From www.bloodjournal.org by guest on February 16, 2015. For personal use only. Human Bone Marrow Microvascular Endothelial Cells Support Long-Term Proliferation and Differentiation of Myeloid and Megakaryocytic Progenitors By Shahin Rafii, Fred Shapiro, Ruth Pettengell, Barbara Ferris, Ralph L. Nachman, Malcolm A.S. Moore, and Adam S. Asch 19% were megakaryocytic,expressingGPllb/llla orGPlb. Endothelial cellsare a major component of the bone marrow CD34+ cells derived from umbilical cord blood, cultured in (BM) microenvironment that regulate the traffickingand the upper chamber of transwell culture plates, as well as homing of hematopoietic progenitor and stem cells. In this the cells grown in direct contact with BMEC monolayers, paper, we provide evidence thatBM endothelial cells generatedprogenitorsforup to 70 days. Unstimulated (BMECs) also supportmultilineage hematopoiesis by elaboBMEC monolayers constitutively produce interleukin-6, ration of soluble cytokines. Hematopoietic progenitor cells incubated in direct contactwith BMEC monolayers, or physi- Kit-ligand, granulocyte colony-stimulating factor, and granulocytemacrophagecolony-stimulatingfactor.Thesedata cally separated by microporous membrane, expanded fivesuggest that BMEC regulate proliferation of hematopoietic fold to sevenfold at 7 days, in the absence of exogenous long-termculture initiating cells by elabcytokines. Plow cytometric analysis of proliferating progeni-progenitor cells and tor cells grown in the presence of BMEC monolayers showed oration of lineage-specific cytokines. 0 1995 by The American Societyof Hematology. that by day 14 of coculture, 70% to 80% of hematopoietic cells were myeloid, expressing CD15 or CD14, and 14% to T HE BONE MARROW (BM) microenvironment is a complex three-dimensional structure where hematopoietic cells proliferate, mature, migrate into the sinusoidal space and enter the circulation in an exquisitely regulated fashion. Stromal cells within the BM microenvironment provide a suitable environment for self-renewal, proliferation, and differentiation of hematopoietic stem cells."' BM stromal cells consisting of endothelial cells, fibroblasts, reticular cells, monocytes, osteoclasts, osteoblasts, and adipocytes secrete cytokines and produce extracellular matrix in addition to providing direct cellular contact that regulates hematopoiesis."6 Our understanding of stromal regulation of hematopoiesis derives largely from investigations of long-term human BM culture (LTBMC).2.3.7In LTBMC systems, the irradiated stromal elements, which are comprised ofBM fibroblasts, adipocytes, occasional endothelial cells, and macrophages, are seeded with hematopoietic stem and progenitor cells in the presence of standard cell culture medium supplemented with horse serum, fetal calf serum (FCS), and hydrocortisone.' BM stroma used in LTBMC system support the proliferation of long-term culture initiating cells (LTCICs),' and proliferation of hematopoietic progenitors for several BM stromal cells and fibroblast cell lines support the proliferation of predominantly myeloid progenitors. Murine lymphoid progenitors can only be expanded in selected culture conditions originally described by Whitlock et Although stromal cells used in LTBMC occasionally contain a small percentage of contaminating endothelial cells, the relative contribution of this cell type in the regulation of hematopoiesis is not well established.'0*'' The anatomic location and complex network ofBM endothelial cells (BMECs) within the BM microenvironment and its close association with mature hematopoietic elements suggests that it may regulate both early and late proliferation of hematopoietic elements. Much of the study of regulation of hematopoiesis by endothelial cells derives from studies of human umbilical vein endothelial cells (HUVECs). Other than macrophage colony-stimulating factor (M-CSF) and Kit-ligand, resting vascular endothelial cells such as HUVECs have not been reported to constitutively produce significant quantities Blood, Vol86, No 9 (November l), 1995: pp 3353-3363 of hematopoietic cytokines.'*." However, stimulation of HUVEC monolayers with interleukin-1 (IL- 1) or tumor necrosis factor results in production of cytokines which include IL1, IL-4, IL-6, granulocyte-macrophage CSF (GM-CSF), and granulocyte CSF (G-CSF).'2s'4-20 Phorbol ester-stimulated HUVEC monolayers express messenger RNA for IL- 1 1, but IL-11 protein has notbeen detected either in resting or phorbol myristate acetate (PMA)-activated HUVECs by IL-11 bioassays or enzyme-linked immunosorbent assay (ELISA)." In addition, resting vascular endothelium constitutively produces factors that may regulate hematopoiesis, such as basic fibroblast growth factor (FGF),22-25transforming growth factor p (TGF-p),22 and platelet-derived growth factor.26Human endothelial cells have recently been reported to express receptors for IL-3, kit-ligand, erythropoietin, thrombopoietin, and basic FGF."~.27~29 Finally, expression of adhesion molecules by resting and activated endothelium may play a critical role in regulating the transit of CD34+ progenitor and mature blood cells in and out of the BM. We have recently reported the isolation and characterization ofBMECs." In this report we provide evidence that resting BMEC monolayers support long-term hematopoiesis, specifically myelopoiesis and megakaryocytopoiesis, by the From the Department of Hematology-Oncology, New York Hospital-Come11 Medical Center: and The Laboratory of Developmental Hematopoiesis, Sloan-Kettering Institute, New York, NY. Submitted March 24, 1995: accepted June 28, 1995. Supported by Grants No. KO8-HL-02926, ROI-HL-44389,K08HL-02541, P50-HL-18828,ROI-DK-42693,ROI-CA-59461, and ROI-HL-46546 from the National Institutes of Health. A.S.A. and S.R. received support from the Dorothy Rodbell Cohen Foundation for Sarcoma Research and The Rich Foundation. Address reprint requests to Shahin Rafii, MD, Department of Hematology-Oncology, NewYork Hospital-Cornel1 Medical Center, Room C-648, 1300 York Ave, New York, NY 10021. The publication costs of this article were defrayed in part by page charge