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Zhang L, Li J, Liang W, Zhang X, Chen S, Shi Y, Hao M, Zhao X, Gong M, Wei J, He Y, Jiang E, Han M, Zhang F, Feng S. Comparison of hematopoietic stem cell transplantation and repeated intensified immunosuppressive therapy as second-line treatment for relapsed/refractory severe aplastic anemia. Front Immunol 2024; 15:1425076. [PMID: 39221245 PMCID: PMC11361938 DOI: 10.3389/fimmu.2024.1425076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
The optimal treatment for patients with severe aplastic anemia (SAA) who fail an initial course of antithymocyte globulin (ATG) plus cyclosporine has not yet been established. We compared the effectiveness of allogeneic hematopoietic stem cell transplantation (allo-HSCT) (n = 36) with repeated immunosuppressive therapy (IST) (n = 33) for relapsed/refractory SAA between 2007 and 2022. In the IST group, patients were retreated with ATG (n = 16) or high-dose cyclophosphamide (n = 17). The overall response rate was 57.6% at 6 months and 60.6% at 12 months. In the allo-HSCT group, patients received a transplant from a matched sibling donor (n = 6), matched unrelated donor (n = 7), or haploidentical donor (n = 23). All patients achieved neutrophil engraftment, and there were no cases of primary graft failure. The cumulative incidences (CIs) of grades II-IV and III-IV acute graft-versus-host disease (GVHD) were 36.1% ± 0.7% and 13.9% ± 0.3% at day +100, respectively. The 4-year CI of chronic GVHD (cGVHD) was 36.2% ± 0.7%, with moderate to severe cGVHD at 14.9% ± 0.4%. Compared with IST, HSCT recipients showed much higher hematologic recovery rate at 3, 6, and 12 months (63.9%, 83.3%, and 86.1%, respectively, p < 0.001). The estimated 4-year overall survival (OS) (79.8% ± 6.8% vs. 80.0% ± 7.3%, p = 0.957) was similar; however, the failure-free survival (FFS) was significantly better in the HSCT group (79.8% ± 6.8% vs. 56.6% ± 8.8%, p = 0.049). Of note, children in the HSCT cohort were all alive without treatment failures, exhibiting superior OS (100% vs. 50.0% ± 17.7%, p = 0.004) and FFS (100% vs. 50.0% ± 17.7%, p = 0.004) than children in the IST cohort. Subgroup analysis revealed that younger patients (age ≤ 35 years), especially children, and those with refractory SAA benefited more from HSCT. Therefore, for these patients, salvage HSCT may be more preferable than a second course of IST.
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Affiliation(s)
- Lining Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Jianping Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Weiru Liang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaoyu Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Shulian Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yuanyuan Shi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Mengze Hao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaoli Zhao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Ming Gong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Jialin Wei
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yi He
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Mingzhe Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Fengkui Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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Shimano KA, Sasa G, Broglie L, Gloude NJ, Myers K, Nakano TA, Sharathkumar A, Rothman JA, Pereda MA, Overholt K, Narla A, McGuinn C, Lau BW, Geddis AE, Dror Y, de Jong JLO, Castillo P, Allen SW, Boklan J. Treatment of relapsed/refractory severe aplastic anemia in children: Evidence-based recommendations. Pediatr Blood Cancer 2024; 71:e31075. [PMID: 38764170 DOI: 10.1002/pbc.31075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/27/2024] [Accepted: 04/30/2024] [Indexed: 05/21/2024]
Abstract
Severe aplastic anemia (SAA) is a rare potentially fatal hematologic disorder. Although overall outcomes with treatment are excellent, there are variations in management approach, including differences in treatment between adult and pediatric patients. Certain aspects of treatment are under active investigation in clinical trials. Because of the rarity of the disease, some pediatric hematologists may have relatively limited experience with the complex management of SAA. The following recommendations reflect an up-to-date evidence-based approach to the treatment of children with relapsed or refractory SAA.
