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Gong Y, Li Y, Chen X, Yang H, Zhang Y, He G, Fan L. Refractory pure red cell aplasia associated with T-cell large granular lymphocyte leukemia treated by ruxolitinib. Ann Hematol 2024:10.1007/s00277-024-05856-z. [PMID: 38935319 DOI: 10.1007/s00277-024-05856-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
Acquired pure red cell aplasia (PRCA) is a rare syndrome characterized by normocytic normochromic anemia with severe reticulocytopenia and absence of erythroid precursors in the bone marrow. For refractory PRCA patients, the low response rate and high toxicity of alternative therapies pose a great challenge. T-cell large granular lymphocyte (T-LGL) leukemia is one of the most common conditions in secondary PRCA and also the most difficult form to manage with an inferior treatment response to other secondary PRCA forms. T-LGL leukemia exhibits sustained activation of the intracellular JAK-STAT signaling pathway. We herein report a case of PRCA associated with T-LGL leukemia that had been refractory to multiple lines of therapies and was successfully treated by ruxolitinib. The patient achieved complete remission and tolerated ruxolitinib well without occurrence of neutropenia or thrombocytopenia. This preliminary finding favors ruxolitinib as a potential salvage therapy for refractory PRCA associated with T-LGL leukemia.
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Affiliation(s)
- Yuemin Gong
- Department of Hematology, Jiangsu Province Hospital, Key Laboratory of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital, Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210000, China
| | - Yue Li
- Department of Hematology, Jiangsu Province Hospital, Key Laboratory of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital, Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210000, China
| | - Xiaoyu Chen
- Department of Hematology, Jiangsu Province Hospital, Key Laboratory of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital, Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210000, China
| | - Hui Yang
- Department of Hematology, Jiangsu Province Hospital, Key Laboratory of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital, Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210000, China
| | - Yawen Zhang
- Department of Hematology, Jiangsu Province Hospital, Key Laboratory of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital, Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210000, China
| | - Guangsheng He
- Department of Hematology, Jiangsu Province Hospital, Key Laboratory of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital, Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210000, China.
| | - Lei Fan
- Department of Hematology, Jiangsu Province Hospital, Key Laboratory of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, The First Affiliated Hospital, Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210000, China
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Yang L, Niu H, Zhang T, Cao Q, Liu M, Liu Y, Yan L, Qi W, Wang T, Liu C, Li L, Xing L, Wang H, Shao Z, Fu R. A nomogram model for predicting the efficacy of cyclosporine in patients with pure red cell aplasia. Ann Hematol 2024; 103:1877-1885. [PMID: 38308019 DOI: 10.1007/s00277-024-05636-9] [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: 10/05/2023] [Accepted: 01/19/2024] [Indexed: 02/04/2024]
Abstract
Pure red cell aplasia (PRCA) is a rare bone marrow disorder characterized by a severe reduction or absence of erythroid precursor cells, without affecting granulocytes and megakaryocytes. Immunosuppressive therapies, particularly cyclosporine, have demonstrated efficacy as a primary treatment. This study aims to develop a predictive model for assessing the efficacy of cyclosporine in acquired PRCA (aPRCA). This retrospective study encompasses newly treated aPRCA patients at the General Hospital of Tianjin Medical University. Diagnosis criteria include severe anemia, and absolute reticulocyte count below 10 × 109/L, with normal white blood cell and platelet counts, and a severe reduction in bone marrow erythroblasts. Cyclosporine therapy was administered, with dose adjustments based on blood concentration. Response to cyclosporine was evaluated according to established criteria. Statistical analysis involved logistic multi-factor regression, generating a predictive model. The study included 112 aPRCA patients with a median age of 63.5 years. Patients presented with severe anemia (median Hb, 56 g/L) and reduced reticulocyte levels. Eighty-six patients had no bone marrow nucleated erythroblasts. Primary PRCA accounted for 62 cases (55.4%), and secondary PRCA accounted for 50 cases (44.6%). Univariate analysis revealed that ferritin, platelet to lymphocyte ratio (PLR), and CD4/CD8 ratio influenced treatment response. Multivariate analysis further supported the predictive value of these factors. A prediction model was constructed using ferritin, PLR, and CD4/CD8 ratio, demonstrating high sensitivity and specificity. The ferritin, PLR, and CD4/CD8-based nomogram showed good predictive ability for aPRCA response to cyclosporine. This model has potential clinical value for individualized diagnosis and treatment of aPRCA patients.
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Affiliation(s)
- Liyan Yang
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Haiyue Niu
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Tian Zhang
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Qiuying Cao
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Mengyuan Liu
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Yumei Liu
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Li Yan
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Weiwei Qi
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Ting Wang
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Chunyan Liu
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Lijuan Li
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Limin Xing
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China
| | - Huaquan Wang
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China.
| | - Zonghong Shao
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China.
| | - Rong Fu
- Department of Hematology, General Hospital, Tianjin Medical University, No. 154 Anshandao Road, Heping District, Tianjin, 300052, China.
