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Kusne Y, Badar T, Lasho T, Ferrer A, Mangaonkar AA, Finke C, Marando L, Foran JM, Al-Kali A, Alkhateeb HB, Chlon T, Patnaik MM. Absence of PNH-clones in DDX41mutant-GPS aids in their distinction from acquired BM failure syndromes. Leuk Res 2024; 145:107561. [PMID: 39182344 DOI: 10.1016/j.leukres.2024.107561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 07/09/2024] [Accepted: 08/14/2024] [Indexed: 08/27/2024]
Affiliation(s)
- Yael Kusne
- Division of Hematology/Oncology, Mayo Clinic, AZ, United States; Division of Hematopathology, Mayo Clinic, MN, United States.
| | - Talha Badar
- Division of Hematology/Oncology and Bone Marrow Transplant Program, Mayo Clinic, FL, United States; Division of Hematopathology, Mayo Clinic, MN, United States
| | - Terra Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, United States; Division of Hematopathology, Mayo Clinic, MN, United States
| | - Alejandro Ferrer
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, United States; Division of Hematopathology, Mayo Clinic, MN, United States
| | - Abhishek A Mangaonkar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, United States; Division of Hematopathology, Mayo Clinic, MN, United States
| | - Christy Finke
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, United States; Division of Hematopathology, Mayo Clinic, MN, United States
| | - Ludovica Marando
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, United States; Division of Hematopathology, Mayo Clinic, MN, United States
| | - James M Foran
- Division of Hematology/Oncology and Bone Marrow Transplant Program, Mayo Clinic, FL, United States; Division of Hematopathology, Mayo Clinic, MN, United States
| | - Aref Al-Kali
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, United States; Division of Hematopathology, Mayo Clinic, MN, United States
| | - Hassan B Alkhateeb
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, United States; Division of Hematopathology, Mayo Clinic, MN, United States
| | - Timothy Chlon
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN, United States; Division of Hematopathology, Mayo Clinic, MN, United States
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Lee BC, Gin A, Wu C, Singh K, Grice M, Mortlock R, Abraham D, Fan X, Zhou Y, AlJanahi A, Choi U, DeRavin SS, Shin T, Hong S, Dunbar CE. Impact of CRISPR/HDR editing versus lentiviral transduction on long-term engraftment and clonal dynamics of HSPCs in rhesus macaques. Cell Stem Cell 2024; 31:455-466.e4. [PMID: 38508195 PMCID: PMC10997443 DOI: 10.1016/j.stem.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/11/2024] [Accepted: 02/26/2024] [Indexed: 03/22/2024]
Abstract
For precise genome editing via CRISPR/homology-directed repair (HDR), effective and safe editing of long-term engrafting hematopoietic stem cells (LT-HSCs) is required. The impact of HDR on true LT-HSC clonal dynamics in a relevant large animal model has not been studied. To track the output and clonality of HDR-edited cells and to provide a comparison to lentivirally transduced HSCs in vivo, we developed a competitive rhesus macaque (RM) autologous transplantation model, co-infusing HSCs transduced with a barcoded GFP-expressing lentiviral vector (LV) and HDR edited at the CD33 locus. CRISPR/HDR-edited cells showed a two-log decrease by 2 months following transplantation, with little improvement via p53 inhibition, in comparison to minimal loss of LV-transduced cells long term. HDR long-term clonality was oligoclonal in contrast to highly polyclonal LV-transduced HSCs. These results suggest marked clinically relevant differences in the impact of current genetic modification approaches on HSCs.