payment. This article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C. section 1734 solely to indicate this fact. 0 1995 by The American Society of Hematology. OOO6-4971/95/8609-0036$3.00/0 3353 From www.bloodjournal.org by guest on February 16, 2015. For personal use only. 3354 elaboration of lineage-specific cytokines. BMEC monolayers maintain their cellular integrity during long-term coculture experiments, and do not require immortalization or growth inhibition with irradiation, allowing the study of the physiologic role of these cells in regulation of hematopoietic cell trafficking, proliferation, and differentiation in vitro. In addition, we provide evidence thatdirect contact between BMECs and CD34+ progenitor cells may augment megakaryocyte proliferation and enhance hematopoietic progenitor cell expansion. RAFll ET AL at 4°C. The majority of MoAb used in these experiments (Table I wereconjugated with fluorescein(FITC),phycoerythrin(PE). or rhodamine (RDI j. Even though the endothelial cell monolayers re- mained intact during the experimental period reported here. a few endothelial cells could have detached during demidepopulation of hematopoieticcellsgrown in directcontact with BMECs or HUVECs. As a result. the demidepopulated cells were initially stained with CD45, which stains all hematopoieticcells. All subsequent staining was gated on CD45" cells. Megakaryocyteswere quantified by MoAbstoGPIlb/IlIaand GPlb. Three different conjugated MoAbs that were specific for different epitopes of GPllb/lIla, were 10E5, PLTI-FITC (Coulter), and MATERIALS AND METHODS P2-FITC(Immunotech).UnconjugatedMoAb lOE5 gavesimilar results to P2 and PLTI. CD61 (GPIlIa) was another marker used to Isolation of endothelial cells from BM aspirate. After obtaining consent, BM aspirates were obtained with a standard Jamshidi needle confirm the presence of megakaryocytes. Ulex europeaus is a lectin that binds to human endothelial cells as well as subtypes of human in preservative free heparin (SO UlmL) from posterior or anterior erythroid precursors and megakaryocytes (unpublished data. Novemiliac crests of normal volunteer donors undergoing BM harvest at ber 1994). Because no glycophorin A+ cells were detected in coculMemorial Sloan-Kettering Cancer Center (New York, NY). BMECs ture experiments, we used Ulex europeaus conjugated with PE o r were isolated as described recently."' Briefly, the BM aspirate was FITC to confirm the presence of megakaryocytes proliferating on passaged through a 40-pm nylon filter (Falcon, Lincoln Park, NJ), the transwell plates. and the retained stromal elements were digested withS mL of 0.I % A relatively high number of CD34' cells isolated from umbilical collagenase for 20 to30 minutes at 37°C. Subsequently, the digested cord blood (CB)orperipheral blood (PB) mononuclearcells by material was passaged througha 22-gauge needle, and thenrefiltered immunoadsorption technique stain positively with GPllb/lIla antithrough another 40-pm filter to obtain microvessel fragments. The body. This false-positive result is caused by nonspecific binding o f microvessel explants were cultured in endothelial cell growth meplatelets or platelet dust to CD34+ cells. To circumvent this problem, dium (ECGM) containing M199 medium (MA Bioproducts, WalkCD34' cells were washed three timeswith phosphate-buffered saline ersville, MD), heparin 90 pg/mL (Sigma Chemical CO, St Louis, (PBS) and 1 mmol/L EDTA and resuspendedin PBS for immunohisMO), 20% FCS, endothelial cell growth factor (ECGF) 20 &mL tochemicalstaining or flow cytometryanalysis with antibodies to (OrganonTeknikaCorp,Durham,NC) or l0 ng/mL of vascular GPIIb/IlIa complex.By this method. only 2% of cytospun cells were ECGF (VEGF) (PeproTech, Rocky Hill, NJ), L-glutamine 2 mmoll GPIIb/lIIa+. L (Sigma) penicillin (80 U/mL), and streptomycin (80 ,ug/mL), for CD2-RDI (Leu-%), CD3-RD1, CD4-RDI (T4), CD8-RDI (TXj. 5 to 7days.Subsequently,theendothelialcellswereselectively CDI9-FITC (B4), and CD20-FITC (B 1 ) were used for detection of isolatedby Ulex europeausselectionasdescribed previously'" or lymphoid series. CD14 (Leu"3-FITC. and M02-RDI clone) were alternatively,thefibroblastscontaminatingtheculturesweremeused for detection of monocytes. CD33-PE (Leu-MY), which binds chanically weeded out." The purity of the BMEC monolayers were to myeloidcells in additiontoearlymegakaryocyticprecursors, assessed by metabolic labeling with Dil-ac-LDL, and immunohistowas used as a marker for determination of differentiation state of chemical staining with monoclonal antibody (MoAb) to factor VIW hematopoietic progenitor cells. CDI5-FTTC (Leu-M1) was used for von Willebrand factor (vWF). On average, 9.5% to 98% of BMEC detection of early and late myeloid precursors. Although CD I3 (Leumonolayers had characteristic staining with factor VIII/vWF antiM7) is a suitable marker for detection of myeloid precursors, we body, or were metabolically labeled with Dil-ac-LDL. could not use this marker in coculture experiments because it is also The pure BMEC collected from each wash were pooled, centriexpressed and released by endothelial cells. HPCA-2-PE. QBEndfuged, then resuspended in ECGM and plated on gelatin-coated sixIO-FITC, and 1 1, I .6 were three MoAbs used for detection of CD34 well Costar tissue culture dishes (Costar, Cambridge, MA). For cocells during coculture experiments. culture experiments confluent monolayers of BMEC, HUVEC, or Controls were isotype-matched nonimmune lgGs and FITC. PE. BM, stroma were incubatedwith CD34' cells in a moditied coculture or RDl-conjugated antimouse IgG F(ab)2. Cell-associated immunomedium containing Iscove's modified Dulbeccos medium (IMDM; fluorescencewasassayed by quantitative flow cytometryCoulter MABioproducts),20%FCS, penicillin (80 U/mLj,streptomycin EPICS, available at Cornell Medical College (New York, NY). (80 pg/mL), with or without 0.5 pg/mL of heparin and 0.5 ng/mL Immunohistochemit.altechnique.