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Gao X, Bian ZL, Qiao XH, Qian XW, Li J, Shen GM, Miao H, Yu Y, Meng JH, Zhu XH, Jiang JY, Le J, Yu L, Wang HS, Zhai XW. Population Pharmacokinetics of Cyclosporine in Chinese Pediatric Patients With Acquired Aplastic Anemia. Front Pharmacol 2022; 13:933739. [PMID: 35979231 PMCID: PMC9377374 DOI: 10.3389/fphar.2022.933739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
Cyclosporine (CsA) is a component of the first-line treatment for acquired aplastic anemia (acquired AA) in pediatric patients. This study aimed to develop a population pharmacokinetic (PK) model of CsA in Chinese pediatric patients with acquired AA to inform individual dosage regimens. A total of 681 CsA whole blood concentrations and laboratory data of 157 pediatric patients with acquired AA were retrospectively collected from two hospitals in Shanghai. A nonlinear mixed-effect model approach was used to build the population PK model. Potential covariate effects of age, body weight, and biochemical measurements (renal and liver functions) on CsA PK disposition were evaluated. Model fit was assessed using the basic goodness of fit and a visual predictive check. The CsA concentration data were accurately described using a two-compartment disposition model with first-order absorption and elimination. Body weight value was implemented as a fixed allometric function on all clearance and volume of distribution parameters. Total bilirubin level was identified as a significant covariate on apparent clearance (CL/F), with a 1.07% reduction per 1 nmol/L rise in total bilirubin level. The final estimates for CL/F and central volume (Vc/F) were 29.1 L/h and 325 L, respectively, for a typical 28 kg child. Other covariates (e.g., gender, age, albumin, hemoglobin, hematocrit, serum creatinine, and concomitant medication) did not significantly affect the PK properties of CsA. This population PK model, along with a maximum a posteriori Bayesian approach, could estimate individual PK parameters in pediatric patients with acquired AA to conduct individual CsA therapy.
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Affiliation(s)
- Xuan Gao
- Outpatient and Emergency Management Office, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Zhu-Li Bian
- Department of Pediatrics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiao-Hong Qiao
- Department of Pediatrics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiao-Wen Qian
- Department of Hematology and Oncology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Jun Li
- Department of Hematology and Oncology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Guo-Mei Shen
- Outpatient and Emergency Management Office, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Hui Miao
- Department of Hematology and Oncology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Yi Yu
- Department of Hematology and Oncology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Jian-Hua Meng
- Department of Hematology and Oncology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Xiao-Hua Zhu
- Department of Hematology and Oncology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Jun-Ye Jiang
- Department of Hematology and Oncology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Jun Le
- Department of Hematology and Oncology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Ling Yu
- Department of Hematology and Oncology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Hong-Sheng Wang
- Department of Hematology and Oncology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
- *Correspondence: Xiao-Wen Zhai, ; Hong-Sheng Wang,
| | - Xiao-Wen Zhai
- Department of Hematology and Oncology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
- *Correspondence: Xiao-Wen Zhai, ; Hong-Sheng Wang,
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Kakiuchi T, Eguchi K, Koga D, Eguchi H, Nishi M, Sonoda M, Ishimura M, Matsuo M. Changes in bone marrow and peripheral blood lymphocyte subset findings with onset of hepatitis-associated aplastic anemia. Medicine (Baltimore) 2022; 101:e28953. [PMID: 35212305 PMCID: PMC8878616 DOI: 10.1097/md.0000000000028953] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/11/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Hepatitis-associated aplastic anemia (HAAA) is a rare illness that results in bone marrow failure following hepatitis development. The etiological agent remains unknown in most HAAA cases. However, clinical features of the disease and immunotherapy response indicate that immune-mediated factors play a central role in the pathogenesis of HAAA. Activation of cytotoxic T cells and increase in CD8 cells could exert cytotoxic effects on the myelopoietic cells in the bone marrow. PATIENT CONCERNS A 15-month-old boy was brought to our hospital with complaints of generalized petechiae and purpura observed a week prior to hospitalization. His liver was palpated 3 cm below the costal margin, platelet count was 0 × 104/μL, and alanine aminotransferase level was 1346 IU/L. A blood test indicated cytomegalovirus infection, and 3 bone marrow examinations revealed progressive HAAA. As the disease progressed to the 3rd, 6th, and 9th week after onset, CD4+ T cells were markedly decreased, CD8+ T cells were markedly increased, and the CD4/CD8 ratio was significantly decreased. The number of B cells and natural killer cells decreased with time, eventually reaching 0.0%. DIAGNOSIS HAAA. INTERVENTIONS Rabbit antithymocyte globulin and eltrombopag olamine (a thrombopoietin receptor agonist) were administered. OUTCOMES The patient's platelet count returned to normal, and bone marrow transplantation was avoided. The peripheral blood lymphocytes (PBLs) improved as the patient's general condition recovered. LESSONS This case demonstrates that HAAA induced by cytomegalovirus infection features decreasing CD4+ and increasing CD8+ PBLs as the bone marrow hypoplasia progresses. The PBLs return to their normal levels with the recovery from the disease. Our case findings thus support the involvement of immunological abnormality in HAAA.
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Affiliation(s)
- Toshihiko Kakiuchi
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Katsuhide Eguchi
- Department of Pediatrics, Faculty of Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Daisuke Koga
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Hiroi Eguchi
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Masanori Nishi
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Motoshi Sonoda
- Department of Pediatrics, Faculty of Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Masataka Ishimura
- Department of Pediatrics, Faculty of Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Muneaki Matsuo
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
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Shimano KA, Narla A, Rose MJ, Gloude NJ, Allen SW, Bergstrom K, Broglie L, Carella BA, Castillo P, Jong JLO, Dror Y, Geddis AE, Huang JN, Lau BW, McGuinn C, Nakano TA, Overholt K, Rothman JA, Sharathkumar A, Shereck E, Vlachos A, Olson TS, Bertuch AA, Wlodarski MW, Shimamura A, Boklan J. Diagnostic work-up for severe aplastic anemia in children: Consensus of the North American Pediatric Aplastic Anemia Consortium. Am J Hematol 2021; 96:1491-1504. [PMID: 34342889 DOI: 10.1002/ajh.26310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/19/2022]
Abstract
The North American Pediatric Aplastic Anemia Consortium (NAPAAC) is a group of pediatric hematologist-oncologists, hematopathologists, and bone marrow transplant physicians from 46 institutions in North America with interest and expertise in aplastic anemia, inherited bone marrow failure syndromes, and myelodysplastic syndromes. The NAPAAC Bone Marrow Failure Diagnosis and Care Guidelines Working Group was established with the charge of harmonizing the approach to the diagnostic workup of aplastic anemia in an effort to standardize best practices in the field. This document outlines the rationale for initial evaluations in pediatric patients presenting with signs and symptoms concerning for severe aplastic anemia.
