1
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Zhang Y, Li J, Li X, Geng Q, Xie Y, Zhang G, Wei M, Ma Y. Efficacy and safety of immunosuppressive therapy combined with eltrombopag for severe aplastic anemia: a systematic review and meta-analysis. Syst Rev 2024; 13:101. [PMID: 38576005 PMCID: PMC10993616 DOI: 10.1186/s13643-024-02515-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/17/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Immunosuppressive therapy (IST) is the first choice for severe aplastic anemia (SAA) patients with hematopoietic stem cell transplantation (HSCT) limitation, and the main factor limiting its efficacy is too few residual hematopoietic stem/progenitor cells (HSPC). Eltrombopag (EPAG), as a small molecule thrombopoietin receptor agonist, can stimulate the proliferation of residual HSPC and restore the bone marrow hematopoietic function of patients. In recent years, many studies have observed the efficacy and safety of IST combined with EPAG in the treatment of SAA, but the results are still controversial. The aim of this study is to systematically evaluate the efficacy and safety of IST combined with or without EPGA in the treatment of SAA. METHODS We conducted a systematic review of all relevant literature published up to January 19, 2024. Pooled odds ratio (OR) was calculated to compare the rates, along with 95% confidence intervals (CI) and p value to assess whether the results were statistically significant by Review Manager 5.4.1. The p values for the interactions between each subgroup were calculated by Stata 15.1. The Newcastle-Ottawa Scale and the Cochrane bias risk assessment tools were respectively used to evaluate the quality of the literature with cohort studies and randomized controlled trials. The Review Manager 5.4.1 and Stata 15.1 were used to assess bias risk and perform the meta-analysis. RESULTS A total of 16 studies involving 2148 patients were included. The IST combined with the EPAG group had higher overall response rate (ORR) than the IST group at 3 months (pooled OR = 2.10, 95% CI 1.58-2.79, p < 0.00001) and 6 months (pooled OR = 2.13, 95% CI 1.60-2.83, p < 0.00001), but the difference between the two groups became statistically insignificant at 12 months (pooled OR = 1.13, 95% CI 0.75-1.72, p = 0.55). The results of complete response rate (CRR) (pooled OR at 3 months = 2.73, 95% CI 1.83-4.09, p < 0.00001, 6 months = 2.76, 95% CI 2.08-3.67, p < 0.00001 and 12 months = 1.38, 95% CI 0.85-2.23, p = 0.19) were similar to ORR. Compared with the IST group, the IST combined with the EPAG group had better overall survival rate (OSR) (pooled OR = 1.70, 95% CI 1.15-2.51, p = 0.008), but there were no statistically significant differences in event-free survival rate (EFSR) (pooled OR = 1.40, 95% CI 0.93-2.13, p = 0.11), clonal evolution rate (pooled OR = 0.68, 95% CI 0.46-1.00, p = 0.05) and other adverse events between the two groups. The results of subgroup analysis showed that different ages were a source of heterogeneity, but different study types and different follow-up times were not. Moreover, all p-values for the interactions were greater than 0.05, suggesting that the treatment effect was not influenced by subgroup characteristics. CONCLUSION EPAG added to IST enables patients to achieve earlier and faster hematologic responses with a higher rate of complete response. Although it had no effect on overall EFSR, it improved OSR and did not increase the incidence of clonal evolution and other adverse events.
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Affiliation(s)
- Yan Zhang
- Department of Hematology, Heji Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China
| | - Jie Li
- Department of Oncology and Hematology, Liuyang Hospital of Traditional Chinese Medicine, Hunan University of Chinese Medicine, Changsha, 410300, Hunan, China
| | - Xi Li
- Department of Nephrology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China
| | - Qianshuang Geng
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China
| | - Yuqin Xie
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China
| | - Guoxiang Zhang
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China
| | - Mingxia Wei
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China.
| | - Yanmei Ma
- Department of Hematology, Heji Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China.
