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Abdalhadi A, Omar NE, Kohla S, Aakel H, Ekeibed Y, Mohsen R. Aplastic anemia secondary to adjuvant Osimertinib therapy: a case report and a review of literature. Front Oncol 2024; 14:1275275. [PMID: 38454933 PMCID: PMC10917982 DOI: 10.3389/fonc.2024.1275275] [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: 08/09/2023] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
Aplastic anemia is a rare hematological disorder characterized by suppressed hematopoiesis and pancytopenia. Although several drugs have been associated with aplastic anemia, its occurrence in response to Osimertinib, a third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), is extremely rare. We present a case report of a 63-year-old patient with locally advanced non-small cell lung cancer (NSCLC) who developed aplastic anemia following adjuvant treatment with Osimertinib. Extensive investigations ruled out infectious etiology, and the absence of bone marrow involvement or other identifiable causes suggested a drug-induced etiology, specifically Osimertinib. This case report emphasizes the importance of recognizing this adverse event and considering it as a potential complication of Osimertinib therapy. Vigilant monitoring and prompt management are essential for optimizing patient outcomes. Further studies are needed to better understand the risk factors, underlying mechanisms, and management strategies for Osimertinib-induced aplastic anemia in the adjuvant settings.
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Affiliation(s)
- Ahmed Abdalhadi
- Medical Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Nabil E. Omar
- Pharmacy Department, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
- Health Sciences Program, Clinical and Population Health Research, College of Pharmacy, Qatar University, Doha, Qatar
| | - Samah Kohla
- Lab Medicine and Pathology, Hematopathology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
- Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Hassan Aakel
- Medical Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Yeslem Ekeibed
- Clinical Hematology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Reyad Mohsen
- Medical Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
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Youssef MAM, Ghazaly MH, Abdelfattah MA. Alternative treatment modality for severe aplastic anemia in a resource-limited setting: a single-institution prospective cohort study from Upper Egypt. Ann Hematol 2023; 102:2997-3006. [PMID: 37704874 PMCID: PMC10567959 DOI: 10.1007/s00277-023-05440-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/03/2023] [Indexed: 09/15/2023]
Abstract
This study compared the efficacy and safety of CsA monotherapy with eltrombopag (E-PAG) + CsA combined treatment in children with severe aplastic anemia (SAA). The study including 30 children had SAA. Ten were a retrospective cohort treated with CsA monotherapy. The other 20 were prospective cohort received E-PAG + CsA. All patients were evaluated for partial (PR) and complete (CR) hematological response at 3, 6, and 12 months. overall response (OR), overall survival rates (OS), and treatment safety. OR for the E-PAG patients was 40% after 3 months of therapy. At 6 months, this had increased to 75% with significantly higher CR rate (40%) than in the CsA group (p = 0.0001). After a year of treatment, the CR for the E-PAG + CsA regimen had increased to 50% and the OR to 85%, compared to 20% in the CsA group (p = 0.0001). The OS at 12 months was 100% in the E-PAG+ CsA group compared to 80% in the CsA cohort. At 24 months, the OS in the E-PAG + CsA group was 90%. In conclusion, E-PAG+ CsA was found to be a safe and effective alternative treatment for children with SAA particularly in countries with limited resources.
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Affiliation(s)
- Mervat A M Youssef
- Children Hospital, Hematology Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohammed H Ghazaly
- Children Hospital, Hematology Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mai A Abdelfattah
- Children Hospital, Hematology Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
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Nassani M, Fakih RE, Passweg J, Cesaro S, Alzahrani H, Alahmari A, Bonfim C, Iftikhar R, Albeihany A, Halkes C, Ahmed SO, Dufour C, Aljurf M. The role of androgen therapy in acquired aplastic anemia and other bone marrow failure syndromes. Front Oncol 2023; 13:1135160. [PMID: 37223686 PMCID: PMC10200973 DOI: 10.3389/fonc.2023.1135160] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/06/2023] [Indexed: 05/25/2023] Open
Abstract
Bone marrow failure syndromes are a heterogeneous group of diseases. With the major advancements in diagnostic tools and sequencing techniques, these diseases may be better classified and therapies may be further tailored. Androgens, a historic group of drugs, were found to stimulate hematopoiesis by enhancing the responsiveness of progenitors. These agents have been used for decades to treat different forms of bone marrow failure. With the availability of more effective pathways to treat BMF, androgens are less used currently. Nevertheless, this group of drugs may serve BMF patients where standard therapy is contraindicated or not available. In this article, we review the published literature addressing the use of androgens in BMF patients and we make recommendations on how to best use this class of drugs within the current therapeutic landscape.
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Affiliation(s)
- Momen Nassani
- Department of Hematology, Stem Cell Transplant & Cellular Therapy, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Riad El Fakih
- Department of Hematology, Stem Cell Transplant & Cellular Therapy, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Jakob Passweg
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Hazzaa Alzahrani
- Department of Hematology, Stem Cell Transplant & Cellular Therapy, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ali Alahmari
- Department of Hematology, Stem Cell Transplant & Cellular Therapy, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Carmem Bonfim
- Transplantation Unit, Department of Hematology, Hospital de Clinicas, Federal University of Parana, Curitiba, Brazil
| | - Raheel Iftikhar
- Department of Hematology, Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan
| | - Amal Albeihany
- Department of Hematology, Stem Cell Transplant & Cellular Therapy, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Constantijn Halkes
- Department of Hematology, Leiden University Medical Center, Leiden, Netherlands
| | - Syed Osman Ahmed
- Department of Hematology, Stem Cell Transplant & Cellular Therapy, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Carlo Dufour
- Hematology Unit, Hemato.Oncology Department, IRCCS, G. Gaslini Children Research Institute, Genova, Italy
| | - Mahmoud Aljurf
- Department of Hematology, Stem Cell Transplant & Cellular Therapy, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Akçay A, Atay D, Erbey F, Akıncı B, Demir Yenigürbüz F, Eyüboğlu F, Ovalı E, Öztürk G. Safety and Efficacy of Co-transplantation of Hematopoietic Stem Cells Combined With Human Umbilical Cord-Derived Mesenchymal Stem Cells in Children With Severe Aplastic Anemia: A Single-Center Experience. EXP CLIN TRANSPLANT 2022; 20:1114-1121. [PMID: 34142939 DOI: 10.6002/ect.2021.0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The mostimportant problems thatlimitthe effectiveness of allogeneic hematopoietic stem cell transplantation in patients with severe aplastic anemia are graft failure and graft-versus-host disease. Mesenchymal stem cells can support normal hematopoiesis and prevent graft-versus-host disease. We aimed to analyze the effects of combined transplant of human umbilical cord-derived mesenchymal stem cells and matched donor allogeneic hematopoietic stem cells in children with severe aplastic anemia. MATERIALS AND METHODS We retrospectively examined 15 pediatric patients with severe aplastic anemia who received fludarabine-based reduced intensity conditioning regimen and intravenously infused human umbilical cord-derived mesenchymal stem cells at a dose of 1 × 106/kg recipient body weight within 12 to 18 hours before hematopoietic stem cells infusion. We evaluated the engraftment rate, the frequency and severity of graft-versus-host disease, and the overall survival rate. RESULTS No patients had adverse events related to intravenously human umbilical cord-derived mesenchymal stem cells infusion. All patients achieved successful engraftment and sustained donor chimerism. The median time for neutrophil and platelet engraftment was 14 and 25 days,respectively. The frequency was 20% for grade III/IV acute graftversus- host disease and 15.3% for chronic graftversus-host disease. Patients were followed-up for a median of 33 months (range, 2-89 months). The 5-year overall survival rate was 80%. CONCLUSIONS Combined transplant of matched donor hematopoietic stem cells with human umbilical cord-derived mesenchymal stem cells is safe in pediatric patients with severe aplastic anemia. The achievement of engraftment in all of our patients and the acceptable frequency of acute and chronic graft-versus-host disease and survival rate are encouraging.
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Affiliation(s)
- Arzu Akçay
- From the Pediatric Hematology and Oncology/Bone Marrow Transplantation Unit, Department of Pediatrics, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
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Liu L, Miao M, He H, Wang S, Zhang Y, Guo A, Jiao W, Lei M, Cai Y, Shangguan X, Liu Z, Xu J, Li X, Zhang L, Wu D. Severe aplastic anemia patients with infection who received an allogeneic hematopoietic stem cell transplantation had a better chance: Long-term outcomes of a multicenter study. Front Immunol 2022; 13:955095. [PMID: 36131940 PMCID: PMC9483095 DOI: 10.3389/fimmu.2022.955095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background and aimsHow to select the treatment is a challenge for the management of acquired patients with infections. This study aimed at comparing the outcomes of SAA with infections who had an allogeneic hematopoietic stem cell transplantation (allo-HSCT)with that of patients who had an infection and received non-HSCT therapy.MethodsWe retrospectively compared the outcomes of patients with acquired SAA and infections who had an allo-HSCT (n = 141) with that of patients who had an infection and received non-HSCT therapy (n = 186) between July 2004 and January 2020.ResultsThe treatment-related mortality (TRM) of grade 1-2 infections in the HSCT and non-HSCT groups was 24.99% and 13.68%, respectively (P = 0.206), while the TRM of grade 3-4 infections was lower in the HSCT group than that observed in the non-HSCT group (18.54% vs. 33.33%, P = 0.036). At 6 months post-treatment, 91.30% patients in the HSCT group and 8.78% patients in the non-HSCT group had achieved a normal blood profile (P < 0.0001). The time required to discontinue transfusions of red blood cells and platelets in the non-HSCT group was longer than in the HSCT group (P < 0.0001). Estimated overall survival (OS) at 6 years was similar in the two groups (75.5% ± 3.9% vs. 76.3% ± 3.1%, P = 0.996), while the estimated failure-free survival (FFS) at 6 years was 75.2% ± 3.8% in the HSCT group and 48.9% ± 3.7% in the non-HSCT group (P < 0.0001). Multivariate analysis showed that younger age, lower grade of infection (grade 1-2), and SAA (vs. very SAA) were favorable factors for OS (P < 0.05), and that the choice of HSCT and younger age were favorable factors for FFS (P < 0.0001).ConclusionThese results suggest that allo-HSCT has a better chance of a successful outcome than non-HSCT in SAA patients with an infection.
