First-line allogeneic hematopoietic stem cell transplantation of HLA-matched sibling donors compared with first-line ciclosporin and/or antithymocyte or antilymphocyte globulin for acquired severe aplastic anemia

Cyclophosphamide and horse anti-thymocyte globulin versus fludarabine, reduced cyclophosphamide and rabbit anti-thymocyte globulin conditioning regimen for allogeneic hematopoietic stem cell transplantation from matched sibling donors in patients with acquired aplastic anemia

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative treatment for acquired aplastic anemia (acquired AA) in young patients. The objective of the study was to compare patient outcomes after Cyclophosphamide and horse antithymocyte globulin (Cy-hATG) versus Fludarabine-cyclophosphamide and rabbit ATG (Flu-Cy-rATG) as part of conditioning regimen in allo-HSCT for acquired AA.

RESEARCH DESIGN AND METHODS

Descriptive retrospective study conducted on patients with acquired AA who received allo-HSCT from HLA-matched sibling donors between January 2008 and August 2022 after conditioning regimen with Cy-hATG or Flu-Cy-rATG.

RESULTS

A total of 121 patients were enrolled. Cumulative incidence of graft failure was 11.2% in Cy-hATG and 5.3% Flu-Cy-rATG group. There were no significant differences between the two groups in terms of acute GVHD, chronic GVHD and transplant related mortality. Flu-Cy-rATG group was associated with significantly higher CMV and EBV reactivation(s) compared to Cy-hATG group (p = 0.008 and 0.035, respectively). After a median follow-up of 58 months, estimated overall survival, event-free survival and graft rejection-free survival were not statistically different between the two groups.

CONCLUSIONS

In high-risk population, Flu-Cy-rATG is associated with comparable outcomes to Cy-hATG in allo-HSCT from MSD. However, it seems to be associated with significant risk of viral infections.

Idiopathic Aplastic anemia: Indian Perspective

Aplastic anemia (AA) is a rare immunologically mediated bone marrow failure syndrome, characterized by progressive loss of hematopoietic stem cells resulting in peripheral pancytopenia. Elaborative investigation including molecular tests is required to exclude inherited bone marrow failure syndrome (IMBFS) as the treatment and prognosis vary dramatically between them. Haematopoietic stem cell transplant with a fully matched sibling donor (MSD-HSCT) is still the only curative treatment. Management of AA is a real-time challenge in India, because of the delay in the diagnosis, lack of proper supportive care, limited availability of the expertise centre, and the patient's affordability. Recently, results with intensified immunosuppressive therapy that includes anti-thymocyte globulin with cyclosporine-A (CsA) and eltrombopag, are enough encouraging to consider it as treatment of choice in patients lacking MSD or who are not fit for HSCT. However, limitations in resource constraints settings including the cost of therapy limit its full utilization. Relapse of the disease or evolution to myelodysplasia or paroxysmal nocturnal haemoglobinuria (PNH) in a proportion of patients is another challenge with immunosuppressants. The majority of the AA patients still receive CsA with or without androgens in India, mostly because of increased cost and limited availability of HSCT and ATG. The use of the unrelated or alternative donor is still upcoming in India, with unavailable data in terms of response and survival. Therefore, there is an utmost need for novel agents for the better management of AA having a balanced efficacy and toxicity profile to improve the survival and quality of life.

Comparison of hematopoietic stem cell transplantation and immunosuppressive therapy as the first-line treatment option for patients with severe hepatitis−associated aplastic anemia

Hepatitis-associated aplastic anemia (HAAA) is a rare variant of acquired aplastic anemia characterized with a syndrome of bone marrow failure after hepatitis. We retrospectively analyzed the outcomes of consecutive severe HAAA patients who received immunosuppressive therapy (IST, n = 70), matched-sibling donor hematopoietic stem cell transplantation (MSD-HSCT, n = 26) or haploidentical-donor (HID) HSCT (n = 11) as the first-line treatment. In the IST group, the hematologic response (HR) rate was 55.71% at 6 months. In contrast, HSCT recipients exhibited significantly more rapid and sustained hematopoiesis (HR 76.92%, 96.15% and 96.15% at 3, 6 and 12months, respectively). The 5-year overall survival (OS) was not different among IST (83.7 ± 4.9%), MSD-HSCT (93.3 ± 6.4%) and HID-HSCT group (80.8 ± 12.3%). Compared with IST, MSD and HID-HSCT demonstrated a trend of superiority in the estimated 5-year failure-free survival rates (93.3 ± 6.4% vs 64.3 ± 6.0%, p = 0.05; 80.8 ± 12.3% vs 64.3 ± 6.0%, p = 0.57). In subsequent stratified analysis on age, we found that HID-HSCT showed its efficacy and safety among young patients. In sum, MSD-HSCT remains first-line treatment choice for HAAA, whereas HID-HSCT represents an alternative treatment choice in addition to IST for young patients (< 40 years) without a matched sibling donor.

