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Sakamoto AS, Sequeira FS, Blanco BP, Garanito MP. Pediatric autoimmune hemolytic anemia: A single-center retrospective study. Hematol Transfus Cell Ther 2024:S2531-1379(24)00016-6. [PMID: 38402032 DOI: 10.1016/j.htct.2023.12.006] [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: 08/02/2023] [Revised: 11/11/2023] [Accepted: 12/27/2023] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Autoimmune hemolytic anemia (AIHA) is a rare, life-threatening disease in pediatrics. This article describes the clinical features, diagnostic workup, treatment and outcome in patients with AIHA. METHOD Medical charts of under 18-year-old patients with AIHA treated at a tertiary Brazilian institution from 2006 to 2021 were retrospectively reviewed. Data analysis was primarily descriptive, using medians, interquartile ranges, and categorical variables presented as absolute frequencies. MAIN RESULTS Twenty-four patients (14 female, 10 male) were evaluated in this study. The median age at diagnosis was 5.99 years (range: 0.25-17.1 years) and the median hemoglobin level was 4.85 g/dL (range: 4.17-5.57 g/dL). Most had warm antibodies (83.3 %). Twelve patients (50 %) had known underlining diseases, four (16.6 %) presented with AIHA concomitant with acute infectious diseases and three (12.5 %) had an undetermined post-vaccine association. Steroids and intravenous immunoglobulin were first-line therapy in 23 cases. Seven patients (29.1 %) required second and third-line treatments (rituximab, cyclophosphamide and splenectomy). The median follow-up period was 4.4 years (range: 1.0-6.7 years). Thirteen patients (54.1 %) were discharged, five cases (20.8 %) were lost to follow-up and no patient died. The median age for the six remaining patients was 11.53 years (8.5-14.7) with all of them having complete responses with no further therapies. CONCLUSION Most cases of AIHA are secondary to an underlying systemic disease or have a possible correlation with infections/vaccines and respond to steroids. The second and third-line therapies for refractory and relapse cases remain a dilemma. A prospective, multicenter study is essential to address the best therapeutic combinations.
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Moulinet T, Moussu A, Pierson L, Pagliuca S. The many facets of immune-mediated thrombocytopenia: Principles of immunobiology and immunotherapy. Blood Rev 2024; 63:101141. [PMID: 37980261 DOI: 10.1016/j.blre.2023.101141] [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: 08/30/2023] [Revised: 10/08/2023] [Accepted: 11/05/2023] [Indexed: 11/20/2023]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune condition, due to peripheral platelet destruction through antibody-dependent cellular phagocytosis, complement-dependent cytotoxicity, cytotoxic T lymphocyte-mediated cytotoxicity, and megakaryopoiesis alteration. This condition may be idiopathic or triggered by drugs, vaccines, infections, cancers, autoimmune disorders and systemic diseases. Recent advances in our understanding of ITP immunobiology support the idea that other forms of thrombocytopenia, for instance, occurring after immunotherapy or cellular therapies, may share a common pathophysiology with possible therapeutic implications. If a decent pipeline of old and new agents is currently deployed for classical ITP, in other more complex immune-mediated thrombocytopenic disorders, clinical management is less harmonized and would deserve further prospective investigations. Here, we seek to provide a fresh overview of pathophysiology and current therapeutical algorithms for adult patients affected by this disorder with specific insights into poorly codified scenarios, including refractory ITP and post-immunotherapy/cellular therapy immune-mediated thrombocytopenia.
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Affiliation(s)
- Thomas Moulinet
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France; UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France
| | - Anthony Moussu
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Ludovic Pierson
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Simona Pagliuca
- UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France; Department of Hematology, Regional Competence Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Nancy University Hospital, Vandœuvre-lès-Nancy, France.
