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Jain A, Jandial A, Mani T, Kishore K, Singh C, Lad D, Prakash G, Khadwal A, Das R, Varma N, Varma S, Malhotra P. Comparable outcomes with low-dose and standard-dose horse anti-thymocyte globulin in the treatment of severe aplastic anemia. Blood Res 2024; 59:6. [PMID: 38485832 PMCID: PMC10903521 DOI: 10.1007/s44313-024-00003-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/10/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND The standard dose (SD) of horse anti-thymocyte globulin (hATG) ATGAM (Pfizer, USA) or its biosimilar thymogam (Bharat Serum, India) for the treatment of Aplastic Anemia (AA) is 40 mg/kg/day for 4 days in combination with cyclosporine. Data on the impact of hATG dose on long-term outcomes are limited. Here, we describe our comparative experience using 25 mg/kg/day (low-dose [LD]) hATG for 4 days with SD for the treatment of AA. METHODS We retrospectively studied patients with AA (age > 12 years) who received two doses of hATG combined with cyclosporine. Among 93 AA patients who received hATG, 62 (66.7%) and 31 (33.3%) patients received LD and SD hATG with cyclosporine, respectively. Among these,seventeen(18.2%) patients also received eltrombopag with hATG and cyclosporine. Overall response rates [complete response (CR) and partial response (PR)] of LD and SD hATG groups at 3 months (50% vs. 48.4%; p = 0.88), 6 months (63.8% vs. 71.4%; p = 0.67), and 12 months (69.6% vs. 79.2%; p = 0.167) were comparable. The mean (Standard Deviation) 5-year Kaplan-Meier estimate of overall survival and event-free survival was 82.1 (4.6)% and 70.9 (5.5)% for the study population. The mean (standard deviation) 5-year Kaplan-Meier estimate of overall survival and event-free survival of those who received LD hATG versus SD hATG dose was 82.9 (5·3)% versus 74.8 (10·3)% (P = 0·439), and 75.2 (6.2)% versus 61.4(11.2)% (P = 0·441). CONCLUSION Our study revealed that the response rates of patients with AA and LD were similar to those of patients with SD to hATG combined with cyclosporine in a real-world setting.
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Affiliation(s)
- Arihant Jain
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Aditya Jandial
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Thenmozhi Mani
- Department of Biostatistics, CMC, Vellore, Hematology, India
| | - Kamal Kishore
- Department of Biostatistics, PGIMER, Chandigarh, India
| | - Charanpreet Singh
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Deepesh Lad
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Gaurav Prakash
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Alka Khadwal
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Reena Das
- Department of Hematology, PGIMER, Chandigarh, India
| | - Neelam Varma
- Department of Hematology, PGIMER, Chandigarh, India
| | | | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India.
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Dolai TK, Jain M, Mahapatra M. Idiopathic Aplastic anemia: Indian Perspective. Indian J Hematol Blood Transfus 2023; 39:357-370. [PMID: 37304471 PMCID: PMC10247658 DOI: 10.1007/s12288-022-01592-4] [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: 07/11/2022] [Accepted: 09/26/2022] [Indexed: 06/13/2023] Open
Abstract
Aplastic anemia (AA) is a rare immunologically mediated bone marrow failure syndrome, characterized by progressive loss of hematopoietic stem cells resulting in peripheral pancytopenia. Elaborative investigation including molecular tests is required to exclude inherited bone marrow failure syndrome (IMBFS) as the treatment and prognosis vary dramatically between them. Haematopoietic stem cell transplant with a fully matched sibling donor (MSD-HSCT) is still the only curative treatment. Management of AA is a real-time challenge in India, because of the delay in the diagnosis, lack of proper supportive care, limited availability of the expertise centre, and the patient's affordability. Recently, results with intensified immunosuppressive therapy that includes anti-thymocyte globulin with cyclosporine-A (CsA) and eltrombopag, are enough encouraging to consider it as treatment of choice in patients lacking MSD or who are not fit for HSCT. However, limitations in resource constraints settings including the cost of therapy limit its full utilization. Relapse of the disease or evolution to myelodysplasia or paroxysmal nocturnal haemoglobinuria (PNH) in a proportion of patients is another challenge with immunosuppressants. The majority of the AA patients still receive CsA with or without androgens in India, mostly because of increased cost and limited availability of HSCT and ATG. The use of the unrelated or alternative donor is still upcoming in India, with unavailable data in terms of response and survival. Therefore, there is an utmost need for novel agents for the better management of AA having a balanced efficacy and toxicity profile to improve the survival and quality of life.