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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, Suzhou, China
- *Correspondence: Limin Liu, ; Liansheng Zhang, ; Depei Wu,
| | - Miao Miao
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hailong He
- Department of Hematology, Children’s Hospital of Soochow University, Suzhou, China
| | - Shunqing Wang
- Department of Hematology, Guangzhou First People’s Hospital, Guangzhou Medical University, Guangzhou, 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, China
| | - Ailian Guo
- Department of Hematology, Children’s Hospital of Soochow University, Suzhou, China
| | - Wenjing Jiao
- Department of Hematology, Xian Yang Central Hospital, Xianyang, China
| | - Meiqing Lei
- Department of Hematology in Haikou Municipal People’s Hospital, Affiliated Haikou Hospital, Haikou, China
| | - Yifeng Cai
- Department of Hematology, The Affiliated Hospital of Nantong University, Nantong, China
| | - Xiaohui Shangguan
- Department of Hematology, Longyan First Hospital, Affiliated to Fujian Medical University, Longyan, China
| | - Zefa Liu
- Department of Hematology, People Hospital of Xinghua, Xinghua, China
| | - Jinge Xu
- Department of Hematology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xiaoli Li
- Department of Hematology, Soochow Hopes Hematonosis Hospital, Suzhou, China
| | - Liansheng Zhang
- Department of Hematology, The Second Hospital of Lanzhou University, Lanzhou, China
- *Correspondence: Limin Liu, ; Liansheng Zhang, ; Depei Wu,
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- *Correspondence: Limin Liu, ; Liansheng Zhang, ; Depei Wu,
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Haploidentical BMT for severe aplastic anemia with intensive GVHD prophylaxis including posttransplant cyclophosphamide. Blood Adv 2021; 4:1770-1779. [PMID: 32343796 DOI: 10.1182/bloodadvances.2020001729] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/25/2020] [Indexed: 12/15/2022] Open
Abstract
Severe aplastic anemia (SAA) is a stem cell disorder often treated with bone marrow transplantation (BMT) to reconstitute hematopoiesis. Outcomes of related HLA-haploidentical (haplo) donors after reduced-intensity conditioning with intensive graft-versus-host disease (GVHD) prophylaxis including posttransplantation cyclophosphamide are presented here from 37 SAA, 20 relapsed/refractory (R/R), and 17 treatment-naïve (TN) SAA patients. Median follow-up is 32 months (90% confidence interval [CI], 29-44). The median age was 25 (range, 4-69) years. The median time to neutrophil recovery was 17 days (range, 15-88). Four of 37 patients (11%) experienced graft failure (GF). There was 1 primary GF of 20 patients in the R/R group and 3 of 17 in the TN group at 200 cGy (1 primary, 2 secondary), but none in the 10 patients who received 400 cGy total body irradiation. Two patients with GF succumbed to infection and 2 were rescued with second haplo BMT. The overall survival for all patients is 94% (90% CI, 88-100) at 1 and 2 years. The cumulative incidence of grade II-IV acute GVHD at day 100 is 11%. The cumulative index of chronic GVHD at 2 years is 8%. Similar results were seen in 10 SAA patients who received the identical nonmyeloablative regimen with posttransplant cyclophosphamide but matched donor transplants. Haplo BMT with posttransplant cyclophosphamide represents a potential cure in SAA, with all 20 R/R currently alive, disease-free, and with no evidence of active GVHD. Extending this approach to TN patients was associated with higher GF rates, but an increase in total body irradiation dose to 400 cGy was associated with durable engraftment without greater early toxicity. Nonmyeloablative haplo BMT in TN SAA could lead to a paradigm shift, such that essentially all patients can proceed quickly to safe, curative BMT. These trials were registered at www.cincialtrials.gov as #NCT02224872) and #NCT02833805.
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Lan Y, Liu F, Chang L, Liu L, Zhang Y, Yi M, Cai Y, Feng J, Han Z, Han Z, Zhu X. Combination of umbilical cord mesenchymal stem cells and standard immunosuppressive regimen for pediatric patients with severe aplastic anemia. BMC Pediatr 2021; 21:102. [PMID: 33639900 PMCID: PMC7912947 DOI: 10.1186/s12887-021-02562-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 02/19/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Defects of bone marrow mesenchymal stem cells (BM-MSCs) in proliferation and differentiation are involved in the pathophysiology of aplastic anemia (AA). Infusion of umbilical cord mesenchymal stem cells (UC-MSCs) may improve the efficacy of immunosuppressive therapy (IST) in childhood severe aplastic anemia (SAA). METHODS We conducted an investigator-initiated, open-label, and prospective phase IV trial to evaluate the safety and efficacy of combination of allogenic UC-MSCs and standard IST for pediatric patients with newly diagnosed SAA. In mesenchymal stem cells (MSC) group, UC-MSCs were injected intravenously at a dose of 1 × 106/kg per week starting on the 14th day after administration of rabbit antithymocyte globulin (ATG), for a total of 3 weeks. The clinical outcomes and adverse events of patients with UC-MSCs infusion were assessed when compared with a concurrent control group in which patients received standard IST alone. RESULTS Nine patients with a median age of 4 years were enrolled as the group with MSC, while the data of another 9 childhood SAA were analysed as the controls. Four (44%) patients in MSC group developed anaphylactic reactions which were associated with rabbit ATG. When compared with the controls, neither the improvement of blood cell counts, nor the change of T-lymphocytes after IST reached statistical significance in MSC group (both p > 0.05) and there were one (11%) patient in MSC group and two (22%) patients in the controls achieved partial response (PR) at 90 days after IST. After a median follow-up of 48 months, there was no clone evolution occurring in both groups. The 4-year estimated overall survival (OS) rate in two groups were both 88.9% ± 10.5%, while the 4-year estimated failure-free survival (FFS) rate in MSC group was lower than that in the controls (38.1% ± 17.2% vs. 66.7% ± 15.7%, p = 0.153). CONCLUSIONS Concomitant use of IST and UC-MSCs in SAA children is safe but may not necessarily improve the early response rate and long-term outcomes. This clinical trial was registered at ClinicalTrials.gov, identifier: NCT02218437 (registered October 2013).
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Affiliation(s)
- Yang Lan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
| | - Fang Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
| | - Lixian Chang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
| | - Lipeng Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
| | - Yingchi Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
| | - Meihui Yi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
| | - Yuli Cai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
| | - Jing Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
| | - Zhibo Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China.,National Engineering Research Center of Cell Products, Tianjin AmCellGene Engineering Co., Ltd, Tianjin, 300020, China
| | - Zhongchao Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China.,National Engineering Research Center of Cell Products, Tianjin AmCellGene Engineering Co., Ltd, Tianjin, 300020, China
| | - Xiaofan Zhu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China.
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Cotoraci C, Ciceu A, Sasu A, Hermenean A. Natural Antioxidants in Anemia Treatment. Int J Mol Sci 2021; 22:ijms22041883. [PMID: 33668657 PMCID: PMC7918704 DOI: 10.3390/ijms22041883] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/07/2021] [Accepted: 02/11/2021] [Indexed: 01/03/2023] Open
Abstract
Anemia, characterized by a decrease of the hemoglobin level in the blood and a reduction in carrying capacity of oxygen, is a major public health problem which affects people of all ages. The methods used to treat anemia are blood transfusion and oral administration of iron-based supplements, but these treatments are associated with a number of side effects, such as nausea, vomiting, constipation, and stomach pain, which limit its long-term use. In addition, oral iron supplements are poorly absorbed in the intestinal tract, due to overexpression of hepcidin, a peptide hormone that plays a central role in iron homeostasis. In this review, we conducted an analysis of the literature on biologically active compounds and plant extracts used in the treatment of various types of anemia. The purpose of this review is to provide up-to-date information on the use of these compounds and plant extracts, in order to explore their therapeutic potential. The advantage of using them is that they are available from natural resources and can be used as main, alternative, or adjuvant therapies in many diseases, such as various types of anemia.
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Affiliation(s)
- Coralia Cotoraci
- Department of Hematology, Faculty of Medicine, Vasile Goldis Western University of Arad, Rebreanu 86, 310414 Arad, Romania;
- Correspondence:
| | - Alina Ciceu
- “Aurel Ardelean” Institute of Life Sciences, Vasile Godis Western University of Arad, Rebreanu 86, 310414 Arad, Romania; (A.C.); (A.H.)
| | - Alciona Sasu
- Department of Hematology, Faculty of Medicine, Vasile Goldis Western University of Arad, Rebreanu 86, 310414 Arad, Romania;
| | - Anca Hermenean
- “Aurel Ardelean” Institute of Life Sciences, Vasile Godis Western University of Arad, Rebreanu 86, 310414 Arad, Romania; (A.C.); (A.H.)