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2
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Scheinberg P. Progress in medical therapy in aplastic anemia: why it took so long? Int J Hematol 2024; 119:248-254. [PMID: 38403842 DOI: 10.1007/s12185-024-03713-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/27/2023] [Accepted: 01/15/2024] [Indexed: 02/27/2024]
Abstract
The treatment of aplastic anemia (AA) has significantly advanced in the last 50 years, evolving from a fatal condition to one where survival rates now exceed 80-85%. Hematopoietic stem cell transplantation (HSCT) and immunosuppressive therapy (IST) have become the primary treatments, with the latter widely adopted due to factors like the scarcity of compatible donors, patient age, comorbidities, and limited HSCT access. A therapy breakthrough was the introduction of antithymocyte globulin (ATG), with its effectiveness further boosted by cyclosporine. However, it took years to achieve another major milestone in management. Initially, treatments aimed to intensify immunosuppression following the success of the ATG-cyclosporine combination, but these methods fell short of expectations. A major turning point was combining immunosuppression with stem cell stimulation, surpassing the efficacy of IST alone. Earlier, growth factors had shown limited success in AA treatment, but thrombopoietin receptor agonists represented a significant advancement. Initially applied alone as salvage, these were later combined with IST, forming the most effective current regimen for medically managing SAA. Horse ATG is the preferred formulation combined with cyclosporine and eltrombopag. This progress in AA treatment offers improved outcomes for patients afflicted with this once-lethal disease.
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Affiliation(s)
- Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, Rua Martiniano de Carvalho, 951, São Paulo, SP, 01321-001, Brazil.
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3
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Wang J, Liu J, Wang M, Zhao F, Ge M, Liu L, Jiang E, Feng S, Han M, Pei X, Zheng Y. Levamisole Suppresses CD4 + T-Cell Proliferation and Antigen-Presenting Cell Activation in Aplastic Anemia by Regulating the JAK/STAT and TLR Signaling Pathways. Front Immunol 2022; 13:907808. [PMID: 35911766 PMCID: PMC9331934 DOI: 10.3389/fimmu.2022.907808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
Aplastic anemia (AA) is a life-threatening disease primarily caused by a metabolic disorder and an altered immune response in the bone marrow (BM) microenvironment, where cytotoxic immune cells attack resident cells and lead to hematopoietic failure. We previously reported an efficient strategy by applying cyclosporin (CSA) combined with levamisole (CSA+LMS-based regimen) in the treatment of AA, but the immunoregulatory mechanism of LMS was still unclear. Here, the therapeutic effects of LMS were examined in vivo using the BM failure murine model. Meanwhile, the proportion and related function of T cells were measured by flow cytometry in vivo and in vitro. The involved signaling pathways were screened by RNA-seq and virtual binding analysis, which were further verified by interference experiments using the specific antagonists on the targeting cells by RT-PCR in vitro. In this study, the CSA+LMS-based regimen showed a superior immune-suppressive response and higher recession rate than standard CSA therapy in the clinical retrospective study. LMS improved pancytopenia and extended the survival in an immune-mediated BM failure murine model by suppressing effector T cells and promoting regulatory T-cell expansion, which were also confirmed by in vitro experiments. By screening of binding targets, we found that JAK1/2 and TLR7 showed the highest docking score as LMS targeting molecules. In terms of the underlying molecular mechanisms, LMS could inhibit JAK/STAT and TLR7 signaling activity and downstream involved molecules. In summary, LMS treatment could inhibit T-cell activation and downregulate related molecules by the JAK/STAT and TLR signaling pathways, supporting the valuable clinical utility of LMS in the treatment of AA.