Aplastic Anemia as a Roadmap for Bone Marrow Failure: An Overview and a Clinical Workflow

In recent years, it has become increasingly apparent that bone marrow (BM) failures and myeloid malignancy predisposition syndromes are characterized by a wide phenotypic spectrum and that these diseases must be considered in the differential diagnosis of children and adults with unexplained hematopoiesis defects. Clinically, hypocellular BM failure still represents a challenge in pathobiology-guided treatment. There are three fundamental topics that emerged from our review of the existing data. An exogenous stressor, an immune defect, and a constitutional genetic defect fuel a vicious cycle of hematopoietic stem cells, immune niches, and stroma compartments. A wide phenotypic spectrum exists for inherited and acquired BM failures and predispositions to myeloid malignancies. In order to effectively manage patients, it is crucial to establish the right diagnosis. New theragnostic windows can be revealed by exploring BM failure pathomechanisms.

Assessment of Hepatic Profile in Acquired Aplastic Anemia: An Experience From Pakistan

Introduction: Aplastic anemia (AA) is characterized by pancytopenia and hypocellular marrow in the absence of an abnormal infiltrate or increase in reticulin fibrosis. The diagnosis of AA is challenging at times due to decreased cellularity and overlapping morphological features with other bone marrow failure syndromes. Hepatitis-associated aplastic anemia (HAAA) is a rare variant in which patients typically present with jaundice and hepatitis followed by pancytopenia almost within 6 months. Post-hepatitis AA accounts for approximately 1-5% of cases, and invariably such cases are negative for the known hepatitis virus as well. There is limited literature available to understand the correlation of AA with hepatitis with none reported at the national level in our region. As AA is relatively more prevalent in Southeast Asia as compared to the western world and hepatitis is a prevalent disease in our population, the main purpose of this study was to assess the hepatic profile and determine the association of hepatitis in AA at the time of diagnosis.

Materials and methods: A cross-sectional study was carried out at the National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, from November 2019 to December 2020 after the informed consent from patients. The study included all treatment-naïve patients of acquired AA with no prior history of taking steroids, immunosuppressive treatment, or chemoradiation therapy. Liver function tests, complete blood count, prothrombin time (PT), and activated partial thromboplastin time were performed, along with viral profiles (HAV, Hep B, Hep C, and HIV). SPSS version 23 (IBM Corp., Armonk, NY) was used for statistical analysis. Mean and standard deviations were computed for quantitative variables while percentages and frequencies were reported for qualitative variables. T-test was used to observe the main difference between groups and a p-value <0.05 was considered to be significant.

Results: Out of a total of 351 patients, 29 (8.2%) patients with AA tested positive for viral hepatitis. Hepatitis A was the most prevalent hepatitis (4.0%), followed by hepatitis C (3.7%). The comparison of platelet counts in patients with and without hepatitis was reported to be of statistical significance (p-value < 0.05). A significant statistical difference (p-value < 0.0001) was found in platelet count and PT in patients of AA with and without hepatitis.

Conclusion: Overall, this study revealed that <10% of patients of AA had a positive screening for hepatitis A, B, and C and low platelet count, and PT was statistically significant when compared between the patients with and without hepatitis. Hepatitis being prevalent in our part of the world might have an important causal association with AA. Patients with AA should be screened for liver functions and viral hepatitis at the time of diagnosis. In addition to hepatitis A, B, and C and HIV, other causes of hepatitis should also be screened such as parvovirus B19, human herpes virus 16, and adenovirus which are not included in routine diagnostic viral testing panel.

Rapid Administration of Antibiotics for Reducing Fever Days in Patients Receiving Hematopoietic Stem Cell Transplantation

Background and Objectives: Neutropenic fever (NF) is a major cause of mortality and morbidity in patients undergoing hematopoietic stem cell transplantation (HSCT). To date, no study has discussed the relationship of fever days in HSCT with the time between recording the fever and administering antibiotics. This study aimed to examine the association between fever days in HSCT and the time interval between recording the fever and intravenous (IV) antibiotics to the febrile neutropenia patient. Materials and Methods: A total of 22 patients who developed NF after HSCT in one hospital were analyzed. Patients who received IV antibiotics injection within 30 min were categorized in group A and those who received the injection after 30 min were categorized in group B. Fever was defined by an attack with an oral temperature of 38.3 °C. Patients’ characteristics and possible risk factors were recorded and analyzed. Results: Groups A and B had 14 and 8 patients, respectively. Patient characteristics, including age, diagnosis, sex, and antibiotics level, were similar between the two groups. The median duration of fever days was 1.5 (range, 1−5) in group A and 6.5 (range, 1−14) in group B (p = 0.003). Multivariant analysis of possible independent impact factors of “fever days in HSCT” was performed. The odds ratio of “antibiotics given time” was 4.00 (95% confidence interval [CI] = 2.26 to 7.22, p = 0.001). The “antibiotics level” did not affect the NF period (odds ratio = −0.80, 95% CI = −2.40 to 1.07, p = 0.453). Conclusions: Rapid IV administration of antibiotics (<30 min after fever attack) can reduce the fever days in patients undergoing HSCT.