\. MoAbs to factorVIIIIvWF of ECGF. HUVEC monolayers were cultivated in ECGM, by the (Dako,Glostrup,Denmark),CD34(HPCA-2,BectonDickinson. technique described by Jaffe et al." BM stroma were obtained from MountainView, CA), intercellularadhesionmolecule (ICAMj plating BM aspirate, as previously described.x The BM stroma were (AMAC).vascular cell adhesionmolecule(VCAM)(AMAC). maintained in IMDM with 10% FCS, 10% horse serum, 2 mmol/L CDIS-FITC (Leu-MI), CD14-PE (Mo2-RDI), GPIb (SZ2, AMAC). L-glutamine, and 10.' mol/L hydrocortisone. Less than 2% of the GPlIb/llta (10E5, a gift from Dr B.Coller, Mount Sinai Medical VIIVvWF, suggesting established BM stromastainedwithfactor or polyelonal antibodiestofactor VI111 that the predominant cell type in these monolayers are BM fibroblasts Center,NewYork,NYj, vWF (Sigma) at different dilutions were incubated with fixed cells and reticular cells. All monolayers used in these experiments were for 1 hour. BMEC monolayers with bound hematopoietic cells from between passages 2 and 4. different weekly time points of coculture experiments were washed Immunofluorescent flow cyrometry. Hematopoieticcells ( I O6 threetimes in PBSsupplemented with 2 mmol/L of calciumand cells/mL) from the upper chamber of the transwell cultures as well then magnesium, fixed in 3% formalin in PBSfor30minutes, as those proliferating in direct contact with BMECs were obtained quenched with 0.1 glycine for I O minutes, and blocked with 1.5%' by weekly demidepopulation and were placed in Hanks' balanced horseserum,Afterwashing with PBS,biotinylatedantimouse or salt solution (HBSS, Sigma),0.02% azide, 1% bovine serum albumin antirabbit Ig diluted 1 :200 in PBS containing 1 % BSA was incubated (Sigma)containing I mmol/Ladenosine,2 mrnoIL theophylline, with the cells for 30 minutes at room temperature. After 30 minutes and 2 mmoL/L EDTA (buffer A) to inhibit megakaryocyte activation or alkaline phosphatase, of incubation with avidin-labeled peroxidase or aggregation. Subsequently, the cells were incubated with saturatslides were rinsed and incubated with peroxidase substrate amino30 minutes ing doses of conjugated and nonconjugated MoAb for From www.bloodjournal.org by guest on February 16, 2015. For personal use only. OW BONE 3355 Table l.MoAbs Used in This Study Cluster CD2-RD1 CD3-RD1 CD4-FITC CD8-RD1 CD13-PE CDl4-RD1 CD14-PE CDl5-FITC CD19-FITC CDZO-FITC CD33-PE CD34-PE CD34-FITC CD34 CD36-FITC CD4la-FITC IgG1 CD4la CD42b-PE IgM CD4la-FITC CD45-FITC CD61-FITC ND ND 17 CD1 Ulex europeaus-FITC Ulex europeaus-PE MoAb lsotype Cellular Distribution lgGl T cells, thymocytes lgGl T lymphocytes Helper/inducer lgGl cells IgG1 Cytotoxic, suppressor T cells T8 IgG1 Myeloid progenitors, monocytes, endothelial cells Leu-M7 IgM Monocytes M02 IgGm Monocytes, neutrophils, eosinophils Leu-M3 Leu-MI IgM Myeloid precursor cells, granulocytes All B cells including pre-B cells lgGl B4 IgGza All B cells B1 lgGl Myeloid cells, BFU-Meg, CFU-Meg Leu-M9 lgGl Hematopoietic progenitor cells, endothelial cells HPCA-2 IgG1 Hematopoietic progenitor cells, endothelial cells QBEnd-IO IgG1 Hematopoietic progenitor cells, endothelial cells 11.1.6 IOP36 IgG1 erythroid Monocytes, early progenitors P2 lgGl GPllb Meg, platelets 10E5 GPllb/llla Meg, platelets S22 Meg, lgGl GPlb platelets PLT-1 GPllb/llla Meg, platelets All hematopoietic cells KC56 lgGl Meg,lgGl GPllla platelets IOP61 13 Class lgGl II (HM-DR, DP, DO) Glycophorin Erythroid A lgGl progenitors, erythrocytes 95c3 lgGl C-kit receptor, hematopoietic progenitor cells Lectin Endothelial cells, subtype of erythroid cells, Meg Lectin Endothelial cells, subtype of erythroid cells, Biomeda Meg TI 1 T3 T4 Manufacturer C C C C BD C BD BD C C BD BD IM Dr M.A.S Moore IM IM Dr B. Coller IM C C BD C IM IM Sigma Abbreviations: IM, Immunotech; BD, Becton Dickenson; C, Coulter; ND, not defined; Meg, megakaryocyte. ethyl carbazole (red stain) or alkaline phosphatase substrate New Fuchsin (Dako) (red stain) for 10 minutes. After a final rinse, the cells were counter stained with 1% hematoxylin. Samples of BM aspirate or confluent monolayers of BMEC, HUVEC, and BM stroma were grown in chamber slides, air dried, and fixed with acetonelalcohol. Primary mouse MoAbs to factor VIIY vWF (Dako) were incubated on the slide for 1 hour or at 4°C overnight, then washed three times with PBS, and counter stained with goat-antimouse IgGl-FITCIPE. Photographs were taken with a Nikon fluorescence microscope (Tokyo, Japan) on Kodak Ektachrome 160T ASA color film (Kodak Ltd, Liverpool, UK). FITC or PE was visualized using standard FITC/PE excitation/emission filter combinations. Metabolic labeling withDil-Ac-LDL. Near confluent monolayers of HUVEC and BMEC or mixed populations of endothelial cells and fibroblasts were incubated with 1 pg/mL of Dil-Ac-LDL (acetylated low-density lipoprotein labeled with dioctadecyl 1,3,3,3,tetramethyl-indocarbocyanine perchlorate), (Biomedical Technologies Inc, Stoughton, MA) for 4 hours at 37°C.The cells were washed with HBSS supplemented with 2 mmol/L calcium and magnesium chloride for 10 minutes, and examined with a Nikon epifluorescence microscope with phase-contrast optics. Dil-Ac-LDL uptake was visualized using standard rhodamine excitation/emission filter combinations. Isolation of CD34' cells. After informed consent, peripheral blood mononuclear cells (PBMC) mobilized by cyclophosphamide plus G-CSF were obtained from patients with previously treated stage IV breast cancer or untreated ovarian cancer. PBMCs underwent low-density mononuclear cell (<1.077 g/mL) separation over Ficoll-Paque (Pharmacia, Upsala, Sweden). Cells obtained from human umbilical CB were first platelet-depleted using Percoll sepmtion, before Ficoll separation. CD34+ cells were enriched using the CellPro Ceprate System (kindly provided by CellPro, Bothell, WA) following standard instructions provided, or using immunomagnetic beads (Dynal AS, Oslo, Norway). For the CellPro Ceprate System, low-density mononuclear cells were washed twice with 1% BSA in PBS, and resuspended in 1% BSA to a concentration of l to 2 X 10' cells/mL and incubated for 25 minutes with an IgM biotinylated mouse antihuman antibody to CD34 (12.8) at room temperature. The cells were washed with 1 % BSA to remove excess antibody, then were resuspended in 5% BSA at a