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Affiliation(s)
- Kristin A Shimano
- Department of Pediatrics, Division of Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Ghadir Sasa
- Sarah Cannon Transplant and Cellular Therapy Network, San Antonio, Texas, USA
| | - Larisa Broglie
- Department of Pediatric Hematology/Oncology/Blood and Marrow Transplantation, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nicholas J Gloude
- Department of Pediatrics, University of California San Diego, Rady Children's Hospital, San Diego, California, USA
| | - Kasiani Myers
- Department of Pediatrics, Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Taizo A Nakano
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Anjali Sharathkumar
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jennifer A Rothman
- Division of Pediatric Hematology/Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Maria A Pereda
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Kathleen Overholt
- Department of Pediatrics, Pediatric Hematology/Oncology, Riley Hospital for Children at Indiana University, Indianapolis, Indiana, USA
| | - Anupama Narla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Catherine McGuinn
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Bonnie W Lau
- Department of Pediatrics, Pediatric Hematology-Oncology, Dartmouth-Hitchcock, Lebanon, Pennsylvania, USA
| | - Amy E Geddis
- Department of Paediatrics, Division of Hematology/Oncology, Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Yigal Dror
- Department of Pediatrics, Marrow Failure and Myelodysplasia Program, The Hospital for Sick Children, Toronto, Canada
| | - Jill L O de Jong
- Department of Pediatrics, Section of Hematology/Oncology/Stem Cell Transplantation, University of Chicago, Chicago, Illinois, USA
| | - Paul Castillo
- Department of Pediatrics, Division of Pediatric Hematology Oncology, UF Health Shands Children's Hospital, Gainesville, Florida, USA
| | - Steven W Allen
- Department of Pediatrics, Pediatric Hematology/Oncology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica Boklan
- Department of Pediatrics, Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona, USA
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Sakamoto T, Obara N, Maruyama Y, Kato T, Kurita N, Hattori K, Suehara Y, Nishikii H, Yokoyama Y, Sakata-Yanagimoto M, Usuki K, Chiba S. Repeated immunosuppressive rabbit antithymocyte globulin therapy for adult patients with relapsed or refractory aplastic anemia. Eur J Haematol 2023; 111:768-776. [PMID: 37549934 DOI: 10.1111/ejh.14075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVES Immunosuppressive therapy (IST) with antithymocyte globulin (ATG) and cyclosporin A is the standard treatment for aplastic anemia (AA). However, the efficacy of repeated IST with rabbit ATG (rATG) as salvage therapy remains unclear in patients with relapsed or refractory AA. METHODS We retrospectively evaluated the efficacy and safety of IST2 with rATG (IST2-rATG) in 19 consecutive patients with relapsed or refractory AA who received first-line IST with rATG in two centers between 2009 and 2020. RESULTS The overall 6-month response rate of the patients was 58%. The response rates were similar between patients with relapsed and refractory AA. The presence of glycophosphatidylinositol-deficient blood cells was associated with a better response to IST2-rATG. Despite retreatment with the same rATG, serum disease and severe allergic reactions were not observed. CONCLUSION IST2-rATG is effective and safe for the treatment of adult patients with relapsed and refractory AA after receiving first-line IST with rATG.
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Affiliation(s)
- Tatsuhiro Sakamoto
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Naoshi Obara
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yumiko Maruyama
- Department of Transfusion Medicine, University of Tsukuba Hospital, Tsukuba, Japan
| | - Takayasu Kato
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Naoki Kurita
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Keiichiro Hattori
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasuhito Suehara
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Hidekazu Nishikii
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Transfusion Medicine, University of Tsukuba Hospital, Tsukuba, Japan
| | - Yasuhisa Yokoyama
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Mamiko Sakata-Yanagimoto
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
- Division of Advanced Hemato-Oncology, Transborder Medical Research Center, Tsukuba, Japan
| | | | - Shigeru Chiba
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Young DJ, Fan X, Groarke EM, Patel B, Desmond R, Winkler T, Larochelle A, Calvo KR, Young NS, Dunbar CE. Long-term eltrombopag for bone marrow failure depletes iron. Am J Hematol 2022; 97:791-801. [PMID: 35312200 DOI: 10.1002/ajh.26543] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 11/09/2022]
Abstract
Eltrombopag (EPAG) has been approved for the treatment of aplastic anemia and for immune thrombocytopenia, and a subset of patients require long-term therapy. Due to polyvalent cation chelation, prolonged therapy leads to previously underappreciated iron depletion. We conducted a retrospective review of patients treated at the NIH for aplastic anemia, myelodysplastic syndrome, and unilineage cytopenias, comparing those treated with EPAG to a historical cohort treated with immunosuppression without EPAG. We examined iron parameters, duration of therapy, response assessment, relapse rates, and common demographic parameters. We included 521 subjects treated with (n = 315) or without EPAG (n = 206) across 11 studies with multiyear follow-up (3.6 vs. 8.5 years, respectively). Duration of EPAG exposure correlated with ferritin reduction (p = 4 × 10-14 ) regardless of response, maximum dose, or degree of initial iron overload. Clearance followed first-order kinetics with faster clearance (half-life 15.3 months) compared with historical responders (47.5 months, p = 8 × 10-10 ). Risk of iron depletion was dependent upon baseline ferritin and duration of therapy. Baseline ferritin did not correlate with response of marrow failure to EPAG or to relapse risk, and timing of iron clearance did not correlate with disease response. In conclusion, EPAG efficiently chelates total body iron comparable to clinically available chelators. Prolonged use can deplete iron and ultimately lead to iron-deficiency anemia mimicking relapse, responsive to iron supplementation.