- Department of Histology, Faculty of Medicine, Vasile Goldis Western University of Arad, Rebreanu 86, 310414 Arad, Romania
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Iftikhar R, Chaudhry QUN, Mahmood SK, Ghafoor T, Satti HS, Shahbaz N, Khan MA, Khattak TA, Shamshad GU, Rehman J, Farhan M, Humayun S, Risalat A, Wahab A, Satti TM, Anwer F, Ahmed P. Single-Agent Cyclosporine for Graft-versus-Host Disease Prophylaxis in Patients with Acquired Aplastic Anemia Receiving Fludarabine-Based Conditioning. Biol Blood Marrow Transplant 2020; 26:2245-2251. [PMID: 32717437 DOI: 10.1016/j.bbmt.2020.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 11/20/2022]
Abstract
Cyclosporine (CsA) combined with short-course methotrexate is considered standard-of-care graft-versus-host disease (GVHD) prophylaxis for patients with severe aplastic anemia (AA) who undergo transplantation using cyclophosphamide (Cy) plus anti-thymocyte globulin (ATG) conditioning. However, there is no consensus on optimal post-transplant GVHD prophylaxis for patients undergoing matched related donor (MRD) transplantation using fludarabine (Flu)-based conditioning. We conducted a single-center retrospective analysis of patients with acquired AA (n = 106) undergoing MRD transplantation from July 2007 through January 2019. All patients received Flu-Cy-ATG conditioning and single-agent CsA as GVHD prophylaxis. Median age of the study cohort was 20 years (range, 3 to 52) and male to female ratio was 3.8:1. Median time from diagnosis to transplant was 11.5 months (range, 2.8 to 62). Graft source was bone marrow harvest in 71 (68%), combined bone marrow and peripheral blood stem cells in 34 (31%), and peripheral blood alone in 1 (1%) patient. Cumulative incidence of neutrophil engraftment at day 28 was 93.4% (95% confidence interval [CI], 87.3% to 97.1%) while that of platelet engraftment at day 100 was 90.5% (95% CI, 84% to 96%). Cumulative incidence of primary graft failure at day 28 was 6.6% (95% CI, 4% to 8%) while secondary graft failure occurred at a median of 190 days (range, 90 to 415) at a cumulative incidence of 3.7% (95% CI, 2% to 5%). Cumulative incidence of grade II to IV acute GVHD at day 100 was 3.8% (95% CI, 1.4% to 9.9%), while a 1-year probability of chronic GVHD was calculated as 7.5% (95% CI, 2.6% to 15%). Median follow-up post-transplant was 61 months (range, 6 to 144). Overall survival was 84.9%, disease-free survival was 80.2%, and GVHD-free relapse-free survival was 76.3%. This study indicates that single-agent cyclosporine is a feasible option for GVHD prophylaxis in MRD hematopoietic stem cell transplantation using Flu-Cy-ATG conditioning and is associated with very low rates of acute and chronic GVHD.
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Affiliation(s)
- Raheel Iftikhar
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan.
| | - Qamar Un Nisa Chaudhry
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Syed Kamran Mahmood
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Tariq Ghafoor
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Humayun Shafique Satti
- Department of Molecular Hematology, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Nighat Shahbaz
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Mehreen Ali Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Tariq Azam Khattak
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Ghassan Umair Shamshad
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Jahanzeb Rehman
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Muhammad Farhan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Saima Humayun
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Amina Risalat
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Ahsan Wahab
- Baptist Medical Center South, Montgomery, Alabama
| | | | - Faiz Anwer
- Department of Hematology, Medical Oncology, Tausig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Parvez Ahmed
- Department of Hematology Oncology and Stem Cell Transplant, Quaid-e-Azam International Hospital, Islamabad, Pakistan
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10
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Dang BN, De Oliveira S, Gray A, Bowles L, Moore TB. Successful engraftment of haploidentical bone marrow with post-transplantation cyclophosphamide in patients with aplastic anemia. Pediatr Transplant 2020; 24:e13652. [PMID: 31944531 DOI: 10.1111/petr.13652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 08/09/2019] [Accepted: 12/17/2019] [Indexed: 12/01/2022]
Abstract
Patients with severe aplastic anemia (SAA) may benefit from hematopoietic stem cell transplantation, but many of them lack a matched donor. Haploidentical transplantation is increasingly utilized for the treatment of nonmalignant disease where patients lack a matched donor. We report patients with aplastic anemia who experienced successful engraftments of haploidentical stem cells with post-transplantation cyclophosphamide (PTCy). Case series and review of the literature. We present two cases of pediatric patients with severe aplastic anemia who experienced successful engraftment of haploidentical related bone marrow. Both patients received conditioning consisting of rabbit ATG, cyclophosphamide, fludarabine, and total body irradiation pretransplant, with PTCy. The conditioning regimen was well tolerated by both patients, and they achieved full donor engraftment and were weaned off all immunosuppressants. Haploidentical stem cell transplantation in patients with severe aplastic anemia may be an effective alternative when fully matched donors are not available. PTCy can facilitate successful engraftment and therefore expand the pool of eligible donors for patients with aplastic anemia.
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Affiliation(s)
| | | | - Ashley Gray
- UCLA David Geffen School of Medicine, Los Angeles, California
| | - LaVette Bowles
- UCLA David Geffen School of Medicine, Los Angeles, California
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11
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Bastola S, Kc O, Khanal S, Halalau A. Hepatitis-associated aplastic anemia from workout supplement: Rare but potentially fatal entity. SAGE Open Med Case Rep 2020; 8:2050313X20901937. [PMID: 32030129 PMCID: PMC6977214 DOI: 10.1177/2050313x20901937] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 12/31/2019] [Indexed: 02/06/2023] Open
Abstract
Hepatitis-associated aplastic anemia (HAAA) is a rare clinical syndrome characterized by bone marrow failure 1–3 months after development of hepatitis. Untreated, hepatitis-associated aplastic anemia has poor outcome and the mainstay of treatment remains either bone marrow transplant or immunosuppressive therapy. A previously healthy 21-year-old man presented with a 1-week history of right upper quadrant pain and jaundice. Admission labs revealed mixed hyperbilirubinemia and elevated transaminases ranging in 2000s IU/dl. Extensive workup for etiologies of acute hepatitis including viruses, autoimmune, toxins etc. were negative. He admitted to taking “Dust V2,” a workout supplement, for 4 months prior to the presentation. His liver function tests started to improve after conservative treatment. Two months after his discharge, he was found to have severe pancytopenia on routine labs. Bone marrow biopsy revealed hypocellular marrow consistent with aplastic anemia. Extensive workup for etiologies of aplastic anemia were negative. On literature review, none of the components of the supplement were found to cause aplastic anemia. A diagnosis of hepatitis-associated aplastic anemia was made as there was a lag time before development of anemia. His counts failed to improve despite treatment with filgrastim and he was referred for hematopoietic cell transplant.
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Affiliation(s)
- Sanjog Bastola
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Ojbindra Kc
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Sumesh Khanal
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Alexandra Halalau
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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12
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Sanz J, Moscardó F, Montoro J, Cano I, Guerreiro M, Dasí MA, Solves P, Lorenzo I, Gómez-Segui I, Montesinos P, Mora E, Arnao M, Sempere A, Jarque I, Carretero C, Senent L, Vicente A, Andreu R, Luna I, Balaguer-Roselló A, Carpio N, Sanz GF, Sanz MA, Piñana JL. Partial T Cell-Depleted Peripheral Blood Stem Cell Transplantation from HLA-Identical Sibling Donors for Patients with Severe Aplastic Anemia. Biol Blood Marrow Transplant 2019; 26:83-87. [PMID: 31493538 DOI: 10.1016/j.bbmt.2019.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/28/2019] [Accepted: 08/28/2019] [Indexed: 10/26/2022]
Abstract
We analyzed the outcomes of 26 consecutive patients with acquired severe aplastic anemia (SAA) undergoing peripheral blood stem cell transplantation (PBSCT) with partial ex vivo T cell depletion with a targeted T cell dose from HLA-identical sibling donors. The median patient age was 37 years (range, 3 to 63 years). Four patients with uncontrolled pneumonia at the time of transplantation died, on days +1, +2, +21, and +26. All evaluable patients engrafted, with a median time to neutrophil recovery of 11 days (range, 10 to 14 days) and a median time to platelet recovery of 19 days (range, 8 to 53 days). Two patients had transient grade I acute graft-versus-host disease (GVHD) with skin involvement, but no patients developed grade II-IV acute GVHD. Two patients had mild skin chronic GVHD, and 1 patient had moderate chronic GVHD with ocular involvement. No relapse was observed after a median follow-up of 114 months (range, 4 to 233 months). The overall cumulative incidence of TRM at 10 years was 19%, whereas it was 5% for those with a Karnofsky Performance Status (KPS) score >60 at the time of transplantation. Disease-free survival, overall survival, and GVHD and relapse-free survival at 10 years were 81%, 81%, and 80%, respectively, for all patients and 95%, 95%, and 90%, respectively, for patients with a KPS score >60 at transplantation. Our data indicate that PBSCT with partial ex vivo T cell-depleted targeted cell dose grafts from an HLA-identical sibling donor is a feasible, safe, and effective approach to reduce GVHD and cure patients with SAA.
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Affiliation(s)
- Jaime Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigacion Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain; Faculty of Medicine, University of Valencia, Valencia, Spain.