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3
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Mingot-Castellano ME, Canaro Hirnyk M, Sánchez-González B, Álvarez-Román MT, Bárez-García A, Bernardo-Gutiérrez Á, Bernat-Pablo S, Bolaños-Calderón E, Butta-Coll N, Caballero-Navarro G, Caparrós-Miranda IS, Entrena-Ureña L, Fernández-Fuertes LF, García-Frade LJ, Gómez del Castillo MDC, González-López TJ, Grande-García C, Guinea de Castro JM, Jarque-Ramos I, Jiménez-Bárcenas R, López-Ansoar E, Martínez-Carballeira D, Martínez-Robles V, Monteagudo-Montesinos E, Páramo-Fernández JA, Perera-Álvarez MDM, Soto-Ortega I, Valcárcel-Ferreiras D, Pascual-Izquierdo C. Recommendations for the Clinical Approach to Immune Thrombocytopenia: Spanish ITP Working Group (GEPTI). J Clin Med 2023; 12:6422. [PMID: 37892566 PMCID: PMC10607106 DOI: 10.3390/jcm12206422] [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: 09/04/2023] [Revised: 09/25/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is a complex autoimmune disease whose hallmark is a deregulation of cellular and humoral immunity leading to increased destruction and reduced production of platelets. The heterogeneity of presentation and clinical course hampers personalized approaches for diagnosis and management. In 2021, the Spanish ITP Group (GEPTI) of the Spanish Society of Hematology and Hemotherapy (SEHH) updated a consensus document that had been launched in 2011. The updated guidelines have been the reference for the diagnosis and management of primary ITP in Spain ever since. Nevertheless, the emergence of new tools and strategies makes it advisable to review them again. For this reason, we have updated the main recommendations appropriately. Our aim is to provide a practical tool to facilitate the integral management of all aspects of primary ITP management.
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Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, 41013 Sevilla, Spain
| | | | | | - María Teresa Álvarez-Román
- Hematology Department, Hospital Universitario La Paz-IdiPAZ, Universidad Autónoma de Madrid, 28046 Madrid, Spain;
| | | | - Ángel Bernardo-Gutiérrez
- Hematology Department, Hospital Central de Asturias, 33011 Oviedo, Spain; (Á.B.-G.); (D.M.-C.); (I.S.-O.)
| | - Silvia Bernat-Pablo
- Hematology Department, Hospital Universitario de la Plana, 12540 Villarreal, Spain;
| | | | - Nora Butta-Coll
- Hematology Department, Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), 28046 Madrid, Spain;
| | | | | | - Laura Entrena-Ureña
- Hematology Department, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain;
| | - Luis Fernando Fernández-Fuertes
- Hematology Department, Complejo Hospitalario Universitario Insular Materno-Infantil, 35016 Las Palmas de Gran Canaria, Spain;
| | - Luis Javier García-Frade
- Hematology Department, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León, 47012 Valladolid, Spain;
| | | | | | | | | | - Isidro Jarque-Ramos
- Hematology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | | | - Elsa López-Ansoar
- Hematology Department, Complejo Hospitalario Universitario de Vigo, 36312 Vigo, Spain;
| | | | | | | | | | - María del Mar Perera-Álvarez
- Hematology Department, Hospital Universitario de Gran Canaria Doctor Negrín, 35010 Las Palmas de Gran Canaria, Spain;
| | - Inmaculada Soto-Ortega
- Hematology Department, Hospital Central de Asturias, 33011 Oviedo, Spain; (Á.B.-G.); (D.M.-C.); (I.S.-O.)
| | - David Valcárcel-Ferreiras
- Hematology Department, Vall d’Hebron Instituto de Oncología (VHIO), Universitat Autònoma de Barcelona, 08035 Barcelona, Spain;
| | - Cristina Pascual-Izquierdo
- Hematology Department, Hospital General Universitario Gregorio Marañón (HGUGM) Madrid, Instituto de Investigación Gregorio Marañón, 28007 Madrid, Spain;
- Spanish Immune Thrombocytopenia Group, 28040 Madrid, Spain
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4
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González-López TJ, Provan D, Bárez A, Bernardo-Gutiérrez A, Bernat S, Martínez-Carballeira D, Jarque-Ramos I, Soto I, Jiménez-Bárcenas R, Fernández-Fuertes F. Primary and secondary immune thrombocytopenia (ITP): Time for a rethink. Blood Rev 2023; 61:101112. [PMID: 37414719 DOI: 10.1016/j.blre.2023.101112] [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: 03/23/2023] [Revised: 06/07/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023]
Abstract
There are not many publications that provide a holistic view of the management of primary and secondary ITP as a whole, reflecting the similarities and differences between the two. Given the lack of major clinical trials, we believe that comprehensive reviews are much needed to guide the diagnosis and treatment of ITP today. Therefore, our review addresses the contemporary diagnosis and treatment of ITP in adult patients. With respect to primary ITP we especially focus on establishing the management of ITP based on the different and successive lines of treatment. Life-threatening situations, "bridge therapy" to surgery or invasive procedures and refractory ITP are also comprehensively reviewed here. Secondary ITP is studied according to its pathogenesis by establishing three major differential groups: Immune Thrombocytopenia due to Central Defects, Immune Thrombocytopenia due to Blocked Differentiation and Immune Thrombocytopenia due to Defective Peripheral Immune Response. Here we provide an up-to-date snapshot of the current diagnosis and treatment of ITP, including a special interest in addressing rare causes of this disease in our daily clinical practice. The target population of this review is adult patients only and the target audience is medical professionals.
