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Means RT. Pure red cell aplasia: The second hundred years. Am J Med Sci 2023; 366:160-166. [PMID: 37327996 DOI: 10.1016/j.amjms.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/05/2023] [Accepted: 06/13/2023] [Indexed: 06/18/2023]
Abstract
Pure red cell aplasia (PRCA) is a rare hematologic syndrome, characterized by an isolated normocytic anemia with severe reticulocytopenia, and defined by absence or near absence of erythroid precursors in the bone marrow. First described in 1922, PRCA may be a primary autoimmune or clonal myeloid or lymphoid disorder, but may also be secondary to other disorders of immune dysregulation/autoimmunity, to infections, to neoplasms, or to drugs. Insights from the study of PRCA have helped illuminate the understanding of the regulation of erythropoiesis. This review summarizes the classification, diagnostic, and therapeutic approach to PRCA as it begins its second century, with a particular focus on opportunities and challenges provided by new developments in the role of T-cells and T-cell regulatory mutations; the role of clonal hematopoiesis; and new developments in therapy for refractory PRCA and PRCA associated with ABO incompatible stem cell transplantation.
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Affiliation(s)
- Robert T Means
- Departments of Internal Medicine, Medical Education, and Pathology, James H. Quillen College of Medicine, Johnson City, TN, USA.
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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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Chen XM, Li H, Wu Y, Wang LL, Bai YJ, Shi YY. Case report: Dynamic antibody monitoring in a case of anti-recombinant human erythropoietin-mediated pure red cell aplasia with prolonged course after kidney transplantation. Front Immunol 2022; 13:1049444. [PMID: 36524109 PMCID: PMC9744924 DOI: 10.3389/fimmu.2022.1049444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/11/2022] [Indexed: 11/30/2022] Open
Abstract
Anti-erythropoietin (anti-EPO) antibody-mediated pure red cell aplasia (PRCA) is a rarely seen disease. Anti-EPO antibodies were mostly found in patients with chronic kidney disease who received recombinant human erythropoietin (rHuEPO) injections subcutaneously. The treatment against anti-EPO antibody-mediated PRCA included discontinuation of rHuEPO, immunosuppressive agents, intravenous immunoglobulin, plasmapheresis, or kidney transplantation. We reported a case of kidney transplant recipient with anti-EPO antibody-mediated PRCA, who had no trend of recovery after stopping rHuEPO, receiving regular induction and maintenance immunosuppressive regimens. He was further given 6 consecutive plasmapheresis sessions, cyclophosphamide, and adjusted maintenance immunosuppressive regimen into cyclosporine, sirolimus and prednisone. We monitored his anti-EPO antibody levels with a self-created simple mixing test. At 10 months post kidney transplant, his anti-EPO antibody finally turned negative, and his reticulocyte count dramatically increased. Cyclosporine, sirolimus and prednisone combined with roxadustat eventually alleviated the patient's anti-EPO antibody-mediated PRCA. Our self-created simple mixing test for anti-EPO antibody titer was very helpful in disease monitoring and therapeutic guidance.
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Affiliation(s)
- Xiao-Mei Chen
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hui Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Wu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lan-Lan Wang
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yang-Juan Bai
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China,*Correspondence: Yun-Ying Shi, ; Yang-Juan Bai,
| | - Yun-Ying Shi
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China,*Correspondence: Yun-Ying Shi, ; Yang-Juan Bai,
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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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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: 28] [Impact Index Per Article: 9.3] [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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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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