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Affiliation(s)
- Tuphan Kanti Dolai
- Department of Haematology, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| | - Manisha Jain
- Department of Medical oncology and Haematology, Medanta Medcity, India
| | - Manoranjan Mahapatra
- Department of Haematology, All India Institute of Medical science, New Delhi, India
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Huang J, Huang L, Liu S, Lin S, Cheng Y, Jiang X, Xue H, Li C, Chen C. Clinical Outcome of Acquired Post-Immunosuppressive-Therapy Aplastic Anemia in Pediatric Patients: A 13-Year Experience in Two Southern China Tertiary Care Centers. Int J Gen Med 2021; 14:3133-3144. [PMID: 34239322 PMCID: PMC8259937 DOI: 10.2147/ijgm.s313898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/14/2021] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of the present study is to evaluate the efficacy, complications, and contributing factors of immunosuppressive therapy (IST) response in children with acquired aplastic anemia (AA) and to explore optimal therapeutic methods for different clinical AA types. Methods A total of 130 children diagnosed with acquired AA underwent IST in the Department of Pediatrics at Sun Yat-sen Memorial Hospital and the Department of Pediatrics at Seventh Affiliated Hospital, Sun Yat-sen University, between January 1, 2006, and July 15, 2020. The overall survival (OS), response rates, complications, and response predictors were analyzed. The response rates were compared according to clinical AA type. Results All 130 children with AA were followed up with for a median of 50.6 months. Among the patients, 25 had non-severe AA (NSAA), 64 had severe AA (SAA), and 41 had very severe AA (VSAA). All patients initially received IST. In 13 patients, the IST failed; these patients received an allo-hematopoietic stem cell transplant as a salvage regimen. The OS rate was 90.3% ± 2.8%, and the response rates at 3, 6, 9, and 12 months were 34.19%, 39.32%, 49.57%, and 66.67%, respectively. The prolonged follow-up period might have led to higher response rates, especially in patients with SAA and VSAA. A multivariate logistic regression analysis of prognostic factors was conducted; the results showed that high red blood cell (RBC) and platelet (PLT) counts were associated with a high overall response rate and that the RBC count at diagnosis is a major contributing factor. Conclusion With the use of rabbit anti-thymocyte globulin, proper cyclosporine management, and a prolonged IST follow-up period, a higher number of patients with acquired AA than normal achieved response. Proportionally, the number of patients who achieved remission within 12 months was higher in the SAA group (38.18%→63.64%) and VSAA group (28.95%→65.79%) than in the NSAA group (58.33%→75%). Higher RBC and PLT counts at diagnosis can predict a favorable outcome.