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Affiliation(s)
- Jiali Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Hematopoietic Stem Cell Transplant Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Jia Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Hematopoietic Stem Cell Transplant Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Mingyang Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Hematopoietic Stem Cell Transplant Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Fei Zhao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Hematopoietic Stem Cell Transplant Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Meili Ge
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Anemia Disease Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Li Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Hematopoietic Stem Cell Transplant Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Hematopoietic Stem Cell Transplant Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Hematopoietic Stem Cell Transplant Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Mingzhe Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Hematopoietic Stem Cell Transplant Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Xiaolei Pei
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Hematopoietic Stem Cell Transplant Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yizhou Zheng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Anemia Disease Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
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4
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Unresponsive Severe Aplastic Anemia in a Young Patient: Case Report and Short Review of the Literature. JOURNAL OF INTERDISCIPLINARY MEDICINE 2021. [DOI: 10.2478/jim-2021-0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Abstract
Aplastic anemia or medullary aplasia is a medical condition characterized by pancytopenia and is associated with a high prevalence of morbidity and mortality. In patients in whom bone marrow transplantation cannot be attempted, an immunosuppressive regimen is considered to be the first-line therapy. Also, the addition of eltrombopag from the first day of immunosuppressive treatment seems to significantly increase response rate. Unfortunately, there are a small number of patients who remain unresponsive to all these therapies. Here we present the case of a young woman who was referred by the family doctor complaining of marked physical asthenia, new onset dyspnea, and dizziness. Apart from a severe pancytopenia, no further changes have been brought to light by paraclinical investigations. After multiple secondary causes were excluded, the patient was diagnosed with idiopathic aplastic anemia. Even if bone marrow transplant was the first-line therapy in this case, because of the severe leukopenia, it was not possible to determine the HLA type. Therefore, the patient was prescribed immunosuppressive treatment. Despite the three drug-associated therapy (horse anti-thymocyte globulin, cyclosporin A, and eltrombopag), the response was unsatisfactory, with the persistence of severe pancytopenia.
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5
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Scheinberg P. Acquired severe aplastic anaemia: how medical therapy evolved in the 20th and 21st centuries. Br J Haematol 2021; 194:954-969. [PMID: 33855695 DOI: 10.1111/bjh.17403] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
The progress in aplastic anaemia (AA) management is one of success. Once an obscure entity resulting in death in most affected can now be successfully treated with either haematopoietic stem cell transplantation (HSCT) or immunosuppressive therapy (IST). The mechanisms that underly the diminution of haematopoietic stem cells (HSCs) are now better elucidated, and include genetics and immunological alterations. Advances in supportive care with better antimicrobials, safer blood products and iron chelation have greatly impacted AA outcomes. Working somewhat 'mysteriously', anti-thymocyte globulin (ATG) forms the base for both HSCT and IST protocols. Efforts to augment immunosuppression potency have not, unfortunately, led to better outcomes. Stimulating HSCs, an often-sought approach, has not been effective historically. The thrombopoietin receptor agonists (Tpo-RA) have been effective in stimulating early HSCs in AA despite the high endogenous Tpo levels. Dosing, timing and best combinations with Tpo-RAs are being defined to improve HSCs expansion in AA with minimal added toxicity. The more comprehensive access and advances in HSCT and IST protocols are likely to benefit AA patients worldwide. The focus of this review will be on the medical treatment advances in AA.