| | - Federico Moscardó
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Juan Montoro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Isabel Cano
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Manuel Guerreiro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - María A Dasí
- Hematology Unit, Department of Pediatrics, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pilar Solves
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigacion Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain
| | - Ignacio Lorenzo
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigacion Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain
| | - Inés Gómez-Segui
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigacion Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain
| | - Pau Montesinos
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigacion Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain
| | - Elvira Mora
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Mario Arnao
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Amparo Sempere
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigacion Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain
| | - Isidro Jarque
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigacion Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain
| | - Carlos Carretero
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Leonor Senent
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigacion Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain
| | - Ana Vicente
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Rafael Andreu
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Irene Luna
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - Nelly Carpio
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Guillermo F Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigacion Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain; Faculty of Medicine, University of Valencia, Valencia, Spain
| | - Miguel A Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigacion Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain; Faculty of Medicine, University of Valencia, Valencia, Spain
| | - José L Piñana
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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13
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Lee JW, Lee SE, Jung CW, Park S, Keta H, Park SK, Kim JA, Oh IH, Jang JH. Romiplostim in patients with refractory aplastic anaemia previously treated with immunosuppressive therapy: a dose-finding and long-term treatment phase 2 trial. LANCET HAEMATOLOGY 2019; 6:e562-e572. [PMID: 31474546 DOI: 10.1016/s2352-3026(19)30153-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 06/15/2019] [Accepted: 06/18/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Aplastic anaemia is a rare, life-threatening condition, characterised by pancytopenia with hypocellular bone marrow. Haematopoietic stem cells and most progenitor cells express thrombopoietin receptor (c-MPL). Romiplostim is a peptibody with c-MPL agonist activity that stimulates endogenous thrombopoietin production and leads to promoting the proliferation and differentiation of megakaryocytes in the bone marrow. In this phase 2 trial we aimed to assess the activity and safety of romiplostim in patients with aplastic anaemia who were previously treated with immunosuppressive therapy. METHODS We did an open-label, phase 2 study including a randomised, parallel, dose-finding part followed by an extension part to evaluate long-term treatment at two clinical centres in Seoul, South Korea. Eligible patients were aged 19 years or older, and had aplastic anaemia confirmed by bone marrow and cytogenetic studies and thrombocytopenia (platelet count ≤30 × 109/L), an Eastern Cooperative Oncology Group performance status score of 2 or lower, and were previously treated with immunosuppressive therapy, including at least one course of antithymocyte globulin plus cyclosporin. In the dose-finding part, patients were randomly assigned to fixed dose cohorts (1, 3, 6, or 10 μg/kg) of subcutaneous romiplostim once weekly for 8 weeks, according to a static allocation procedure after stratification by platelet count. In the extension part of the study, patients continued romiplostim titrated every 4 weeks in single steps (1, 3, 6, 10, 13, 16, and 20 μg/kg once weekly), depending on platelet response and safety up to 1 year (weeks 9-52). Patients who had a platelet response during weeks 46-53 continued dose titration in single steps (3, 6, 10, 13, 16, and 20 μg/kg once weekly) for an additional 2 years (weeks 53-156). The primary endpoint was the proportion of patients achieving a platelet response at week 9 (after completion of the dose-finding part). Activity was assessed per-protocol in all patients evaluable for response at week 9 and safety was assessed in all patients who received at least one dose of romiplostim. This trial is registered with ClinicalTrials.gov, NCT02094417. FINDINGS Between April 14 and Nov 24, 2014, 35 patients were enrolled and randomly assigned to one of four dose cohorts: romiplostim 1 μg/kg (n=7), 3 μg/kg (n=9), 6 μg/kg (n=9), and 10 μg/kg (n=10). Data cutoff for this final analysis was on April 14, 2018. The median duration of treatment for all patients was 53 weeks (IQR 35-155). Ten (30%) of 33 evaluable patients achieved a platelet response at week 9, including seven (70%) of ten patients in the 10 μg/kg cohort, three (33%) of nine patients in the 6 μg/kg cohort, and no patients in both the 3 μg/kg and 1 μg/kg cohorts. During the extension study, 18 (55%) of 33 evaluable patients had a platelet response during weeks 46-53 and were eligible for continued treatment. Ten (30%) patients maintained a platelet response at 2 and 3 years, of whom nine had an erythroid response and five a neutrophil response, and completed protocol treatment. Treatment-related adverse events occurred in three (9%) of 35 patients, including grade 1 or 2 myalgia, fatigue, and dizziness. 17 (49%) of 35 patients had adverse events of grade 3 or higher; seven (20%) had serious adverse events (one event of febrile neutropenia, cataract, retinal detachment, macular fibrosis, inguinal hernia, appendicitis, cellulitis, tendon injury, and transfusion reaction); and one patient died from sepsis during treatment; none of these events were related to treatment. No patients developed clonal evolution. INTERPRETATION Romiplostim seems to be active and has a favourable safety profile in patients with refractory aplastic anaemia. 10 μg/kg once weekly might be used as a recommended starting dose in future studies. These findings warrant further investigation. FUNDING Kyowa Hakko Kirin Korea.
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Affiliation(s)
- Jong Wook Lee
- Division of Hematology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Sung-Eun Lee
- Division of Hematology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Chul Won Jung
- Division of Hematology-Oncology, Samsung Medical Center, Sunghyunkwan University School of Medicine, Seoul, South Korea
| | - Silvia Park
- Division of Hematology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | | | | | - Jin-A Kim
- Catholic High-Performance Cell Therapy Center, Catholic University of Korea, Seoul, South Korea
| | - Il-Hoan Oh
- Catholic High-Performance Cell Therapy Center, Catholic University of Korea, Seoul, South Korea
| | - Jun Ho Jang
- Division of Hematology-Oncology, Samsung Medical Center, Sunghyunkwan University School of Medicine, Seoul, South Korea.
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14
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Hossain MJ, Xie S. Patient features and survival of pediatric aplastic anemia in the USA: a large institution experience. J Public Health (Oxf) 2019; 41:329-337. [PMID: 29901745 DOI: 10.1093/pubmed/fdy104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 05/24/2018] [Accepted: 05/29/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We performed the first epidemiologic investigation to examine association of demographics and clinical characteristics at diagnosis, as well as health care expense coverage, with survival of US children with aplastic anemia (AA). METHODS We obtained electronic medical record data of 1140 children aged 0-19 years diagnosed with AA followed at a pediatric health system between 2004 and 2014. Kaplan-Meier curve and Cox proportional hazards regressions were used. RESULTS Self-pay patients had a mortality risk five times higher than that of those insured by publicly funded insurance (hazards ratio, 95% CI: 6.0, 3.7-9.8). Other features associated with higher mortality risk include pancytopenia (hazards ratio, referent: 4.2, constitutional AA); underweight (2.0, normal-weight); platelet count <50 × 109/l (1.3, ≥50 × 109/l); male sex (1.3, female); and ages at diagnosis 6-11, 11-16 and 16-19 years (1.6, 1.9, 2.3, 1-3 years), respectively. CONCLUSIONS Self-pay was the strongest prognostic factor for pediatric AA mortality. Older age, pancytopenia, underweight, male sex and lower platelet count were also associated with increased risk of mortality. These findings may be useful for providers, researchers and policymakers to ensure effective health care delivery to this population and to motivate future etiologic research and establishment of a surveillance registry.
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Affiliation(s)
- M J Hossain
- Nemours/A. I. DuPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE, USA.,Department of Applied Economics and Statistics, University of Delaware, Newark, DE, USA
| | - S Xie
- Nemours/A. I. DuPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE, USA
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15
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DeZern AE, Brodsky RA. Haploidentical Donor Bone Marrow Transplantation for Severe Aplastic Anemia. Hematol Oncol Clin North Am 2018; 32:629-642. [PMID: 30047416 PMCID: PMC6063510 DOI: 10.1016/j.hoc.2018.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hematopoietic stem cell transplantation (bone marrow transplantation [BMT]) is the only curative treatment of severe aplastic anemia. BMT from an human leukocyte antigen (HLA)-matched sibling donor is the standard of care for young patients; immunosuppressive therapy is used for older patients or those lacking matched sibling donors. Patients with refractory or relapsed disease are increasingly treated with HLA haploidentical BMT. Historically, haploidentical BMT led to high rates of graft rejection and graft-versus-host disease. High-dose post transplant cyclophosphamide, which mitigates the risk of graft-versus-host disease, is a major advance. This article provides an overview of the haploidentical BMT approach in severe aplastic anemia.
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Affiliation(s)
- Amy E DeZern
- Division of Hematologic Malignancies, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD 21287-0013, USA.
| | - Robert A Brodsky
- Division of Hematology, The Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 1025, Baltimore, MD 21205, USA
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16
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DeZern AE, Zahurak M, Symons H, Cooke K, Jones RJ, Brodsky RA. Alternative Donor Transplantation with High-Dose Post-Transplantation Cyclophosphamide for Refractory Severe Aplastic Anemia. Biol Blood Marrow Transplant 2017; 23:498-504. [PMID: 28013015 PMCID: PMC5373094 DOI: 10.1016/j.bbmt.2016.12.628] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/19/2016] [Indexed: 10/20/2022]
Abstract
Severe aplastic anemia (SAA) is a life-threatening hematopoietic stem cell disorder that is treated with bone marrow transplantation (BMT) or immunosuppressive therapy (IST). The management of patients with refractory SAA after IST is a major challenge. Alternative donor BMT is the best chance for cure in refractory SAA, but morbidity and mortality from graft failure and complications of graft-versus-host disease (GVHD) have limited enthusiasm for this approach. Here, we employed post-transplantation high-dose cyclophosphamide in an effort to safely expand the donor pool in 16 consecutive patients with refractory SAA who did not have a matched sibling donor. Between July 2011 and August 2016, 16 patients underwent allogeneic (allo) BMT for refractory SAA from 13 haploidentical donors and 3 unrelated donors. The nonmyeloablative conditioning regimen consisted of antithymocyte globulin, fludarabine, low-dose cyclophosphamide, and total body irradiation. Post-transplantation cyclophosphamide 50 mg/kg/day i.v. on days +3 and +4 was administered for GVHD prophylaxis. Additionally, patients received mycophenolate mofetil on days +5 through 35 and tacrolimus from day +5 through 1 year. The median age of the patients at the time of transplantation was 30 (range, 11 to 69) years. The median time to neutrophil recovery over 1000 × 103/mm3 for 3 consecutive days was 19 (range, 16 to 27) days, to red cell engraftment was 25 (range, 2 to 58) days, and to last platelet transfusion to keep platelets counts over 50 × 103/mm3 was 27.5 (range, 22 to 108) days. Graft failure, primary or secondary, was not seen in any of the patients. All 16 patients are alive, transfusion independent, and without evidence of clonality. The median follow-up is 21 (range, 3 to 64) months. Two patients had grade 1 or 2 skin-only acute GVHD. These same 2 also had mild chronic GVHD of the skin/mouth requiring systemic steroids. One of these GVHD patients was able to come off all IST by 15 months and the other by 17 months. All other patients stopped IST at 1 year. Nonmyeloablative alloBMT using post-transplantation cyclophosphamide allowed for safe expansion of the donor pool to include HLA-haploidentical donors. This approach appears promising in refractory SAA patients. Importantly, engraftment was 100%, pre-existing clonal disease was eradicated, and the risk of GVHD was low.