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Affiliation(s)
- Junbin Huang
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, People's Republic of China
| | - Lifen Huang
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, People's Republic of China
| | - Su Liu
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Shaofen Lin
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Yucai Cheng
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, People's Republic of China
| | - Xiaoyun Jiang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 518000, People's Republic of China
| | - Hongman Xue
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, People's Republic of China
| | - Chikong Li
- Division of Haematology/Oncology/BMT, Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong, 999077, People's Republic of China
| | - Chun Chen
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, People's Republic of China
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Response to Horse ATG (Thymogam, Bharat Serums and Vaccine, India) and Cyclosporine in Aplastic Anemia: A Single Centre, Retrospective Study of 60 Patients from Southern India. Indian J Hematol Blood Transfus 2020; 36:473-476. [PMID: 32647420 DOI: 10.1007/s12288-019-01137-2] [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: 04/08/2019] [Accepted: 05/15/2019] [Indexed: 10/26/2022] Open
Abstract
Immunosuppressive therapy (IST), consisting of anti thymocyte globulin and cyclosporine, is the standard of care for elderly patients and in younger patients without matched donor for stem cell transplant. In this retrospective study of 60 patients, most had non severe AA (51.6%) followed by very severe AA (26.7%) and severe AA (21.7%). The response rate at 6 months was 68.3% (complete response-3.3% and partial response-65%). Of the 45 who completed 12 months follow up, RR was 54.7% (CR-7.5%, PR-47.2 %). Eight patients died during the study period. Also, Indian data on IST is briefly reviewed.
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Liu L, Zhang Y, Jiao W, Zhou H, Wang Q, Jin S, Cai Y, Zhao L, Shangguan X, Liu Z, Xu J, Lei M, Yan X, Miao M, Wu D. Comparison of efficacy and health-related quality of life of first-line haploidentical hematopoietic stem cell transplantation with unrelated cord blood infusion and first-line immunosuppressive therapy for acquired severe aplastic anemia. Leukemia 2020; 34:3359-3369. [PMID: 32591644 DOI: 10.1038/s41375-020-0933-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/06/2020] [Accepted: 06/16/2020] [Indexed: 12/15/2022]
Abstract
We retrospectively compared the efficacy and health-related quality of life (HRQoL) of (1) first-line haploidentical hematopoietic stem cell transplantation (haplo-HSCT, n = 146) combined with unrelated cord blood (UCB) infusion and (2) first-line immunosuppressive therapy (IST, n = 219) in acquired severe aplastic anemia (SAA) patients. At 6 months post treatment, 90.30% patients in the haplo-HSCT group and 18.78% patients in the IST group achieved normal blood routine (P < 0.0001). The time required to discontinue red blood cells and platelets transfusion in the IST group were longer than in the haplo-HSCT group (P < 0.0001). The estimated overall survival at 4 years was similar (80.1 ± 3.5% vs. 80.1 ± 3.0%, P = 0.726); the estimated failure-free survival (FFS) at 4 years was 77.8 ± 3.7% in the haplo-HSCT group and 48.0 ± 3.6% in the IST group (P < 0.0001). Patients treated with haplo-HSCT scored significantly better in the HRQoL than treated with IST (P < 0.0001). In the multivariate analysis, first-line haplo-HSCT was the favorable factor for FFS and HRQoL (P < 0.0001). These results suggest that first-line haplo-HSCT combined with UCB infusion might provide a better chance of success and HRQoL than first-line IST for SAA patients.
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Affiliation(s)
- Limin Liu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, China
| | - Yanming Zhang
- Department of Hematology, The Affiliated Huai'an Hospital of Xuzhou Medical University and The Second People's Hospital of Huai'an, Huai'an, Jiangsu Province, China
| | - Wenjing Jiao
- Department of Hematology, Xian Yang Central Hospital, Xianyang, Shanxi Province, China
| | - Huifen Zhou
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, China
| | - Qingyuan Wang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, China
| | - Song Jin
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, China
| | - Yifeng Cai
- Department of Hematology, The Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Liyun Zhao
- Department of Hematology, People Hospital of Xingtai, Xingtai, Hebei Province, China
| | - Xiaohui Shangguan
- Department of Hematology, Longyan First Hospital Affiliated to Fujian Medical University, Longyan, Fujian Province, China
| | - Zefa Liu
- Department of Hematology, People Hospital of Xinghua, Xinghua, Jiangsu Province, China
| | - Jinge Xu
- The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Meiqing Lei
- Department of Hematology in Haikou Municipal People's Hospital, Affiliated Haikou Hospital Xiangya School of Medicine Central South University, Haikou, Hainan Province, China
| | - Xiaoyun Yan
- Department of Hematology, The Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Miao Miao
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, China.