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Zhang Z, Hu Q, Yang C, Chen M, Han B. Sirolimus is effective for primary refractory/relapsed warm autoimmune haemolytic anaemia/Evans syndrome: a retrospective single-center study. Ann Med 2023; 55:2282180. [PMID: 37967535 PMCID: PMC10653746 DOI: 10.1080/07853890.2023.2282180] [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: 08/28/2023] [Accepted: 10/31/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Some patients with warm autoimmune haemolytic anaemia (wAIHA) or Evans syndrome (ES) have no response to glucocorticoid or relapse. Recent studies found that sirolimus was effective in autoimmune cytopenia with a low relapse rate. METHODS Data from patients with refractory/relapsed wAIHA and ES in Peking Union Medical College Hospital from July 2016 to May 2022 who had been treated with sirolimus for at least 6 months and followed up for at least 12 months were collected retrospectively. Baseline and follow-up clinical data were recorded and the rate of complete response (CR), partial response (PR) at different time points, adverse events, relapse, outcomes, and factors that may affect the efficacy and relapse were analyzed. RESULTS There were 44 patients enrolled, with 9 (20.5%) males and a median age of 44 (range: 18-86) years. 37 (84.1%) patients were diagnosed as wAIHA, and 7 (15.9%) as ES. Patients were treated with sirolimus for a median of 23 (range: 6-80) months and followed up for a median of 25 (range: 12-80) months. 35 (79.5%) patients responded to sirolimus, and 25 (56.8%) patients achieved an optimal response of CR. Mucositis (11.4%), infection (9.1%), and alanine aminotransferase elevation (9.1%) were the most common adverse events. 5/35 patients (14.3%) relapsed at a median of 19 (range: 15-50) months. Patients with a higher sirolimus plasma trough concentration had a higher overall response (OR) and CR rate (p = 0.009, 0.011, respectively). At the time of enrolment, patients were divided into two subgroups that relapsed or refractory to glucocorticoid, and the former had poorer relapse-free survival (p = 0.032) than the other group. CONCLUSION Sirolimus is effective for patients with primary refractory/relapsed wAIHA and ES, with a low relapse rate and mild side effects. Patients with a higher sirolimus plasma trough concentration had a higher OR and CR rate, and patients who relapsed to glucocorticoid treatment had poorer relapse-free survival than those who were refractory.
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Affiliation(s)
- Zhuxin Zhang
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Qinglin Hu
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
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Lobbes H, Lega JC, Le Guenno G, Ruivard M, Mainbourg S. Treatment strategy for acquired pure red cell aplasia: a systematic review and meta-analysis. Blood Adv 2023; 7:6451-6465. [PMID: 37624775 PMCID: PMC10632686 DOI: 10.1182/bloodadvances.2023010587] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/22/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
The treatment of autoimmune acquired pure red cell aplasia (aPRCA) is challenging. Guidelines are based on expert recommendations in the absence of controlled trials. We assessed the efficacy of the main treatment strategy through a systematic review and meta-analysis using MEDLINE, EMBASE, and the Cochrane Library up to September 2022. The overall response rate (ORR) was pooled using random-effects models. In total, 24 observational studies (19 retrospective, median follow-up of 48 months) encompassing 753 patients (49% male) were included. Primary aPRCA represented 57% of the cases. The risk of bias was moderate to high using the ROBINS-I tool. Substantial heterogeneity (I2 > 50%) was retrieved. Corticosteroids as monotherapy as first-line treatment (186 patients, 13 studies) provided an ORR of 47% (95% confidence interval [CI], 34-60). Cyclosporine A was the most frequently used immunosuppressant agent (384 patients, 18 studies), providing an ORR of 74% (95% CI, 66-82) with a similar ORR in first- (73%) and second-line (76%) treatment and when cyclosporin was used as monotherapy (83%) or with corticosteroids (77%). A total of 112 patients (10 studies) received cyclophosphamide, with an ORR of 49% (95% CI, 35-64), which was higher when cyclophosphamide was combined with corticosteroids (48%) and used in second-line treatment (58%) than in monotherapy (31%), and in first-line treatment (44%). Sirolimus use was reported only after cyclosporine A failure and provided an ORR of 87% (95% CI, 68-100; 64 patients, 3 studies). Substantial uncertainty remains regarding the best treatment strategy in the absence of high-quality evidence. This study was registered on the PROPERO database as #CRD42022360452.
