppression was reinstituted in Patient 10 when cellular rejection was diagnosed 2 months after withdrawal of immunosuppression. His renal function improved but remained compromised. Although early development of donor-specific antibodies was observed, especially in the patients who received regimen 2, no donor-specific antibodies have been detected in any of the patients who received regimen 3 with intensified B-cell depletion. The risk of recurrence of original kidney disease, which occurs in patients receiving long-term immunosuppression,2 could be increased if immunosuppression is withdrawn.3 To overcome the engraftment syndrome, which causes transient renal dysfunction,4 we have considered the use of low-dose total-body irradiation rather than cyclophosphamide; to our knowledge, lowdose total-body irradiation has never caused the engraftment syndrome when used in nonhuman primates.5 In conclusion, long-term, stable tolerance can be induced in a substantial proportion of treated patients despite induction of only transient chimerism by means of combined kidney and bone marrow transplantation. Results in the second group of five patients suggest that the current B-cell depletion regimen adequately controlled the development of donor-specific antibodies but that additional modifications of the treatment regimen are needed to overcome the obstacle of the engraftment syndrome.
Tatsuo Kawai, M.D., Ph.D. Massachusetts General Hospital, Boston, MA tkawai@partners.org David H. Sachs, M.D. Massachusetts General Hospital, Boston, MA Megan Sykes, M.D. Columbia University, New York, NY A. Benedict Cosimi, M.D. Massachusetts General Hospital, Boston, MA for the Immune Tolerance Network Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

Choi et al. (Feb. 14 issue)1 describe autophagy activation in several human diseases. However, a worthy point was missed, since autophagic function in autoimmune diseases was not considered. A growing body

of evidence provides support for the involvement of autophagy in immunity and autoimmunity.2,3 Indeed, autophagy is known to have a role in thymic selection of T cells, survival of B cells, immune tolerance, and antigen presentation.2 It enables intracellular self-antigens to enter major-histocompatibility-complex class II pockets, which are subsequently recognized by activated T cells. Accordingly, autophagic dysfunction may promote the development of systemic autoimmune diseases such as lupus,4 and a failure in autophagy may play a role in autoinflammatory and autoimmune diseases such as the tumor necrosis factor receptor associated periodic syndrome and Crohn's disease.3,5 Moreover, several allelic variants of autophagyrelated genes have been linked to autoimmunity4 and autoinflammation.2 Data are lacking to clarify these issues; however, the autophagic process is probably involved in the establishment and maintenance of immune tolerance and the proper effectiveness of the immune system. Andrea Doria, M.D. Mariele Gatto, M.D. Leonardo Punzi, M.D. University of Padua, Padua, Italy

adoria@unipd.it
No potential conflict of interest relevant to this letter was reported.
5 References Author/Editor Response

We strongly agree with Doria et al. about the prospect that autophagy may contribute to the pathogenesis of autoimmune disorders. Autophagy can exert profound effects on inflammation and the regulation of innate and adaptive immunity. Indeed, autophagy can regulate core inflammatory responses (e.g., interferon production, inflammasome activation, and cytokine maturation) and contribute to efferocytosis (removal of dead or dying cells), antigen presentation, B-cell survival, regulation of antibody production, and T-cell maturation1; these processes could affect immune tolerance and the progression of autoimmune disease. In our article, we mention that single-nucleotide polymorphisms (SNPs) of ATG5, an autophagy-related gene (ATG), are associated with systemic lupus erythematosus, an autoimmune disease, and that SNPs in ATG16L1, nucleotide-binding oligomerization domaincontaining protein 2 (NOD2), and immunity-related p47 guanosine triphosphatase M protein (IRGM) genes are associated with Crohn's disease, an autoinflammatory condition. However, the effect of these SNPs on autophagy remains unclear. We add that autoimmunity develops in mice that are deficient in thymic Atg5.1 Furthermore, human and murine lupus T cells have impaired autophagy and increased activation of the mammalian (or mechanistic) target of rapamycin.2 The link between autophagy and autoimmunity remains incompletely understood, but it warrants extensive investigation for therapeutic development. We regret that we could not cite all relevant literature. Augustine M.K. Choi, M.D. Stefan W. Ryter, Ph.D. Brigham and Women's Hospital, Boston, MA

amchoi@rics.bwh.harvard.edu
Beth Levine, M.D. University of Texas Southwestern Medical Center, Dallas, TX

Since publication of their article, the authors report no further potential conflict of interest