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, China.
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Gu C, Zhu X, Qiao X, Zhai X, Shi W, Xie X. Multivariate logistic analysis of predictors of response to immunosuppressive therapy in children with aplastic anemia: a double-center study. ACTA ACUST UNITED AC 2020; 24:282-289. [PMID: 31793407 DOI: 10.1080/16078454.2019.1565149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immunosuppressive therapy (IST) composed of antithymocyte globulin (ATG) and cyclosporine A (CSA) is one of the standard therapies in pediatric patients with acquired aplastic anemia (AA), but predictors of IST are lack of consensus. PROCEDURES Ninety-four patients from two pediatric medical centers in China were included between January 2005 and March 2018. Clinical factors associated with the efficacy were analyzed according to multivariate logistic regression model previously established. RESULTS We discovered that overall responsiveness was 77.66%. Five out of 35 factors were statistically significant in univariate analysis. Based on the cutoff point chosen by receiver operating characteristic (ROC) curve, 5 continuous variables were made categorical, among which 3 variables with significance were employed to establish the logistic regression equation. Based on these 3 variables, we found that starting IST within 126 days of the first appearance of symptoms (X1, p = .003), absolute neutrophil count (ANC) higher than 0.435×109/L (X2, p = .012), and rate of decreased actual lymphocyte count (ALC) higher than 59.2% within the 1st week after IST (X3, p = .001) were three independent risk factors for response to IST. The rate of decreased ALC higher than 59.2% after IST was the most significant variable (OR = 9.355, Log (P) = -2.161 + 2.149X1 + 1.662X2 + 2.236X3). The accuracy, sensitivity, and specificity of the model were 86.2%, 94.5% and 57.1%, respectively. CONCLUSION Duration of AA, ANC and decreased ALC rate after IST might predict the response to IST, among which the rate of decreased ALC after IST is the most important predictive factor.
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Affiliation(s)
- Changjuan Gu
- Department of Paediatrics, Tongji Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Xiaohua Zhu
- Department of Haematology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
| | - Xiaohong Qiao
- Department of Paediatrics, Tongji Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Xiaowen Zhai
- Department of Haematology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
| | - Wei Shi
- Department of Paediatrics, Tongji Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Xiaotian Xie
- Department of Paediatrics, Tongji Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
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Jain R, Trehan A, Bansal D, Varma N. Aplastic anemia in children: How good is immunosuppressive therapy? Pediatr Hematol Oncol 2019; 36:211-221. [PMID: 31287349 DOI: 10.1080/08880018.2019.1621970] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aplastic anemia (AA) is an uncommon disorder in children, with hematopoietic stem cell transplant being the 1st line therapy; immunosuppressive therapy (IST) is the alternative therapy and is the most commonly used modality of treatment. There is paucity of data from the developing countries regarding treatment outcome with IST. We aimed to assess the outcome of IST in children with AA. Data for 43 children treated with IST from January 2012 to January 2017 (5 years) were retrieved from clinic records. IST included equine antithymocyte globulin (ATG) along with cyclosporine A. Complete response, partial response and nonresponse was seen in 9 (21%), 14 (32.5%) and 20(46.5%) patients, respectively. The median time to best response in the whole cohort was 19.1 months. However, complete response occurred nearly 2-year post-IST. There was no difference in outcome related to severity of AA, the presence of PNH clone, higher ALC or different available brands of ATG. There was a significantly better rate of response (p value: .03) at 6 months in patients who went on to achieve a CR vs patients who achieved a final PR only. An overall response rate, including partial and complete response, of 53.5% was seen in our cohort with a 3-year OS of 63%. This is not at par to the outcome reported from developed nations. The available brands of ATG were similar in terms of response kinetics as well as survival. A delayed time to complete response with prolonged requirement of cyclosporine therapy was seen in the cohort.