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Affiliation(s)
- Amy E DeZern
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Department of Medicine, Division of Hematology, Johns Hopkins University, Baltimore, Maryland.
| | - Marianna Zahurak
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Department of Oncology Biostatistics, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Heather Symons
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Kenneth Cooke
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Richard J Jones
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Department of Medicine, Division of Hematology, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Brodsky
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Department of Medicine, Division of Hematology, Johns Hopkins University, Baltimore, Maryland
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17
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18
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Ghavamzadeh A, Alimoghaddam K, Jalili M, Mousavi SA, Bahar B, Kasaeian A, Hamidieh AA, Behfar M, Vaezi M, Jalali A, Jahani M. Peripheral blood versus bone marrow transplant in patients with aplastic anemia, an unresolved issue. Bone Marrow Transplant 2016; 51:1628-1630. [PMID: 27668763 DOI: 10.1038/bmt.2016.235] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- A Ghavamzadeh
- Hematology-Oncology and Stem Cell Transplantation Research Center/Tehran University of Medical Sciences, Tehran, Iran
| | - K Alimoghaddam
- Hematology-Oncology and Stem Cell Transplantation Research Center/Tehran University of Medical Sciences, Tehran, Iran
| | - M Jalili
- Hematology-Oncology and Stem Cell Transplantation Research Center/Tehran University of Medical Sciences, Tehran, Iran
| | - S A Mousavi
- Hematology-Oncology and Stem Cell Transplantation Research Center/Tehran University of Medical Sciences, Tehran, Iran
| | - B Bahar
- Hematology-Oncology and Stem Cell Transplantation Research Center/Tehran University of Medical Sciences, Tehran, Iran
| | - A Kasaeian
- Hematology-Oncology and Stem Cell Transplantation Research Center/Tehran University of Medical Sciences, Tehran, Iran.,Non-communicable Diseases Research Center, Endocrinology & Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - A A Hamidieh
- Hematology-Oncology and Stem Cell Transplantation Research Center/Tehran University of Medical Sciences, Tehran, Iran
| | - M Behfar
- Hematology-Oncology and Stem Cell Transplantation Research Center/Tehran University of Medical Sciences, Tehran, Iran
| | - M Vaezi
- Hematology-Oncology and Stem Cell Transplantation Research Center/Tehran University of Medical Sciences, Tehran, Iran
| | - A Jalali
- Tehran University of Medical Sciences, Tehran, Iran
| | - M Jahani
- Hematology-Oncology and Stem Cell Transplantation Research Center/Tehran University of Medical Sciences, Tehran, Iran
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19
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Gadalla SM, Wang T, Dagnall C, Haagenson M, Spellman SR, Hicks B, Jones K, Katki HA, Lee SJ, Savage SA. Effect of Recipient Age and Stem Cell Source on the Association between Donor Telomere Length and Survival after Allogeneic Unrelated Hematopoietic Cell Transplantation for Severe Aplastic Anemia. Biol Blood Marrow Transplant 2016; 22:2276-2282. [PMID: 27641680 DOI: 10.1016/j.bbmt.2016.09.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 09/07/2016] [Indexed: 11/26/2022]
Abstract
We previously showed an association between donor leukocyte relative telomere length (RTL) and post-hematopoietic cell transplantation (HCT) survival in patients with severe aplastic anemia (SAA) who received bone marrow grafts at ages <40 years. Here, we tested the generalizability of the prior findings in an independent validation cohort and by recipient age and stem cell source in the combined discovery and validation cohorts. We used monoplex quantitative real-time PCR to measure RTL in: (1) a new SAA validation cohort of 428 patients (age range, .2 to 77 years) with available pretransplantation donor blood samples in the Center for International Blood and Marrow Transplant Research repository, and (2) 278 patients from the original cohort who had sufficient DNA to repeat RTL testing. We used Cox proportional hazard models to calculate hazard ratios (HRs), and 95% confidence intervals (CIs) across categories of donor RTL. Data from the validation cohort showed no association between donor RTL and patient survival, but further analysis identified differences by recipient age and stem cell source as the likely explanation. In patients <40 years, the HR comparing longest with shortest and middle RTL tertiles = .75; 95% CI, .44 to 1.30 versus HR = 1.05; 95% CI, .59 to 1.89 for patients ≥40 years, P interaction = .37. In bone marrow recipients, the HR = .68; 95% CI, .72 to 1.10 versus HR = 1.29; 95% CI, .64 to 2.62 for peripheral blood stem cell grafts; P interaction = .88. Analyses using data from the 2 cohorts showed a statistically significant survival benefit only in <40-year-old patients receiving bone marrow graft (HR comparing longest and middle RTL tertiles with shortest = .69; 95% CI, .50 to .95, P = .02). The study suggested that the association between donor RTL and post-HCT outcomes in recipients with SAA may vary by recipient age and stem cell source. A larger study is needed to account for multiple comparisons and to further test the generalizability of our findings.
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Affiliation(s)
- Shahinaz M Gadalla
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland.
| | - Tao Wang
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Casey Dagnall
- Cancer Genomics Research Laboratory, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland; Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, Maryland
| | - Michael Haagenson
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Belynda Hicks
- Cancer Genomics Research Laboratory, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland; Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, Maryland
| | - Kristine Jones
- Cancer Genomics Research Laboratory, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland; Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, Maryland
| | - Hormuzd A Katki
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Stephanie J Lee
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Sharon A Savage
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
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Chuncharunee S, Wong R, Rojnuckarin P, Chang CS, Chang KM, Lu MY, Hwang WL, Koh LP, Chen TY, Leung AY, Norasetthada L, Wang SC, Chang MC, Wu KH, Issaragrisil S. Efficacy of rabbit antithymocyte globulin as first-line treatment of severe aplastic anemia: an Asian multicenter retrospective study. Int J Hematol 2016; 104:454-61. [PMID: 27376944 DOI: 10.1007/s12185-016-2053-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/23/2016] [Accepted: 06/23/2016] [Indexed: 02/01/2023]
Abstract
Due to the unavailability of horse antithymocyte globulin (ATG) in many markets worldwide, patients with severe aplastic anemia (SAA) are limited to the use of rabbit ATG. We aimed to analyze hematologic response and overall survival (OS) of Asian patients treated with rabbit ATG as first-line therapy of SAA. We retrospectively reviewed the medical records of 97 consecutive patients who received rabbit ATG as first-line treatment of SAA from 2006 to 2012 at centers in four Asian countries. The primary endpoint was 6- and 12-month overall response rates (ORR) for patients receiving rabbit ATG within the recommended dose range (2.5-3.75 mg/kg/day). Secondary endpoints included ORR in patients receiving any dose of rabbit ATG and 2-year OS. For patients who received rabbit ATG within the recommended dose range, 6- and 12-month ORRs were 17.4 and 63.6 %, respectively. For patients who received any dose of rabbit ATG, 6- and 12-month ORRs were 24.3 and 68.6 %, respectively. The 2-year OS rate was 86.3 %. Rabbit ATG is effective for treatment of SAA in Asian patients. The 12-month ORR and 2-year OS with rabbit ATG were comparable to historical results obtained with horse ATG.
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Affiliation(s)
| | - Raymond Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital and Sir Y. K. Pao Centre for Cancer, The Chinese University of Hong Kong, Hong Kong, China
| | - Ponlapat Rojnuckarin
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | | | - Meng-Yao Lu
- National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Li Hwang
- Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Tsai-Yun Chen
- National Cheng Kung University Hospital, Tainan, Taiwan
| | | | | | | | | | - Kang-Hsi Wu
- China Medical University Hospital, Taichung, Taiwan
| | - Surapol Issaragrisil
- Division of Hematology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Bangkok, 10700, Thailand.
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Kim BJ, Moon KP, Yoon JH, Lee EJ, Lee JY, Kim SK, Lee JW, Chung NG, Cho B, Kim HK. Subclinical left ventricular dysfunction in children after hematopoietic stem cell transplantation for severe aplastic anemia: a case control study using speckle tracking echocardiography. KOREAN JOURNAL OF PEDIATRICS 2016; 59:190-5. [PMID: 27186230 PMCID: PMC4865643 DOI: 10.3345/kjp.2016.59.4.190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/28/2015] [Accepted: 11/03/2015] [Indexed: 11/27/2022]
Abstract
Purpose Severe aplastic anemia (SAA), a fatal disease, requires multiple transfusion, immunosuppressive therapy, and finally, hematopoietic stem cell transplantation (HSCT) as the definitive treatment. We hypothesized that iron overloading associated with multiple transfusions and HSCTrelated complications may adversely affect cardiac function. Left ventricular (LV) function was assessed in children after HSCT for SAA. Methods Forty-six consecutive patients with a median age of 9.8 years (range, 1.5-18 years), who received HSCT for SAA and who underwent comprehensive echocardiography before and after HSCT, were included in this study. The data of LV functional parameters obtained using conventional echocardiography, tissue Doppler imaging (TDI), and speckle-tracking echocardiography (STE) were collected from pre- and post-HSCT echocardiography. These data were compared to those of 40 age-matched normal controls. Results In patients, the LV ejection fraction, shortening fraction, end-diastolic dimension, mitral early diastolic E velocity, TDI mitral septal E' velocity, and STE LV longitudinal systolic strain rate (SSR) decreased significantly after HSCT. Compared to normal controls, patients had significantly lower post-HSCT early diastolic E velocity and E/A ratio. On STE, patients had significantly decreased LV deformational parameters including LV longitudinal systolic strain (SS), SSR, and diastolic SR (DSR), and circumferential SS and DSR. Serum ferritin levels showed weak but significant correlations (P<0.05) with LV longitudinal SS and SSR and circumferential SS and DSR. Conclusion Subclinical LV dysfunction is evident in patients after HSCT for SAA, and was associated with increased iron load. Serial monitoring of cardiac function is mandatory in this population.