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Affiliation(s)
- Kristin A. Shimano
- Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco California USA
| | - Anupama Narla
- Department of Pediatrics Stanford University School of Medicine Stanford California USA
| | - Melissa J. Rose
- Division of Hematology, Oncology, and Bone Marrow Transplant Nationwide Children's Hospital, The Ohio State University College of Medicine Columbus Ohio USA
| | - Nicholas J. Gloude
- Department of Pediatrics University of California San Diego, Rady Children's Hospital San Diego California USA
| | - Steven W. Allen
- Pediatric Hematology/Oncology University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh Pittsburgh Pennsylvania USA
| | - Katie Bergstrom
- Cancer and Blood Disorders Center Seattle Children's Hospital Seattle Washington USA
| | - Larisa Broglie
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Beth A. Carella
- Department of Pediatrics Kaiser Permanente Washington District of Columbia USA
| | - Paul Castillo
- Division of Pediatric Hematology Oncology UF Health Shands Children's Hospital Gainesville Florida USA
| | - Jill L. O. Jong
- Section of Hematology‐Oncology, Department of Pediatrics University of Chicago Chicago Illinois USA
| | - Yigal Dror
- Marrow Failure and Myelodysplasia Program, Division of Hematology and Oncology, Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
| | - Amy E. Geddis
- Cancer and Blood Disorders Center Seattle Children's Hospital Seattle Washington USA
| | - James N. Huang
- Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco California USA
| | - Bonnie W. Lau
- Pediatric Hematology‐Oncology Dartmouth‐Hitchcock Lebanon New Hampshire USA
| | - Catherine McGuinn
- Department of Pediatrics Weill Cornell Medicine New York New York USA
| | - Taizo A. Nakano
- Center for Cancer and Blood Disorders Children's Hospital Colorado Aurora Colorado USA
| | - Kathleen Overholt
- Pediatric Hematology and Oncology Riley Hospital for Children at Indiana University Indianapolis Indiana USA
| | - Jennifer A. Rothman
- Division of Pediatric Hematology and Oncology Duke University Medical Center Durham North Carolina USA
| | - Anjali Sharathkumar
- Stead Family Department of Pediatrics University of Iowa Carver College of Medicine Iowa City Iowa USA
| | - Evan Shereck
- Department of Pediatrics Oregon Health and Science University Portland Oregon USA
| | - Adrianna Vlachos
- Hematology, Oncology and Cellular Therapy Cohen Children's Medical Center New Hyde Park New York USA
| | - Timothy S. Olson
- Cell Therapy and Transplant Section, Division of Oncology and Bone Marrow Failure, Division of Hematology, Department of Pediatrics Children's Hospital of Philadelphia and University of Pennsylvania Philadelphia Pennsylvania USA
| | | | | | - Akiko Shimamura
- Cancer and Blood Disorders Center Boston Children's Hospital and Dana Farber Cancer Institute Boston Massachusetts USA
| | - Jessica Boklan
- Center for Cancer and Blood Disorders Phoenix Children's Hospital Phoenix Arizona USA
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Fang M, Song H, Zhang J, Li S, Shen D, Tang Y. Efficacy and safety of immunosuppressive therapy with or without eltrombopag in pediatric patients with acquired aplastic anemia: A Chinese retrospective study. Pediatr Hematol Oncol 2021; 38:633-646. [PMID: 33724146 DOI: 10.1080/08880018.2021.1895924] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
To determine the efficacy and safety of eltrombopag (E-PAG) combined with intensive immunosuppressive therapy (IST) for the treatment of pediatric patients with severe aplastic anemia (SAA). A total of 57 pediatric patients with newly diagnosed severe aplastic anemia were enrolled in this study. Thirty nine patients were treated with IST alone, consisting of porcine anti-human thymocyte globulin (30 mg/kg/day × 5 days) and cyclosporine A (CsA) (treated for 2 years, with a trough concentration maintained at 200-250 ng/mL), and 18 patients were treated with IST + E-PAG (12.5-50 mg/day, maintained for 6 months). We found no statistical difference between the response rates at 3 months for the two groups (CR: 12.8% vs. 22.2% p > 0.05, ORR: 56.4% vs. 77.7% p > 0.05). However, we found a statistical difference between the response rates at 6 months for the two groups (CR: 17.9% vs. 50% p < 0.05, ORR: 69.2% vs. 94.4% p < 0.05). The main side-effect during treatment with E-PAG was having a slightly to moderately elevated bilirubin level, which was temporary and controllable, accounting for approximately 66.6% (12/18) of patients in the IST + E-PAG group vs. 20.5% (8/39) of those in the IST group (p < 0.05). IST + E-PAG therapy appears to be more effective than IST alone for the treatment of pediatric SAA, with good tolerability and compliance. This approach deserves further exploration.
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Affiliation(s)
- Meixin Fang
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Hua Song
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Jingying Zhang
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Sisi Li
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Diying Shen
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Yongmin Tang
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
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Jie M, Fu L, Li S, He Y, Yao J, Cheng X, Zhang L, Zheng J, Zhang R, Wu R. Efficacy and safety of eltrombopag in the first-line therapy of severe aplastic anemia in children. Pediatr Hematol Oncol 2021; 38:647-657. [PMID: 33798022 DOI: 10.1080/08880018.2021.1900475] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Eltrombopag is being investigated for the treatment of aplastic anemia (AA) by stimulating hematopoietic stem cell (HSC) proliferation. To evaluate the efficacy and safety of eltrombopag in the first-line therapy of pediatric AA. The present retrospective study assessed pediatric patients with newly diagnosed AA administered immunosuppressive therapy (IST) (rabbit ATG combined with CSA) with eltrombopag at a single center from March to September 2017. All patients were followed up for >2 years. A total of 14 patients (8 males), averagely aged 86 months, were enrolled in this study. Eltrombopag was administered with a median time to initiation of 19.5 days after IST; the median course of treatment was 253 days. Complete and overall response rates at 6 months were 64.3% (9/14 case) and 78.6% (11/14 cases), respectively. The survival rate was 100%, and no relapse occurred in responders. Eltrombopag was well-tolerated; however, the most common adverse events included indirect bilirubin elevation, jaundice, and transient liver-enzyme elevation. By the end of follow-up, bone marrow chromosomes were normal, and no abnormal myelodysplastic syndrome (MDS)-related clones appeared. Addition of eltrombopag to IST is associated with markedly increased complete response with respect to hematology in pediatric patients with SAA compared with a historical cohort, without intolerable side effects.
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Affiliation(s)
- Ma Jie
- Department of Pediatric Hematology and Oncology, Beijing Children Hospital, Beijing, China
| | - Lingling Fu
- Department of Pediatric Hematology and Oncology, Beijing Children Hospital, Beijing, China
| | - Sidan Li
- Department of Pediatric Hematology and Oncology, Beijing Children Hospital, Beijing, China
| | - Yixuan He
- Department of Pediatric Hematology and Oncology, Beijing Children Hospital, Beijing, China
| | - Jiafeng Yao
- Department of Pediatric Hematology and Oncology, Beijing Children Hospital, Beijing, China
| | - Xiaoling Cheng
- Department of Pediatric Hematology and Oncology, Beijing Children Hospital, Beijing, China
| | - Liqiang Zhang
- Department of Pediatric Hematology and Oncology, Beijing Children Hospital, Beijing, China
| | - Jie Zheng
- Department of Pediatric Hematology and Oncology, Beijing Children Hospital, Beijing, China
| | - Rui Zhang
- Department of Pediatric Hematology and Oncology, Beijing Children Hospital, Beijing, China
| | - Runhui Wu
- Department of Pediatric Hematology and Oncology, Beijing Children Hospital, Beijing, China
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Kelaidi C, Makis A, Tzotzola V, Antoniadi K, Petrikkos L, Tsitsikas K, Peristeri I, Kitra V, Stefanaki K, Polychronopoulou S. Severe aplastic anaemia in children: Impact of histopathology profile and treatment on very long-term outcomes. Acta Paediatr 2021; 110:1308-1314. [PMID: 32810910 DOI: 10.1111/apa.15546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 01/13/2023]
Abstract
AIM To assess very long-term outcomes of children with severe aplastic anaemia (SAA) and impact of histopathology and of different treatments over time. METHODS We conducted a retrospective study of 57 consecutive patients with SAA during 1973-2019. According to period, treatment consisted of androgens, immunosuppressive treatment (IST) and haematopoietic cell transplantation (HCT) in 14, 31 and 13 patients, respectively. Histopathology immune profiles were studied on bone marrow (BM). RESULTS Response rate (RR) to androgens was 35%, with long-term survivorship in 4 of 5 responders. RR and 10-year overall survival (OS) after IST was 65% and 80%, respectively. RR was higher in girls (92% vs 43% in boys, P = .02). Mean baseline BM values of CD34 + and of B-lymphocytes in responders vs non-responders were 1.3% vs 0 (P = .08) and 14.1% vs 9.7% (P = .07), respectively. After IST, BM cellularity gradually increased and cytotoxic T-lymphocytes decreased (time variation P = .003 and 0.07, respectively). Outcome did not differ between patients with IST or frontline HCT. Ten-year OS improved over time, increasing from 35.3% to 77.1% and 77% during 1973-1985, 1986-2003 and 2004-2019, respectively. CONCLUSION Histopathology may refine response prediction to IST. The course of SAA in children, a previously fatal disease, was altered in recent times.