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Affiliation(s)
- Byung-Chul Lee
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Department of Biological Sciences, Sookmyung Women's University, Seoul, Korea; Research Institute of Women's Health, Sookmyung Women's University, Seoul, Korea.
| | - Ashley Gin
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Chuanfeng Wu
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Komudi Singh
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Max Grice
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ryland Mortlock
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Diana Abraham
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Xing Fan
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Yifan Zhou
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Wellcome-MRC Cambridge Stem Cell Institute, University of Cambridge, Puddicombe Way, Cambridge, UK; Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge CB10 1SA, UK
| | - Aisha AlJanahi
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Uimook Choi
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Suk See DeRavin
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Taehoon Shin
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Department of Laboratory Animal Medicine, College of Veterinary Medicine, Jeju National University, Jeju, Korea
| | - Sogun Hong
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cynthia E Dunbar
- Translational Stem Cell Biology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
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3
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Shingai N, Mizumaki H, Najima Y, Yamada Y, Tran DC, Haraguchi K, Toya T, Okuyama Y, Doki N, Nannya Y, Ogawa S, Nakao S. Case report: Immune pressure on hematopoietic stem cells can drastically expand glycosylphosphatidylinositol-deficient clones in paroxysmal nocturnal hemoglobinuria. Front Immunol 2024; 14:1329403. [PMID: 38288112 PMCID: PMC10822943 DOI: 10.3389/fimmu.2023.1329403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/27/2023] [Indexed: 01/31/2024] Open
Abstract
Introduction Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematological disease characterized by intravascular hemolysis, thrombosis, and bone marrow (BM) failure. Although PNH is caused by excessive proliferation of hematopoietic stem cell (HSC) clones with loss of function mutations in phosphatidylinositol N-acetylglucosaminyltransferase subunit A (PIGA) genes, what drives PNH clones to expand remains elusive. Case description We present a case of a 26-year-old female who presented with hemolytic anemia, thrombocytopenia, and leukopenia. Flow cytometry analysis of peripheral blood showed that 71.9% and 15.3% of the granulocytes and erythrocytes were glycosylphosphatidylinositol-anchored protein deficient (GPI[-]) cells. The patient was diagnosed with PNH with non-severe aplastic anemia. Deep-targeted sequencing covering 390 different genes of sorted GPI(-) granulocytes revealed three different PIGA mutations (p.I69fs, variant allele frequency (VAF) 24.2%; p.T192P, VAF 5.8%; p.V300fs, VAF 5.1%) and no other mutations. She received six cycles of eculizumab and oral cyclosporine. Although the patient's serum lactate dehydrogenase level decreased, she remained dependent on red blood cell transfusion. Six months after diagnosis, she received a syngeneic bone marrow transplant (BMT) from a genetically identical healthy twin, following an immune ablative conditioning regimen consisting of cyclophosphamide 200 mg/kg and rabbit anti-thymocyte globulin 10 mg/kg. After four years, the patient's blood count remained normal without any signs of hemolysis. However, the peripheral blood still contained 0.2% GPI (-) granulocytes, and the three PIGA mutations that had been detected before BMT persisted at similar proportions to those before transplantation (p.I69fs, VAF 36.1%; p.T192P, VAF 3.7%; p.V300fs, VAF 8.6%) in the small PNH clones that persisted after transplantation. Conclusions The PNH clones that had increased excessively before BMT decreased, but persisted at low percentages for more than four years after the immunoablative conditioning regimen followed by syngeneic BMT. These findings indicate that as opposed to conventional theory, immune pressure on HSCs, which caused BM failure before BMT, was sufficient for PIGA-mutated HSCs to clonally expand to develop PNH.