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Affiliation(s)
- Hervé Lobbes
- Service de Médecine Interne, Hôpital Estaing, Centre Hospitalier Universitaire de Clermont-Ferrand, Centre de Compétence des cytopénies autoimmunes de l’adulte, Clermont-Ferrand, France
- Institut Pascal, Centre Hospitalier Universitaire de Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Clermont-Ferrand, France
| | - Jean-Christophe Lega
- Lyon Immunopathology Federation, Hospices Civils de Lyon, Lyon, France
- Service de Rhumatologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
- Equipe Evaluation et Modélisation des Effets Thérapeutiques, Unité Mixte de Recherche 5558, Laboratoire de Biométrie et Biologie évolutive, Centre National de la Recherche Scientifique, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Guillaume Le Guenno
- Service de Médecine Interne, Hôpital Estaing, Centre Hospitalier Universitaire de Clermont-Ferrand, Centre de Compétence des cytopénies autoimmunes de l’adulte, Clermont-Ferrand, France
| | - Marc Ruivard
- Service de Médecine Interne, Hôpital Estaing, Centre Hospitalier Universitaire de Clermont-Ferrand, Centre de Compétence des cytopénies autoimmunes de l’adulte, Clermont-Ferrand, France
- Institut Pascal, Centre Hospitalier Universitaire de Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Clermont-Ferrand, France
| | - Sabine Mainbourg
- Lyon Immunopathology Federation, Hospices Civils de Lyon, Lyon, France
- Equipe Evaluation et Modélisation des Effets Thérapeutiques, Unité Mixte de Recherche 5558, Laboratoire de Biométrie et Biologie évolutive, Centre National de la Recherche Scientifique, Université Claude Bernard Lyon 1, Villeurbanne, France
- Département de Médecine Interne, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
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Sorin B, Fadlallah J, Garzaro M, Vigneron J, Bertinchamp R, Boutboul D, Oksenhendler E, Fieschi C, Malphettes M, Galicier L. Real-life use of mTOR inhibitor-based therapy in adults with autoimmune cytopenia highlights strong efficacy in relapsing/refractory multi-lineage autoimmune cytopenia. Ann Hematol 2023:10.1007/s00277-023-05340-0. [PMID: 37386347 DOI: 10.1007/s00277-023-05340-0] [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: 03/01/2023] [Accepted: 06/25/2023] [Indexed: 07/01/2023]
Abstract
Data on mTOR inhibitors (mTORi) in autoimmune cytopenia (AIC), in adults are scarce. We retrospectively analysed 30 cases of refractory or relapsing AIC treated with an mTORi-based therapy. Eleven warm autoimmune hemolytic anaemia, 10 autoimmune thrombocytopenia, 6 acquired pure red cell aplasia, 3 autoimmune neutropenia were included. Twenty were multilineage AIC (67%) and 21 were secondary AIC (70%). mTORi were associated with other therapies in 23 AIC (77%). Twenty-two AIC (73%) responded to mTORi-based therapy: 5 reached a partial response (17%) and 17 a complete response (57%). Survival without unfavourable outcome (failure, requirement of a new therapy, or death) was longer in multilineage AIC compared to single-lineage AIC (p = 0.049) with a median event-free survival of 48 versus 12 months. Median event-free survival was 48 months in secondary AIC and 33 months in primary AIC (p = 0.79). mTORi were discontinued in 4 patients (15%) for safety reasons and in 3 patients for patient's choice (12%). In conclusion, mTORi could be considered as an alternative or an add-on therapy in refractory or relapsing AIC in adult patients, especially in multilineage AIC.
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Affiliation(s)
- Boris Sorin
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France.
| | - Jehane Fadlallah
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Margaux Garzaro
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Julien Vigneron
- Department of Biostatistics and Medical Information, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Rémi Bertinchamp
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - David Boutboul
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Eric Oksenhendler
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Claire Fieschi
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Marion Malphettes
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Lionel Galicier
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
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Yang Y, Tang Z, Huang Y, Hu Q, Wang S, Ji J, Du Y, Yang C, Chen M, Hu S, Han B. Sirolimus versus cyclosporine A in patients with primary acquired pure red cell aplasia: a prospective cohort study. Blood Cancer J 2023; 13:74. [PMID: 37160872 PMCID: PMC10169841 DOI: 10.1038/s41408-023-00845-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/17/2023] [Accepted: 04/24/2023] [Indexed: 05/11/2023] Open
Affiliation(s)
- Yuan Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Zengwei Tang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, Zhejiang, China
| | - Yuzhou Huang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
- Department of Gastroenterology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qinglin Hu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Shuqing Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Jiang Ji
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yali Du
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Shimin Hu
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Xu Z, Chu M. Advances in Immunosuppressive Agents Based on Signal Pathway. Front Pharmacol 2022; 13:917162. [PMID: 35694243 PMCID: PMC9178660 DOI: 10.3389/fphar.2022.917162] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/02/2022] [Indexed: 12/13/2022] Open
Abstract
Immune abnormality involves in various diseases, such as infection, allergic diseases, autoimmune diseases, as well as transplantation. Several signal pathways have been demonstrated to play a central role in the immune response, including JAK/STAT, NF-κB, PI3K/AKT-mTOR, MAPK, and Keap1/Nrf2/ARE pathway, in which multiple targets have been used to develop immunosuppressive agents. In recent years, varieties of immunosuppressive agents have been approved for clinical use, such as the JAK inhibitor tofacitinib and the mTOR inhibitor everolimus, which have shown good therapeutic effects. Additionally, many immunosuppressive agents are still in clinical trials or preclinical studies. In this review, we classified the immunosuppressive agents according to the immunopharmacological mechanisms, and summarized the phase of immunosuppressive agents.