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Affiliation(s)
- Charikleia Kelaidi
- Department of Pediatric Hematology‐Oncology “Aghia Sophia” Children's Hospital Athens Greece
| | - Alexandros Makis
- Department of Pediatrics University Hospital of Ioannina Ioannina Greece
| | - Vasiliki Tzotzola
- Department of Pediatric Hematology‐Oncology “Aghia Sophia” Children's Hospital Athens Greece
| | - Kondylia Antoniadi
- Department of Pediatric Hematology‐Oncology “Aghia Sophia” Children's Hospital Athens Greece
| | - Loizos Petrikkos
- Department of Pediatric Hematology‐Oncology “Aghia Sophia” Children's Hospital Athens Greece
| | - Konstantinos Tsitsikas
- Department of Pediatric Hematology‐Oncology “Aghia Sophia” Children's Hospital Athens Greece
| | - Ioulia Peristeri
- Bone Marrow Transplantation Unit “Aghia Sophia” Children's Hospital Athens Greece
| | - Vasiliki Kitra
- Bone Marrow Transplantation Unit “Aghia Sophia” Children's Hospital Athens Greece
| | - Kalliopi Stefanaki
- Department of Pathology “Aghia Sophia” Children's Hospital Athens Greece
| | - Sophia Polychronopoulou
- Department of Pediatric Hematology‐Oncology “Aghia Sophia” Children's Hospital Athens Greece
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Alshaibani A, Dufour C, Risitano A, de Latour R, Aljurf M. Hepatitis-associated aplastic anemia. Hematol Oncol Stem Cell Ther 2020; 15:8-12. [PMID: 33197413 DOI: 10.1016/j.hemonc.2020.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/24/2020] [Indexed: 02/08/2023] Open
Abstract
Hepatitis-associated aplastic anemia (HAAA) is a rare illness, characterized by onset of pancytopenia with a hypoplastic bone marrow that traditionally occurs within 6 months of an increase in serum aminotransferases. HAAA is observed in 1% to 5% of all newly diagnosed cases of acquired aplastic anemia. Several hepatitis viruses have been linked to the disease, but in many cases no specific virus is detected. The exact pathophysiology is unknown; however, immune destruction of hematopoietic stem cells is believed to be the underlying mechanism. HAAA is a potentially lethal disease if left untreated. Management includes immunosuppression with antithymocyte globulin and cyclosporine and allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Alfadel Alshaibani
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
| | - Carlo Dufour
- Hematology-Oncology-HSCT Pole, G.Gaslini IRCCS Children Hospital, Genova, Italy.
| | - Antonio Risitano
- Department of Clinical Medicine and Surgery, Bone Marrow Transplant Center, Federico II University of Naples, Naples, Italy.
| | - Regis de Latour
- Saint Louis Hospital, Paris Diderot University, Paris, France.
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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Ali N, Butt A, Altaf B, Adil SN, Shaikh MU. Transplant in Aplastic Anemia Using Combined Granulocyte Colony-Stimulating Factor Primed Blood and Bone Marrow Stem Cells: A Retrospective Analysis. Transplant Proc 2020; 53:386-390. [PMID: 32773285 DOI: 10.1016/j.transproceed.2020.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/05/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Aplastic anemia (AA) is characterized by diminished hematopoietic precursors in the bone marrow, most often due to injury to the pluripotent stem cell. In Pakistan, AA is not uncommon, and allogeneic hematopoietic stem cell transplant remains the only curative option for these patients. OBJECTIVE The objective of this study was to determine the transplant outcome of combined granulocyte colony-stimulating factor (G-CSF) primed blood and bone marrow grafts in adult and pediatric patients with AA. METHODS We retrospectively collected the data of all transplant procedures performed from 2004 to 2019 at Aga Khan University in Karachi, Pakistan. Variables analyzed included age, sex, type of stem cells used, conditioning regimens, and overall survival for patients undergoing transplant in AA. RESULTS A total of 351 transplants were performed during the study period. Out of these, 239 were allogeneic transplants, whereas 112 were autologous procedures. We performed 70 transplants for AA during the study period, of which 52 were male patients and 18 were female patients. The median age ± standard deviation (SD) was 17.5 ± 9.4 years (range, 2-43 years). Cyclophosphamide/antithymocyte globulin (ATG) was used as a conditioning regimen in 65 patients, while ATG/cyclophosphamide/fludarabine was used in 5 patients. In 60 patients, a combination of G-CSF primed blood and bone marrow stem cells were used. The mean CD34 count was 5.2 × 106/kg. Graft-vs-host disease (GVHD) prophylaxis was done with cyclosporine and methotrexate. All patients received standard infection prophylaxis. Engraftment was achieved in 86% of patients. The median day of myeloid engraftment was 15 (range, 10-22 days). Chronic GVHD was present in 3 patients while 4 had acute GVHD. The overall survival was 71.2% (median duration of 80 months). The main cause of mortality was gram-negative sepsis. CONCLUSION A combination of blood and bone marrow stem cells results in early engraftment with decreased frequency of GVHD in AA. The overall survival was comparable to international literature.
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Affiliation(s)
- Natasha Ali
- Department of Pathology & Laboratory Medicine/Oncology, Aga Khan University, Karachi, Pakistan.
| | | | - Bakhtawer Altaf
- Department of Oncology, Aga Khan University, Karachi, Pakistan
| | - Salman Naseem Adil
- Department of Pathology & Laboratory Medicine/Oncology, Aga Khan University, Karachi, Pakistan
| | - Mohammad Usman Shaikh
- Department of Pathology & Laboratory Medicine/Oncology, Aga Khan University, Karachi, Pakistan
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Altay D, Yılmaz E, Özcan A, Karakükçü M, Ünal E, Arslan D. Hepatitis-associated aplastic anemia in pediatric patients: single center experience. Transfus Apher Sci 2020; 59:102900. [PMID: 32773318 DOI: 10.1016/j.transci.2020.102900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/22/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Hepatitis-associated aplastic anemia is a rare type of acquired aplastic anemia that occurs after hepatitis. This study investigated cases with hepatitis-associated aplastic anemia. METHODS The files of patients with hepatitis-associated aplastic anemia who were followed up in our hospital between 2011-2019 were reviewed retrospectively. RESULTS A total of 15 patients with hepatitis-associated aplastic anemia (10 males, 5 girls; mean age 10.26 ± 3.61 years) were analyzed. The mean duration between hepatitis and aplastic anemia was 5.06 ± 4.19 months. The majority of patients had mild hepatitis. The causes of hepatitis were detected only in six patients: three had hepatitis B, one had hepatitis A, one had autoimmune hepatitis and, one had a hydatid cyst. The cause of hepatitis was not found in nine patients. Only one patient with hepatitis-associated aplastic anemia developed spontaneous remission, and the others required immunosuppressive therapy and/or hematopoietic stem cell transplantation. Only one patient died because of sepsis. The other patients are still under follow-up and treatment. CONCLUSION Patients with hepatitis-associated aplastic anemia, mostly of unknown cause, can be successfully treated with immunosuppressive therapy and/or hematopoietic stem cell transplantation.