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Affiliation(s)
- Naoki Shingai
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hiroki Mizumaki
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuta Yamada
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Dung Cao Tran
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | - Kyoko Haraguchi
- Division of Transfusion and Cell Therapy, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yoshiki Okuyama
- Division of Transfusion and Cell Therapy, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yasuhito Nannya
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Seishi Ogawa
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Nakao
- Department of Hematology, Kanazawa University, Kanazawa, Japan
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4
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Long noncoding RNA FAM157C contributes to clonal proliferation in paroxysmal nocturnal hemoglobinuria. Ann Hematol 2023; 102:299-309. [PMID: 36607351 PMCID: PMC9889514 DOI: 10.1007/s00277-022-05055-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 11/13/2022] [Indexed: 01/07/2023]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare clonal disease of hematopoietic stem cells (HSCs). Long noncoding RNAs (lncRNAs) perform a wide range of biological functions, including the regulation of gene expression, cell differentiation, and proliferation, but their role in PNH remains unclear.CD59- and CD59+ granulocytes and monocytes from 35 PNH patients were sorted. High-throughput sequencing was analyzed in 5 PNH patients, and differentially expressed lncRNAs and mRNAs were identified. The mRNAs with fragments per kilobase of exon model per million mapped fragments (FPKM) > 10 in at least 3 patients were selected, and experiments were performed to identify their upstream regulatory lncRNAs. The expression of selected mRNAs and lncRNAs was verified by qRT‒PCR, and the correlation of these expression patterns with clinical data from other 30 PNH patients was analyzed. Then, the functions of the lncRNAs were studied in the PIGA-KO-THP-1 cell line.Transcription analysis revealed 742 upregulated and 1376 downregulated lncRNAs and 3276 upregulated and 213 downregulated mRNAs. After deep screening, 8 highly expressed mRNAs that were related to the NF-κB pathway were analyzed to determine coexpression patterns. LINC01002, FAM157C, CTD-2530H12.2, XLOC-064331 and XLOC-106677 were correlated with the 8 mRNAs. After measuring the expression of these molecules in 30 PNH patients by qRT‒PCR, lncRNA FAM157C was verified to be upregulated in the PNH clone, and its expression levels were positively correlated with the LDH levels and CD59- granulated and monocyte cell ratios. After knockdown of the FAM157C gene in the PIGA-KO-THP-1 cell line, we found that the cells were arrested in the G0/G1 phase and S phase, the apoptosis rate increased, and the cell proliferation decreased.LncRNA FAM157C was proven to promote PNH clone proliferation, and this is the first study to explore the role of lncRNAs in PNH.
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5
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Shin TH, Zhou Y, Chen S, Cordes S, Grice MZ, Fan X, Lee BC, Aljanahi AA, Hong SG, Vaughan KL, Mattison JA, Kohama SG, Fabre MA, Uchida N, Demirci S, Corat MA, Métais JY, Calvo KR, Buscarlet M, Natanson H, McGraw KL, List AF, Busque L, Tisdale JF, Vassiliou GS, Yu KR, Dunbar CE. A macaque clonal hematopoiesis model demonstrates expansion of TET2-disrupted clones and utility for testing interventions. Blood 2022; 140:1774-1789. [PMID: 35714307 PMCID: PMC9837449 DOI: 10.1182/blood.2021014875] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/26/2022] [Indexed: 01/21/2023] Open
Abstract
Individuals with age-related clonal hematopoiesis (CH) are at greater risk for hematologic malignancies and cardiovascular diseases. However, predictive preclinical animal models to recapitulate the spectrum of human CH are lacking. Through error-corrected sequencing of 56 human CH/myeloid malignancy genes, we identified natural CH driver mutations in aged rhesus macaques matching genes somatically mutated in human CH, with DNMT3A mutations being the most frequent. A CH model in young adult macaques was generated via autologous transplantation of clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9-mediated gene-edited hematopoietic stem and progenitor cells (HSPCs), targeting the top human CH genes with loss-of-function (LOF) mutations. Long-term follow-up revealed reproducible and significant expansion of multiple HSPC clones with heterozygous TET2 LOF mutations, compared with minimal expansion of clones bearing other mutations. Although the blood counts of these CH macaques were normal, their bone marrows were hypercellular and myeloid-predominant. TET2-disrupted myeloid colony-forming units isolated from these animals showed a distinct hyperinflammatory gene expression profile compared with wild type. In addition, mature macrophages purified from the CH macaques showed elevated NLRP3 inflammasome activity and increased interleukin-1β (IL-1β) and IL-6 production. The model was used to test the impact of IL-6 blockage by tocilizumab, documenting a slowing of TET2-mutated expansion, suggesting that interruption of the IL-6 axis may remove the selective advantage of mutant HSPCs. These findings provide a model for examining the pathophysiology of CH and give insights into potential therapeutic interventions.