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Affiliation(s)
- Zhiqing Xu
- Department of Immunology, National Health Commission (NHC) Key Laboratory of Medical Immunology (Peking University), School of Basic Medical Sciences, Peking University, Beijing, China
- Department of Pharmacology, Jilin University, Changchun, China
| | - Ming Chu
- Department of Immunology, National Health Commission (NHC) Key Laboratory of Medical Immunology (Peking University), School of Basic Medical Sciences, Peking University, Beijing, China
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Sirolimus is effective for refractory/relapsed/intolerant acquired pure red cell aplasia: results of a prospective single-institutional trial. Leukemia 2022; 36:1351-1360. [PMID: 35256763 DOI: 10.1038/s41375-022-01532-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/07/2022] [Accepted: 02/14/2022] [Indexed: 11/08/2022]
Abstract
Some patients with acquired pure red cell aplasia (aPRCA) have no response or are intolerant to cyclosporine A. From April 2017 to August 2020, patients diagnosed with aPRCA at Peking Union Medical College Hospital who were refractory/recurrent/intolerant to at least 6 months of full-dose cyclosporin A (CsA) with/without steroids were recruited and treated with sirolimus for at least 6 months. Finally, a total of 64 patients were enrolled. The overall response rate and complete response rate after 3, 6 and 12 months of sirolimus were 60.9%, 84.4%, and 73.5% and 50.0%, 65.6%, and 66.0%, respectively. At a median of 14.5 (6-47) months of follow-up, 14.8% (8/54) of the patients relapsed. Apart from haemoglobin improvement, patients had decreased creatine levels and serum ferritin levels at the end of the follow-up compared with the baseline (169.3 μmol/L vs. 146.4 μmol/L, p = 0.041; 2121.5 ng/mL vs. 1018.3 ng/mL, p = 0.013). Adverse events were recorded in 19 patients, including infections and increase of creatine. Secondary aPRCA with stable underlying diseases had similar results as those with primary aPRCA. In summary, sirolimus is effective for patients with refractory/recurrent/intolerant aRPCA with a low recurrence rate and toxicities.
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Xing L, Wang Y, Liu H, Gao S, Shao Q, Yue L, Liu Z, Wang H, Shao Z, Fu R. Case Report: Sirolimus Alleviates Persistent Cytopenia After CD19 CAR-T-Cell Therapy. Front Oncol 2022; 11:798352. [PMID: 35004324 PMCID: PMC8733571 DOI: 10.3389/fonc.2021.798352] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/30/2021] [Indexed: 12/15/2022] Open
Abstract
Chimeric antigen receptor T (CAR-T) cells show good efficacy in the treatment of relapsed and refractory B-cell tumors, such as acute B-cell leukemia (ALL) and diffuse large B-cell lymphoma (DLBCL). The main toxicities of CAR-T include cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, cytopenia, and severe infection. It is still very difficult for CAR-T to kill tumor cells to the maximum extent and avoid damaging normal organs. Here, we report a case of DLBCL with persistent grade 4 thrombocytopenia and severe platelet transfusion dependence treated with CD19 CAR-T cells. We used sirolimus to inhibit the sustained activation of CAR-T cells and restore normal bone marrow hematopoiesis and peripheral blood cells. Moreover, sirolimus treatment did not affect the short-term efficacy of CAR-T cells, and DLBCL was in complete remission at the end of follow-up. In conclusion, sirolimus can represent a new strategy for the management of CAR-T cell therapy-related toxicity, including but not limited to hematotoxicity. However, further controlled clinical studies are required to confirm these findings.