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Affiliation(s)
- Beom Joon Kim
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyung Pil Moon
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji-Hong Yoon
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun-Jung Lee
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Young Lee
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seong Koo Kim
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Wook Lee
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Nack Gyun Chung
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bin Cho
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hack Ki Kim
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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22
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Haploidentical hematopoietic stem cell transplantation for nonresponders to immunosuppressive therapy against acquired severe aplastic anemia. Bone Marrow Transplant 2015; 51:424-7. [PMID: 26479978 DOI: 10.1038/bmt.2015.249] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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23
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Abstract
Severe aplastic anemia is a disorder of stem cell failure, leading to pancytopenia. The condition is characterized by an impairment of the function of hematopoietic stem cells. Patients typically have fatigue, infections, and increased or unusual bleeding. A bone marrow biopsy establishes the diagnosis. Treatment includes hematopoietic stem cell transplant or immunosuppressive therapy.
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24
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Xie LN, Zhou F. Unexpected unrelated umbilical cord blood stem cell engraft in two patients with severe aplastic anemia that received immunosuppressive treatment: A case report and literature review. Exp Ther Med 2015; 10:1563-1565. [PMID: 26622526 DOI: 10.3892/etm.2015.2698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 07/17/2015] [Indexed: 01/07/2023] Open
Abstract
Severe aplastic anemia (SAA) is a life-threatening bone marrow disorder. Bone marrow transplantation is the primary therapy for SAA; however, its efficacy is limited by numerous factors, including lack of histocompatible sibling donor, patient age and graft-versus-host-disease (GVHD) following transplantation. Immunosuppressive treatment (IST) is the first procedure developed for patients without a sibling donor. Our previous study reported that patients administered enhanced IST, in addition to a regime of unrelated umbilical cord blood (UCB) transfusion, exhibited higher efficiency and a reduced rate of relapse. Therefore, the present study reported the cases of 2 patients that received enhanced IST plus unrelated UCB transfusion. These patients exhibited complete hematological recovery with an increased rate of mixed chimerism and demonstrated no signs of GVHD or relapse during the 2-year follow-up period. Thus, enhanced immunosuppressive treatment (low-dose cyclophosphamide and antithymocyte globulin) combined with UCB transfusion may be an effective treatment for patients with SAA.
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Affiliation(s)
- Lin-Na Xie
- Department of Hematology, The General Hospital of Jinan Military, Jinan, Shandong 250031, P.R. China
| | - Fang Zhou
- Department of Hematology, The General Hospital of Jinan Military, Jinan, Shandong 250031, P.R. China
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Abstract
Eltrombopag (Promacta®) is an orally active thrombopoietin receptor agonist recently approved in the US for the treatment of patients with severe aplastic anaemia who have had an insufficient response to immunosuppressive therapy. This article reviews the efficacy and tolerability of eltrombopag in this indication and overviews its pharmacological properties. Eltrombopag does not compete with thrombopoietin and binds to a different site on the receptor, producing additive effects. It stimulates haematopoietic stem cells and promotes haematopoietic recovery in patients with aplastic bone marrow. Eltrombopag increased platelet counts and can also increase red blood cell and neutrophil counts. In patients with severe aplastic anaemia refractory to prior immunosuppressive therapy, oral eltrombopag at dosages ≤150 mg once daily for 12-16 weeks produced a haematological response in at least one cell lineage in 40 % of patients. Trilineage responses were achieved in nearly one-half of the responders during extended treatment. In robust responders, stable haematological counts were maintained after eltrombopag discontinuation. Eltrombopag was generally well tolerated, with increased liver transaminases as the only dose-limiting toxicity. Clonal cytogenetic abnormalities were observed in 19 % of patients and dysplasia in 5 % of patients.
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26
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Androgens added to immunosuppressive regimen in patients with aplastic anaemia. A retrospective study. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2015. [DOI: 10.1016/j.hgmx.2015.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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27
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Kudo K, Muramatsu H, Yoshida N, Kobayashi R, Yabe H, Tabuchi K, Kato K, Koh K, Takahashi Y, Hashii Y, Kawano Y, Inoue M, Cho Y, Sakamaki H, Kawa K, Kato K, Suzuki R, Kojima S. Second allogeneic hematopoietic stem cell transplantation in children with severe aplastic anemia. Bone Marrow Transplant 2015; 50:1312-5. [PMID: 26121106 DOI: 10.1038/bmt.2015.153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/27/2015] [Accepted: 05/15/2015] [Indexed: 11/09/2022]
Abstract
The outcome of 55 children with severe aplastic anemia (SAA) who received a second hematopoietic stem cell transplantation (HSCT) was retrospectively analyzed using the registration data of the Japanese Society for Hematopoietic Cell Transplantation. The 5-year overall survival (OS) and failure-free survival (FFS) after the second transplantation were 82.9% (95% confidence interval (CI), 69.7-90.8)) and 81.2% (95% CI, 67.8-89.4), respectively. FFS was significantly better when the interval between the first and second transplantation was >60 days (88.9%; 95% CI, 73.0-95.7) than when it was ⩽60 days (61.4%; 95% CI, 33.3-80.5; P=0.026). All 12 patients who were conditioned with regimens containing fludarabine and melphalan were alive with hematopoietic recovery. These findings justify the recommendation of a second HSCT for children with SAA who have experienced graft failure after first HSCT.
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Affiliation(s)
- K Kudo
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
| | - H Muramatsu
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - N Yoshida
- Division of Pediatric Hematology/Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - R Kobayashi
- Department of Pediatrics, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - H Yabe
- Department of Cell Transplantation and Regeneration Medicine, Tokai University School of Medicine, Isehara, Japan
| | - K Tabuchi
- Division of Pediatrics, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - K Kato
- Division of Pediatric Hematology and Oncology, Ibaraki Children's Hospital, Mito, Japan
| | - K Koh
- Department of Hematology and Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Y Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Y Hashii
- Department of Pediatrics, Osaka University Hospital, Suita, Japan
| | - Y Kawano
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
| | - M Inoue
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
| | - Y Cho
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | - H Sakamaki
- Division of Hematology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - K Kawa
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Japan
| | - K Kato
- Division of Pediatric Hematology/Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - R Suzuki
- Department of Hematopoietic Stem Cell Transplantation, Data Management and Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - S Kojima
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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28
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Chen M, Liu C, Zhuang J, Zou N, Xu Y, Zhang W, Li J, Duan M, Zhu T, Cai H, Cao X, Wang S, Zhou D, Han B. Long-term follow-up study of porcine anti-human thymocyte immunoglobulin therapy combined with cyclosporine for severe aplastic anemia. Eur J Haematol 2015; 96:291-6. [PMID: 25996247 DOI: 10.1111/ejh.12590] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Miao Chen
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
| | - Chao Liu
- LMIB of the Ministry of Education; School of Mathematics and Systems Science; Beihang University; Beijing China
| | - Junling Zhuang
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
| | - Nong Zou
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
| | - Ying Xu
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
| | - Wei Zhang
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
| | - Jian Li
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
| | - Minghui Duan
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
| | - Tienan Zhu
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
| | - Huacong Cai
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
| | - Xinxin Cao
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
| | - Shujie Wang
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
| | - Daobin Zhou
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
| | - Bing Han
- Department of Hematology; Peking Union Medical College Hospital; Peking Union Medical College & Chinese Academy of Medical Sciences; Beijing China
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29
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Ma X, Wang J, Zhang W, Cao X, Chen Y, He A, Liu J, Yang N, Wang J, Yang Y, Xu Y. Comparison of porcine anti-human lymphocyte globulin and rabbit anti-human thymocyte globulin in the treatment of severe aplastic anemia: a retrospective single-center study. Eur J Haematol 2015; 96:260-8. [PMID: 25966958 DOI: 10.1111/ejh.12584] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2015] [Indexed: 01/10/2023]
Affiliation(s)
- Xiaorong Ma
- Department of Hematology; The Second Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shanxi Province China
| | - Jin Wang
- Department of Hematology; The Second Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shanxi Province China
| | - Wanggang Zhang
- Department of Hematology; The Second Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shanxi Province China
| | - Xingmei Cao
- Department of Hematology; The Second Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shanxi Province China
| | - Yinxia Chen
- Department of Hematology; The Second Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shanxi Province China
| | - Aili He
- Department of Hematology; The Second Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shanxi Province China
| | - Jie Liu
- Department of Hematology; The Second Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shanxi Province China
| | - Nan Yang
- The Second Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shanxi Province China
| | - Jianli Wang
- Department of Hematology; The Second Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shanxi Province China
| | - Yun Yang
- Department of Hematology; The Second Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shanxi Province China
| | - Yan Xu
- Department of Hematology; The Second Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shanxi Province China
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30
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Wang Y, Yan T, Ma L, Liu B. Effects of the Total Saponins fromDioscorea nipponicaon Immunoregulation in Aplastic Anemia Mice. THE AMERICAN JOURNAL OF CHINESE MEDICINE 2015; 43:289-303. [PMID: 25787297 DOI: 10.1142/s0192415x15500196] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Dioscorea nipponica Makino, a popular folk medicine, exerts anti-inflammation properties. The present study investigated the therapeutic effect of the total saponins from Dioscorea nipponica Makino (TSDN) on aplastic anemia (AA) and possible immune regulation mechanisms. Using a mouse model of AA, three different doses of TSDN were orally administrated for 14 consecutive days. We first demonstrated that TSDN was found to be effective in alleviating pancytopenia with a hypocellular bone marrow as compared with AA model group. Moreover, gastrogavage administration of a medium dose of TSDN was found to dramatically increase the percentage of CD4+cells in bone marrow nucleated cells (BMNC) and restore the CD4+/CD8+ratio. The pro-inflammatory cytokine concentrations of IL-2 and IFN-γ were significantly decreased, and anti-inflammatory cytokine IL-4 was significantly increased in culture supernatant of BMNC. Further investigations showed that TSDN obviously inhibited Fas–FasL-induced BMNC apoptosis as well as effectively suppressed intracellular apoptosis protein of caspase-3 and -8 expressions. Taken together, these findings suggested that TSDN could alleviate AA by elevating the CD4+/CD8+T-cell ratio, inhibiting inflammatory Th1-cytokines, and exerting anti-apoptosis effects.