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Affiliation(s)
- David J. Young
- Translational Stem Cell Biology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Xing Fan
- Translational Stem Cell Biology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Emma M. Groarke
- Hematology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Bhavisha Patel
- Hematology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Ronan Desmond
- Hematology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
- Department of Haematology (Laboratory) Tallaght University Hospital Dublin Ireland
| | - Thomas Winkler
- Translational Stem Cell Biology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Andre Larochelle
- Cellular and Molecular Therapeutics Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Katherine R. Calvo
- Department of Laboratory Medicine Clinical Center, NIH Bethesda Maryland USA
| | - Neal S. Young
- Hematology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
| | - Cynthia E. Dunbar
- Translational Stem Cell Biology Branch National Heart, Lung, and Blood Institute, NIH Bethesda Maryland USA
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5
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Ding S, Fu R. New Trends of Nontransplant therapy for Acquired Aplastic Anemia. Curr Pharm Des 2022; 28:1730-1737. [PMID: 35440301 DOI: 10.2174/1381612828666220418132432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/03/2022] [Indexed: 11/22/2022]
Abstract
Aplastic anemia (AA) is a hematological disease that is characterized by pancytopenia and hypofunctional bone marrow hematopoiesis. Patients with AA are treated with either immunosuppressive therapy (IST) using anti-thymocyte globulin (ATG) and Cyclosporine (CsA) or hematopoietic stem cell transplantation (HSCT), if a matched donor is available. The standard IST regimen for AA patients which results in response rates up to 70%, and even higher overall survival. However, primary and secondary failures after IST remain frequent, and to date all attempts aiming to overcome this problem have been unfruitful. The nontransplant therapeutic options for AA have significantly expanded during the last few years. Here, we review the new trends of nontransplant therapy for AA and summarize the current therapeutic effect of AA.
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Affiliation(s)
- Shaoxue Ding
- Department of Hematology, Tianjin Medical University General Hospital, No. 154, Anshan Road, Heping District, Tianjin, 300052, China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, No. 154, Anshan Road, Heping District, Tianjin, 300052, China
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6
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Patel BA, Townsley DM, Scheinberg P. Immunosuppressive therapy in severe aplastic anemia. Semin Hematol 2022; 59:21-29. [DOI: 10.1053/j.seminhematol.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/11/2022]
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7
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Scheinberg P. Acquired severe aplastic anaemia: how medical therapy evolved in the 20th and 21st centuries. Br J Haematol 2021; 194:954-969. [PMID: 33855695 DOI: 10.1111/bjh.17403] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
The progress in aplastic anaemia (AA) management is one of success. Once an obscure entity resulting in death in most affected can now be successfully treated with either haematopoietic stem cell transplantation (HSCT) or immunosuppressive therapy (IST). The mechanisms that underly the diminution of haematopoietic stem cells (HSCs) are now better elucidated, and include genetics and immunological alterations. Advances in supportive care with better antimicrobials, safer blood products and iron chelation have greatly impacted AA outcomes. Working somewhat 'mysteriously', anti-thymocyte globulin (ATG) forms the base for both HSCT and IST protocols. Efforts to augment immunosuppression potency have not, unfortunately, led to better outcomes. Stimulating HSCs, an often-sought approach, has not been effective historically. The thrombopoietin receptor agonists (Tpo-RA) have been effective in stimulating early HSCs in AA despite the high endogenous Tpo levels. Dosing, timing and best combinations with Tpo-RAs are being defined to improve HSCs expansion in AA with minimal added toxicity. The more comprehensive access and advances in HSCT and IST protocols are likely to benefit AA patients worldwide. The focus of this review will be on the medical treatment advances in AA.