concentration of 1 to 2 X 108/mL, and passedthrough an avidin column. Cells collected in the CD34+ fraction were resuspended inmodified coculture medium. For separation using immunomagnetic beads, low-density mononuclear cells were washed twice with 0.1% BSA in PBS and were resuspended to 1 X lo8 cells/mL. A mouse IgGl antihuman CD34' antibody developed in our laboratory ( 11.1.6; licensed to Oncogene Science, Uniondale, NY) was added to the cells at a concentration of 50 pg/mL for 30 minutes at 4°C. The cells were washed twice with 0.1%BSA in PBS and resuspended to a concentration of 1 X IO' cells/mL. Sheep-antimouse IgGl(Fc) immunomagnetic beads (30 pg/mL), providing a 16:l bead-to-cell ratio, were added for 30 minutes at 4°C. The bead-positive fraction was selected with a magnetic separator, resuspended in 20% FCS, and kept overnight at 37°C in 100% humidified air with 5% CO2. The following day, the cells in the bead-negative fraction were recovered. Coculture model. CD34+ cells (4 X 104/mL)isolated from CB or PB were plated in triplicate in six-well plates (Costar) in direct contact with HUVEC, BMEC, or BM stromal monolayer. CD34' cells (4 X I@/mL) were plated on transwell plates (Costar, 0.4 pm porosity) on the upper chamber with HUVEC, BMEC, or BM stromal layers grown as confluent monolayers separately on the lower chamber. Each week, hematopoietic cells were demidepopulated and replaced with fresh modified coculture medium. For hematopoietic cells grown in contact with BMECs, HUVECs, or stromal monolayers, one half of the coculture medium was removed and replaced with fresh medium. Hematopoietic cells grown on the transwells were demidepopulated as follows: one half of the volumecontaining From www.bloodjournal.org by guest on February 16, 2015. For personal use only. 3356 RAFll ET AL the cells growing on the transwell were demidepopulated each week and replaced with fresh coculture medium. In addition, one half of the medium on the lower chamber of the transwells was removed and replaced with fresh coculture medium. To determine the phenotype of hematopoietic cells adherent to BMECs,HUVECs, or stromal monolayers, each week the monolayers were washed three times with HBSS supplemented with 2 mmol/L magnesium and 2 m o l / L calcium chloride to remove the nonadherent cells, and fixed with formalin or acetone for immunohistochemical staining. Days In Liquid Culture B =a, 10B- I -Contact --+- Transwell Days In Liquid Culture C For BMEC activation studies, BMEC monolayers were incubated with 10 UlmL of IL-lP for 18 hours at 37°C. Subsequently, BMEC monolayers were washed five times with ECGM to remove IL-I@ and resuspended in modified coculture medium. Long-tern culrures. CD34' cells (4 X 104/mL)from CB or PB were suspended in modified coculture medium and were placed in either direct contact with BMECs, HUVECs, or stromal monolayers (contact) or separated by a 0.4 pm transwell membrane (noncontact). Eachweekthe wells were demidepopulated, cells counted on a Coulter Counter ZM (Hialeah, FL), and replaced with an equal volume of fresh modified coculture medium. Cultures were continued untilno detectable progenitors were generated, though cells were still present. After complete removal of nonadherent cells from the stroma, the adherent cells were removed with 1 mmollL EDTA and 0.1 % trypsin. Trypsin was deactivated with FCS and the cells were washed three times with PBS. Cells were quantified by hemocytometer and were evaluated for progenitor content using agarose assays and cell surface markers using either flow cytometry or immunocytochemistry as described. All of the trypsinized cells were plated for the agarose assays. Progenitor assay (agarose assay). Starting at day zero, and then weekly thereafter, escalating numbers of cells (1 X lo3 to 4 X IO4) collected after demidepopulation were placed in triplicate in 35-mm tissue culture dishes (Coming, Coming, NY), containing 20% FCS in IMDM supplemented with 50 pg/mL gentamicin (GIBCO), monothioglycerol (7.3 X IO-' mom; Sigma), 0.36% agarose (FMC Bioproducts, Rockland, ME), and a combination of five cytokines: 20 nglmL human kit-ligand (kindly provided by Immunex, Seattle, WA); 50 ng/mL human IL-3 (Immunex); 20 ng/mL mutein IL-6 (kindly provided by Imclone Systems Inc, New York, NY); 6 U/ mL erythropoietin (Amgen, Thousand Oaks, CA); and 100 ng/mL human G-CSF (Amgen). This combination is abbreviated as K36EG. Cultures were incubated at 37°C in 100% humidified 5% CO2 in air and removed from the incubator at 14 days. Colonies definedas greater than 40 cells were counted using an inverted microscope. Burst-forming unit erythroid (BFU-E) and granulocyte-macrophageCFU (CFU-GM) were observed using this assay. To determine total progenitors generated over time, the area under the curve (AUC) was calculated as the sum of the parallelograms created from the data points (Fig 1, A and B). A simplified formula is: AUC = nA + nB + . . . . . + nX, where nA is the number of progenitors at day zero and nX is the number of progenitors on the last day of culture. cDNA-PCR technique. Hematopoietic cells proliferating in direct contact with BMECs or on the transwell plates separated from BMEC monolayers were removed for determination of GPIIb expression each week. Total RNAwas isolated from 2 X 10' cells proliferating on days 7, 14, and 21 of coculture by RNAzol reagent (Biotecx Lab, Houston, TX). Total RNA was also isolated from intact resting BMEC monolayers. Total RNA was precipitated with 30000 Transwell 0 NA+A 2 20000 p m Non-Adherent ~ .