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Affiliation(s)
| | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Abelardo Bárez
- Department of Hematology. Complejo Asistencial de Ávila, Ávila, Spain
| | | | - Silvia Bernat
- Department of Hematology, Hospital Universitario de la Plana, Villarreal, Castellón, Spain
| | | | - Isidro Jarque-Ramos
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Inmaculada Soto
- Department of Hematology, Hospital Central de Asturias, Oviedo, Asturias, Spain
| | | | - Fernando Fernández-Fuertes
- Department of Hematology, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
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Spadea M, Saglio F, Ceolin V, Barone M, Zucchetti G, Quarello P, Fagioli F. Immune-mediated cytopenias (IMCs) after HSCT for pediatric non-malignant disorders: epidemiology, risk factors, pathogenesis, and treatment. Eur J Pediatr 2023; 182:2471-2483. [PMID: 36967419 PMCID: PMC10257634 DOI: 10.1007/s00431-023-04912-6] [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: 12/21/2022] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 06/11/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) represents a curative option for pediatric patients affected by malignant and non-malignant disorders. Several complications may arise during the post-transplantation period, including immune-mediated disorders. Immune-mediated cytopenias (IMCs) account for up to 22% of pediatric HSCT complications, representing an important cause of morbidity and mortality post-HSCT. So far, their pathogenesis is not well-understood, and their management may be very challenging. Further, most patients are refractory to first-line treatment which is based on high-dose intravenous steroids, immunoglobulin, and the monoclonal anti-CD20 antibody - rituximab. No clear consensus has been reached for second- and third-line therapeutic options. CONCLUSION We reviewed the epidemiology, risk factors, pathogenesis, and treatment of IMCs, aiming to offer a deeper understanding of these complications as a guide to improving the management of these fragile patients and a cue for the design of tailored clinical trials. WHAT IS KNOWN • IMCs arising in the post-HSCT setting represent a rare but potentially life-threatening complication. Younger patients affected by non-malignant disorders are at the greatest risk of IMCs arising after HSCT. Corticosteroids, intravenous immunoglobulin, and rituximab represent the undiscussed first-line therapeutic approach. WHAT IS NEW • This review highlitghts how children present unique risk factors for post HSCT IMCs, which are the result of the complex relationship between the immaturity of their infantile immune system and all the perturbing agents and factors which characterize the post-HSCT setting. Future efforts are warranted to establish the best option for refractory patients, for whom a standard and validated approach is not currently available. Among new agents, ibrutinib or bortezomib and fostamatinib or low-dose IL-2 could represent a good therapeutic option for patients with graft-versus-host disease and hemolytic anemia or graft-versus-host disease and thrombocytopenia, respectively.
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Affiliation(s)
- Manuela Spadea
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
- University of Torino, Turin, Italy
| | - Francesco Saglio
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - Valeria Ceolin
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
- Erasmus University MC-Sophia Childrens Hospital, Rotterdam, Netherlands
| | - Marta Barone
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - Giulia Zucchetti
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - Paola Quarello
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy.
- University of Torino, Turin, Italy.
| | - Franca Fagioli
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
- University of Torino, Turin, Italy
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Yuan J, Liang ZY, Dong YJ, Ren HY. Autoimmune Hemolytic Anemia After Cord Blood Transplantation: A Retrospective Single-Center Experience. J Inflamm Res 2023; 16:1-6. [PMID: 36627884 PMCID: PMC9826633 DOI: 10.2147/jir.s395375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/21/2022] [Indexed: 01/05/2023] Open
Abstract
Objective To describe the incidence, possible risk factors, and treatment options of autoimmune hemolytic anemia (AIHA) occurring after cord blood transplantation (CBT). Methods We retrospectively analyzed the patients who underwent CBT at Peking University First Hospital between January 2004 and July 2022. Results We totally identified thirty-six patients who received CBT. Median age was 27.5 years (range, 1.6-52). With a median 6 (range 0.6-10.0) years survivor follow-up, six patients developed AIHA (2 Evans syndrome included) at a median of 168 (range, 122-264) days post-CBT for 8% cumulative incidence density 3 years. Its mortality was 50% and mainly associated with concomitant infections (CMV reactivation rate nearly 100%). The possible risk factors for developing AIHA are CMV reactivation, GvHD and HLA mismatch. Conclusion AIHA is a clinically significant common complication in recipients post-CBT. Corticosteroids combined with intravenous immunoglobulin (IvIg) is recommended for the treatment of warm antibody AIHA after CBT.