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Affiliation(s)
- Phillip Scheinberg
- Division of Haematology, Hospital A Beneficência Portuguesa, São Paulo, Brazil
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8
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Elazhary S, Alawyat HA. Bradycardia associated with antithymocyte globulin treatment of a pediatric patient with sickle cell disease: a case report and literature review. Hematol Transfus Cell Ther 2020; 44:284-287. [PMID: 33281113 PMCID: PMC9123584 DOI: 10.1016/j.htct.2020.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/17/2020] [Accepted: 08/31/2020] [Indexed: 11/17/2022] Open
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9
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Pierri F, Dufour C. Management of aplastic anemia after failure of frontline immunosuppression. Expert Rev Hematol 2019; 12:809-819. [PMID: 31311355 DOI: 10.1080/17474086.2019.1645003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: About 60% of aplastic anemia (AA) patients are in need of further treatment after frontline standard immunosuppressive therapy (IST). This along with the prolonged survival of AA subjects who do not respond to or relapse after this treatment makes management of these patients a rising and very challenging issue. Areas covered: Literature research, carried out from the most commonly used databases, included the following keywords: aplastic anemia, immunosuppressive treatment, antithymocyte globuline, ciclosporine A, refractory aplastic anemia, relapsing aplastic anemia, hematopoietic stem cell transplantation including haploidentical and cord blood transplantations thrombopoietin mimetics, supportive treatment, chelation and infections. Studies on the treatment of aplastic anemia with different levels of evidence were included. Top level of evidence studies (metanalyses and randomized prospective controlled trials) were a minority because severe AA, particularly in the subset of patients who fail upfront IST, is an extremely rare disease. Guidelines from National Societies and review articles were also included. Expert opinion: The most commonly used treatments after failure of upfront immunosuppression are hematopoietic stem cell transplantation, a second course of immunosuppression and thrombopoietin mimetics alone or in combination with immunosuppression. Other potential options are alemtuzumab, androgens, oral cyclosporine A in monotherapy. Not many comparative studies exist to clearly establish the superiority of one over another strategy. Therefore, the choice of the best treatment for these patients should rely on major driving factors like patient's age and comorbidities, availability of a matched unrelated donor, donor's characteristics and drug-availability.
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Affiliation(s)
- Filomena Pierri
- Hematology Unit, G. Gaslini Children's Research Hospital , Genova , Italy
| | - Carlo Dufour
- Hematology Unit, G. Gaslini Children's Research Hospital , Genova , Italy
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10
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Ding SX, Fu R. [Progress in prediction and recovery of immunosuppressive therapy in patients with severe aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:960-964. [PMID: 30486598 PMCID: PMC7342355 DOI: 10.3760/cma.j.issn.0253-2727.2018.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Indexed: 11/05/2022]
Affiliation(s)
| | - R Fu
- Tianjin Medical University General Hospital, Tianjin 300052, China
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11
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Scheinberg P. Recent Advances and Long-Term Results of Medical Treatment of Acquired Aplastic Anemia: Are Patients Cured? Hematol Oncol Clin North Am 2018; 32:609-618. [PMID: 30047414 DOI: 10.1016/j.hoc.2018.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Horse antithymocyte globulin plus cyclosporine remains standard immunosuppressive therapy in severe aplastic anemia, with hematologic response rates of 60% to 70%. In those refractory to this regimen, a second course of therapy with rabbit antithymocyte globulin plus cyclosporine or alemtuzumab produces responses in 30% to 40%. Eltrombopag, a thrombopoietin receptor agonist, showed activity as a single agent in those refractory to initial immunosuppression with hematologic response rates of 40% to 50%. When combined with immunosuppression as frontline therapy, eltrombopag increased the rate of overall and complete response rates. Longer follow-up is needed to better define these outcomes.
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Affiliation(s)
- Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, Rua Martiniano de Carvalho, 951, São Paulo 01321-001, Brazil.
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12
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Peffault de Latour R, Tabrizi R, Marcais A, Leblanc T, Lamy T, Mohty M, Tavitian S, Jubert C, Pasquet M, Galambrun C, Nguyen S, Cahn JY, Braun T, Deconinck E, Bay JO, Sicre de Fontbrune F, Barraco F, Socié G. Nationwide survey on the use of horse antithymocyte globulins (ATGAM) in patients with acquired aplastic anemia: A report on behalf of the French Reference Center for Aplastic Anemia. Am J Hematol 2018; 93:635-642. [PMID: 29377260 DOI: 10.1002/ajh.25050] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 01/18/2018] [Accepted: 01/22/2018] [Indexed: 12/16/2022]
Abstract
Antithymocyte globulins (ATG) plus cyclosporine (CSA) is the gold standard immunosuppressive treatment (IST) for patients with aplastic anemia. A prospective randomized trial showed in 2011 that hATG was superior to rabbit ATG for first-line treatment of severe AA. The French Health Agency (ANSM) permitted a patient-named authorization for temporary use (ATU) program of hATG (ATGAM, Pfizer) in patients with AA in 2011 since commercial access to hATG is not approved. We took advantage of this program to analyze the outcomes of 465 patients who received antithymocyte globulins (ATGAM) plus CSA as first line treatment (n = 379; 81.5%), or for refractory (n = 26) or relapsed disease (n = 33), from September 2011 to March 2017. In the entire cohort one year, 72% of the patients had partial and 13% had complete response, with worse response for patients with severe AA and a longer interval between diagnosis and IST (more than 6 months). Severe adverse events were mainly linked to infections (24%), hemorrhages (6%), and elevated liver function tests (5%). Overall at 12 months, 9.7% of patients required second line IST and 15.6% received transplantation. Fifty-five patients died during the study mainly because of infections (53%). Factors predicting independently worse survival were age over 40 years, neutrophils less than 0.5 × 109 /L, male gender and longer delay between diagnosis and hATG (>6 months period). This study does illustrate the results of ATGAM with CSA in a true-life perspective and confirms ATGAM as standard of care IST to treat patients with AA not eligible for HSCT.