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Affiliation(s)
- Richa Jain
- a Division of Pediatric Hematology & Oncology, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Amita Trehan
- a Division of Pediatric Hematology & Oncology, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Deepak Bansal
- a Division of Pediatric Hematology & Oncology, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education & Research , Chandigarh , India.,b Department of Hematology, Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Neelam Varma
- b Department of Hematology, Postgraduate Institute of Medical Education & Research , Chandigarh , India
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Shah S, Jain P, Shah K, Patel K, Parikh S, Patel A, Panchal H, Anand A. Immunosuppressive therapy for aplastic anemia: a single-center experience from western India. Ann Hematol 2018; 98:41-46. [PMID: 30173288 PMCID: PMC6334724 DOI: 10.1007/s00277-018-3487-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 08/25/2018] [Indexed: 01/15/2023]
Abstract
Immunosuppressive therapy (IST) with antithymocyte globulin (ATG) and cyclosporine A (CsA) is the first-line therapy for acquired aplastic anemia (AA) in those not suitable for bone marrow transplant. Horse ATG (hATG) is preferred for this purpose, but its use is often impeded by shortages and costs. Being a rare disease, there is limited data on this therapy. This study aimed to evaluate this therapy in a large cohort of AA patients from western India. We retrospectively analyzed AA patients who received an indigenous preparation of hATG along with CsA as first-line treatment, between 2012 and 2015, at our center and evaluated the response, survival, and occurrence of adverse events. The response was further assessed separately for adults and children. During the period, 91 AA patients (4 non-severe, 57 severe and 30 very severe) were treated with IST. At 2 years, 23.5% adults and 39.1% children showed complete response and an overall of 68.1% cases became transfusion independent. More than half of the patients developed febrile neutropenia while roughly one sixth of the patients developed gum hypertrophy and/or hypertension. Two patients had clonal evolution. Mortality rate was calculated to be 31%; most common causes of death were infection and intracranial hemorrhage. The results of the study substantiate the effectiveness of IST in AA, using an inexpensive indigenous preparation of hATG along with CsA.
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Affiliation(s)
- Sandip Shah
- Civil Hospital Campus, Gujarat Cancer & Research Institute, Asarwa, Ahmedabad, Gujarat, 380 016, India.
| | - Preetam Jain
- Civil Hospital Campus, Gujarat Cancer & Research Institute, Asarwa, Ahmedabad, Gujarat, 380 016, India
| | - Kamlesh Shah
- Civil Hospital Campus, Gujarat Cancer & Research Institute, Asarwa, Ahmedabad, Gujarat, 380 016, India
| | - Kinnari Patel
- Civil Hospital Campus, Gujarat Cancer & Research Institute, Asarwa, Ahmedabad, Gujarat, 380 016, India
| | - Sonia Parikh
- Civil Hospital Campus, Gujarat Cancer & Research Institute, Asarwa, Ahmedabad, Gujarat, 380 016, India
| | - Apurva Patel
- Civil Hospital Campus, Gujarat Cancer & Research Institute, Asarwa, Ahmedabad, Gujarat, 380 016, India
| | - Harsha Panchal
- Civil Hospital Campus, Gujarat Cancer & Research Institute, Asarwa, Ahmedabad, Gujarat, 380 016, India
| | - Asha Anand
- Civil Hospital Campus, Gujarat Cancer & Research Institute, Asarwa, Ahmedabad, Gujarat, 380 016, India
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Yoshida N, Kobayashi R, Yabe H, Kosaka Y, Yagasaki H, Watanabe KI, Kudo K, Morimoto A, Ohga S, Muramatsu H, Takahashi Y, Kato K, Suzuki R, Ohara A, Kojima S. First-line treatment for severe aplastic anemia in children: bone marrow transplantation from a matched family donor versus immunosuppressive therapy. Haematologica 2014; 99:1784-91. [PMID: 25193958 DOI: 10.3324/haematol.2014.109355] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The current treatment approach for severe aplastic anemia in children is based on studies performed in the 1980s, and updated evidence is required. We retrospectively compared the outcomes of children with acquired severe aplastic anemia who received immunosuppressive therapy within prospective trials conducted by the Japanese Childhood Aplastic Anemia Study Group or who underwent bone marrow transplantation from an HLA-matched family donor registered in the Japanese Society for Hematopoietic Cell Transplantation Registry. Between 1992 and 2009, 599 children (younger than 17 years) with severe aplastic anemia received a bone marrow transplant from an HLA-matched