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Affiliation(s)
- Jing Yuan
- Department of Hematology, The Second Hospital of Hebei Medical University, Shijiazhuang, People’s Republic of China
| | - Ze-Yin Liang
- Department of Hematology, Peking University First Hospital, Beijing, People’s Republic of China,Correspondence: Ze-Yin Liang; Han-Yun Ren, Department of Hematology, Peking University First Hospital, Beijing, People’s Republic of China, Email ;
| | - Yu-Jun Dong
- Department of Hematology, Peking University First Hospital, Beijing, People’s Republic of China
| | - Han-Yun Ren
- Department of Hematology, Peking University First Hospital, Beijing, People’s Republic of China
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Wan C, Hu M, Peng X, Lei N, Ding H, Luo Y, Yu X. Novel multifunctional dexamethasone carbon dots synthesized using the one-pot green method for anti-inflammatory, osteogenesis, and osteoimmunomodulatory in bone regeneration. Biomater Sci 2022; 10:6291-6306. [PMID: 36135326 DOI: 10.1039/d2bm01153k] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Bone tissue regeneration is still a major orthopedic challenge. The process of bone regeneration is often disrupted by inflammation. Elevated levels of reactive oxygen species (ROS) can lead to aggravated inflammation and even hinder tissue repairs. Therefore, inhibiting the inflammatory response during the process of bone regeneration and promoting bone tissue regeneration under inflammatory conditions are the goals that need to be achieved urgently. In this work, dexamethasone carbon dots (DCDs) were developed by a one-pot facile hydrothermal method using citric acid, ammonium fluoride, and a trace amount of dexamethasone. The obtained DCDs exhibited good biocompatibility and could promote the differentiation of rBMSCs under both normal and inflammatory conditions. Owing to the abundant-reducing groups, DCDs could also scavenge ROS (˙OH) and retain the pharmacological activity of dexamethasone, thereby reducing the inflammatory response. Moreover, DCDs presented a good osteoimmunomodulatory activity to induce a bone immune microenvironment and further promote the differentiation of BMSCs. DCDs could promote macrophage phenotype switching (from M1-type macrophages to M2-type macrophages) under inflammatory conditions, which was beneficial to the anti-inflammatory response. All in all, DCDs could reduce the inflammatory response of bone tissue and accelerate bone regeneration in combination with the regulation of the bone immune. Undoubtedly, it also provided a new idea for developing a novel carbon nanomaterial for repairing bone tissue defects.
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Affiliation(s)
- Chang Wan
- College of Polymer Science and Engineering, Sichuan University, Chengdu 610065, P.R. China.
| | - Mengyue Hu
- College of Polymer Science and Engineering, Sichuan University, Chengdu 610065, P.R. China.
| | - Xu Peng
- College of Polymer Science and Engineering, Sichuan University, Chengdu 610065, P.R. China. .,Experimental and Research Animal Institute, Sichuan University, Chengdu 610065, P.R. China
| | - Ningning Lei
- College of Polymer Science and Engineering, Sichuan University, Chengdu 610065, P.R. China.
| | - Hongmei Ding
- College of Polymer Science and Engineering, Sichuan University, Chengdu 610065, P.R. China.
| | - Yihao Luo
- College of Polymer Science and Engineering, Sichuan University, Chengdu 610065, P.R. China.
| | - Xixun Yu
- College of Polymer Science and Engineering, Sichuan University, Chengdu 610065, P.R. China.