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Affiliation(s)
- Limin Xing
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Yihao Wang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Hui Liu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Shan Gao
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Qing Shao
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Lanzhu Yue
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Zhaoyun Liu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Huaquan Wang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Zonghong Shao
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Rong Fu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
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[Evaluation of the efficacy and safety of recombined human erythropoietin combined with cyclosporin A in the treatment of patients with pure red cell aplasia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:952-955. [PMID: 35045658 PMCID: PMC8763588 DOI: 10.3760/cma.j.issn.0253-2727.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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11
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Zhang Y, Zhang J, Wang S. The Role of Rapamycin in Healthspan Extension via the Delay of Organ Aging. Ageing Res Rev 2021; 70:101376. [PMID: 34089901 DOI: 10.1016/j.arr.2021.101376] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 05/07/2021] [Accepted: 05/30/2021] [Indexed: 12/17/2022]
Abstract
Aging can not only shorten a healthy lifespan, but can also lead to multi-organ dysfunction and failure. Anti-aging is a complex and worldwide conundrum for eliminating the various pathologies of senility. The past decade has seen great progress in the understanding of the aging-associated signaling pathways and their application for developing anti-aging approaches. Currently, some drugs can improve quality of life. The activation of mammalian target of rapamycin (mTOR) signaling is one of the core and detrimental mechanisms related to aging; rapamycin can reduce the rate of aging, improve age-related diseases by inhibiting the mTOR pathway, and prolong lifespan and healthspan effectively. However, the current evidence for rapamycin in lifespan extension and organ aging is fragmented and scattered. In this review, we summarize the efficacy and safety of rapamycin in prolonging a healthy lifespan by systematically alleviating aging in multiple organ systems, i.e., the nervous, urinary, digestive, circulatory, motor, respiratory, endocrine, reproductive, integumentary and immune systems, to provide a theoretical basis for the future clinical application of rapamycin in anti-aging.
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Affiliation(s)
- Yan Zhang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China; National Clinical Research Center for Obstetrical and Gynecological Diseases, Huazhong University of Science and Technology, Wuhan, 430030, China; Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jinjin Zhang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China; National Clinical Research Center for Obstetrical and Gynecological Diseases, Huazhong University of Science and Technology, Wuhan, 430030, China; Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Shixuan Wang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China; National Clinical Research Center for Obstetrical and Gynecological Diseases, Huazhong University of Science and Technology, Wuhan, 430030, China; Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Huazhong University of Science and Technology, Wuhan, 430030, China.
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12
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Gurnari C, Maciejewski JP. How I manage acquired pure red cell aplasia in adults. Blood 2021; 137:2001-2009. [PMID: 33657207 PMCID: PMC8057257 DOI: 10.1182/blood.2021010898] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/18/2021] [Indexed: 12/19/2022] Open
Abstract
Pure red cell aplasia (PRCA) is a rare hematological disorder with multiple etiologies. The multifaceted nature of this disease is emphasized by the variety of concomitant clinical features. Classic idiopathic presentation aside, prompt recognition of pathogenetic clues is important because of their diagnostic and therapeutic implications. As a consequence, treatment of PRCA is diverse and strictly dependent on the presented clinical scenario. Here, we propose a series of clinical vignettes that showcase instructive representative situations derived from our routine clinical practice. Using these illustrative clinical cases, we review the diagnostic workup needed for a precise diagnosis and the currently available therapeutic options, discussing their applications in regard to the various PRCA-associated conditions and individual patients' characteristics. Finally, we propose a treatment algorithm that may offer guidance for personalized therapeutic recommendations.
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Affiliation(s)
- Carmelo Gurnari
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH; and
- Department of Biomedicine and Prevention, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Jaroslaw P Maciejewski
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH; and
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13
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Feng Y, Chen X, Cassady K, Zou Z, Yang S, Wang Z, Zhang X. The Role of mTOR Inhibitors in Hematologic Disease: From Bench to Bedside. Front Oncol 2021; 10:611690. [PMID: 33489922 PMCID: PMC7821787 DOI: 10.3389/fonc.2020.611690] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/27/2020] [Indexed: 02/05/2023] Open
Abstract
The mTOR pathway plays a central role in many cellular processes, such as cellular growth, protein synthesis, glucose, and lipid metabolism. Aberrant regulation of mTOR is a hallmark of many cancers, including hematological malignancies. mTOR inhibitors, such as Rapamycin and Rapamycin analogs (Rapalogs), have become a promising class of agents to treat malignant blood diseases-either alone or in combination with other treatment regimens. This review highlights experimental evidence underlying the molecular mechanisms of mTOR inhibitors and summarizes their evolving role in the treatment of hematologic disease, including leukemia, lymphoma, myeloma, immune hemocytopenia, and graft-versus-host disease (GVHD). Based on data presented in this review, we believe that mTOR inhibitors are becoming a trusted therapeutic in the clinical hematologist's toolbelt and should be considered more routinely in combination therapy for the management of hematologic disease.