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Affiliation(s)
- Régis Peffault de Latour
- Service Hématologie Greffe, Centre de Référence Aplasies Médullaires Acquises et Constitutionnelles; Université Paris Diderot, Sorbonne Paris Cité, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris; Paris France
| | - Reza Tabrizi
- Service d'Hématologie Clinique, Centre de Compétence Aplasies Médullaires Acquises et Constitutionnelles; Hôpital Haut Lévêque; Bordeaux France
| | - Ambroise Marcais
- Service d'hématologie Clinique, Hôpital Necker, Assistance Publique Hôpitaux de Paris; Paris France
| | - Thierry Leblanc
- Service Hématologie Pédiatrique, Centre de Référence Aplasies Médullaires Acquises et Constitutionnelles, Hôpital Robert Debré; Assistance Publique Hôpitaux de Paris; Paris France
| | - Thierry Lamy
- Service d'hématologie Clinique, Hôpital Pontchaillou; France
| | - Mohamad Mohty
- Service d'Hématologie Clinique, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris; Paris France
| | - Suzanne Tavitian
- Service d'Hématologie, Institut Universitaire du Cancer de Toulouse Oncopole, Centre hospitalier universitaire de Toulouse; France
| | - Charlotte Jubert
- Service Hématologie Pédiatrique, Centre de Compétence Aplasies Médullaires Acquises et Constitutionnelles; Hôpital universitaire; Bordeaux France
| | - Marlène Pasquet
- Service d'Hématologie Pédiatrique, Oncopôle; Toulouse France
| | - Claire Galambrun
- Service Hématologie Pédiatrique, Centre de Compétence Aplasies Médullaires Acquises et Constitutionnelles, Hôpital La Timone; Marseille France
| | - Stéphanie Nguyen
- Service d'Hématologie Clinique, Hôpital Pitié-Salpétrière, Assistance Publique Hôpitaux de Paris; Paris France
| | - Jean Yves Cahn
- Service d'Hématologie Clinique, Hôpital universitaire; Grenoble France
| | - Thorsten Braun
- Service d'Hématologie Clinique, Hôpital Avicennes, Bobigny, Assistance Publique Hôpitaux de Paris; Paris France
| | - Eric Deconinck
- Service d'Hématologie Clinique, Hôpital universitaire; Besançon France
| | | | - Flore Sicre de Fontbrune
- Service Hématologie Greffe, Centre de Référence Aplasies Médullaires Acquises et Constitutionnelles; Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris; Paris France
| | - Fiorenza Barraco
- Service d'Hématologie Clinique, Hôpital universitaire; Lyon France
| | - Gérard Socié
- Service Hématologie Greffe, Centre de Référence Aplasies Médullaires Acquises et Constitutionnelles; Université Paris Diderot, Sorbonne Paris Cité, Inserm UMR 1160, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris; Paris France
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13
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Vaht K, Göransson M, Carlson K, Isaksson C, Lenhoff S, Sandstedt A, Uggla B, Winiarski J, Ljungman P, Brune M, Andersson PO. Low response rate to ATG-based immunosuppressive therapy in very severe aplastic anaemia - A Swedish nationwide cohort study. Eur J Haematol 2018. [DOI: 10.1111/ejh.13057] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Krista Vaht
- Section of Haematology and Coagulation; Sahlgrenska University Hospital; Gothenburg Sweden
- Institute of Medicine; Sahlgrenska Academy at Gothenburg University; Gothenburg Sweden
| | - Magnus Göransson
- Department of Pediatrics; The Queen Silvia Children's Hospital; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Kristina Carlson
- Department of Haematology; Uppsala University Hospital; Uppsala Sweden
| | - Cecilia Isaksson
- Department of Haematology; Cancer Centre; University Hospital; Umeå Sweden
| | - Stig Lenhoff
- Department of Haematology; Skåne University Hospital; Lund University; Lund Sweden
| | - Anna Sandstedt
- Department of Haematology; Linköping University Hospital; Linköping Sweden
| | - Bertil Uggla
- Section of Haematology Department of Medicine; Faculty of Medicine and Health; Örebro University; Örebro Sweden
| | - Jacek Winiarski
- Astrid Lindgren Children's Hospital; Karolinska Institutet; Karolinska University Hospital and CLINTEC; Stockholm Sweden
| | - Per Ljungman
- Centre of Allogeneic Stem Cell Transplantation Unit (CAST); Department of Medicine; Karolinska Institutet; Karolinska University Hospital; Stockholm Sweden
| | - Mats Brune
- Section of Haematology and Coagulation; Sahlgrenska University Hospital; Gothenburg Sweden
- Institute of Medicine; Sahlgrenska Academy at Gothenburg University; Gothenburg Sweden