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8
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Faraci M, Dell'Orso G, Giardino S, Pierri F. Autoimmune diseases after allogeneic stem cell transplantation: a clinician's guide and future outlook. Expert Rev Clin Immunol 2022; 18:1-14. [PMID: 35500169 DOI: 10.1080/1744666x.2022.2072299] [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: 03/11/2022] [Accepted: 04/27/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Autoimmune disease (AD) may occur after allogeneic hematopoietic stem cell transplantation (HSCT). The autoimmune mechanism seems to be related to an imbalance of the immune regulation effect of T-regulatory lymphocytes on autoreactive T-lymphocytes. AREAS COVERED ADs include hematological ADs (HADs) and nonhematologic ADs (NHADs) involving organs such as thyroid, peripheral and central nervous system, skin, liver, connective tissue, gastrointestinal tract, and kidney. To identify the risk factors for ADs, to report their clinical characteristics, and to discuss new approaches represent the areas covered in this review. EXPERT OPINION Some risk factors for HAD and NHAD are common and include nonmalignant diseases, young age, cord blood as a stem cell source, conditioning regimens without total body irradiation, alemtuzumab, antithymocyte globulin, T-cell-depleted transplant, some viral infection, mixed chimerism, and chronic Graft versus Host Disease. In NHADs, the detection of autoantibodies is more frequent and the transfer of autoimmunity from the donor to the recipient represents the pathogenetic mechanism responsible for these complications. New therapeutic approaches such as bortezomib, daratumumab, sirolimus, eculizumab, and eltrombopag appear to be promising in terms of better efficacy and reduced toxicity compared to traditional therapies. New horizons based on personalized therapies will allow us to improve the prognosis of AD.
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Affiliation(s)
- Maura Faraci
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy
| | - Gianluca Dell'Orso
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy
| | - Stefano Giardino
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy
| | - Filomena Pierri
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy
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9
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Zama D, Pancaldi L, Baccelli F, Guida F, Gottardi F, Dentale N, Esposito F, Masetti R, Viale P, Pession A. Autoimmune hemolytic anemia in children with COVID-19. Pediatr Blood Cancer 2022; 69:e29330. [PMID: 34490986 PMCID: PMC8661945 DOI: 10.1002/pbc.29330] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/05/2021] [Accepted: 08/23/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Daniele Zama
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli,” Pediatric Unit, IRCCSAzienda Ospedaliero‐Universitaria di Bologna, Alma Mater Studiorum, University of BolognaBolognaItaly
| | - Livia Pancaldi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, IRCCSAzienda Ospedaliero‐Universitaria di Bologna, Alma Mater Studiorum, University of BolognaBolognaItaly
| | - Francesco Baccelli
- Specialty School of Pediatrics, Alma Mater StudiorumUniversity of Bologna, IRCCS, Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Fiorentina Guida
- Specialty School of Pediatrics, Alma Mater StudiorumUniversity of Bologna, IRCCS, Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Francesca Gottardi
- Specialty School of Pediatrics, Alma Mater StudiorumUniversity of Bologna, IRCCS, Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Nicola Dentale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, IRCCSAzienda Ospedaliero‐Universitaria di Bologna, Alma Mater Studiorum, University of BolognaBolognaItaly
| | - Fabio Esposito
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, IRCCSAzienda Ospedaliero‐Universitaria di Bologna, Alma Mater Studiorum, University of BolognaBolognaItaly
| | - Riccardo Masetti
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli,” Pediatric Unit, IRCCSAzienda Ospedaliero‐Universitaria di Bologna, Alma Mater Studiorum, University of BolognaBolognaItaly
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, IRCCSAzienda Ospedaliero‐Universitaria di Bologna, Alma Mater Studiorum, University of BolognaBolognaItaly
| | - Andrea Pession
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli,” Pediatric Unit, IRCCSAzienda Ospedaliero‐Universitaria di Bologna, Alma Mater Studiorum, University of BolognaBolognaItaly
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10
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Michniacki TF, Choi SW, Peltier DC. Immune Suppression in Allogeneic Hematopoietic Stem Cell Transplantation. Handb Exp Pharmacol 2022; 272:209-243. [PMID: 34628553 PMCID: PMC9055779 DOI: 10.1007/164_2021_544] [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] [Indexed: 01/03/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative treatment for high-risk hematologic disorders. There are multiple immune-mediated complications following allo-HSCT that are prevented and/or treated by immunosuppressive agents. Principal among these immune-mediated complications is acute graft-versus-host disease (aGVHD), which occurs when the new donor immune system targets host tissue antigens. The immunobiology of aGVHD is complex and involves all aspects of the immune system. Due to the risk of aGVHD, immunosuppressive aGVHD prophylaxis is required for nearly all allogeneic HSCT recipients. Despite prophylaxis, aGVHD remains a major cause of nonrelapse mortality. Here, we discuss the clinical features of aGVHD, the immunobiology of aGVHD, the immunosuppressive therapies used to prevent and treat aGVHD, how to mitigate the side effects of these immunosuppressive therapies, and what additional immune-mediated post-allo-HSCT complications are also treated with immunosuppression.