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Affiliation(s)
- Yuliang Wang
- Department of Clinical Laboratory Medicine, Tianjin First Central Hospital, Key Laboratory for Critical Care Medicine of the Ministry of Health, Tianjin 300192, China
| | - Tiangai Yan
- Department of Traditional Chinese Medicine, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Lin Ma
- Department of Traditional Chinese Medicine, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Baoshan Liu
- Department of Traditional Chinese Medicine, Tianjin Medical University General Hospital, Tianjin 300052, China
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31
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Liu L, Ding L, Hao L, Zhang X, Li X, Zhang L, Hao Z, Lei M, Zhang Y, Wu D. Efficacy of porcine antihuman lymphocyte immunoglobulin compared to rabbit antithymocyte immunoglobulin as a first-line treatment against acquired severe aplastic anemia. Ann Hematol 2015; 94:729-37. [DOI: 10.1007/s00277-014-2279-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 12/07/2014] [Indexed: 12/13/2022]
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Oncostatin M maintains the hematopoietic microenvironment in the bone marrow by modulating adipogenesis and osteogenesis. PLoS One 2014; 9:e116209. [PMID: 25551451 PMCID: PMC4281151 DOI: 10.1371/journal.pone.0116209] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 12/04/2014] [Indexed: 12/14/2022] Open
Abstract
The bone marrow (BM) is an essential organ for hematopoiesis in adult, in which proliferation and differentiation of hematopoietic stem/progenitor cells (HSPC) is orchestrated by various stromal cells. Alterations of BM hematopoietic environment lead to various hematopoietic disorders as exemplified by the linking of fatty marrow with increased adipogenesis to anemia or pancytopenia. Therefore, the composition of mesenchymal stromal cell (MSC)-derived cells in the BM could be crucial for proper hematopoiesis, but the mechanisms underlying the MSC differentiation for hematopoiesis remain poorly understood. In this study, we show that Oncostatin M (OSM) knock out mice exhibited pancytopenia advancing fatty marrow with age. OSM strongly inhibited adipogenesis from BM MSC in vitro, whereas it enhanced their osteogenesis but suppressed the terminal differentiation. Intriguingly, OSM allowed the MSC-derived cells to support the ex vivo expansion of HSPC effectively as feeder cells. Furthermore, the administration of OSM in lethally irradiated wild-type mice blocked fatty marrow and enhanced the recovery of HSPC number in the BM and peripheral blood cells after engraftment of HSPC. Collectively, OSM plays multiple critical roles in the maintenance and development of the hematopoietic microenvironment in the BM at a steady state as well as after injury.
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Abstract
Recent advances in the treatment of aplastic anemia (AA) made most of patients to expect to achieve a long-term survival. Allogeneic stem cell transplantation (SCT) from HLA-matched sibling donor (MSD-SCT) is a preferred first-line treatment option for younger patients with severe or very severe AA, whereas immunosuppressive treatment (IST) is an alternative option for others. Horse anti-thymocyte globuline (ATG) with cyclosporin A (CsA) had been a standard IST regimen with acceptable response rate. Recently, horse ATG had been not available and replaced with rabbit ATG in most countries. Subsequently, recent comparative studies showed that the outcomes of patients who received rabbit ATG/CsA were similar or inferior compared to those who received horse ATG/CsA. Therefore, further studies to improve the outcomes of IST, including additional eltrombopag, are necessary. On the other hand, the upper age limit of patients who are able to receive MSD-SCT as first-line treatment is a current issue because of favorable outcomes of MSD-SCT of older patients using fludarabine-based conditioning. In addition, further studies to improve the outcomes of patients who receive allogeneic SCT from alternative donors are needed. In this review, current issues and the newly emerging trends that may improve their outcomes in near futures will be discussed focusing the management of patients with AA.
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Affiliation(s)
- Seung Hwan Shin
- Department of Hematology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Eun Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Abstract
The treatment of aplastic anemia is currently with immunosuppressive therapy (IST) with anti-thymocyte globulin (ATG) and cyclosporine, to which two thirds of patients respond. However, a significant proportion of these responders relapse and many have persistent cytopenias. The management of these patients is challenging. Modifications to this standard approach using alternative immunosuppressive agents or adding hematopoietic cytokines such as granulocyte colony-stimulating factor (G-CSF) and erythropoietin (EPO) have not improved outcome. A recent trial has shown that eltrombopag, a thrombopoeitin mimetic, is efficacious in the treatment of patients with severe aplastic anemia (SAA) refractory to IST. There is evidence that this drug works by directly stimulating marrow stem and progenitor cells thereby promoting hematopoietic recovery in patients with bone marrow failure. Several trials are ongoing in our institution using this very promising drug in combination therapy in the upfront treatment of SAA, in IST-refractory SAA and in moderate disease.
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Affiliation(s)
- Ronan Desmond
- Department of Haematology, Tallaght Hospital, Dublin, Ireland; National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD.
| | - Danielle M Townsley
- National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD
| | - Cynthia Dunbar
- National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD
| | - Neal S Young
- National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD
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Garanito MP, Carneiro JDA, Filho VO, Scheinberg P. Outcome of children with severe acquired aplastic anemia treated with rabbit antithymocyte globulin and cyclosporine A. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2014. [DOI: 10.1016/j.jpedp.2014.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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36
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Outcome of children with severe acquired aplastic anemia treated with rabbit antithymocyte globulin and cyclosporine A. J Pediatr (Rio J) 2014; 90:523-7. [PMID: 24878006 DOI: 10.1016/j.jped.2014.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 02/15/2014] [Accepted: 02/17/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the outcome of children with severe acquired aplastic anemia treated with rabbit antithymocyte globulin and cyclosporine as first-line treatment at this institution. METHODS Retrospective analysis of 26 pediatric patients with aplastic anemia, treated between 1996 and 2011 with rabbit antithymocyte globulin plus cyclosporine. RESULTS The overall response rate at six months was 34.6% (9/26), and the cumulative incidence of relapse was 26.5% (95% confidence interval [CI]: 1.4%-66%) at 5 years. The cumulative incidence of clonal evolution after immunosuppressive therapy was 8.3% (95% CI: 0.001%-53.7%) at five years with both clonal evolutions in non -responders who acquired monosomy 7 karyotype. The overall survival at five years was 73.6% (95% CI: 49.2%-87.5%). CONCLUSIONS The present results confirm the poor response rate with rabbit antithymocyte globulin as first therapy in pediatrics patients, similar to what has been reported for patients of all ages. This confirmation is problematic in Brazil, given the lack of horse antithymocyte globulin in many markets outside the United States.
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Peinemann F, Labeit AM. Stem cell transplantation of matched sibling donors compared with immunosuppressive therapy for acquired severe aplastic anaemia: a Cochrane systematic review. BMJ Open 2014; 4:e005039. [PMID: 25031191 PMCID: PMC4120307 DOI: 10.1136/bmjopen-2014-005039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Acquired severe aplastic anaemia is a rare and potentially fatal disease. The aim of this Cochrane review was to evaluate the effectiveness and adverse events of first-line allogeneic haematopoietic stem cell transplantation of human leucocyte antigen (HLA)-matched sibling donors compared with first-line immunosuppressive therapy. SETTING Specialised stem cell transplantations units in primary care hospitals. PARTICIPANTS We included 302 participants with newly diagnosed acquired severe aplastic anaemia. The age ranged from early childhood to young adulthood. We excluded studies on participants with secondary aplastic anaemia. INTERVENTIONS We included allogeneic haematopoietic stem cell transplantation as the test intervention harvested from any source of matched sibling donor and serving as a first-line therapy. We included immunosuppressive therapy as comparator with either antithymocyte/antilymphocyte globulin or ciclosporin or a combination of the two. PRIMARY AND SECONDARY OUTCOME MEASURES PLANNED AND FINALLY MEASURED: The primary outcome was overall mortality. Secondary outcomes were treatment-related mortality, graft failure, graft-versus-host disease, no response to immunosuppressive therapy, relapse after initial successful treatment, secondary clonal disease or malignancies, health-related quality of life and performance scores. RESULTS We identified three prospective non-randomised controlled trials with a study design that was consistent with the principle of 'Mendelian randomisation' in allocating patients to treatment groups. All studies had a high risk of bias due to the study design and were conducted more than 15 years. The pooled HR for overall mortality for the donor group versus the no donor group was 0.95 (95% CI 0.43 to 2.12, p=0.90). CONCLUSIONS There are insufficient and biased data that do not allow any firm conclusions to be made about the comparative effectiveness of first-line allogeneic haematopoietic stem cell transplantation of HLA-matched sibling donors and first-line immunosuppressive therapy of patients with acquired severe aplastic anaemia.
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Affiliation(s)
- Frank Peinemann
- Children's Hospital, University of Cologne, Cologne, Germany
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Abstract
Thrombocytopenia means low platelet count. This is the most frequent cause of bleeding abnormalities. Petechias, purpuras, mucosal bleeding are typical clinical findings. Severe, even life threatening gastrointestinal or intracranial bleeding may also occur. Diagnostic laboratory finding is the prolonged bleeding time. There are several causes of thrombocytopenia. The major mechanisms for a reduced platelet count are decreased production and increased destruction of platelets, or both. The major task is to reveal the underlying cause. Examination of the bone marrow and the peripheral blood smear can be helpful as well as special diagnostics of the assumed disease. Therapy targets the underlying disease, and also involves platelet transfusion. However, in case of diseases with increased platelet activation and consumption, platelet transfusion is contraindicated because it may lead to aggravation of the pathologic process.