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Affiliation(s)
- Yimei Feng
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
- Chongqing Sub-center of National Clinical Research Center for Hematologic Disease, Chongqing, China
| | - Xiaoli Chen
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
- Chongqing Sub-center of National Clinical Research Center for Hematologic Disease, Chongqing, China
| | - Kaniel Cassady
- Irell and Manella Graduate School of Biological Sciences of City of Hope, Duarte, CA, United States
| | - Zhongmin Zou
- Department of Chemical Defense Medicine, School of Military Preventive Medicine, Third Military Medical University, Chongqing, China
| | - Shijie Yang
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
- Chongqing Sub-center of National Clinical Research Center for Hematologic Disease, Chongqing, China
| | - Zheng Wang
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
- Chongqing Sub-center of National Clinical Research Center for Hematologic Disease, Chongqing, China
| | - Xi Zhang
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
- Chongqing Sub-center of National Clinical Research Center for Hematologic Disease, Chongqing, China
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14
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[Chinese expert consensus on the diagnosis and treatment of acquired pure red cell aplasia (2020)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:177-184. [PMID: 32311886 PMCID: PMC7357928 DOI: 10.3760/cma.j.issn.0253-2727.2020.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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15
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Li H, Ji J, Du Y, Huang Y, Gu H, Chen M, Wu R, Han B. Sirolimus is effective for primary relapsed/refractory autoimmune cytopenia: a multicenter study. Exp Hematol 2020; 89:87-95. [PMID: 32771553 DOI: 10.1016/j.exphem.2020.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/31/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022]
Abstract
Autoimmune cytopenia includes autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), and Evans syndrome (ES) caused by abnormal activation of autoimmunity and has a considerable refractory/relapse rate. To evaluate the efficacy and toxicity of sirolimus of primary relapsed/refractory autoimmune cytopenia, records of 45 patients with primary relapsed/refractory AIHA, ES, or ITP from October 2016 to January 2019 in two institutions, were collected; there were 3 pediatric patients and 42 adult patients. The median age at diagnosis was 31 (1-84) years. Patients were treated for a median of 14 (6-39) months and followed-up for a median of 18 (10-40) months. Thirty-eight patients responded to sirolimus, with 28 complete responses (CRs) and a median of 2 (2-5) months to response. Five patients had mucositis; the incidences of other adverse events were all less than 5%. Four patients relapsed, making the CR and overall response rate 46.7% and 75.6% at the end of follow-up. There were no differences in patient age, sex, time from diagnosis to sirolimus, serum sirolimus concentration, and disease distribution between CR and non-CR patients, or between responders and nonresponders, though AIHA patients were likely to relapse less and respond better. In conclusion, sirolimus is effective for patients with primary relapsed/refractory autoimmune cytopenia with a low relapse rate and good tolerance.
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Affiliation(s)
- Hongmin Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiang Ji
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yali Du
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuzhou Huang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Gu
- Hematology-Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - RunHui Wu
- Hematology-Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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16
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Huang Y, Jiang X, Han B. Effective treatment of refractory acquired pure red blood cell aplasia with eltrombopag and sirolimus: a case report. Ther Adv Hematol 2020; 11:2040620720940144. [PMID: 32733663 PMCID: PMC7372523 DOI: 10.1177/2040620720940144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/11/2020] [Indexed: 12/17/2022] Open
Abstract
Acquired pure red cell aplasia (aPRCA) is a kind of anemia characterized
by severe reticulocytopenia and reduced bone marrow erythroblastic
cells. For patients who are refractory to the first-line therapy
(cyclosporin A with/without glucocorticoids), second-line therapy is
considered less effective. We report on a patient with primary aPRCA
who was refractory to cyclosporin A, glucocorticoids, and several
second-line regimens. The patient was treated with sirolimus for
10 months with no improvement in hemoglobin but complete response was
achieved after adding eltrombopag at a dosage of 25 mg/day.
Eltrombopag was well tolerated with no evidence of clonal evolution at
the end of follow up. This case provided a new attempt at treating
patients with refractory/relapse aPRCA with eltrombopag, probably in
combination with sirolimus.