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Affiliation(s)
- Derya Altay
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Erciyes University, Faculty of Medicine, Kayseri, Turkey.
| | - Ebru Yılmaz
- Department of Pediatric Hematology and Oncology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Alper Özcan
- Department of Pediatric Hematology and Oncology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Musa Karakükçü
- Department of Pediatric Hematology and Oncology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Ekrem Ünal
- Department of Pediatric Hematology and Oncology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Duran Arslan
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Erciyes University, Faculty of Medicine, Kayseri, Turkey
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Jain R, Trehan A, Bansal D, Varma N. Aplastic anemia in children: How good is immunosuppressive therapy? Pediatr Hematol Oncol 2019; 36:211-221. [PMID: 31287349 DOI: 10.1080/08880018.2019.1621970] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aplastic anemia (AA) is an uncommon disorder in children, with hematopoietic stem cell transplant being the 1st line therapy; immunosuppressive therapy (IST) is the alternative therapy and is the most commonly used modality of treatment. There is paucity of data from the developing countries regarding treatment outcome with IST. We aimed to assess the outcome of IST in children with AA. Data for 43 children treated with IST from January 2012 to January 2017 (5 years) were retrieved from clinic records. IST included equine antithymocyte globulin (ATG) along with cyclosporine A. Complete response, partial response and nonresponse was seen in 9 (21%), 14 (32.5%) and 20(46.5%) patients, respectively. The median time to best response in the whole cohort was 19.1 months. However, complete response occurred nearly 2-year post-IST. There was no difference in outcome related to severity of AA, the presence of PNH clone, higher ALC or different available brands of ATG. There was a significantly better rate of response (p value: .03) at 6 months in patients who went on to achieve a CR vs patients who achieved a final PR only. An overall response rate, including partial and complete response, of 53.5% was seen in our cohort with a 3-year OS of 63%. This is not at par to the outcome reported from developed nations. The available brands of ATG were similar in terms of response kinetics as well as survival. A delayed time to complete response with prolonged requirement of cyclosporine therapy was seen in the cohort.
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Affiliation(s)
- Richa Jain
- a Division of Pediatric Hematology & Oncology, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Amita Trehan
- a Division of Pediatric Hematology & Oncology, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Deepak Bansal
- a Division of Pediatric Hematology & Oncology, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education & Research , Chandigarh , India.,b Department of Hematology, Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Neelam Varma
- b Department of Hematology, Postgraduate Institute of Medical Education & Research , Chandigarh , India
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Mori T, Onishi Y, Ozawa Y, Kato C, Kai T, Kanda Y, Kurokawa M, Tanaka M, Ashida T, Sawayama Y, Fukuda T, Ichinohe T, Atsuta Y, Yamazaki H. Outcome of allogeneic hematopoietic stem cell transplantation in adult patients with hepatitis-associated aplastic anemia. Int J Hematol 2019; 109:711-717. [DOI: 10.1007/s12185-019-02644-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 12/18/2022]
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Gupta A, Fu P, Hashem H, Vatsayan A, Shein S, Dalal J. Outcomes and healthcare utilization in children and young adults with aplastic anemia: A multiinstitutional analysis. Pediatr Blood Cancer 2017; 64. [PMID: 28696061 DOI: 10.1002/pbc.26704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/04/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Aplastic anemia is a bone marrow failure syndrome with high mortality affecting children and young adults. Although current treatment guidelines recommend hematopoietic stem cell transplant (HCT) for patients with matched sibling donors, outcomes with alternate donor options have been improving. PROCEDURE We analyzed a validated multiinstitutional pediatric cohort using one of the largest pediatric and young adult database, the Pediatric Health Information System, for patients diagnosed with aplastic anemia (AA) from 2006 to 2015. Outcomes with upfront and salvage transplants were analyzed along with healthcare utilization. RESULTS Among 2,169 patients in the study period, almost 20% underwent HCT, while others received immunosuppressive therapy. In a multivariate model, there was no significant difference in mortality with upfront or salvage transplants (odds ratio [OR] 1.24, 95% confidence interval [CI] 0.6-2.58, P = 0.567), while every platelet transfusion was associated with higher mortality (OR 1.37, 95% CI 1.12-1.67, P = 0.002). Healthcare utilization was significantly higher in salvage transplants requiring frequent hospitalization and transfusion requirements. Treatment mortality and graft failure rates were significantly reduced in the salvage transplant group in recent years (2011-2015 as compared to 2006-2010). CONCLUSION As outcomes with HCT continue to improve in severe AA, transplant with good alternate donors should be considered upfront in children and young adults.
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Affiliation(s)
- Ashish Gupta
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Pingfu Fu
- Department of Biostatistics, Case Western Reserve University, Cleveland, Ohio
| | - Hasan Hashem
- Division of Pediatric Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
| | - Anant Vatsayan
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Steven Shein
- Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Jignesh Dalal
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
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Clinico-laboratory features and outcome of therapy of bone marrow failure among Egyptian children. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2017. [DOI: 10.1016/j.epag.2017.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Choi YB, Yi ES, Lee JW, Sung KW, Koo HH, Yoo KH. Immunosuppressive therapy versus alternative donor hematopoietic stem cell transplantation for children with severe aplastic anemia who lack an HLA-matched familial donor. Bone Marrow Transplant 2016; 52:47-52. [PMID: 27668766 DOI: 10.1038/bmt.2016.223] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 07/11/2016] [Accepted: 07/17/2016] [Indexed: 01/03/2023]
Abstract
We compared the outcomes of immunosuppressive treatment (IST) with those of alternative donor hematopoietic stem cell transplantation (HSCT) in children and adolescents with severe aplastic anemia (SAA). The medical records of 42 patients with SAA who received frontline IST (N=19) or frontline HSCT with an alternative donor (N=23) between 1998 and 2012 were analyzed retrospectively. Six patients responded in the frontline IST group, whereas 11 underwent salvage HSCT after IST failure. Twenty-one of 23 patients who underwent frontline HSCT survived without treatment failure. The estimated failure-free survival rate of the frontline HSCT group was higher than that of the frontline IST group (91.3% vs 30.7% respectively, P<0.001). Six of 11 patients who underwent salvage HSCT experienced event-free survival (EFS). The estimated EFS of the frontline HSCT group was higher than that of the salvage HSCT group (91.3% vs 50.9% respectively, P=0.015). The outcome of alternative donor HSCT was better than commonly reported rates, especially in patients who underwent frontline HSCT. These results suggest that frontline alternative donor HSCT may be a better treatment option than IST for children and adolescents with SAA who lack a human leukocyte Ag-matched familial donor.