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Affiliation(s)
- Tae-Hoon Shin
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
- Department of Laboratory Animal Medicine, College of Veterinary Medicine, Jeju National University, Jeju, Republic of Korea
| | - Yifan Zhou
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
- Haematological Cancer Genetics, Wellcome Trust Sanger Institute, Cambridge, United Kingdom
- Wellcome-Medical Research Council (MRC) Cambridge Stem Cell Institute, University of Cambridge, Cambridge, United Kingdom
| | - Shirley Chen
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
| | - Stefan Cordes
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
| | - Max Z. Grice
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
| | - Xing Fan
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
| | - Byung-Chul Lee
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
| | - Aisha A. Aljanahi
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
| | - So Gun Hong
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
| | - Kelli L. Vaughan
- Translational Gerontology Branch, National Institute on Aging, NIH Animal Center, Dickerson, MD
| | - Julie A. Mattison
- Translational Gerontology Branch, National Institute on Aging, NIH Animal Center, Dickerson, MD
| | - Steven G. Kohama
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health and Science University, Beaverton, OR
| | - Margarete A. Fabre
- Haematological Cancer Genetics, Wellcome Trust Sanger Institute, Cambridge, United Kingdom
- Wellcome-Medical Research Council (MRC) Cambridge Stem Cell Institute, University of Cambridge, Cambridge, United Kingdom
| | - Naoya Uchida
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD
| | - Selami Demirci
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD
| | - Marcus A.F. Corat
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
- Multidisciplinary Center for Biological Research, University of Campinas, Campinas, Brazil
| | - Jean-Yves Métais
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN
| | - Katherine R. Calvo
- Hematology Section, Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD
| | - Manuel Buscarlet
- Hôpital Maisonneuve-Rosemont, Universite de Montreal, Montreal, QC, Canada
| | - Hannah Natanson
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
| | - Kathy L. McGraw
- Laboratory of Receptor Biology and Gene Expression, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD
| | | | - Lambert Busque
- Hôpital Maisonneuve-Rosemont, Universite de Montreal, Montreal, QC, Canada
| | - John F. Tisdale
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD
| | - George S. Vassiliou
- Haematological Cancer Genetics, Wellcome Trust Sanger Institute, Cambridge, United Kingdom
- Wellcome-Medical Research Council (MRC) Cambridge Stem Cell Institute, University of Cambridge, Cambridge, United Kingdom
| | - Kyung-Rok Yu
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
- Department of Agricultural Biotechnology and Research Institute of Agriculture and Life Sciences, Seoul National University, Seoul, Republic of Korea
| | - Cynthia E. Dunbar
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD
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6
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Schmidt JK, Jones KM, Van Vleck T, Emborg ME. Modeling genetic diseases in nonhuman primates through embryonic and germline modification: Considerations and challenges. Sci Transl Med 2022; 14:eabf4879. [PMID: 35235338 PMCID: PMC9373237 DOI: 10.1126/scitranslmed.abf4879] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Genetic modification of the embryo or germ line of nonhuman primates is envisioned as a method to develop improved models of human disease, yet the promise of such animal models remains unfulfilled. Here, we discuss current methods and their limitations for producing nonhuman primate genetic models that faithfully genocopy and phenocopy human disease. We reflect on how to ethically maximize the translational relevance of such models in the search for new therapeutic strategies to treat human disease.
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Affiliation(s)
- Jenna K. Schmidt
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Kathryn M. Jones
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Trevor Van Vleck
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Marina E. Emborg
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, WI, USA
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, USA
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7
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Colden MA, Kumar S, Munkhbileg B, Babushok DV. Insights Into the Emergence of Paroxysmal Nocturnal Hemoglobinuria. Front Immunol 2022; 12:830172. [PMID: 35154088 PMCID: PMC8831232 DOI: 10.3389/fimmu.2021.830172] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
Paroxysmal Nocturnal Hemoglobinuria (PNH) is a disease as simple as it is complex. PNH patients develop somatic loss-of-function mutations in phosphatidylinositol N-acetylglucosaminyltransferase subunit A gene (PIGA), required for the biosynthesis of glycosylphosphatidylinositol (GPI) anchors. Ubiquitous in eukaryotes, GPI anchors are a group of conserved glycolipid molecules responsible for attaching nearly 150 distinct proteins to the surface of cell membranes. The loss of two GPI-anchored surface proteins, CD55 and CD59, from red blood cells causes unregulated complement activation and hemolysis in classical PNH disease. In PNH patients, PIGA-mutant, GPI (-) hematopoietic cells clonally expand to make up a large portion of patients’ blood production, yet mechanisms leading to clonal expansion of GPI (-) cells remain enigmatic. Historical models of PNH in mice and the more recent PNH model in rhesus macaques showed that GPI (-) cells reconstitute near-normal hematopoiesis but have no intrinsic growth advantage and do not clonally expand over time. Landmark studies identified several potential mechanisms which can promote PNH clonal expansion. However, to what extent these contribute to PNH cell selection in patients continues to be a matter of active debate. Recent advancements in disease models and immunologic technologies, together with the growing understanding of autoimmune marrow failure, offer new opportunities to evaluate the mechanisms of clonal expansion in PNH. Here, we critically review published data on PNH cell biology and clonal expansion and highlight limitations and opportunities to further our understanding of the emergence of PNH clones.