| | - Per-Ola Andersson
- Institute of Medicine; Sahlgrenska Academy at Gothenburg University; Gothenburg Sweden
- Department of Medicine; Södra Älvsborg Hospital Borås; Borås Sweden
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14
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Kállay K, Zakariás D, Csordás K, Benyó G, Kassa C, Sinkó J, Stréhn A, Horváth O, Vásárhelyi B, Kriván G. Antithymocyte Globuline Therapy and Bradycardia in Children. Pathol Oncol Res 2018. [PMID: 29524166 DOI: 10.1007/s12253-018-0403-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In antithymocyte globulin (ATG) treated patients occasionally bradycardia has been noticed. Therefore, we retrospectively analyzed the occurrence of bradycardia in ATG-treated children. Using medical records between 2007 and 2012 we identified children undergoing a combined therapy with ATG and glucocorticoids (ATG group, n = 22). The incidence of bradycardia was compared to that registered in children treated with glucocorticoids alone (glucocorticoid alone group, n = 21). Heart rates (HR) were registered before and on days 0-3, 4-7 and 8-14 after the ATG or steroid administration. The rate of bradycardic episodes was higher during ATG therapy than in the steroid alone group, while severe bradycardia occurred only in the ATG group (97 versus 32, p = 0.0037, and 13 versus 0, p = 0.0029, respectively). There was an interaction between the time and treatment group on HR (p = 0.046). Heart rates in ATG and steroid alone groups differed significantly on day 0-3 and day 4-7 (p = 0.046, p = 0.006, respectively). Within the ATG group HR was lower on days 4-7 compared to the days before and the days 8-14 values (p < 0.001, 95%CI: 0.020-0.074). These findings indicate that transient asymptomatic bradycardia is probably more common with ATG therapy than previously reported. HR should be closely monitored during and after ATG therapy.
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Affiliation(s)
- Krisztián Kállay
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary.
| | - Dávid Zakariás
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - Katalin Csordás
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - Gábor Benyó
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - Csaba Kassa
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - János Sinkó
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - Anita Stréhn
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - Orsolya Horváth
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - Barna Vásárhelyi
- Department of Laboratory Medicine, Semmelweis University, Budapest, Hungary
| | - Gergely Kriván
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
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15
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Intravenous infusion of allogeneic mesenchymal stromal cells in refractory or relapsed aplastic anemia. Cytotherapy 2016; 17:1696-705. [PMID: 26589752 DOI: 10.1016/j.jcyt.2015.09.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 09/01/2015] [Accepted: 09/15/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AIMS For patients with aplastic anemia (AA) who are refractory to anti-thymocyte globulin (ATG) and cyclosporine, a second course of immunosuppression is successful in only one-fourth to one-third of cases. METHODS We conducted a phase 1/2 study to evaluate the addition of two to five weekly intravenous infusions of allogeneic unrelated non-human leukocyte antigen-matched bone marrow-derived mesenchymal stromal cells (MSCs) (median, 2.7 × 10(6) cells/kg/infusion; range, 1.3-4.5) to standard rabbit ATG and cyclosporine in nine patients with refractory or relapsed AA. RESULTS After a median follow-up of 20 months, no infusion-related adverse event was observed, but four deaths occurred as the result of heart failure and bacterial or invasive fungal infections; only two patients achieved partial hematologic responses at 6 months. We failed to demonstrate by fluorescence in situ hybridization or variable number tandem repeat any MSC engraftment in patient marrow 30, 90 or 180 days after infusions. CONCLUSIONS Infusion of allogeneic MSCs in AA is safe but does not improve clinical hematologic response or engraft in recipient bone marrow. This study was registered at clinicaltrials.gov, identifier: NCT01297972.