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Affiliation(s)
- Thomas F Michniacki
- Division of Hematology/Oncology, Department of Pediatrics, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - Sung Won Choi
- Division of Hematology/Oncology, Department of Pediatrics, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA.
- University of Michigan Rogel Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA.
| | - Daniel C Peltier
- Division of Hematology/Oncology, Department of Pediatrics, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA.
- University of Michigan Rogel Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA.
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Bussel JB, Soff G, Balduzzi A, Cooper N, Lawrence T, Semple JW. A Review of Romiplostim Mechanism of Action and Clinical Applicability. Drug Des Devel Ther 2021; 15:2243-2268. [PMID: 34079225 PMCID: PMC8165097 DOI: 10.2147/dddt.s299591] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Thrombocytopenia results from a variety of conditions, including radiation, chemotherapy, autoimmune disease, bone marrow disorders, pathologic conditions associated with surgical procedures, hematopoietic stem cell transplant (HSCT), and hematologic disorders associated with severe aplastic anemia. Immune thrombocytopenia (ITP) is caused by immune reactions that accelerate destruction and reduce production of platelets. Thrombopoietin (TPO) is a critical component of platelet production pathways, and TPO receptor agonists (TPO-RAs) are important for the management of ITP by increasing platelet production and reducing the need for other treatments. Romiplostim is a TPO-RA approved for use in patients with ITP in the United States, European Union, Australia, and several countries in Africa and Asia, as well as for use in patients with refractory aplastic anemia in Japan and Korea. Romiplostim binds to and activates the TPO receptor on megakaryocyte precursors, thus promoting cell proliferation and viability, resulting in increased platelet production. Through this mechanism, romiplostim reduces the need for other treatments and decreases bleeding events in patients with thrombocytopenia. In addition to its efficacy in ITP, studies have shown that romiplostim is effective in improving platelet counts in various settings, thereby highlighting the versatility of romiplostim. The efficacy of romiplostim in such disorders is currently under investigation. Here, we review the structure, mechanism, pharmacokinetics, and pharmacodynamics of romiplostim. We also summarize the clinical evidence supporting its use in ITP and other disorders that involve thrombocytopenia, including chemotherapy-induced thrombocytopenia, aplastic anemia, acute radiation syndrome, perisurgical thrombocytopenia, post-HSCT thrombocytopenia, and liver disease.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Gerald Soff
- Department of Medicine, Hematology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | | | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
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12
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Galvin RT, Cao Q, Miller WP, Knight-Perry J, Smith AR, Ebens CL. Characterizing Immune-Mediated Cytopenias After Allogeneic Hematopoietic Cell Transplantation for Pediatric Nonmalignant Disorders. Transplant Cell Ther 2021; 27:316.e1-316.e8. [PMID: 33836874 PMCID: PMC8036237 DOI: 10.1016/j.jtct.2021.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 01/12/2021] [Accepted: 01/17/2021] [Indexed: 11/30/2022]
Abstract
Immune-mediated cytopenias (IMC)-isolated or combined hemolytic anemia, thrombocytopenia, or neutropenia-are increasingly recognized as serious complications after allogeneic hematopoietic cell transplantation (HCT) for nonmalignant disorders (NMD). However, IMC incidence, duration, response to therapy, and risk factors are not well defined. This retrospective chart review identified cases of IMC with serologic confirmation among patients who underwent HCT for NMD at a single institution between 2010 and 2017. IMC after HCT for NMD in a large pediatric cohort (n = 271) was common with a cumulative incidence of 18%, identified at a median of 136 days after HCT. Treatment included prolonged immune suppression (>3 months) in 58% of all IMC cases, 91% when multiple cell lines were affected. Multiple therapeutic agents were used for the majority affected, and median time to resolution of IMC was 118 days from diagnosis. Fine-Gray competing risk multivariate regression analysis identified a combined risk factor of younger age (<3 years) and inherited metabolic disorder, as well as hemoglobinopathy (at any age) associated with 1-year incidence of IMC (P < .01). We expand these findings with the observation of declining donor T-lymphoid chimerism from day 60 to 100 and lower absolute CD4+ counts at day 100 (P < .01), before median onset of IMC, for patients with IMC compared to those without. In this cohort, 4 deaths (8%) were associated with IMC, including 2 requiring second transplantation for secondary graft failure. Although the pathogenesis of IMC post-HCT for NMD remains elusive, further research may identify approaches to prevent and better treat this HCT complication.