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Affiliation(s)
- Melissa A. Colden
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sushant Kumar
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Bolormaa Munkhbileg
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Daria V. Babushok
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- *Correspondence: Daria V. Babushok,
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8
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Chen Y, Liu H, Zeng L, Li L, Lu D, Liu Z, Fu R. A Pig-a conditional knock-out mice model mediated by Vav-iCre: stable GPI-deficient and mild hemolysis. Exp Hematol Oncol 2022; 11:1. [PMID: 35033195 PMCID: PMC8760646 DOI: 10.1186/s40164-022-00254-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/05/2022] [Indexed: 11/10/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria is a clonal disease caused by PIG-A mutation of hematopoietic stem cells. At present, there is no suitable PNH animal model for basic research, therefore, it is urgent to establish a stable animal model. We constructed a Pig-a conditional knock-out mice model by ES targeting technique and Vav-iCre. The expressions of GPI and GPI-AP were almost completely absent in CKO homozygote mice, and the proportion of the deficiency remained stable from birth. In CKO heterozygote mice, the proportion of the deficiency of GPI and GPI-AP was partially absent and decreased gradually from birth until it reached a stable level at 3 months after birth and remained there for life. Compared with normal C57BL/6N mice and Flox mice, pancytopenia was found in CKO homozygous mice, and leukopenia and anemia were found in CKO heterozygotes mice. Meanwhile, in CKO mice, the serum LDH, TBIL, IBIL, complement C5b-9 levels were increased, and the concentration of plasma FHb was increased. Hemosiderin granulosa cells can be seen more easily in the spleens of CKO mice. What's more, CKO mice had stable transcription characteristics. In conclusion, our mouse model has stable GPI-deficient and mild hemolysis, which may be an ideal in vivo experimental model for PNH.
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Affiliation(s)
- Yingying Chen
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China
| | - Hui Liu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China
| | - Lijie Zeng
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China
| | - Liyan Li
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China
| | - Dan Lu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China
| | - Zhaoyun Liu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin, 300052, People's Republic of China.
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9
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AlJanahi AA, Lazzarotto CR, Chen S, Shin TH, Cordes S, Fan X, Jabara I, Zhou Y, Young DJ, Lee BC, Yu KR, Li Y, Toms B, Tunc I, Hong SG, Truitt LL, Klermund J, Andrieux G, Kim MY, Cathomen T, Gill S, Tsai SQ, Dunbar CE. Prediction and validation of hematopoietic stem and progenitor cell off-target editing in transplanted rhesus macaques. Mol Ther 2022; 30:209-222. [PMID: 34174439 PMCID: PMC8753565 DOI: 10.1016/j.ymthe.2021.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/18/2021] [Accepted: 06/21/2021] [Indexed: 01/07/2023] Open
Abstract
The programmable nuclease technology CRISPR-Cas9 has revolutionized gene editing in the last decade. Due to the risk of off-target editing, accurate and sensitive methods for off-target characterization are crucial prior to applying CRISPR-Cas9 therapeutically. Here, we utilized a rhesus macaque model to compare the predictive values of CIRCLE-seq, an in vitro off-target prediction method, with in silico prediction (ISP) based solely on genomic sequence comparisons. We use AmpliSeq HD error-corrected sequencing to validate off-target sites predicted by CIRCLE-seq and ISP for a CD33 guide RNA (gRNA) with thousands of off-target sites predicted by ISP and CIRCLE-seq. We found poor correlation between the sites predicted by the two methods. When almost 500 sites predicted by each method were analyzed by error-corrected sequencing of hematopoietic cells following transplantation, 19 off-target sites revealed insertion or deletion mutations. Of these sites, 8 were predicted by both methods, 8 by CIRCLE-seq only, and 3 by ISP only. The levels of cells with these off-target edits exhibited no expansion or abnormal behavior in vivo in animals followed for up to 2 years. In addition, we utilized an unbiased method termed CAST-seq to search for translocations between the on-target site and off-target sites present in animals following transplantation, detecting one specific translocation that persisted in blood cells for at least 1 year following transplantation. In conclusion, neither CIRCLE-seq or ISP predicted all sites, and a combination of careful gRNA design, followed by screening for predicted off-target sites in target cells by multiple methods, may be required for optimizing safety of clinical development.