family donor (n=213) or immunosuppressive therapy (n=386) as first-line treatment. While the overall survival did not differ between patients treated with immunosuppressive therapy or bone marrow transplantation [88% (95% confidence interval: 86-90) versus 92% (90-94)], failure-free survival was significantly inferior in patients receiving immunosuppressive therapy than in those undergoing bone marrow transplantation [56% (54-59) versus 87% (85-90); P<0.0001]. There was no significant improvement in outcomes over the two time periods (1992-1999 versus 2000-2009). In multivariate analysis, age <10 years was identified as a favorable factor for overall survival (P=0.007), and choice of first-line immunosuppressive therapy was the only unfavorable factor for failure-free survival (P<0.0001). These support the current algorithm for treatment decisions, which recommends bone marrow transplantation when an HLA-matched family donor is available in pediatric severe aplastic anemia.
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Affiliation(s)
- Nao Yoshida
- Department of Hematology and Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital, Nagoya
| | | | - Hiromasa Yabe
- Department of Cell Transplantation and Regenerative Medicine, Tokai University School of Medicine, Isehara
| | | | - Hiroshi Yagasaki
- Department of Pediatrics, Nihon University School of Medicine, Tokyo
| | | | - Kazuko Kudo
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake
| | - Akira Morimoto
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke
| | - Shouichi Ohga
- Department of Perinatal and Pediatric Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka
| | - Hideki Muramatsu
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Tokyo, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Tokyo, Japan
| | - Koji Kato
- Department of Hematology and Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital, Nagoya
| | - Ritsuro Suzuki
- Department of HSCT Data Management & Biostatistics, Nagoya University Graduate School of Medicine, Tokyo, Japan
| | - Akira Ohara
- Department of Pediatrics, Toho University School of Medicine, Tokyo, Japan
| | - Seiji Kojima
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Tokyo, Japan;
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10
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Agarwal MB, Jijina F, Shah S, Malhotra P, Damodar S, Ross C. Safety and efficacy of indigenous equine antithymocyte globulin along with cyclosporine in subjects with acquired aplastic anemia. Indian J Hematol Blood Transfus 2014; 31:174-9. [PMID: 25825555 DOI: 10.1007/s12288-014-0423-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 06/10/2014] [Indexed: 11/25/2022] Open
Abstract
To confirm the safety and efficacy of an indigenous equine antithymocyte globulin (eATG) along with cyclosporine in Indian subjects with acquired aplastic anaemia. Subjects >2 years old with acquired aplastic anaemia were enrolled at six hospitals between April 2011 and February 2013, after approval from respective Ethics Committees. Equine ATG at a dose of 40 mg/kg/day was infused for 4 days. Efficacy analysis defined a priori, was in subjects, who had completed eATG treatment and followed-up on day 90 and/or 180. Complete response (CR) was defined as-transfusion independent, haemoglobin ≥11 g/dL, absolute neutrophil count (ANC) >1.5 10(9)/L and platelet ≥150 10(9)/L; partial response (PR) was transfusion independent, haemoglobin ≥8 g/dL, ANC >0.5 10(9)/L and platelet ≥20 10(9)/L; non responders were transfusion dependent. Lymphocyte subsets (CD 2, 3, 4 and 8) in the blood were tested on days 0 (pre eATG infusion), 3, 5, 7, 14 and 21 after eATG. Of the 30 subjects (two children <12 years old) enrolled, 19 completed day 90 and 18 completed day 180 visit. Of the remaining 11 subjects, two died on days 12 and 45 due to septicaemia and pneumonia, one was withdrawn after the first dose of eATG due to jaundice and eight were lost to follow-up. The median age was 30 (9-58) years and weight was 57 (26-84) kg. On day 90, 12 of 30 subjects responded (CR 1, PR 11) and 15 of 30 (CR 2, PR 13) on day 180. The most common adverse event was fever related to eATG infusion. There were two serious adverse events (acute renal failure, febrile neutropenia) and both recovered with treatment. There were no unusual adverse events noted during the study period. Blood T lymphocytes showed a mean decrease of 91 % from baseline that recovered by day 21. We conclude that eATG is safe and in combination with cyclosporine showed overall response in 50 % of enrolled subjects. The trial was registered with the clinical trial registry-india (Registration no. CTRI/2012/03/002498).