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Affiliation(s)
- Robert T Galvin
- University of Minnesota, Department of Pediatrics; Minneapolis, MN, USA
| | - Qing Cao
- University of Minnesota, Biostatistics Core at Masonic Cancer Center; Minneapolis, MN, USA
| | | | - Jessica Knight-Perry
- University of Colorado, Department of Pediatric Hematology, Oncology, and Bone Marrow Transplantation; Denver, CO, USA
| | - Angela R Smith
- University of Minnesota, Department of Pediatric Blood and Marrow Transplant; Minneapolis, MN, USA
| | - Christen L Ebens
- University of Minnesota, Department of Pediatric Blood and Marrow Transplant; Minneapolis, MN, USA.
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13
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Immune cytopenia after allogeneic haematopoietic stem-cell transplantation: challenges, approaches, and future directions. LANCET HAEMATOLOGY 2021; 8:e229-e239. [PMID: 33636143 DOI: 10.1016/s2352-3026(20)30404-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/24/2020] [Accepted: 11/30/2020] [Indexed: 12/20/2022]
Abstract
Immune-mediated cytopenia after allogeneic haematopoietic stem-cell transplantation is rare. The pathophysiology of immune-mediated anaemia, thrombocytopenia, and neutropenia, which occur alone or in combination with other cytopenias, is unclear and most probably a consequence of immune dysregulation. Risk factors for this complication have been identified in retrospective studies but these should be interpreted with caution and should not be generalised to this heterogeneous patient population. Diagnosis is challenging, requires awareness of such complications, and has to be differentiated from a multitude of other, and sometimes overlapping, possible complications. The clinical course of immune-mediated cytopenia is highly variable. Treatment requires an interdisciplinary approach and ranges from observation to symptomatic measures and directed therapies. Intensive immunosuppression is associated with an increased risk of infections and relapse, and current treatments are based on approaches in patients who have not undergone transplantation. Plasma cell-directed therapies, immunomodulation, and receptor-stimulating agents can be used to treat immune-mediated cytopenia.
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14
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Oikonomopoulou C, Paisiou A, Komitopoulou A, Ioannidou ED, Kaisari A, Tzannou I, Mpourazani E, Vessalas G, Peristeri I, Kitra-Roussou V, Goussetis E. Increased incidence of autoimmune cytopenias after allogeneic haematopoietic stem cell transplantation using a matched unrelated donor in children with β-thalassaemia. Br J Haematol 2021; 192:e127-e129. [PMID: 33522599 DOI: 10.1111/bjh.17335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
| | - Anna Paisiou
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Anna Komitopoulou
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | | | - Aikaterini Kaisari
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Ifigeneia Tzannou
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Evdoxia Mpourazani
- Pediatric Intensive Care Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - George Vessalas
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Ioulia Peristeri
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | | | - Evgenios Goussetis
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
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15
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Djerrou Z, Chettoum A, Guedri K, Khatabi L, Boudjerda S, Djeffali R. Epidemiological profile, clinical, paraclinical, and evolutionary of adult autoimmune cytopenia cases in East of Algeria. JOURNAL OF APPLIED HEMATOLOGY 2021. [DOI: 10.4103/joah.joah_169_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Michalak SS, Olewicz-Gawlik A, Rupa-Matysek J, Wolny-Rokicka E, Nowakowska E, Gil L. Autoimmune hemolytic anemia: current knowledge and perspectives. Immun Ageing 2020; 17:38. [PMID: 33292368 PMCID: PMC7677104 DOI: 10.1186/s12979-020-00208-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 11/10/2020] [Indexed: 02/07/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is an acquired, heterogeneous group of diseases which includes warm AIHA, cold agglutinin disease (CAD), mixed AIHA, paroxysmal cold hemoglobinuria and atypical AIHA. Currently CAD is defined as a chronic, clonal lymphoproliferative disorder, while the presence of cold agglutinins underlying other diseases is known as cold agglutinin syndrome. AIHA is mediated by autoantibodies directed against red blood cells (RBCs) causing premature erythrocyte destruction. The pathogenesis of AIHA is complex and still not fully understood. Recent studies indicate the involvement of T and B cell dysregulation, reduced CD4+ and CD25+ Tregs, increased clonal expansions of CD8 + T cells, imbalance of Th17/Tregs and