-0c tsm Adherent CI P) m 2 10000 P 0 Days In Llquid CultUt'e Fig1.Long-termcultureof CDW+ progenitor cdb: CD%+ cdls from PB (A) or CB (B) were placed either in contact with BMEC or separated by a 0.4-Fm microporoustramell membrane. Each week the nonadherent d h were domidepopulated and progenitors (mean f SEM, n = 3) were determined in an agarose assay. On days 14, 28, and 42, the adherent hematopoietic cells were removed with enzymatic digestionof the adherent monolayer, and the progenitors were quantified by agarose assay (C). The number of progenitors (mean 2 SEM, n = 4) adherent to the BMECs during the coculture experiment compriseda small perwntage of ovorall expanding progenitors. Thereis no d h e n c e betweanthe total number of progenitors (NA + A) that were generated from contact cultures and those from the transwell plates( P > .05 for all time points). From www.bloodjournal.org by guest on February 16, 2015. For personal use only. BONEMARROWENDOTHELIUMSUPPORTSHEMATOPOIESIS 0.2 volume of sodiumacetateand 2.5 volume of 1 0 0 % ethanol, dried,andresuspendedinDEPC-treated dH20. RNAwasreverse transcribed using the Moloney murine leukemia virus reverse transcriptase, and oligo dT as the primer for 15 minutes at 42°C. DNA amplicationwasperformedinpolymerasechainreaction(PCR) bufferusingtheGPIIbprimerpair(5”CTCGCTGCTCTITGACCTCC-3’) and (5’-AAGTCGCGGCTCAGGGTGTTCC-3’).33 For thrombopoietindetermination,theprimerpair5“AGAAATTGCTCCTCGTGGTCATGCTTCT-3’andthereverseprimer 5’-CAGTCTGCCGTGAAGGACATGG-3’34 were used for DNA amplification.Sampleswere cycled 35timesandthePCRproductswere analyzed on a 2% NuSieve agarose gel. Theexpectedproductat 265forGPIIbbasepairwascutandsequencedtoconfirmthe identity of the product. Quant$cation of cytokines elaborated by BMEC and HUVEC monlayers. BMEC or HUVEC-conditioned medium were collected from 3-day-old cultures from equally confluent culture flasks (5.56 X lo6 cells/flask), filtered, and 200 microliter samples were used in asandwichELISA(R & D Systems, Minneapolis,MN)for the quantitative determinationof IL-6, G-CSF, GM-CSF, and kit-ligand. Controlmedium,whichcontained M199 medium, 20% FCS,was used to sustain endothelialcell monolayers during these experiments. Statistical analysis. Theresultsarepresentedasthemean ? SEM of the data obtainedfrom three or more experiments performed in triplicates. Statistical significance was determined using the Student’s r-test. RESULTS BMEC monolayers induce proliferation of CD34+ cells. CD34+ cells isolated by immunoadsorption from PB or CB were placed in liquid culture in direct cellular contact with BMEC monolayer, or on 0.4-pm microporous transwell plates to separate them from BMEC monolayers. Each week, the nonadherent hematopoietic cells were demidepopulated and placed in agarose assays to evaluate progenitor content. Progenitors grown in direct contact with BMEC expanded fivefold by 7 days and were detectable for up to 56 days in experiments with PB-derived CD34+ cells, and 70 days for CB-derived CD34+ cells (Fig 1, A and B). CB CD34+ cells, grown physically separated from BMEC monolayers in the transwell plates, generated progenitors for up to 63 days, whereas PB CD34+ cells generated progenitors for 49 days. Total progenitors generated from CB CD34+ cells over time as calculated by integrating the AUC was 88,300 progenitors in experiments in which cells were in BMEC contact and 80,200 progenitors in BMEC noncontact experiments. For the first 28 days, a time when the majority of progenitors were generated, AUC for the two conditions was almost identical. However, after 28 days, BMEC contact generated approximately 1 log greater number of progenitors per week. For PB, AUC for BMEC contact was 39,500 progenitors and for BMEC noncontact, 17,500 progenitors. The contact cultures show a slight but consistent advantage in generating progenitors over those of noncontact cultures. However, this difference does not reach statistical significance. Fig 1C shows the number of progenitors from CB that are adherent to the BMEC monolayers during the coculture period. On day 14 of coculture, approximately 10% of expanding progenitors are adherent to BMEC monolayers. On day 28 and 42 of coculture, a comparable number of progenitors are attached to the underlying stroma. However, the relative number of adherent to nonadherent progenitors are 3357 significantly higher because the nonadherent progenitors are decreased. There was no statistical difference between the total number of progenitors (NA + A) generated from contact cultures as compared with those generated from transwell plates. Phenotype ofproliferating hematopoietic cells. Flow cytometric and immunohistochemical staining of the proliferating hematopoietic cells grown in direct contact with BMEC showed that by day 7, 3% 5 2%of hematopoietic cells remained CD34+, 88% 5 2% of cells expressed CD33,40% 5 5% expressed CD15, and 12% ? 1% were monocytic, expressing CD14 antigen (Table 2). By day 14, the number of mature myeloid precursors CD15 were increased to 47% ? 2%, and monocytic cells expressing CD14 increased to 22% L 5%. Similar results were obtained in experiments performed in transwell plates (Table 2). Compared withBM stroma and HUVEC monolayers, BMEC supported greater megakaryocyte proliferation as determined by expression of GPIIb/IIIa and GPIb in Table 2 and Fig 2. Flow cytometric analysis of cells grown on the transwell plates showed that by day 14, 14% 5 3% of proliferating cells were GPIIb/IIIa+, and CD34+ cells grown in direct contact with BMEC gave rise to 17% ? 5% GPIIb/ IIIa+ cells. Because a significant number of megakaryocytes were attached to BMEC and HUVEC monolayers, the number of attached megakaryocytes were quantified each week by direct immunohistochemistry of monolayers with GPIIb/ IIIa antibodies. Figure 3 displays the total number of adherent and nonadherent megakaryocytes on day 14 of coculture, which comprised =19% of hematopoietic cells grown in contact with BMECs. No adherent GPIIb/IIIa+ cells were detected on the surface of transwell plates. Even though HUVEC and BM stromal monolayers support expansion of myeloid series (85% ? 8% of expanding cells), they support the expansion of only a small percentage of megakaryocytic GPIIb/IIIa+ cells (Table 2), and Fig 2. The presence of megakaryocytes was also confirmed by reverse transcriptase-PCR(RT-PCR) (using oligonucleotide primers specific for GPIIb cDNA) on total RNA that was isolated from the hematopoietic cells proliferating in transwells as well as cells grown in direct contact with BMECs. In parallel studies, hematopoietic progenitors proliferating in the coculture experiments were also stained with MoAbs to lymphoid and erythroid progenitors. Only a small number of CD2 or CD19 cells were detected. No staining was detected with MoAbs to glycophorin A, CD3, CD20, CD4, or CD8. IL-Ip stimulationofBMEC monolayers. To study the effect of stimulated endothelium on hematopoiesis, endothelial cells were stimulated with IL-lp (10 U/mL) for 18 hours. Incubation of CD34+ cells on the transwell plates with ILlp-activated endothelium resulted in 10-fold expansion of progenitor cells over 7 days, and induced a relatively rapid maturation of myeloid cells as evidenced by expression of CD15 (53 5 3, day 7), and CD14 (25% ? 