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Affiliation(s)
- Klára Gadó
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Budapest Korányi S. u. 2/A 1083
| | - Gyula Domján
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Budapest Korányi S. u. 2/A 1083
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Abikoff CM, Cairo MS. Reduced intensity conditioning and hematopoietic stem cell transplantation in pediatric nonmalignant disease: a new therapeutic paradigm. J Pediatr 2014; 164:952-953.e2. [PMID: 24742647 DOI: 10.1016/j.jpeds.2014.01.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Cori M Abikoff
- Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Mitchell S Cairo
- Department of Pediatrics, New York Medical College, Valhalla, NY; Department of Medicine, New York Medical College, Valhalla, NY; Department of Pathology, New York Medical College, Valhalla, NY; Department of Microbiology & Immunology, New York Medical College, Valhalla, NY; Department of Cell Biology & Anatomy, New York Medical College, Valhalla, NY.
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Abstract
PURPOSE OF REVIEW Survival outcomes from haematopoietic stem cell transplantation (HSCT) in severe aplastic anaemia (SAA) have improved steadily over the past decades, largely reflecting progress in supportive care and conditioning regimens. Here we review recently published data that highlight the improvements and current issues. RECENT FINDINGS Human leukocyte antigen (HLA)-matched sibling donor (MSD) HSCT remains the gold standard for SAA patients younger than 40-50 years, with HLA-matched unrelated donor (MUD) HSCT for second line after failure to respond to immunosuppressive therapy (IST). The use of alternative donor sources for aplastic anaemia patients remains limited and problematic, but novel conditioning regimens, particularly in the haploidentical setting, justify further evaluation. In recent studies when comparing alemtuzumab-based conditioning with standard antithymocyte globulin conditioning regimens, lower rates of acute and chronic graft-versus-host disease and better tolerance in older patients are seen. SUMMARY Improving outcomes may lead to an expanded frontline HSCT role in the future. In children lacking a MSD, increasingly MUD HSCT is being considered as first-line treatment and is also being considered more for young adults. Further research is needed to advance our understanding of the role HSCT has to play in SAA with particular emphasis on alternative donor sources and identifying optimal conditioning regimens.
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Paiva RMA, Calado RT. Telomere dysfunction and hematologic disorders. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2014; 125:133-57. [PMID: 24993701 DOI: 10.1016/b978-0-12-397898-1.00006-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Aplastic anemia is a disease in which the hematopoietic stem cell fails to adequately produce peripheral blood cells, causing pancytopenia. In some cases of acquired aplastic anemia and in inherited type of aplastic anemia, dyskeratosis congenita, telomere biology gene mutations and telomere shortening are etiologic. Telomere erosion hampers the ability of hematopoietic stem and progenitor cells to adequately replicate, clinically resulting in bone marrow failure. Additionally, telomerase mutations and short telomeres are genetic risk factors for the development of some hematologic cancers, including myelodysplastic syndrome, acute myeloid leukemia, and chronic lymphocytic leukemia.
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Affiliation(s)
- Raquel M A Paiva
- Department of Internal Medicine, University of São Paulo at Ribeirão Preto School of Medicine, Ribeirão Preto, São Paulo, Brazil
| | - Rodrigo T Calado
- Department of Internal Medicine, University of São Paulo at Ribeirão Preto School of Medicine, Ribeirão Preto, São Paulo, Brazil
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Reduced intensity conditioning and co-transplantation of unrelated peripheral stem cells combined with umbilical cord mesenchymal stem/stroma cells for young patients with refractory severe aplastic anemia. Int J Hematol 2013; 98:658-63. [DOI: 10.1007/s12185-013-1425-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 08/24/2013] [Accepted: 08/27/2013] [Indexed: 01/14/2023]
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Peinemann F, Bartel C, Grouven U. First-line allogeneic hematopoietic stem cell transplantation of HLA-matched sibling donors compared with first-line ciclosporin and/or antithymocyte or antilymphocyte globulin for acquired severe aplastic anemia. Cochrane Database Syst Rev 2013; 2013:CD006407. [PMID: 23881658 PMCID: PMC6718216 DOI: 10.1002/14651858.cd006407.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Acquired severe aplastic anemia is a rare and potentially fatal disease, which is characterized by hypocellular bone marrow and pancytopenia. The major signs and symptoms are severe infections, bleeding, and exhaustion. First-line allogeneic hematopoietic stem cell transplantation (HSCT) of a human leukocyte antigen (HLA)-matched sibling donor (MSD) is a treatment for newly diagnosed patients with severe aplastic anemia. First-line treatment with ciclosporin and/or antithymocyte or antilymphocyte globulin (as first-line immunosuppressive therapy) is an alternative to MSD-HSCT and is indicated for patients where no MSD is found. OBJECTIVES To evaluate the effectiveness and adverse events of first-line allogeneic hematopoietic stem cell transplantation of HLA-matched sibling donors compared to first-line immunosuppressive therapy including ciclosporin and/or antithymocyte or antilymphocyte globulin in patients with acquired severe aplastic anemia. SEARCH METHODS We searched the electronic databases MEDLINE (Ovid), EMBASE (Ovid), and The Cochrane Library CENTRAL (Wiley) for published articles from 1946 to 22 April 2013. Further searches included trial registries, reference lists of recent reviews, and author contacts. SELECTION CRITERIA The following prospective study designs were eligible for inclusion: randomized controlled trials (RCTs) and non-randomized controlled trials if the allocation of patients to treatment groups was consistent with 'Mendelian randomization'. We included participants with newly diagnosed severe aplastic anemia who received MSD-HSCT or immunosuppressive therapy without prior HSCT or immunosuppressive therapy, and with a minimum of five participants per treatment group. We did not apply limits on publication year or languages. DATA COLLECTION AND ANALYSIS Two review authors abstracted the data on study and patient characteristics and assessed the risk of bias independently. We resolved differences by discussion or by appeal to a third review author. The primary outcome was overall mortality. Secondary outcomes were treatment-related mortality, graft failure, no response to first-line immunosuppressive therapy, graft-versus-host-disease (GVHD), relapse after initial successful treatment, secondary clonal and malignant disease, health-related quality of life, and performance score. MAIN RESULTS We identified three trials that met the inclusion criteria. None of these trials was a RCT. 302 participants are included in this review. The three included studies were prospectively conducted and had features consistent with the principle of 'Mendelian randomization' as defined in the present review. All studies had a high risk of bias due to the study design. All studies were conducted more than 10 years ago and may not be applicable to the standard of care of today. Primary and secondary outcome data showed no statistically significant difference between treatment groups. We present results for first-line allogeneic hematopoietic stem cell transplantation of an HLA-matched sibling donor, which we denote as the MSD-HSCT group, versus first-line treatment with ciclosporin and/or antithymocyte or antilymphocyte globulin, which we denote as the immunosuppressive therapy group in the following section.The pooled hazard ratio for overall mortality for the MSD-HSCT group versus the immunosuppressive therapy group was 0.95 (95% confidence interval 0.43 to 2.12, P = 0.90, low quality evidence). Therefore, overall mortality was not statistically significantly different between the groups. Treatment-related mortality ranged from 20% to 42% for the MSD-HSCT group and was not reported for the immunosuppressive therapy group (very low quality evidence). The authors reported graft failure from 3% to 16% for the MSD-HSCT group and GVHD from 26% to 51% (both endpoints not applicable for the immunosuppressive therapy group, very low quality evidence). The authors did not report any data on response and relapse for the MSD-HSCT group. For the immunosuppressive therapy group, the studies reported no response from 15% (not time point stated) to 64% (three months) and relapse in one of eight responders after immunosuppressive therapy at 5.5 years (very low quality evidence). The authors reported secondary clonal disease or malignancies for the MSD-HSCT group versus the immunosuppressive therapy group in 1 of 34 versus 0 of 22 patients in one study and in 0 of 28 versus 4 of 86 patients in the other study (low quality evidence). None of the included studies addressed health-related quality of life. The percentage of the evaluated patients with a Karnofsky performance status score in the range of 71% to 100% was 92% in the MSD-HSCT group and 46% in the immunosuppressive therapy group. AUTHORS' CONCLUSIONS There are insufficient and biased data that do not allow any conclusions to be made about the comparative effectiveness of first-line allogeneic hematopoietic stem cell transplantation of an HLA-matched sibling donor and first-line treatment with ciclosporin and/or antithymocyte or antilymphocyte globulin (as first-line immunosuppressive therapy). We are unable to make firm recommendations regarding the choice of intervention for treatment of acquired severe aplastic anemia.
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Scheinberg P. Prognostic value of telomere attrition in patients with aplastic anemia. Int J Hematol 2013; 97:553-7. [PMID: 23636667 DOI: 10.1007/s12185-013-1332-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Accepted: 04/10/2013] [Indexed: 11/25/2022]
Abstract
The decision to pursue hematopoietic stem cell transplantation or immunosuppression as first therapy in severe aplastic anemia is currently based on age and availability of a histocompatible donor. The ability to predict hematologic response, relapse and clonal evolution could improve treatment allocation. In the past 15 years, telomeres have been implicated in clinical diseases such as aplastic anemia, pulmonary fibrosis, cirrhosis and cancer development. The clinical relevance of varying telomere lengths (TL) and/or mutations in genes of the telomerase complex (TERC, TERT) is evolving in aplastic anemia. A large retrospective analysis suggests that baseline TL associate with late events of hematologic relapse and clonal evolution in aplastic anemia patients treated initially with anti-thymocyte globulin-based therapy. Further laboratory experiments propose possible mechanistic insight into genomic instability of bone marrow cells derived from patients with critically short telomeres and/or mutation in telomerase genes. The possibility of modulating telomere attrition rate with sex hormones could positively affect clonal evolution rates in humans. This review will summarize studies in marrow failure that explore the association between telomeres and aplastic anemia outcomes.
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Affiliation(s)
- Phillip Scheinberg
- Hematology Service, Oncology Center, Hospital São Jose, Beneficência Portuguesa, Rua Martiniano de Carvalho, 951, São Paulo, SP 01321-001, Brazil.
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