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Affiliation(s)
- Yuzhou Huang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xianyong Jiang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No. 1, Dongcheng District, Beijing 100730, China
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17
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Wang Q, Ma JX, Li BH, Wang XQ, Hu Q, Zhang MX. [Clinical analysis of 67 cases of pure red cell aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:506-510. [PMID: 32654466 PMCID: PMC7378292 DOI: 10.3760/cma.j.issn.0253-2727.2020.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Indexed: 11/17/2022]
Abstract
Objective: To investigate secondary factors, laboratory features, treatment options, and prognosis of pure red cell aplastic anemia (PRCA) . Methods: This was a multicenter retrospective clinical study. Patients aged above 18 years newly diagnosed with PRCA between June 1, 2010, and June 1, 2019, were recruited as the main study object. A comparative analysis of remission rate and overall survival rate was made according to different treatment schemes adopted by patients and different drug reduction rates. Results: A total of 67 patients with PRCA were included in this study and the secondary PRCA group accounted for 44.8% (30/67) . The most common secondary factors were thymoma (n=10) and T-cell large lymphocytic leukemia (T-LGLL) (n=6) . The overall response rate of PRCA was 85.7% and the 3-year overall survival rate of PRCA was (74.3±7.5) %. The remission rate of cyclosporine A alone was slightly higher than that of oral glucocorticoid alone or combined with glucocorticoid[90.0% (36/40) vs 75.0% (12/16) , P=0.147]. After patients applied with cyclosporine A treatment reached CR/PR and remained stable for 3-6 months, the dose of cyclosporine A was reduced by 25 mg each time. The cyclosporine A reduction interval of a 25 mg/d reduction in more than 1 month significantly prolonged the median disease-free survival compared with a 25 mg/d reduction in less than 1 month [not reached vs 15 (95% CI 7-23) months, P<0.001]. There were 62.5% (10/16) of patients who responded to the initial or incremental treatment regimen after relapse. Conclusion: PRCA has features of various secondary factors, high overall survival rate, and high remission rate. Treatment with cyclosporine A alone is preferred, and cyclosporine A should be slowly tapered to reduce the risk of later relapse after it takes effect and patients reach a steady state.
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Affiliation(s)
- Q Wang
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - J X Ma
- Department of Hematology, Huadong Hospital, Fudan University, Shanghai 200040, China
| | - B H Li
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - X Q Wang
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Q Hu
- Department of Hematology, Shanghai Hospital of Traditional Chinese Medicine, Shanghai 200071, China
| | - M X Zhang
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai 200040, China
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18
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Immunosuppression therapy is effective for both acquired tumor-associated and primary pure red cell aplasia: a match pair case-control study. Ann Hematol 2020; 99:1485-1491. [PMID: 32488602 DOI: 10.1007/s00277-020-04105-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
No agreement had been reached on the treatment of patients with pure red cell aplasia (PRCA) secondary to indolent malignancies. Data was collected from patients with acquired PRCA from May, 2014 to May, 2018 in Peking Union Medical College Hospital. Tumor-associated PRCA and primary PRCA patients were matched at a ratio of 1:2 with compatible baseline characteristics. All patients had been treated with CsA or sirolimus for at least 6 months with the efficacy and adverse events recorded. Twelve tumor-associated PRCA patients (3 thymoma, 8 lymphoproliferative disorders, and 1 smoldering multiple myeloma) with stable underling disease and 24 acquired primary PRCA patients were selected. 83.3% tumor-associated PRCA patients and 100% primary PRCA patients (P = 0.436) responded to immunosuppression therapy (IST) at a median of 2.5 and 3.5 months (P = 0.137), respectively. No different was found in side effects. The ORR at the end of a median of 21.5-month follow-up was 75% and 70.8% (P = 0.795), respectively. No tumor progression was reported except one secondary patient had lymphoma relapse after 2 years of IST and was given chemotherapy again. These results suggested IST had similar effect, safety on patients with tumor-associated, and primary PRCA patients when the tumors were stable.
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19
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Feng Y, Xiao Y, Yan H, Wang P, Zhu W, Cassady K, Zou Z, Wang K, Chen T, Quan Y, Wang Z, Yang S, Wang R, Li X, Gao L, Zhang C, Liu Y, Kong P, Gao L, Zhang X. Sirolimus as Rescue Therapy for Refractory/Relapsed Immune Thrombocytopenia: Results of a Single-Center, Prospective, Single-Arm Study. Front Med (Lausanne) 2020; 7:110. [PMID: 32296709 PMCID: PMC7136762 DOI: 10.3389/fmed.2020.00110] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 03/10/2020] [Indexed: 02/05/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease which arises due to self-destruction of circulating platelets. Failure to respond or maintain a response to first-line treatment can lead to refractory/relapsed (R/R) ITP. The mechanism remains complicated and lacks a standard clinical treatment. Sirolimus (SRL) is a mammalian target of rapamycin (mTOR) inhibitor that has been demonstrated to inhibit lymphocyte activity, indicating potential for SRL in treatment of ITP. Activation of the mTOR pathway in autoimmune diseases suggests that SRL might be a useful agent for treating ITP. Accordingly, we initiated an open-label, prospective clinical trial using SRL for patients with R/R ITP (ChiCTR-ONC-17012126). The trial enrolled 86 patients, each dosed with 2–4 mg/day of SRL. By the third month, 40% of patients (34 of 86) achieved complete remission (CR) and 45% of patients (39 of 86) achieved partial remission (PR), whereby establishing an overall response rate (ORR) of 85%. By 6 months of treatment, 41% of patients (32 of 78) achieved CR and 29% of patients (23 of 78) achieved PR, establishing an ORR of 70% without serious side effects. After 12 months follow-up, the ORR remained at 65%. We also found that SRL treatment exhibited higher efficacy in achieving CR in ITP patients who were younger than 40 years old or steroid dependent by univariate analysis. Importantly, in patients who responded, SRL treatment was associated with a reduction in the percentage of Th2, Th17 cells, and increase in the percentage of M-MDSCs and Tregs, indicating that SRL may reestablish peripheral tolerance. Taken together, Sirolimus demonstrated efficacy as a second-line agent for R/R ITP.