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Affiliation(s)
- Y B Choi
- Department of Pediatrics, Chung-Ang University Hospital, Seoul, Korea
| | - E S Yi
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - J W Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - K W Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - H H Koo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - K H Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Korea
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Dietz AC, Lucchini G, Samarasinghe S, Pulsipher MA. Evolving hematopoietic stem cell transplantation strategies in severe aplastic anemia. Curr Opin Pediatr 2016; 28:3-11. [PMID: 26626557 PMCID: PMC4725196 DOI: 10.1097/mop.0000000000000299] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Significant improvements in unrelated donor hematopoietic stem cell transplantation (HSCT) in recent years have solidified its therapeutic role in severe aplastic anemia (SAA) and led to the evolution of treatment algorithms, particularly for children. RECENT FINDINGS Advances in understanding the genetics of inherited bone marrow failure syndromes (IBMFS) have allowed more confidence in accurately diagnosing SAA and avoiding treatments that could be dangerous and ineffective in individuals with IBMFS, which can be diagnosed in 10-20% of children presenting with a picture of SAA. Additionally long-term survival after matched sibling donor and matched unrelated donor HSCT now exceed 90% in children. Late effects after HSCT for SAA are minimal with current strategies, and compare favorably to late effects after upfront immunosuppressive therapy, except for patients with chronic graft versus host disease. SUMMARY Careful assessment for signs or symptoms of IBMFS, along with genetic screening for these disorders, is of major importance. Matched sibling donor HSCT is already considered the standard of care for upfront therapy and some groups are evaluating matched unrelated donor HSCT as primary therapy. Ongoing studies will continue to challenge treatment algorithms and may lead to an even more expanded role for HSCT in SAA.
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Affiliation(s)
- Andrew C Dietz
- aChildren's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA bDepartment of Paediatric Bone Marrow Transplant cDepartment of Paediatric Haematology, Great Ormond Street Hospital, London, UK *Andrew C. Dietz and Giovanna Lucchini contributed equally to the writing of this article
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Rodríguez L, González-Llano Ó, Villarreal L, Gómez-Almaguer D, Ortiz M, Olaya-Vargas A, Pérez-García M, Ruíz-Argüelles GJ, Ruíz-Delgado GJ, Muñiz T, De-Diego J, Reyes N, Flores-Villegas V, Colunga J, Sandoval A, González-Ramella Ó. Matched sibling donors versus alternative donors in allogeneic hematopoietic stem cell transplantation for pediatric severe aplastic anemia in México. Hematology 2014; 20:449-454. [DOI: 10.1179/1607845414y.0000000224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Laura Rodríguez
- Servicio de Hematología del Hospital Universitario “Dr. José E. González”, Universidad Autónoma de Nuevo León (UANL), Monterrey, México
| | - Óscar González-Llano
- Servicio de Hematología del Hospital Universitario “Dr. José E. González”, Universidad Autónoma de Nuevo León (UANL), Monterrey, México
| | - Laura Villarreal
- Servicio de Hematología del Hospital Universitario “Dr. José E. González”, Universidad Autónoma de Nuevo León (UANL), Monterrey, México
| | - David Gómez-Almaguer
- Servicio de Hematología del Hospital Universitario “Dr. José E. González”, Universidad Autónoma de Nuevo León (UANL), Monterrey, México
| | - Magdalena Ortiz
- Instituto de Investigación en Cáncer Infantil y de la Adolescencia Servicio de Hematología y Oncología Hospital Civil de Guadalajara “Dr. Juan I. Menchaca”, Guadalajara, Jalisco, México
| | - Alberto Olaya-Vargas
- Servicio de Hematología y Oncología, Instituto Nacional de Pediatría, Secretaría de Salud (SSA), Ciudad de México, México
| | - Martín Pérez-García
- Servicio de Hematología y Oncología, Instituto Nacional de Pediatría, Secretaría de Salud (SSA), Ciudad de México, México
| | | | | | - Teodoro Muñiz
- Servicio de Hematología y Oncología, Hospital Infantil de México, SSA, Ciudad de México, México
| | - José De-Diego
- Servicio de Hematología, Centro Médico Nacional 20 de Noviembre, ISSSTE, Ciudad de México, México
| | - Nancy Reyes
- Servicio de Hematología, Centro Médico Nacional 20 de Noviembre, ISSSTE, Ciudad de México, México
| | - Victoria Flores-Villegas
- Servicio de Hematología, Centro Médico Nacional 20 de Noviembre, ISSSTE, Ciudad de México, México
| | - Julia Colunga
- Departamento de Pediatría del Hospital Universitario “Dr. José E. González”, Universidad Autónoma de Nuevo León (UANL), Monterrey, México
| | | | - Óscar González-Ramella
- Instituto de Investigación en Cáncer Infantil y de la Adolescencia Servicio de Hematología y Oncología Hospital Civil de Guadalajara “Dr. Juan I. Menchaca”, Guadalajara, Jalisco, México
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Severe Aplastic Anemia following Acute Hepatitis from Toxic Liver Injury: Literature Review and Case Report of a Successful Outcome. Case Reports Hepatol 2014; 2014:216570. [PMID: 25587471 PMCID: PMC4283356 DOI: 10.1155/2014/216570] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 12/01/2014] [Indexed: 01/06/2023] Open
Abstract
Hepatitis associated aplastic anemia (HAAA) is a rare syndrome in which severe aplastic anemia (SAA) complicates the recovery of acute hepatitis (AH). HAAA is described to occur with AH caused by viral infections and also with idiopathic cases of AH and no clear etiology of liver injury. Clinically, AH can be mild to fulminant and transient to persistent and precedes the onset SAA. It is assumed that immunologic dysregulation following AH leads to the development of SAA. Several observations have been made to elucidate the immune mediated injury mechanisms, ensuing from liver injury and progressing to trigger bone marrow failure with the involvement of activated lymphocytes and severe T-cell imbalance. HAAA has a very poor outcome and often requires bone marrow transplant (BMT). The findings of immune related myeloid injury implied the use of immunosuppressive therapy (IST) and led to improved survival from HAAA. We report a case of young male who presented with AH resulting from the intake of muscle building protein supplements and anabolic steroids. The liver injury slowly resolved with supportive care and after 4 months of attack of AH, he developed SAA. He was treated with IST with successful outcome without the need for a BMT.
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Pilot study using tacrolimus rather than cyclosporine plus antithymocyte globulin as an immunosuppressive therapy regimen option for severe aplastic anemia in adults. Blood Cells Mol Dis 2014; 53:157-60. [DOI: 10.1016/j.bcmd.2014.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 08/08/2013] [Accepted: 01/21/2014] [Indexed: 12/16/2022]
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19
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Xie X, Shi W, Zhou X, Shao Y, Qiao X. Comparison of rabbit antithymocyte globulin and Jurkat cell-reactive anti-t lymphocyte globulin as a first-line treatment for children with aplastic anemia. Exp Hematol 2014; 42:431-8. [DOI: 10.1016/j.exphem.2014.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 12/05/2013] [Accepted: 02/07/2014] [Indexed: 01/13/2023]
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Ramzan M, Yadav SP, Zafar MSH, Dinand V, Sachdeva A. Outcome of pediatric acquired aplastic anemia: a developing world experience. Pediatr Hematol Oncol 2014; 31:29-38. [PMID: 23802844 DOI: 10.3109/08880018.2013.807898] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Outcome data of children with acquired aplastic anemia (AA) are lacking from the developing world. Here, we describe the same from a centre in North India. METHODS Retrospective data regarding medical history, physical examination, complete blood count, bone marrow aspirate, and biopsy were retrieved for all children <18 years, with acquired AA admitted between January 2005 and June 2012. In addition, the outcome data after immunosuppressive therapy (IST) or bone marrow transplant (BMT) was obtained. RESULTS A total of 61 children were diagnosed with AA (Inherited-18 and acquired-43). Among 43 children with acquired AA, 3 had nonsevere and 40 had severe. One patient with nonsevere AA died of sepsis and 2 recovered spontaneously. Of the 40 remaining children with severe AA, 10 refused therapy and 3 died due to severe sepsis prior to any therapy. Five underwent upfront matched sibling donor BMT and one post-IST failure. Four year overall survival (OS) and event free survival (EFS) for children undergoing BMT was 100% and 80 ± 17.9, respectively. Out of 22 treated with IST, 20 were evaluable for response. Seventeen received one course and 3 received two course of IST. The overall response to IST was seen in 14/20 (70%). Only two achieved complete response while remaining 12 had partial response. The 4-year estimated OS and EFS for children treated with IST was 74.4 ± 12.1% and 65.6 ± 12.2. CONCLUSION Outcomes for children with AA are encouraging in the developing world although barriers like sepsis and treatment abandonment remain. BMT offers faster and complete recovery.