Tfh/Tfr, and impaired lymphocyte apoptosis. Changes in some RBC membrane structures, under the influence of mechanical stimuli or oxidative stress, may promote autohemolysis. The clinical presentation and treatment of AIHA are influenced by many factors, including the type of AIHA, degree of hemolysis, underlying diseases, presence of concomitant comorbidities, bone marrow compensatory abilities and the presence of fibrosis and dyserthropoiesis. The main treatment for AIHA is based on the inhibition of autoantibody production by mono- or combination therapy using GKS and/or rituximab and, rarely, immunosuppressive drugs or immunomodulators. Reduction of erythrocyte destruction via splenectomy is currently the third line of treatment for warm AIHA. Supportive treatment including vitamin supplementation, recombinant erythropoietin, thrombosis prophylaxis and the prevention and treatment of infections is essential. New groups of drugs that inhibit immune responses at various levels are being developed intensively, including inhibition of antibody-mediated RBCs phagocytosis, inhibition of B cell and plasma cell frequency and activity, inhibition of IgG recycling, immunomodulation of T lymphocytes function, and complement cascade inhibition. Recent studies have brought about changes in classification and progress in understanding the pathogenesis and treatment of AIHA, although there are still many issues to be resolved, particularly concerning the impact of age-associated changes to immunity.
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Affiliation(s)
- Sylwia Sulimiera Michalak
- Department of Pharmacology and Toxicology Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Zielona Góra, Poland.
| | - Anna Olewicz-Gawlik
- Department of Anatomy and Histology Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Zielona Góra, Poland
- Department of Infectious Diseases, Hepatology and Acquired Immune Deficiencies, Poznan University of Medical Sciences, Poznan, Poland
- Department of Immunology, Poznan University of Medical Sciences, Poznan, Poland
| | - Joanna Rupa-Matysek
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | - Edyta Wolny-Rokicka
- Department of Radiotherapy, Multidisciplinary Hospital, Gorzów Wielkopolski, Poland
| | - Elżbieta Nowakowska
- Department of Pharmacology and Toxicology Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Zielona Góra, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
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Wada F, Nishikori M, Hishizawa M, Watanabe M, Aiba A, Kitano T, Shimazu Y, Shindo T, Kondo T, Takaori-Kondo A. Secondary failure of platelet recovery in patients treated with high-dose thiotepa and busulfan followed by autologous stem cell transplantation. Int J Hematol 2020; 112:609-613. [PMID: 32980953 DOI: 10.1007/s12185-020-03007-4] [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: 08/05/2020] [Revised: 09/01/2020] [Accepted: 09/13/2020] [Indexed: 12/18/2022]
Abstract
Autologous stem cell transplantation (ASCT) with high-dose thiotepa and busulfan is a treatment option for patients with central nervous system (CNS) lymphoma. We report here the occurrence of secondary failure of platelet recovery (SFPR) in three out of 24 patients who received high-dose thiotepa and busulfan followed by ASCT. Although there was no obvious abnormality in the primary platelet engraftment as well as the recovery of other blood cells, they developed SFPR with a median time to onset of day 38, and the platelets gradually recovered over several months with steroid therapy. During the same period, there was no development of SFPR among 50 patients who received ASCT with a conditioning regimen of MEAM (ranimustine, etoposide, cytarabine, and melphalan) or high-dose melphalan. However, one of the two patients who received a conditioning regimen of busulfan and melphalan developed SFPR, suggesting that the use of a busulfan-based conditioning regimen may be one of the risk factors for SFPR. It is important to be aware of this possible adverse effect of ASCT with high-dose thiotepa and busulfan to ensure timely diagnosis and prevention of subsequent serious complications.
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Affiliation(s)
- Fumiya Wada
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Momoko Nishikori
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Masakatsu Hishizawa
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Mitsumasa Watanabe
- Department of Hematology, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Akiko Aiba
- Department of Hematology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Toshiyuki Kitano
- Department of Hematology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Yayoi Shimazu
- Department of Hematology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Takero Shindo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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