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Affiliation(s)
- Aisha A AlJanahi
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA; Department of Biochemistry and Molecular Biology, Georgetown University, Washington, DC 20057, USA
| | - Cicera R Lazzarotto
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Shirley Chen
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Tae-Hoon Shin
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Stefan Cordes
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Xing Fan
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Isabel Jabara
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Yifan Zhou
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - David J Young
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Byung-Chul Lee
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Kyung-Rok Yu
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA; Department of Agricultural Biotechnology and Research Institute of Agriculture and Life Sciences, Seoul National University, Seoul 08826, Republic of Korea
| | - Yuesheng Li
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | | | - Ilker Tunc
- Bioinformatics and Computational Biology Laboratory, NHLBI, NIH, Bethesda, MD 20892, USA
| | - So Gun Hong
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Lauren L Truitt
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Julia Klermund
- Institute for Transfusion Medicine and Gene Therapy, Medical Center - University of Freiburg, 79106 Freiburg, Germany; Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany
| | - Geoffroy Andrieux
- Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; Institute of Medical Bioinformatics and Systems Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Partner Site Freiburg, 79106 Freiburg, Germany
| | - Miriam Y Kim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, Division of Oncology, Washington University School of Medicine, Saint Louis, MO 63110, USA
| | - Toni Cathomen
- Institute for Transfusion Medicine and Gene Therapy, Medical Center - University of Freiburg, 79106 Freiburg, Germany; Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany
| | - Saar Gill
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Shengdar Q Tsai
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Cynthia E Dunbar
- Translational Stem Cell Biology Branch, NHLBI, NIH, Building 10-CRC, 5E-3332, 9000 Rockville Pike, Bethesda, MD 20892, USA.
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10
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Visconte V, Maciejewski JP. Clonal dynamics of hematopoietic stem cell compartment in aplastic anemia. Semin Hematol 2022; 59:47-53. [DOI: 10.1053/j.seminhematol.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/27/2021] [Accepted: 12/30/2021] [Indexed: 11/11/2022]
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11
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Babushok DV. When does a PNH clone have clinical significance? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:143-152. [PMID: 34889408 PMCID: PMC8791108 DOI: 10.1182/hematology.2021000245] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired blood disease caused by somatic mutations in the phosphatidylinositol glycan class A (PIGA) gene required to produce glycophosphatidyl inositol (GPI) anchors. Although PNH cells are readily identified by flow cytometry due to their deficiency of GPI-anchored proteins, the assessment of the clinical significance of a PNH clone is more nuanced. The interpretation of results requires an understanding of PNH pathogenesis and its relationship to immune-mediated bone marrow failure. Only about one-third of patients with PNH clones have classical PNH disease with overt hemolysis, its associated symptoms, and the highly prothrombotic state characteristic of PNH. Patients with classical PNH benefit the most from complement inhibitors. In contrast, two-thirds of PNH clones occur in patients whose clinical presentation is that of bone marrow failure with few, if any, PNH-related symptoms. The clinical presentations are closely associated with PNH clone size. Although exceptions occur, bone marrow failure patients usually have smaller, subclinical PNH clones. This review addresses the common scenarios that arise in evaluating the clinical significance of PNH clones and provides practical guidelines for approaching a patient with a positive PNH result.