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Affiliation(s)
- Mohammed Ramzan
- Pediatric Hematology Oncology & BMT Unit, Department of Pediatrics, Sir Ganga Ram Hospital , New Delhi , India
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Karapinar DY, Karadaş N, Ay Y, Akin M, Balkan C, Aydinok Y, Kavakli K. Rabbit antithymocyte globulin treatment in childhood acquired severe aplastic anemia. Pediatr Hematol Oncol 2014; 31:20-8. [PMID: 23627541 DOI: 10.3109/08880018.2013.792894] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Acquired severe aplastic anemia (SAA) is a life threatening bone marrow failure characterized by pancytopenia and hypocellular bone marrow. Matched sibling donor is not available for majority of the patients and many children receive immunosuppressive therapy (IST). Although horse antithymocyte globuline (ATG) is the preferred option, our patients received rabbit ATG; since horse ATG is not available in Turkey. We reviewed the medical records of children with SAA who were treated with rabbit ATG, cyclosporine, and granulocyte colony stimulating factor (GCSF) between 2006 and 2012. Fifteen children with SAA aged between 1.5 and 17 years received rabbit ATG as first line treatment. Only two of them showed partial response and the others did not give any response at 3rd, 6th, and 12th months after the first course of IST. The second course of ATG was given to 8 of the patients; Rabbit ATG at the same dosage was used for 3 of them, and others were given horse ATG. None of the patients responded to the second course of ATG. Invasive fungal infection (IFI) which was seen in 80% of the patients was the most significant problem. Overall survival rate was 60%. The median time between the diagnosis and initiation of IST was 57 (range; 29-144) days. This delay might be significantly contributed to unresponsiveness. In our series, the use of rabbit ATG was not effective for these patients as first line treatment modality. Response rate was very low and the incidence of fungal infections was very high in the SAA patients who received rabbit ATG.
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Abstract
The diagnosis of aplastic anemia in children requires exclusion of a variety of inherited or acquired BM failure syndromes with similar phenotypes. An efficient diagnostic plan is important because time from diagnosis to 'final' treatment is directly related to outcome regardless of the therapeutic option chosen. The gold standard of therapy remains hematopoietic SCT with a graft of BM cells for those children with matched sibling donors. Conversely for children without a sibling donor the high response and markedly improved overall survival rates of combined immunosuppressive therapy have proven robust, especially when horse derived anti-thymocyte globuline plus ciclosporine A are used. Incomplete response, relapse and progression to myelodysplasia/leukemia however have emerged as significant long-term issues. Improvements in outcome of alternative donor transplantation and the use of established and novel immunosuppressive agents provide multiple alternatives for treating refractory or relapsed patients. Regardless of the type of therapeutic approach, patients require centralized treatment in a center of excellence, ongoing monitoring for recurrence of disease and/or therapy-related immediate side effects and long-term effects.
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Urban C, Benesch M, Sovinz P, Sipurzynski S, Lackner H, Müller E, Schwinger W. Alternative donor HSCT in refractory acquired aplastic anemia - prevention of graft rejection and graft versus host disease by immunoablative conditioning and graft manipulation. Pediatr Transplant 2012; 16:577-81. [PMID: 22462513 DOI: 10.1111/j.1399-3046.2012.01692.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Early alternative donor HSCT is a potentially curative therapeutic option for patients with AAA not responding to IST. Seven patients (median age at diagnosis, 11 yr) with refractory AAA without a MSD underwent HSCT from matched unrelated (n = 6) or haploidentical (n = 1) donors. Conditioning regimens included CY (n = 7), muromonab-CD3/ATG (n = 7), TT (n = 6), FLU (n = 5), and TLI (n = 2). Grafts were either CD34 purified and/or CD3/19 depleted and contained a median of 10.17 × 10(6) /kg CD34 and 5.5 × 10(4) /kg CD3 cells. All patients engrafted rapidly. Median time to leukocyte engraftment was 10 days. With a median follow-up of 26 (range, 11-153) months, six patients are alive and well with complete donor hematopoiesis. One heavily pretreated patient developed GVHD grade III and died from progressive renal failure (resulting from microangiopathic hemolytic anemia) and disseminated aspergillosis. Early alternative donor HSCT can help to avoid complications from prolonged IST and presumably improve survival of patients with refractory AAA. Administration of high doses of CD34 purified and/or CD3/19 depleted stem cells following novel immunoablative conditioning may prevent graft rejection and GVHD. However, a long interval from diagnosis to HSCT seems to be associated with poor outcome.
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Affiliation(s)
- Christian Urban
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Yıldırmak Y, Erdem E, Telhan L, Kepekçi L. Immunosuppressive treatment in children with acquired aplastic anemia. Turk J Haematol 2012; 29:150-5. [PMID: 24744646 PMCID: PMC3986953 DOI: 10.5505/tjh.2012.26779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 03/05/2011] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Immunosuppressive treatment (IST) is an alternative for children with acquired aplastic anemia (AA) that do not have HLA-matched donors. The objective of this study was to evaluate the outcome of IST in children with acquired AA. MATERIAL AND METHODS The study included 18 pediatric acquired AA patients that were retrospectively evaluated. The patients either did not have an HLA-matched related donor or were unable to undergo transplantation within 6 months despite having an HLA-matched donor. RESULTS In all, 6 of the patients were characterized as very severe AA, 6 as severe AA, and 6 as moderate AA. Mean duration of follow-up was 44.5 months. In total, 9 patients that could not be treated with equine anti-thymocyte globulin (hATG) following diagnosis received high-dose methylprednisolone treatment. Among the 6 very severe AA patients, 2 achieved complete remission (22%); the other 16 patients received hATG+cyclosporine and short-term methylprednisolone. In total, 4 of the patients died during the first month of treatment. Of the remaining 12 patients, 3 responded to the treatment (25%). Of the 9 patients that did not respond after 3 months of treatment, 7 received a second course of immunosuppressive treatment with rabbit ATG (rATG)+cyclosporine and short-term methylprednisolone; 2 of the 7 patients responded (22%), but 5 did not respond to any treatment. Median survival among the patients was as 64 ± 8 months CONCLUSION Combination IST with ATG+cyclosporine and low-dose methylprednisolone was an effective treatment in the pediatric acquired AA patients with non-identical HLA donors. In the patients that couldn't be treated with ATG high-dose methylprednisolone treatment was safe and effective.