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Affiliation(s)
- Yimei Feng
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Yunshuo Xiao
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Hongju Yan
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Ping Wang
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Wen Zhu
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Kaniel Cassady
- Irell and Manella Graduate School of Biological Sciences of City of Hope, Duarte, CA, United States
| | - Zhongmin Zou
- Department of Chemical Defense, School of Preventive Medicine, Third Military Medical University, Chongqing, China
| | - Kaifa Wang
- School of Mathematics and Statistics, Southwest University, Chongqing, China
| | - Ting Chen
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Yao Quan
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Zheng Wang
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Shijie Yang
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Rui Wang
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Xiaoping Li
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Lei Gao
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Cheng Zhang
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Yao Liu
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Peiyan Kong
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Li Gao
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
| | - Xi Zhang
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
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20
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[How I diagnose and treat pure red cell aplasia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:5-9. [PMID: 32023747 PMCID: PMC7357908 DOI: 10.3760/cma.j.issn.0253-2727.2020.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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21
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Chen Z, Liu X, Chen M, Yang C, Han B. Successful sirolimus treatment of patients with pure red cell aplasia complicated with renal insufficiency. Ann Hematol 2020; 99:737-741. [PMID: 32030447 DOI: 10.1007/s00277-020-03946-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 01/27/2020] [Indexed: 10/25/2022]
Abstract
For patients with pure red cell aplasia (PRCA), cyclosporine (CsA) is the first line therapy. Occasionally, some patients who suffer from renal insufficiency cannot tolerate CsA. To explore the efficacy and tolerance of sirolimus treatment for those patients, twelve PRCA patients with renal insufficiency from May 2014 to May 2018 in Peking Union Medical College Hospital were enrolled, treated with sirolimus, and followed up at the median time of 16 (10-50) months. Eleven patients (91.7%) responded to sirolimus, with 58.3% complete response (CR) and 41.7% partial response (PR). The median time to achieve the optimum effect was 4 (1-7) months. The serum creatinine level remained stable or even reduced during the treatment period for eleven patients. Seven patients (58.3%) reported adverse events during sirolimus therapy, including increased blood glucose, infection, skin rash, elevated triglyceride or total cholesterol, and elevated serum creatinine compared with baseline. No treatment-related death was noticed during the follow-up time. Three patients relapsed with an overall response rate of 75.0% at 1 year. These results suggested that sirolimus was effective and tolerable for patients with PRCA complicated with renal insufficiency.
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Affiliation(s)
- Zesong Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xinjian Liu
- Department of Hematology, Institute of Hematology of Henan Province, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, 127 Dongming Road, Zhengzhou, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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22
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Pure Red Cell Aplasia with Del(20q) Sensitive for Immunosuppressive Treatment. Case Rep Hematol 2020; 2020:1262038. [PMID: 32082654 PMCID: PMC6995481 DOI: 10.1155/2020/1262038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 12/13/2019] [Accepted: 12/28/2019] [Indexed: 11/17/2022] Open
Abstract
Pure red cell aplasia (PRCA) is a rare syndrome that only affects the erythroid lineage. It is defined by a normocytic, normochromic anemia with a marked reticulocytopenia and severe reduction or absence of erythroid precursors in the bone marrow. Treatment of primary, idiopathic PRCA is immunosuppressive therapy. Although it is rare, isolated cytogenetic abnormalities can be seen in PRCA, and abnormal karyotype is associated with poor response to immunosuppressive therapy and poor prognosis. We describe a 77-year-old male with primary, idiopathic PRCA and a deletion of chromosome 20q, del(20q), in the bone marrow cells. He was successfully treated with immunosuppressive therapy and became transfusion-independent. The same cytogenetic abnormality has also been described in a few other reports; taken together, these observations suggest that del(20q) may represent a recurrent cytogenetic abnormality in PRCA. Our case report clearly illustrates that even patients with primary PRCA and an abnormal karyotype can respond to immunosuppression and become transfusion-independent.
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