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Affiliation(s)
- M B Agarwal
- Hematology Centre, Ghamat Lodge, 2nd Floor, Above ING Vaishya Bank, 804 A, Dr. B. Ambedkar Road, Dadar TT, Mumbai, India
| | - Farah Jijina
- Department of Haematology, Seth GS Medical College & KEM Hospital, Ernest Borges Road, Parel, Mumbai, India
| | - Sandip Shah
- Hemato-Oncology Clinic, Vedanta Institute of Medical Sciences, 1st Floor, Stadium Commerce College Road, Navrangpura, Ahmedabad, India
| | - Pankaj Malhotra
- Clinical Hematology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, India
| | - Sharat Damodar
- Narayana Hrudayalaya, 258/A, Bommasandra Industrial Area, Anekal Taluk, Bangalore, India
| | - Cecil Ross
- Department of Haematology, St. John's Medical College, Sarjapur Road, Bangalore, India
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Ramzan M, Yadav SP, Zafar MSH, Dinand V, Sachdeva A. Outcome of pediatric acquired aplastic anemia: a developing world experience. Pediatr Hematol Oncol 2014; 31:29-38. [PMID: 23802844 DOI: 10.3109/08880018.2013.807898] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Outcome data of children with acquired aplastic anemia (AA) are lacking from the developing world. Here, we describe the same from a centre in North India. METHODS Retrospective data regarding medical history, physical examination, complete blood count, bone marrow aspirate, and biopsy were retrieved for all children <18 years, with acquired AA admitted between January 2005 and June 2012. In addition, the outcome data after immunosuppressive therapy (IST) or bone marrow transplant (BMT) was obtained. RESULTS A total of 61 children were diagnosed with AA (Inherited-18 and acquired-43). Among 43 children with acquired AA, 3 had nonsevere and 40 had severe. One patient with nonsevere AA died of sepsis and 2 recovered spontaneously. Of the 40 remaining children with severe AA, 10 refused therapy and 3 died due to severe sepsis prior to any therapy. Five underwent upfront matched sibling donor BMT and one post-IST failure. Four year overall survival (OS) and event free survival (EFS) for children undergoing BMT was 100% and 80 ± 17.9, respectively. Out of 22 treated with IST, 20 were evaluable for response. Seventeen received one course and 3 received two course of IST. The overall response to IST was seen in 14/20 (70%). Only two achieved complete response while remaining 12 had partial response. The 4-year estimated OS and EFS for children treated with IST was 74.4 ± 12.1% and 65.6 ± 12.2. CONCLUSION Outcomes for children with AA are encouraging in the developing world although barriers like sepsis and treatment abandonment remain. BMT offers faster and complete recovery.
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Affiliation(s)
- Mohammed Ramzan
- Pediatric Hematology Oncology & BMT Unit, Department of Pediatrics, Sir Ganga Ram Hospital , New Delhi , India
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Good outcome with ATG in aplastic anemia: welcome news, though thought-provoking! Indian Pediatr 2012; 49:839-40. [PMID: 23144107 DOI: 10.1007/s13312-012-0171-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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