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Affiliation(s)
- Yıldız Yıldırmak
- Sisli Etfal Training and Research Hospital, Department of Pediatrics, İstanbul, Turkey
| | - Ela Erdem
- Sisli Etfal Training and Research Hospital, Department of Pediatrics, İstanbul, Turkey
| | - Leyla Telhan
- Sisli Etfal Training and Research Hospital, Department of Pediatrics, İstanbul, Turkey
| | - Laliz Kepekçi
- Sisli Etfal Training and Research Hospital, Department of Pediatrics, İstanbul, Turkey
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Antithymocyte globulin and cyclosporine in children with aplastic anemia: a developing country experience. J Pediatr Hematol Oncol 2012; 34:93-5. [PMID: 22278201 DOI: 10.1097/mph.0b013e31823c287b] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Human leukocyte antigen-matched bone marrow transplant in the treatment of aplastic anemia is generally not feasible in developing countries due to lack of resources and expertise and immunosuppressive therapy (IST) has been used as an alternative. This study aims to report the long-term outcome of children with aplastic anemia treated with IST [antithymocyte globulin (ATG) and cyclosporine] in our hospital. PROCEDURE Case files of children with aplastic anemia who received IST from January 2001 to November 2009 were reviewed. RESULTS Thirty-five patients with aplastic anemia (14 very severe aplastic anemia; 21 severe aplastic anemia) were given IST. Seven patients expired within 3 months of therapy and were excluded. The analysis was done in 28 patients (24 male and 4 female; 12 very severe aplastic anemia and 16 severe aplastic anemia). The median age was 10 years (range, 5 to 12 y). Ten patients achieved partial response and 4 patients complete response at 1 year with overall response rate of 50%. Three nonresponders received a second course of ATG after 12 months out of which 2 responded. Hence, overall response including second course was 16 (57%). Three patients relapsed after a median interval of 23 months. The median duration of follow-up of 16 responders was 40 months (range, 15 to 119 mo). In the patients with long-term follow-up for >4 years (n = 7), all were surviving and independent of transfusions. CONCLUSIONS In a developing country setting, IST with ATG and cyclosporine seems to be a good alternative treatment for aplastic anemia in children.
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Nair V, Sondhi V, Sharma A, Das S, Sharma S. Survival after immunosuppressive therapy in children with aplastic anemia. Indian Pediatr 2011; 49:371-6. [PMID: 22080620 DOI: 10.1007/s13312-012-0086-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 06/21/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the survival of children =18 y, treated with immunosuppressive therapy (IST) using equine antithymocyte globulin (e-ATG) and cyclosporine (CsA). DESIGN Prospective data entry as per a specified format. SETTING Tertiary care hospital. PATIENTS From January 1998 to December 2009, 40 children were diagnosed with acquired aplastic anemia; 33 patients, who received IST, were analyzed. 31 children (94%) received one course of e-ATG and CsA. 2 patients (6%) received two courses of ATG. INTERVENTION Immunosuppressive therapy using equine ATG and cyclosporine. MAIN OUTCOME MEASURES Overall response and overall survival. RESULTS The overall response (complete response + partial response) to IST at 6 months was 87.9%. 8 (24.2%) patients achieved CR, 21 (63.6%) patients had PR and 4 (12.1%) patients did not respond to IST. Median follow-up was 24 (6-102) months. Overall survival at 24 months was 90%, with an actual survival of 85.4% at 5 years. Seventeen patients (51.5%) received G-CSF for a median duration of 32 (23-64) days. The patients who received G-CSF had fewer infectious complications (P=0.002), but G-CSF administration did not influence survival/ outcome. No patient developed myelodysplastic syndrome or acute leukemia. CONCLUSIONS The survival of patients who respond to IST is excellent. Also, G-CSF reduces the infectious complications without conferring any survival advantage.
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Affiliation(s)
- Velu Nair
- Department of Medicine, Armed Forces Medical College, Pune, Maharashtra, India.
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Deyell RJ, Shereck EB, Milner RA, Schultz KR. Immunosuppressive therapy without hematopoietic growth factor exposure in pediatric acquired aplastic anemia. Pediatr Hematol Oncol 2011; 28:469-78. [PMID: 21707222 DOI: 10.3109/08880018.2011.568043] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Immunosuppressive therapy (IST) is recommended for children with acquired aplastic anemia (AA) who lack a human leukocyte antigen (HLA)-matched sibling donor for hematopoietic cell transplantation (HCT). Hematopoietic growth factors have often been included in IST supportive care, but prolonged exposure may increase the risk of secondary clonal evolution. The authors evaluated response, survival, and the incidence of clonal evolution following cyclosporine-based IST without hematopoietic growth factor exposure in a population-based pediatric cohort, identified retrospectively. Forty-five patients with a median age of 7.3 years (range 1.2-17.0 years) were included. Partial (PR) and complete (CR) response was achieved in 82% and 64%, at a median of 55 days (range 11-414 days) and 7.6 months (range 2.8-82.2 months), respectively. Patients with associated seronegative hepatitis had an increased likelihood of PR and CR on multivariate analyses (PR: hazard ratio [HR] 3.15, 95% confidence interval [CI] 1.40, 7.11; CR: HR 2.99, 95% CI 1.35, 6.62), whereas older children were less likely to achieve IST response than children younger than 5 years at diagnosis. Five- and 10-year overall survival was 96% ± 4% and 90% ± 7%, respectively, and 5-year failure-free survival was 63% ± 8%. There was no infection-related mortality, although 16.4% of patients had at least 1 episode of documented bacteremia. The 5-year cumulative incidence of relapse was 12.9% and of clonal evolution was 3.2%. The authors conclude that children with AA who receive IST without hematopoietic growth factor support have excellent response and survival outcomes and a low incidence of clonal evolution.
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Affiliation(s)
- Rebecca J Deyell
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplantation, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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He G, Zhang X, Wu D, Sun A, Wang X. Relapse of aplastic anemia responsive to sirolimus combined with cyclosporine. Pediatr Blood Cancer 2011; 56:1133-5. [PMID: 21488160 DOI: 10.1002/pbc.22865] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 09/13/2010] [Indexed: 12/25/2022]
Abstract
Aplastic anemia (AA) is an immune-mediated disease. Although most patients are responsive to immunosuppressive therapy (IST) with a combination of anti-thymocyte globulin (ATG) and cyclosporine (CsA), some patients relapse or are refractory to IST. Sirolimus (rapamysin) inhibits the serine-threonine kinase mammalian target of rapamysin (mTOR), and blocks CsA-resistant and calcium-independent pathways late in the progression of the T-cell cycle. We report two cases of AA which relapsed after CsA and ATG plus CsA, respectively. They achieved transfusion independence after retreatment with sirolimus in combination with a CsA.
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Affiliation(s)
- Guangsheng He
- Key Laboratory of Thrombosis and Hematostasis of Ministry of Health, Jiangsu Insititute of Hematology, Department of Hematology of First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, P.R. China.
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Audino AN, Blatt J, Carcamo B, Castaneda V, Dinndorf P, Wang WC, Whitlock JA, Hord JD. High-dose cyclophosphamide treatment for refractory severe aplastic anemia in children. Pediatr Blood Cancer 2010; 54:269-72. [PMID: 19827142 DOI: 10.1002/pbc.22312] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine if high-dose cyclophosphamide is an effective therapy for children with refractory severe aplastic anemia (SAA). BACKGROUND SAA is an illness characterized by the depletion of hematopoietic precursors associated with life-threatening complications. Hematopoietic stem cell transplant (HSCT) is the treatment of choice if a human leukocyte antigen (HLA)-related donor is available. Immunosuppression with anti-thymocyte globulin (ATG) and cyclosporine A (CSA) is an option for patients who are not HSCT candidates. Unrelated donor HSCT has been used with limited success. High-dose cyclophosphamide has been used successfully in the treatment of adults with SAA, but experience in children is limited. PROCEDURE Five pediatric patients who had failed previous immunosuppressive therapy for SAA were treated with high-dose cyclophosphamide (45 mg/kg/day x 4 days). RESULTS After 12 months of treatment, two of five patients experienced a complete response with high-dose cyclophosphamide therapy. The two complete responders achieved red cell recovery with a hematocrit of >36% at days 212 and 112 and platelet recovery with a platelet count of >100 x 10(9)/L at days 126 and 324. Of the remaining patients, one patient failed to respond, and two patients expired from infectious complications. CONCLUSIONS High-dose cyclophosphamide can lead to complete responses in children with SAA who have failed to respond to traditional immunosuppressive therapy.