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16
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Schrezenmeier H, Körper S, Höchsmann B. Immunosuppressive therapy for transplant-ineligible aplastic anemia patients. Expert Rev Hematol 2015; 8:89-99. [PMID: 25572607 DOI: 10.1586/17474086.2015.978759] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Aplastic anemia is a rare life-threatening bone marrow failure that is characterized by bicytopenia or pancytopenia in the peripheral blood and a hypoplastic or aplastic bone marrow. The patients are at risk of infection and hemorrhage due to neutropenia and thrombocytopenia and suffer from symptoms of anemia. The main treatment approaches are allogeneic stem cell transplantation and immunosuppression. Here, we review current standard immunosuppression and the attempts that have been made in the past two decades to improve results: review of recent developments also reveals that sometimes not only the advent of new drugs, good ideas and well-designed clinical trials decide the progress in the field but also marketing considerations of pharmaceutical companies. Aplastic anemia experts unfortunately had to face the situation that efficient drugs were withdrawn simply for marketing considerations. We will discuss the current options and challenges in first-line treatment and management of relapsing and refractory patients with an emphasis on adult patients. Some promising new approaches are currently under investigation in prospective, randomized trials.
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17
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Clé DV, Atta EH, Dias DSP, Lima CBL, Bonduel M, Sciuccati G, Medeiros LA, de Oliveira MM, Salvino MA, Garanito M, Saad STO, Calado RT, Scheinberg P. Repeat course of rabbit antithymocyte globulin as salvage following initial therapy with rabbit antithymocyte globulin in acquired aplastic anemia. Haematologica 2015; 100:e345-7. [PMID: 25862703 DOI: 10.3324/haematol.2015.123760] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Diego V Clé
- Division of Hematology, University of São Paulo at Ribeirão Preto School of Medicine, Ribeirão Preto, Brasil
| | - Elias H Atta
- CEMO, National Cancer Institute, Rio de Janeiro, Brasil
| | | | - Carlos B L Lima
- Hematopoietic Stem Cell Program, Hemorio, Rio de Janeiro, Brasil
| | - Mariana Bonduel
- Servicio de Hematología-Oncología, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Gabriela Sciuccati
- Servicio de Hematología-Oncología, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Larissa A Medeiros
- Bone Marrow Transplantation unit, Federal University of Paraná, Curitiba, Brasil
| | - Michel M de Oliveira
- Bone Marrow Transplantation unit, Federal University of Paraná, Curitiba, Brasil
| | - Marco A Salvino
- Bone Marrow Transplantation unit, Federal University of Bahia, Salvador
| | | | - Sara T Ollala Saad
- National Institute of Science and Technology of Blood, University of Campinas, Brasil
| | - Rodrigo T Calado
- Division of Hematology, University of São Paulo at Ribeirão Preto School of Medicine, Ribeirão Preto, Brasil
| | - Phillip Scheinberg
- Division of Hematology, University of São Paulo at Ribeirão Preto School of Medicine, Ribeirão Preto, Brasil Clinical Hematology, Antônio Ermírio de Moraes Cancer Center, Hospital São José e Beneficência Portuguesa, São Paulo, Brasil
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18
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Haploidentical BMT and post-transplant Cy for severe aplastic anemia: a multicenter retrospective study. Bone Marrow Transplant 2015; 50:685-9. [PMID: 25730184 DOI: 10.1038/bmt.2015.20] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 12/29/2014] [Accepted: 12/31/2014] [Indexed: 12/14/2022]
Abstract
Patients with refractory severe aplastic anemia (SAA) who lack a matched sibling or unrelated donor need new therapeutic approaches. Hematopoietic SCT (HSCT) using mismatched or haploidentical related donors has been used in the past, but was associated with a significant risk of GVHD and mortality. Recently, the use of post-transplant cyclophosphamide (Cy) has been shown to be an effective strategy to prevent GVHD in recipients of haploidentical HSCT, but the majority of reports have focused on patients with hematology malignancies. We describe the outcome of 16 patients who underwent haploidentical transplantation using a reduced-intensity conditioning regimen with post-transplant Cy. Stem cell sources were BM (N=13) or PBSCs (N=3). The rate of neutrophil engraftment was 94% and of platelet engraftment was 75%. Two patients had secondary graft failure and were successfully salvaged with another transplant. Three patients developed acute GVHD being grades 2-4 in two. Five patients have died and the 1-year OS was 67.1% (95% confidence interval: 36.5-86.4%). In our small series, the use of a reduced-intensity conditioning with post-transplant Cy in haploidentical BMT was associated with high rates of engraftment and low risk of GVHD in patients with relapsed/refractory SAA.