[A clinical study of haploidentical hematopoietic stem cell transplantation in the treatment of pediatric patients with acquired severe aplastic anemia: single center experience]

目的

探讨单倍型造血干细胞移植（haplo-HSCT）治疗儿童获得性重型再生障碍性贫血（SAA）的疗效。

方法

回顾性分析2011年12月1日至2017年12月1日接受haplo-HSCT的59例SAA患者。

结果

①全部59例SAA患儿中男37例、女22例，中位年龄4.5（1.2~14.8）岁，中位体重43（12~80）kg；SAA-Ⅰ型47例，SAA-Ⅱ型12例，26例为极重型再生障碍性贫血（VSAA）；首次移植56例，二次移植3例。②预处理选用白消安+环磷酰胺+抗胸腺细胞球蛋白（ATG）方案或白消安+氟达拉滨+环磷酰胺+ATG方案；采用环孢素A（CsA）+霉酚酸酯+甲氨蝶呤方案预防急性GVHD；回输单个核细胞中位数为15.60（7.74~21.04）×10⁸/kg，CD34⁺细胞中位数为4.86（3.74~7.14）×10⁶/kg。③全部59例患儿均获得中性粒细胞和血小板植入。中性粒细胞植入中位时间为13（10~19）d，血小板植入中位时间为19（9~62）d。④Ⅰ~Ⅱ、Ⅲ/Ⅳ度急性GVHD发生率分别为45.76%（27/59）、13.56%（8/59），慢性GVHD发生率为8.47%（5/59）。巨细胞病毒血症发生率为59.32%（35/59）、EB病毒血症发生率为28.81%（17/59）。⑤中位随访时间30（8~80）个月，57例无病存活，2例死亡（均死于GVHD），5年总生存率、无失败生存率均为（96.4±2.5）%。

结论

haplo-HSCT是儿童SAA疗效较好的治疗方法。

Efficacy and Safety of Eltrombopag for Aplastic Anemia: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Eltrombopag seems to be effective in treating patients with aplastic anemia in several clinical trials. This paper aims to perform the first meta-analysis analyzing the efficacy and safety of eltrombopag for aplastic anemia.

METHODS

Literatures were retrieved from PubMed, EMBASE, OVID, Web of Science, Cochrane, Wanfang, http://clinicaltrials.gov and World Health Organization International Clinical Trials Registry Platform search portal from establishment to July 2018. Using Stata statistical software version 12.0, subgroup analyses and sensitivity analyses were conducted.

RESULTS

The overall hematologic response rate is 88% (95% CI 83-94%) for patients treated with eltrombopag plus immunosuppressive therapy, and 47% (95% CI 38-56%) for patients with refractory aplastic anemia using eltrombopag alone. Karyotype abnormality rates include an overall rate of 10% (95% CI 7-14%), a subtotal rate of 8% (95% CI 3-13%) for patients who are treated with eltrombopag plus immunosuppressive therapy without using antithymocyte globulin before, and a subtotal rate of 17% (95% CI 10-24%) for patients with refractory aplastic anemia treated with eltrombopag alone.

CONCLUSIONS

With different treatments and in different conditions eltrombopag showed a distinctive effect for aplastic anemia. However, clone evolution and adverse events were associated with treatment.

Spiritual Well-Being in Hispanic and Non-Hispanic Survivors of Allogeneic Hematopoietic Stem Cell Transplantation

Research suggests that spiritual well-being positively contributes to quality of life during and following cancer treatment. This relationship has not been well-described in ethnically diverse survivors of allogeneic transplantation.  This study compares spiritual well-being and quality of life of Hispanic (n = 69) and non-Hispanic (n = 102) survivors. Hispanic participants were significantly younger and reported significantly greater spiritual well-being than non-Hispanic survivors. Survivors with higher spiritual well-being had significantly better quality of life. Meaning and Peace significantly predicted quality of life. Although Hispanic survivors report greater spiritual well-being, Meaning and Peace, irrespective of ethnicity, have a salutary effect on quality of life.

Development of an algorithm to provide awareness in choosing study designs for inclusion in systematic reviews of healthcare interventions: a method study

OBJECTIVES

To develop an algorithm that aims to provide guidance and awareness for choosing multiple study designs in systematic reviews of healthcare interventions.