5%, day 7) (Table 3). By day 14, 70% 5 6% of cells were myeloid, expressing CD33, CD15, or CD14 markers; 6% t 1% were megakaryocytic, expressing GPIlb/IIIa or GPIb markers. Morphologicanalysis. Figure 2A shows a typical day 1 coculture experiment where CD34+ cells were added to From www.bloodjournal.org by guest on February 16, 2015. For personal use only. 3358 RAFll ET AL Table 2. Flow Cytometric Analysis of Hematopoietic Cells Proliferating in the Presence of BMECs, HUVECs, and BM Stroma Myeloid/Monocytic CD34' 1 1 Phenotype of proliferating hematopoietic cells On direct cellular contact with BMEC Day 1 Day 7 Day 14 Day 21 Day 28 Day 35 On Transwell plates in the presence of BMEC Day 1 Day 7 Day 14 Day 21 Day 28 Day 35 On direct cellular contact withHUVEC Day Day 7 Day 14 Day 21 Day 28 Day 35 On direct contact with BM stroma Day Day 7 Day 14 Day 2 1 Day 28 Day 35 (CD33/CD15/CD14) Megakaryocytic (CD41iCD42b) 92 t 6 3 2 2 ND ND ND ND 54 88 85 82 86 80 i 615 t 2/ND 92 i 6 ND ND ND ND ND 54 92 80 83 86 80 t 615 t 2/ND t 5/47 t 6/12 t 2/54 t 2/24 t 8/62 t 1/29 t 4/50 t 3/28 t 6/49 t 9/30 92 t 6 ND ND ND ND ND 54 90 91 95 95 92 t 615 t 2/ND t 4/47 f 10115 t 7 t 6/56 t 6/30 f 9 t 9/59 c 3/35 c 7 t 4/60 t 7/32 t 2 t 3/40 i 9/34 i 8 2 5 8 4 3 92 t 6 ND ND 54 80 85 88 90 84 t 615 t 2/ND 2 2 1/ND 3 t 2/ND 2 i 1/ND 2 i 1/ND ND ND t 2/40 c 5/12 t 1 t 5/47 t 2/22 t 5 -t 6/52 ? 5/26 i 2 2 4/60 t 6/29 c 5 t 6/56 t 4/28 t 6 t 4/30 t 2/45 t 9/60 t 9/56 i- 6/58 t8 t4 t5 24 i8 2 2/10 i- 2 2 7/26 t 2 2 4/30 t 9 t 3/38 +- 7 2 9/34 t 8 2 t 1/ND 14 t 415 t 3 17 2 519 c 4 10 t 316 t 2 LCNErythrotd (CD4WGlyco A) 9i3/7f4 4 i 213 t 1 95 91 87 92 95 92 t 5/ND L 3/ND i 2/ND t 4/ND f 2/ND t 3/ND 2 t 1/ND 10 t 2/ND 14 t 315 2 2 6 t 313 t 1 3 t 214 t 2 2 i l/ND 95 92 90 94 96 96 t 5/ND t 6/ND rt 6/ND t 4/ND 2 5/ND 2 2/ND 95 91 93 92 95 94 2 5/ND 1/ND t 3/ND t 214 t 1 t 3/ND t 2IND N DIND -t ND/ND NDIND 95 92 94 90 92 94 t 4/ND t 3/ND t 5/ND t 3/ND t 2/ND t 5/ND r 2/ND t 3/ND t 4/ND t 6/ND I 5/ND Phenotype of proliferating hematopoietic cells were determined by flow cytometry.Each week CB CD34' cells proliferating on direct contact with either BMEC, HUVEC, BM stroma, or from transwell plates were washed three times with buffer A and incubated with conjugated MoAbs. The values reported above are the percent positive cells from IO4 labeled hematopoietic cells (mean t SEM, n = 6). Abbreviations: LCA, leukocyte common antigen; ND. none detected; Glyco A, Glycophorin A. confluent monolayers of BMEC. By day 14, large numbers of hematopoietic cell colonies were detected over the underlying intact BMEC monolayer (Fig 2, B and C). Figure 2D shows proliferation of hematopoietic colonies of different size and shape including relatively numerous refractile large cells resembling polyploid megakaryocytes. Wright-Giemsa staining of the cytospins of hematopoietic cells proliferating cells on the transwell, as well as those in direct contact with BMEC, showed cells with morphologic features consistent with myeloid series including granule-rich promyelocytes, myelocytes, metamyelocytes, bands, neutrophils, and large monocytes (Fig 4, A and B). Cytospins performed on day 14 of coculture experiments showed abundant large polyploid megakaryocytes that stained with GPIIbnIIa antibody (Fig 4, C and D). Cytospins performed on day 42 and day 56 showed predominantly mature myeloid cells such as monocytes and neutrophils. Quantification of GPIIb/IIIa' cells detected on the cytospins are consistent with the results obtained from flow cytometry. Continuous monitoring of BMECandHUVEC monolayers during the coculture with hematopoietic cells with phase-contrast microscopyshowedthat endothelial monolayers maintain their morphologic integrity for the first 5 weeks of coculture. However, beyond day 42, the BMEC and HUVECmonolayers grown in direct or indirect conctact with hematopoietic cells form characteristic tube-like structures. Endothelial cells maintained in coculture medium in the absence of hematopoietic cells underwent no major morphologic changes. Determination of cytokines produced by BMEC. ELISA assays performed on the conditioned medium obtained from BMEC and HUVECmonolayers are shown in Table 4. Resting BMEC elaborated high levels of kit-ligand, IL-6, GMCSF, and G-CSF. Resting BMEC monolayers used in these experiments did not express activation-dependent adhesion molecules such as VCAM, ICAM, ELAM, suggesting that constitutive elaboration of cytokines by BMECwasnot caused by activation of BMEC, but rather was caused by a physiologic programming of these cells. DISCUSSION We show that unstimulated human microvascular endothelium derived from BM microenvironment support proliferation and differentiation of CD34' cells by constitutive production of G-CSF, GM-CSF, IL-6, and kit-ligand. Constitutive production of cytokines such as G-CSF, GM-CSF, and IL-6 is a unique feature of microvascular endothelium because vascular endothelium derived from lining of aorta, From www.bloodjournal.org by guest on February 16, 2015. For personal use only. BONE MARROW ENDOTHELIUM SUPPORTSHEMATOPOIESIS 3359 Fig 2. Proliferation of CD34' cells. Phase-contrast micrographs of proliferating hematopoietic progenitors in direct contact with resting BMEC monolayers on day l (A), day 14 (B and C), and day 21 (D).The small 0 3 4 ' cells shown in A (arrows), proliferate to give rise to floating colonies (arrows) consistent with CFU seen in agarose assays (Band C). D shows proliferation of numerous large refractile cells resembling megakaryocytes (short arrows). Only a few colonies