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19
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Chen J, Desierto MJ, Feng X, Biancotto A, Young NS. Immune-mediated bone marrow failure in C57BL/6 mice. Exp Hematol 2014; 43:256-67. [PMID: 25555453 DOI: 10.1016/j.exphem.2014.12.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/17/2014] [Accepted: 12/02/2014] [Indexed: 01/24/2023]
Abstract
We established a model of immune-mediated bone marrow (BM) failure in C57BL/6 (B6) mice with 6.5 G total-body irradiation followed by the infusion of 4-10 × 10(6) lymph node (LN) cells/recipient from Friend leukemia virus B/N (FVB) donors. Forty-three percent of animals succumbed, with surviving animals showing marked declines in blood neutrophils, red blood cells, platelets and total BM cells at 8 to 14 days following LN cell infusion. Lowering the total-body irradiation dose to 5 G or altering the LN source from FVB to BALB/cBy donors failed to produce BM destruction. Affected animals showed significant expansion and activation of CD8 T lymphocytes in both the blood and BM; cytotoxic T cells had elevated Fas ligand expression and were oligoclonal, mainly displaying Vβ7 and Vβ17 T cell receptors. There were significant increases in blood plasma interferon γ and tissue necrosis factor α in affected animals. Chemokine ligands CCL3, CCL4, CCL5, CCL20, CXCL2, and CXCL5 and hematopoietic growth factors G-CSF, M-CSF, GM-CSF, VEGF were also elevated. In B6 mice carrying a Fas gene mutation, BM failure was attenuated when they were infused with FVB LN cells. Our model establishes a useful platform to define the roles of individual genes and their products in immune-mediated BM failure.
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Affiliation(s)
- Jichun Chen
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Marie J Desierto
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Xingmin Feng
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Angélique Biancotto
- Center for Human Immunology, Autoimmunity, and Inflammation, National Institutes of Health, Bethesda, MD, USA
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Center for Human Immunology, Autoimmunity, and Inflammation, National Institutes of Health, Bethesda, MD, USA
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20
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Abstract
Recent advances in the treatment of aplastic anemia (AA) made most of patients to expect to achieve a long-term survival. Allogeneic stem cell transplantation (SCT) from HLA-matched sibling donor (MSD-SCT) is a preferred first-line treatment option for younger patients with severe or very severe AA, whereas immunosuppressive treatment (IST) is an alternative option for others. Horse anti-thymocyte globuline (ATG) with cyclosporin A (CsA) had been a standard IST regimen with acceptable response rate. Recently, horse ATG had been not available and replaced with rabbit ATG in most countries. Subsequently, recent comparative studies showed that the outcomes of patients who received rabbit ATG/CsA were similar or inferior compared to those who received horse ATG/CsA. Therefore, further studies to improve the outcomes of IST, including additional eltrombopag, are necessary. On the other hand, the upper age limit of patients who are able to receive MSD-SCT as first-line treatment is a current issue because of favorable outcomes of MSD-SCT of older patients using fludarabine-based conditioning. In addition, further studies to improve the outcomes of patients who receive allogeneic SCT from alternative donors are needed. In this review, current issues and the newly emerging trends that may improve their outcomes in near futures will be discussed focusing the management of patients with AA.
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Affiliation(s)
- Seung Hwan Shin
- Department of Hematology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Eun Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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21
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Willis L, Rexwinkle A, Bryan J, Kadia TM. Recent Developments in Drug Therapy for Aplastic Anemia. Ann Pharmacother 2014; 48:1469-78. [DOI: 10.1177/1060028014547078] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: This article reviews recent developments in immunosuppressive therapy (IST) for aplastic anemia (AA) patients who are not candidates for stem cell transplant (SCT); including, front-line, salvage, and novel treatment options with a focus on response rates (RRs) and overall survival (OS). Data Sources: A PubMed literature search was performed from 1977 to June 2014 using the search terms aplastic anemia, horse antithymocyte globulin (hATG), rabbit ATG (rATG), thymoglobulin, and cyclosporine (CSA). Additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language studies investigating IST for treatment of AA in non–SCT candidates were evaluated. Data Synthesis: Studies indicate addition of CSA and corticosteroids to hATG for treatment of AA improves RRs, decreases relapse rates, and improves 5-year OS. hATG improved RRs, relapse rates, and OS compared to rATG in the front-line setting. Studies support the use of rATG when front-line IST with hATG fails or when hATG is unavailable. Front-line daclizumab can be considered for nonsevere AA (NAA); however, data is limited. Alemtuzumab or eltrombopag are options for relapsed AA in select patients. Conclusions: hATG with methylprednisolone and CSA is recommended for front-line treatment of AA, whereas rATG is reserved for salvage therapy. Front-line use of daclizumab has been studied in NAA patients, but additional prospective trials are needed before this is adopted into clinical practice. Alemtuzumab and eltrombopag have been studied for treatment of AA; recruiting is ongoing in clinical trials to assess the appropriate dosing strategy and place in therapy.
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Affiliation(s)
- Lauren Willis
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amber Rexwinkle
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Bryan
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M. Kadia
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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