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Affiliation(s)
- Daria V. Babushok
- Division of Hematology-Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; and Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
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12
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Lee BC, Lozano RJ, Dunbar CE. Understanding and overcoming adverse consequences of genome editing on hematopoietic stem and progenitor cells. Mol Ther 2021; 29:3205-3218. [PMID: 34509667 DOI: 10.1016/j.ymthe.2021.09.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/25/2021] [Accepted: 09/03/2021] [Indexed: 12/12/2022] Open
Abstract
Hematopoietic stem and progenitor cell (HSPC) gene therapies have recently moved beyond gene-addition approaches to encompass targeted genome modification or correction, based on the development of zinc finger nucleases (ZFNs), transcription activator-like effector nucleases (TALENs), and CRISPR-Cas technologies. Advances in ex vivo HSPC manipulation techniques have greatly improved HSPC susceptibility to genetic modification. Targeted gene-editing techniques enable precise modifications at desired genomic sites. Numerous preclinical studies have already demonstrated the therapeutic potential of gene therapies based on targeted editing. However, several significant hurdles related to adverse consequences of gene editing on HSPC function and genomic integrity remain before broad clinical potential can be realized. This review summarizes the status of HSPC gene editing, focusing on efficiency, genomic integrity, and long-term engraftment ability related to available genetic editing platforms and HSPC delivery methods. The response of long-term engrafting HSPCs to nuclease-mediated DNA breaks, with activation of p53, is a significant challenge, as are activation of innate and adaptive immune responses to editing components. Lastly, we propose alternative strategies that can overcome current hurdles to HSPC editing at various stages from cell collection to transplantation to facilitate successful clinical applications.
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Affiliation(s)
- Byung-Chul Lee
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Richard J Lozano
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Cynthia E Dunbar
- Translational Stem Cell Biology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA.
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13
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Chen Y, Rong F. Advances in the creation of animal models of paroxysmal nocturnal hemoglobinuria. ACTA ACUST UNITED AC 2021; 26:491-496. [PMID: 34238137 DOI: 10.1080/16078454.2021.1945244] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a disease caused by a phosphatidylinositol glycan anchor biosynthesis class A (PIG-A) mutation in hematopoietic stem cells. There are three theories about the possible mechanism of the pathogenesis of PNH: immune escape, anti-apoptotic mechanism, and secondary gene mutation. There has been little gain in the knowledge regarding its pathogenesis during the last decade owing to the lack of representative cell lines and animal models. There have been recent reports about the successful creation of PNH mouse and PNH rhesus macaque models. The detection of glycosylphosphatidylinositol-anchor protein (GPI-AP)-deficient cells and/or fluorescently labeled variant of aerolysin (FLAER) test, estimation of erythrocyte life span, and hemolysis-related experiments demonstrated that these animal models of PNH had GPI-AP-deficient blood cells with shortened lifespans and increased sensitivity to complement-activated hemolysis. However, there were no clinical manifestations such as hemolysis and thrombosis in these animal models. This suggested that the PIG-A mutation is one of the several conditions required for PNH, but it alone is not enough to cause PNH.