of hematopoietic cells were attached to the underlying BMEC monolayers. As shown here, the BMEC monolayers maintain their cobblestone appearance during coculture experiments (original magnification x 2001. or umbilicalveincanonly produce these cytokines upon stimulation with IL-l or TNF.'','""X Long-term culture studies have shown that BM stroma or fibroblasts support predominantly myelopoiesis.3 BMECs not only support myelopoiesis, but also megakaryocytopoiesis, a feature not seen in BM stroma thatweremaintained in similar culture conditions. Elaboration of cytokines such as IL-6 and kit-ligand by BMECs induce proliferation of megakaryocytic precursors. CD34' cells that were cocultured in direct contact with BMEC monolayers gave rise to a larger number of megakaryocytes than those thatwere cocultured on the transwells. This finding suggests that membrane-bound cytokines such as kit-ligand may influence megakaryocyte precursor committment and proliferation. Previously, it has also been shown that endothelial cell extracellular matrix (ECM), which is rich in heparin sulfate and glycosaminoglycans, functions as a cytokine sink for heparin binding factors. Among these ECM-bound cytokines, bFGF, kit-ligand, and GM-CSF are positive regulatory factors that promote megakaryocytopoiesis,"5.25 whereas TGF-/3 is a potent negative regulatory factor." Thus, it is possible that interaction of CD34' cells with these positive and negative regulatory factors released by BMECs have an overall selective advantage for megakaryocyte lineage committment and proliferation. The critical role of these negative and positive regulatory factors wererecentlyconfirmed by Waegellet aI,j7 who have shown that neutralization of TGF-/3 in Dextertype cultures results in significant proliferation of megakaryocytes. This finding suggests that even though BM stroma produces large amounts of megakaryopoietins such as IL6,'8.3') production of negative regulatory factors such as TGF/3 haspredominant effect in suppressing megakaryocyte production. Although IL-6 and kit-ligandj5may promote proliferation of megakaryocytic precursors, the presence of polyploid megakaryocytes in our coculture experiments suggests that BMECs may also elaborate other cytokines such as thrombopoietin.3'.4"Availability of sensitive ELlSA or bioassays may facilitate detection of thrombopoietin in coculture conditioned medium. We have previously shown that a large number of CD34' cells and megakaryocytes derived from freshly isolated BM mononuclear cells adhere to BMEC monolayers.'" However. during the first 4 weeks of coculture period, only a small fraction of overall proliferating CD34' derived from CB or From www.bloodjournal.org by guest on February 16, 2015. For personal use only. 3360 RAFll ET AL Table 3. Phenotype of Proliferating Hematopoietic Cellson Transwell Platesin the Presence of IL-l-Activated BMECs ..V Day 1 Day 7 Day 14 Day 21 Day 28 c) aP . cp M W W a M E D ". - " 0 I I I 7 14 21 '. l T I 28 35 42 Myeloid/Monocytic Megakaryocytic CD34' (CD33/CD15/CD14l (CD41/CD42bl 92 2 6 ND ND ND ND 54 2 615 t 2/ND 95 5 2/53 t 3/10 f 4 91 t 6/70 2 6/25t 5 90 f 4/68 2 4/40 2 7 91 5 2/60 f 7/35 _f 3 2 f 1/ND 4 t 2IND 6 t I/ND ND/ND N D/ND Flow cytometric analysisof hematopoietic cells proliferatingon the transwell plates in the presence of IL-10 activated cells. CBCD34' cells (4 x IO4)were incubated on transwell plates physically separated from IL-10-stimulated BMEC monolayers. Under this condition, stimulated BMEC resulted in tenfold expansion of CD34' cells with predominance of myeloidand, t o a smaller extent, megakaryocyticcells. As compared with resting BMECs, activated BMECs induce differentiaof CD14' cells tion of CD34' progenitors into a greater percentage (mean 2 SEM, n = 6). Abbreviation: ND, none detected. Days in coculture Fig 3. Megakaryocyte expansion. The percentageof megakaryocytes proliferating on transwell plates was determined by flow cytomedry by using three different M o b s t oGPllb/llla and GPlb. The percentage of proliferating megakaryocytes on direct contact with either BMECs (0).HUMCs (A), or BM stroma (0)was determined by flow cytometry as well as immunohistochemistryto account for adherent megakaryocytes. This figure shows the total percentages of megakaryocytes (meanf SEM, n = 4) that were presentin suspension as well as adherent to BMEC, HUVEC, and BM stromal monolayers at any given week. Compared with BM stroma, BMEC monolayers support expansion of a relatively large number of GPllb/llla+ cells ( P i.05). PB cells were attached to the BMEC monolayers. The low affinity of both megakaryocytes and myeloid precursors for BMEC monolayers under coculture experiments described in this paper is particularly striking. Continued coculturing of proliferating hematopoietic cells beyond day 56 to 63, results in adhesion of relatively large numbers of monocytes, neutrophils, dendrtitic as well as polyploid megakaryocytes to BMEC and HUVEC monolayers (data not shown). This enhanced binding probably reflects complex interaction between maturing hematopoietic cells and endothelial cells. Both HUVEC and BMEC monolayers support proliferation of a large number of myeloid cells. Production of GCSF, GM-CSF, b-FGF, and kit-ligand by resting BMEC account for proliferation and differentiation of myeloid prog e n i t o r ~Although .