DESIGN

Method study: (1) To summarise the literature base on the topic. (2) To apply the integration of various study types in systematic reviews. (3) To devise decision points and outline a pragmatic decision tree. (4) To check the plausibility of the algorithm by backtracking its pathways in four systematic reviews.

RESULTS

(1) The results of our systematic review of the published literature have already been published. (2) We recaptured the experience from our four previously conducted systematic reviews that required the integration of various study types. (3) We chose length of follow-up (long, short), frequency of events (rare, frequent) and types of outcome as decision points (death, disease, discomfort, disability, dissatisfaction) and aligned the study design labels according to the Cochrane Handbook. We also considered practical or ethical concerns, and the problem of unavailable high-quality evidence. While applying the algorithm, disease-specific circumstances and aims of interventions should be considered. (4) We confirmed the plausibility of the pathways of the algorithm.

CONCLUSIONS

We propose that the algorithm can assist to bring seminal features of a systematic review with multiple study designs to the attention of anyone who is planning to conduct a systematic review. It aims to increase awareness and we think that it may reduce the time burden on review authors and may contribute to the production of a higher quality review.

First-line treatment for severe aplastic anemia in children: bone marrow transplantation from a matched family donor versus immunosuppressive therapy

The current treatment approach for severe aplastic anemia in children is based on studies performed in the 1980s, and updated evidence is required. We retrospectively compared the outcomes of children with acquired severe aplastic anemia who received immunosuppressive therapy within prospective trials conducted by the Japanese Childhood Aplastic Anemia Study Group or who underwent bone marrow transplantation from an HLA-matched family donor registered in the Japanese Society for Hematopoietic Cell Transplantation Registry. Between 1992 and 2009, 599 children (younger than 17 years) with severe aplastic anemia received a bone marrow transplant from an HLA-matched family donor (n=213) or immunosuppressive therapy (n=386) as first-line treatment. While the overall survival did not differ between patients treated with immunosuppressive therapy or bone marrow transplantation [88% (95% confidence interval: 86-90) versus 92% (90-94)], failure-free survival was significantly inferior in patients receiving immunosuppressive therapy than in those undergoing bone marrow transplantation [56% (54-59) versus 87% (85-90); P<0.0001]. There was no significant improvement in outcomes over the two time periods (1992-1999 versus 2000-2009). In multivariate analysis, age <10 years was identified as a favorable factor for overall survival (P=0.007), and choice of first-line immunosuppressive therapy was the only unfavorable factor for failure-free survival (P<0.0001). These support the current algorithm for treatment decisions, which recommends bone marrow transplantation when an HLA-matched family donor is available in pediatric severe aplastic anemia.

Stem cell transplantation of matched sibling donors compared with immunosuppressive therapy for acquired severe aplastic anaemia: a Cochrane systematic review

OBJECTIVES

Acquired severe aplastic anaemia is a rare and potentially fatal disease. The aim of this Cochrane review was to evaluate the effectiveness and adverse events of first-line allogeneic haematopoietic stem cell transplantation of human leucocyte antigen (HLA)-matched sibling donors compared with first-line immunosuppressive therapy.

SETTING

Specialised stem cell transplantations units in primary care hospitals.

PARTICIPANTS

We included 302 participants with newly diagnosed acquired severe aplastic anaemia. The age ranged from early childhood to young adulthood. We excluded studies on participants with secondary aplastic anaemia.

INTERVENTIONS

We included allogeneic haematopoietic stem cell transplantation as the test intervention harvested from any source of matched sibling donor and serving as a first-line therapy. We included immunosuppressive therapy as comparator with either antithymocyte/antilymphocyte globulin or ciclosporin or a combination of the two. PRIMARY AND SECONDARY OUTCOME MEASURES PLANNED AND FINALLY MEASURED: The primary outcome was overall mortality. Secondary outcomes were treatment-related mortality, graft failure, graft-versus-host disease, no response to immunosuppressive therapy, relapse after initial successful treatment, secondary clonal disease or malignancies, health-related quality of life and performance scores.

RESULTS

We identified three prospective non-randomised controlled trials with a study design that was consistent with the principle of 'Mendelian randomisation' in allocating patients to treatment groups. All studies had a high risk of bias due to the study design and were conducted more than 15 years. The pooled HR for overall mortality for the donor group versus the no donor group was 0.95 (95% CI 0.43 to 2.12, p=0.90).

CONCLUSIONS

There are insufficient and biased data that do not allow any firm conclusions to be made about the comparative effectiveness of first-line allogeneic haematopoietic stem cell transplantation of HLA-matched sibling donors and first-line immunosuppressive therapy of patients with acquired severe aplastic anaemia.