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Affiliation(s)
- Yingying Chen
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Fu Rong
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
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14
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Paroxysmal nocturnal hemoglobinuria caused by CN-LOH of constitutional PIGB mutation and 70-kbp microdeletion on 15q. Blood Adv 2020; 4:5755-5761. [PMID: 33216889 DOI: 10.1182/bloodadvances.2020002210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/20/2020] [Indexed: 12/31/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematopoietic stem cell (HSC) disorder characterized by defective synthesis of the glycosylphosphatidylinositol (GPI) anchors as a result of somatic mutations in the X-linked PIGA gene. The disease is acquired. No constitutional PNH has been described. Here, we report familial PNH associated with unusual inflammatory symptoms. Genetic analysis revealed a germline heterozygous PIGB mutation on chromosome 15 without mutations in PIGA or any of the other genes involved in GPI biosynthesis. In vitro data confirmed that transfection of the mutant PIGB could not restore the surface expression of GPI-anchored proteins (APs) in PIGB-deficient Chinese hamster ovary cells. Homozygosity was caused by copy number-neutral loss of heterozygosity (CN-LOH) of the germline PIGB mutation, leading to deficient expression of GPI-APs in the affected blood cells of the index patient and her mother. The somatic event leading to homozygosity of the germline mutant PIGB gene involved a 70-kbp microdeletion of chromosome 15q containing the TM2D3 and TARSL2 genes, which was implicated in chromosome 15q mosaicism. Interestingly, we detected the deletion in both the patient and her mother. A sister of the mother, who carried the same germline PIGB mutation but without this microdeletion involving TM2D3 and TARSL2, did not have a PNH clone or CN-LOH. In conclusion, we describe PNH caused by CN-LOH of a germline heterozygous PIGB mutation in a patient and her mother and hypothesize that the 70-kbp microdeletion may have contributed to the PNH clone in both.
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15
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Sun L, Babushok DV. Secondary myelodysplastic syndrome and leukemia in acquired aplastic anemia and paroxysmal nocturnal hemoglobinuria. Blood 2020; 136:36-49. [PMID: 32430502 PMCID: PMC7332901 DOI: 10.1182/blood.2019000940] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/09/2019] [Indexed: 02/06/2023] Open
Abstract
Acquired aplastic anemia (AA) and paroxysmal nocturnal hemoglobinuria (PNH) are pathogenically related nonmalignant bone marrow failure disorders linked to T-cell-mediated autoimmunity; they are associated with an increased risk of secondary myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). Approximately 15% to 20% of AA patients and 2% to 6% of PNH patients go on to develop secondary MDS/AML by 10 years of follow-up. Factors determining an individual patient's risk of malignant transformation remain poorly defined. Recent studies identified nearly ubiquitous clonal hematopoiesis (CH) in AA patients. Similarly, CH with additional, non-PIGA, somatic alterations occurs in the majority of patients with PNH. Factors associated with progression to secondary MDS/AML include longer duration of disease, increased telomere attrition, presence of adverse prognostic mutations, and multiple mutations, particularly when occurring early in the disease course and at a high allelic burden. Here, we will review the prevalence and characteristics of somatic alterations in AA and PNH and will explore their prognostic significance and mechanisms of clonal selection. We will then discuss the available data on post-AA and post-PNH progression to secondary MDS/AML and provide practical guidance for approaching patients with PNH and AA who have CH.
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MESH Headings
- Age of Onset
- Anemia, Aplastic/drug therapy
- Anemia, Aplastic/genetics
- Anemia, Aplastic/pathology
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Benzoates/adverse effects
- Benzoates/therapeutic use
- Bone Marrow/pathology
- Chromosome Aberrations
- Chromosomes, Human, Pair 7/genetics
- Clonal Evolution/drug effects
- Clone Cells/drug effects
- Clone Cells/pathology
- Disease Progression
- Granulocyte Colony-Stimulating Factor/adverse effects
- Granulocyte Colony-Stimulating Factor/therapeutic use
- Hemoglobinuria, Paroxysmal/drug therapy
- Hemoglobinuria, Paroxysmal/genetics
- Hemoglobinuria, Paroxysmal/pathology
- Humans
- Hydrazines/adverse effects
- Hydrazines/therapeutic use
- Leukemia, Myeloid, Acute/epidemiology
- Leukemia, Myeloid, Acute/etiology
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Models, Biological
- Monosomy
- Mutation
- Myelodysplastic Syndromes/epidemiology
- Myelodysplastic Syndromes/etiology
- Myelodysplastic Syndromes/genetics
- Myelodysplastic Syndromes/pathology
- Oncogene Proteins, Fusion/genetics
- Pyrazoles/adverse effects
- Pyrazoles/therapeutic use
- Selection, Genetic
- Telomere Shortening
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Affiliation(s)
- Lova Sun
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA; and
| | - Daria V Babushok
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA; and
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
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