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Huang IA, Jaing TH, Yang CP, Hung IJ, Tsay PK, Luo CC, Sun CF. Single-Center Experience: immunosuppressive therapy as frontline treatment for 33 children with acquired severe aplastic anemia. Pediatr Hematol Oncol 2009; 26:487-95. [PMID: 19863204 DOI: 10.1080/08880010902772364] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The authors retrospectively analyzed the records of 33 children with acquired severe aplastic anemia (SAA) diagnosed from July 1998 to October 2007 and first treated by immunosuppressive therapy (IST). Serial hematologic parameters, complications, transfusion requirements, and time to response were assessed. Allogeneic hematopoietic stem cell transplantation (HSCT) was attempted in 7 patients after failure of IST (n = 6) or relapse following an initial response to IST (n = 1). One child died of post-transplant lymphoproliferative disorder. Thirty of the 33 patients are alive and well after a median follow-up of 45 months (range, 7-116 months). Overall (transfusion-independent) response to IST was 73% (24/33). The actuarial 5 years survival rate was 89.4%. In this study, all patients with SAA received IST as standard front-line therapy. Approximately three-fourths of patients with SAA have durable recovery and excellent overall survival.
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Affiliation(s)
- I-Anne Huang
- Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Gonzalez-Casas R, Garcia-Buey L, Jones EA, Gisbert JP, Moreno-Otero R. Systematic review: hepatitis-associated aplastic anaemia--a syndrome associated with abnormal immunological function. Aliment Pharmacol Ther 2009; 30:436-43. [PMID: 19508613 DOI: 10.1111/j.1365-2036.2009.04060.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatitis-associated aplastic anaemia is a syndrome in which marrow failure follows the development of hepatitis. AIM To review systematically the aetiology, immunopathogenesis, clinical presentation, diagnosis and treatment of hepatitis-associated aplastic anaemia. METHODS Literature searches were undertaken on the MEDLINE electronic database up to December 2008. Twenty-four relevant studies were identified. The clinical and laboratory characteristics of the patients were analysed and reviewed. RESULTS Hepatitis-associated aplastic anemia is a variant of acquired aplastic anemia in which an episode of hepatitis precedes the onset of aplastic anemia. The hepatitis may be acute and severe, even fulminant; it may be self-limiting or chronic. The pathology is often not attributable to a recognized cause of viral hepatitis. The syndrome occurs in 28 percent of young adults after liver transplantation for non-A, non-B, non-C hepatitis. Several features of the syndrome suggest that the marrow aplasia is mediated by immunological mechanisms, possibly mediated by gamma interferon or the cytokine cascade. Survival of patients treated with hematopoietic cell transplantation has been 82%, and the response rate to immunosuppressive therapy 70%. CONCLUSIONS Hepatitis-associated bone marrow aplasia is mediated by immunological mechanisms. Treatment options include hematopoietic cell transplantation and immunosuppressive therapy.
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Affiliation(s)
- R Gonzalez-Casas
- Servicio de Aparato Digestivo and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
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Myers KC, Davies SM. Hematopoietic stem cell transplantation for bone marrow failure syndromes in children. Biol Blood Marrow Transplant 2009; 15:279-92. [PMID: 19203719 DOI: 10.1016/j.bbmt.2008.11.037] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Accepted: 11/28/2008] [Indexed: 02/06/2023]
Abstract
Bone marrow failure (BMF) syndromes include a broad group of diseases of varying etiologies, in which hematopoeisis is abnormal or completely arrested in one or more cell lines. BMF can be an acquired aplastic anemia (AA) or can be congenital, as part of such syndromes as Fanconi anemia (FA), Diamond Blackfan anemia, and Schwachman Diamond syndrome (SDS). In this review, we first address the evolution and current status of bone marrow transplantation (BMT) in the pediatric population in the most common form of BMF, acquired AA. We then discuss pediatric BMT in some of the more common inherited BMF syndromes, with emphasis on FA, in which experience is greatest. It is important to consider the possibility of a congenital etiology in every child (and adult) with marrow failure, because identification of an associated syndrome provides insight into the likely natural history of the disease, as well as prognosis, treatment options for the patient and family, and long-term sequelae both of the disease itself and its treatment.
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Affiliation(s)
- Kasiani C Myers
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Abstract
In comparison to past decades, children who have acquired aplastic anemia (AA) enjoy excellent overall survival that reflects improvements in supportive care, more accurate exclusion of children who have alternate diagnoses, and advances in transplantation and immunosuppressive therapy (IST). Matched sibling-donor hematopoietic stem cell transplants (HSCT) routinely provide long-term survival in the range of 90%, and 75% of patients respond to IST. In this latter group, the barriers to overall and complication-free survival include recurrence of AA, clonal evolution with transformation to myelodysplasia/acute myelogenous leukemia, and therapy-related toxicities. Improvements in predicting responses to IST, in alternative-donor HSCT, and in rationalizing therapy by understanding the pathophysiology in individual patients are likely to improve short- and long-term outcomes for these children.
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Alsultan A, Goldenberg NA, Kaiser N, Graham DK, Hays T. Tacrolimus as an alternative to cyclosporine in the maintenance phase of immunosuppressive therapy for severe aplastic anemia in children. Pediatr Blood Cancer 2009; 52:626-30. [PMID: 19148946 DOI: 10.1002/pbc.21926] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Given the paucity of data on the use of agents other than cyclosporine (CsA) in the maintenance phase of immunosuppressive therapy (IST) for severe aplastic anemia (SAA) in children, we sought to describe our experience with tacrolimus in pediatric SAA, and to compare outcomes with a preceding series of patients who received CsA. METHODS Eight patients with SAA diagnosed between 2003 and 2008 for whom no human leukocyte antigen (HLA)-matched sibling donor was identified underwent tacrolimus-based IST. These children were compared with a previously described series of 13 patients who had undergone CsA-based IST at our institution between 1990 and 2003. All patients initially received equine antithymocyte globulin (ATG) and corticosteroids. RESULTS Complete response (CR) rate was 88% for tacrolimus and 85% for CsA. Median time to CR was approximately 7 months in both groups. Median follow-up duration was 2.4 years for tacrolimus and 8.4 years for CsA. Among responders with de novo SAA, relapse rate was 25% (n = 1) at 2 years for tacrolimus and 0% at 2 years and 23% (n = 3) at 5 years for CsA; no significant difference in relapse-free survival was detected between the two groups (P = 0.07). Paroxysmal nocturnal hemoglobinuria was seen in one patient on tacrolimus who had relapsed after CsA-based IST. Tacrolimus-based IST was well-tolerated. CONCLUSION These data provide evidence that tacrolimus may be a suitable alternative to CsA as part of an IST regimen for SAA in children who lack an HLA-matched sibling and may have a more favorable profile of side effects than CsA.
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Affiliation(s)
- Abdulrahman Alsultan
- Center for Cancer and Blood Disorders, The Children's Hospital, University of Colorado Denver, Aurora, Colorado 80045, USA.
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