~~ cellular contact may be critical for megakaryocyte cell proliferation and maturation, direct cellular contact between CD34+ progenitor cells and BMEC did not offer any advantage with respect to myeloid cell prolifera- tion. The majority of proliferating myeloid cells, particularly early promyelocytes, were highly granular. This finding is striking because myeloid cells proliferating in the presence of cytokines or BM stroma were significantly less granular than those that were grown in the presence of endothelial cell monolayers. The number of progenitors generated by BMECswere estimated by calculation of AUC in Fig 1, A and B. AUC reflects the dynamics of proliferation, differentiation, and depletion of hematopoietic stem cells and indicates the net production of progenitors over several weeks in the face of weekly demidepopulation. Figure 1, A and B, shows that in the first few weeks of coculture, BMEC monolayers were generating progenitors, whereas during the remaining period of coculture, there were preservation of progenitors despite weekly demidepopulation. Verfaille et a14' have shown that direct contact between hematopoietic progenitor cells is not critical for long-term hematopoiesis. Our data show that direct contact cultures consistently show better preservation of progenitors, although this did not reach statistical significance. Adherence of a small subset of proliferating progenitors to BMEC monolayers may preserve or prevent the exhaustion of progenitors during the coculture periodand weekly demidepopulation. IL-ID activation of BMEC results in significant adhesion of CD34' cells to these monolayers. These progenitors remained attached to BMEC monolayers for several days, forming large adherent colonies. Thus, itwasdifficultto assess the progenitor generated from CD34' cells that were grown in contact with IL-IP-activated BMEC or HUVEC Fig 4. Morphologic characteristics of hematopoieticcells proliferating in the presence of BMEC monolayers. Figure4 is the Wright-Giemsa stain of day 14cytospun hematopoieticcells proliferating in the transwell plates separated from BMECs (A) and in direct contact with BMECs (B), ahowingthe presenceof polyploid megakaryocytes aswell as early andlate myeloid precursors. Highly granular promyelocytes, myelocytes. metamyelocytes, and foamy monocytescould be detected as early as day 14of coculture. (Cl is a Wright-Giemsa stain of polyploid megakaryocytes from day 21 of cocultureof hematopoietic cells in direct contact with BMEC. (D) is an immunoh*tochemical stain using MoAb to GPllbl llla (10E5) of day 21 cytospun hematopoietic cells demipopulated from direct contact with BMEC monolayem showing the presence of megakaryocytes (original magnification x 1,OOO). From www.bloodjournal.org by guest on February 16, 2015. For personal use only. HEMATOPOIESIS BONE SUPPORTS MARROW ENDOTHELIUM 3361 From www.bloodjournal.org by guest on February 16, 2015. For personal use only. 3362 RAFil ET A L Table 4. Cytokines Elaborated by BMEC and HUVEC Monolayers ~~~ Control Medium Sample (MDC) IL-6 (3.13) SCF (kit-ligand)110) G-CSF (10) GM-CSF (1.51 ~~ (pg/mL) HUVECs (pg/mL) 0 150 i 32 105 2 19 1141 t 89 0 0 0 26 i 12 BMECs (pglmL) 292 3000 345 373 2 21 2 478 t 32 i 36 BMEC-, or HUVEC-conditionedmedium were collected from 3-dayold cultures from equally confluent culture flasks (5.56 x lo6 cells/ flask), filtered, and 200 microliter samples were used in a sandwich ELlSA for the quantitative determination of IL-6. G-CSF, GM-CSF, and kit-ligand. Control medium, which contains M199 medium, 20% FCS, and 90 pg/mL of heparin, wasused to sustain endothelial monolayers during these experiments. Abbreviation: MDC, minimal detectable concentration. monolayers with BM stroma, which would influence proliferation and maturation of hematopoietic cells. In summary, BMEC monolayers support multilineage hematopoiesis by elaboration of soluble cytokines. Because BMEC monolayers canmaintain their cellular integrity over long periods of coculture with different types of hematopoietic cells, they provide anideal feeder layer for LTBMC studies. The reciprocalinteractionbetween BMEC monolayers and proliferating hematopoietic cells may be crucial for self-renewal of pluripotent stem cells, as well as for regulation of differentiation of committed progenitor cells. The coculture model described in this report can be used to studythis complex interactionaswell asto characterize the cytokines released by BMECs that are responsible for of pluripotent multilineage hematopoiesis andexpansion progenitor cells.The studyof surface glycoproteins expressed on the luminal and subliminal surface of BMECs in resting and activated state is critical to the characterization of the factors that regulate proliferation of CD34' stem cells as well as the characterization of mature and malignant hematopoietic cells. monolayers. However, CD34' cells incubated on transwell plates, physically separated from IL- 10-activated endothelium, show very rapid proliferation. Flowcytometric analysis of the proliferating cells show a predominance of myeloid lineage,suggestingthat BMEC activation may resultin ACKNOWLEDGMENT upregulation of G-CSF and GM-CSFproduction. This result is consistent with studiesthat have shown that I L - l p activaWe are grateful to Janice Godwin, MT, Mike Querijero, and Koji Shido for providing samples and outstanding technical support. tion of HUVEC cells results in upregulation of G-CSF and GM-CSF, which would favor myeloid cell proliferation and differentiation.'*.''.'' REFERENCES The coculture experiments were performed in an IMDM1. Litchman MA: The ultrastructure of the hematopoietic microbased medium to supply adequate nutrition for proliferating environment: A review. Exp Hematol 9:391, 1981 2. Dexter TM, Allen TD, Lajtha LG: Conditions controlling the hematopoietic cells. 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For personal use only. 1995 86: 3353-3363 Human bone marrow microvascular endothelial cells support long-term proliferation and differentiation of myeloid and megakaryocytic progenitors S Rafii, F Shapiro, R Pettengell, B Ferris, RL Nachman, MA Moore and AS Asch Updated information and services can be found at: http://www.bloodjournal.org/content/86/9/3353.full.html Articles on similar topics can be found in the following Blood collections Information about reproducing this article in parts or in its entirety may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#repub_requests Information about ordering reprints may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#reprints Information about subscriptions and ASH membership may be found online at: http://www.bloodjournal.org/site/subscriptions/index.xhtml Blood (print ISSN 0006-4971, online ISSN 1528-0020), is published weekly by the American Society of Hematology, 2021 L St, NW, Suite 900, Washington DC 20036. 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