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Affiliation(s)
- Phillip Scheinberg
- Division of Haematology, Hospital A Beneficência Portuguesa, São Paulo, Brazil
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6
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Luo CJ, Chen J, Wang JM, Qin X, Zhang BH, Zhu H, Wang XN, Cai JY, Luo CY. [Alternative donor HSCT for 109 children with acquired severe aplastic anemia: a single center retrospective analysis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:128-131. [PMID: 32135629 PMCID: PMC7357947 DOI: 10.3760/cma.j.issn.0253-2727.2020.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
目的 了解替代供者(AD)移植一线治疗儿童再生障碍性贫血(AA)的疗效及安全性。 方法 回顾性分析2010年4月1日至2016年12月31日在上海儿童医学中心一线接受AD移植治疗的AA患儿临床资料,统计分析总生存(OS)率、植入成功率、移植物抗宿主病(GVHD)发生率等指标。 结果 共纳入109例患者,极重型AA(VSAA)32例,重型AA(SAA)64例,非重型AA(NSAA)伴输血依赖13例,中位年龄6(0.8~18)岁,其中44例患者接受全相合无关供者(MUD)移植,44例接受8–9/10位点不全相合无关供者(MMUD)移植,21例接受不全相合亲缘供者(MMRD)移植,所有患者均接受以外周血干细胞(PBSC)为主的移植,≥3个位点不合的单倍型移植加第三方脐血(UCB)一份。所有患者移植前均未接受过抗胸腺细胞球蛋白(ATG)治疗,并排除活动性感染。106例(97.2%)获造血重建,中性粒细胞中位重建时间为13(9~19)d,血小板中位重建时间为16(10~81)d。死亡13例,5年OS率为88.1%(95%CI 81.1%~91.4%),MUD、MMUD及MMRD三组患者OS率差异无统计学意义(P=0.361)。总体急性GVHD(aGVHD)及Ⅱ~Ⅳ度aGVHD发生率分别为74.3%和39.4%,总体慢性GVHD(cGVHD)和中度cGVHD发生率分别为30.7%和9.9%,无一例患者发生重度cGVHD。 结论 对于无同胞全相合供者的SAA/VSAA患儿,早期一线接受AD移植可能是一个选择,但需要进一步探索更有效的预防及治疗GVHD的措施。
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Affiliation(s)
- C J Luo
- Shanghai Jiao Tong University, School of Medicine, Shanghai Children's Medical Center, Shanghai 200217, China
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7
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Fox LC, Wood EM, Ritchie DS, Blombery P. Diagnostic evaluation and considerations in hypocellular bone marrow failure—A focus on genomics. Int J Lab Hematol 2020; 42 Suppl 1:82-89. [DOI: 10.1111/ijlh.13179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/09/2020] [Accepted: 02/11/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Lucy C. Fox
- Peter MacCallum Cancer Centre Melbourne Vic. Australia
- University of Melbourne Melbourne Vic. Australia
- Transfusion Research Unit Monash University Melbourne Vic. Australia
| | - Erica M. Wood
- Transfusion Research Unit Monash University Melbourne Vic. Australia
- Monash Health Melbourne Vic. Australia
| | - David S. Ritchie
- Peter MacCallum Cancer Centre Melbourne Vic. Australia
- University of Melbourne Melbourne Vic. Australia
| | - Piers Blombery
- Peter MacCallum Cancer Centre Melbourne Vic. Australia
- University of Melbourne Melbourne Vic. Australia
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8
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Kikkawa E, Shiina T, Shigenari A, Ozaki Y, Suzuki S, Ando K, Onizuka M. Detection of 6pLOH in an aplastic anemia patient by in phase HLA genotyping. HLA 2020; 95:465-469. [PMID: 31970935 DOI: 10.1111/tan.13807] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/08/2020] [Accepted: 01/15/2020] [Indexed: 12/13/2022]
Abstract
Recent studies have reported loss of heterozygosity in the chromosome 6p arms (6pLOH) of acquired aplastic anemia (AA) patients, and in tumor cells trying to escape the autoimmune system. We thus sought to establish detection methods for LOH to investigate the mechanisms underlying AA and tumor immunity. Herein, we report our evaluation of 6pLOH in a patient with severe AA patient using super-high resolution, single-molecule, sequence-based typing (SS-SBT). The highest ratios of 6pLOH detection were observed during the patient's treatment with granulocyte colony stimulating factor (G-CSF). This result suggested that most of the neutrophil precursor cells stimulated by G-CSF already had LOH in the HLA lesion. The SS-SBT method is a simple NGS method that provides complete HLA allele coverage.
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Affiliation(s)
- Eri Kikkawa
- Department of Hematology/Oncology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Takashi Shiina
- Department of Molecular Life Science, Tokai University School of Medicine, Isehara, Japan
| | - Atsuko Shigenari
- Department of Molecular Life Science, Tokai University School of Medicine, Isehara, Japan
| | - Yuki Ozaki
- Department of Molecular Life Science, Tokai University School of Medicine, Isehara, Japan
| | - Shingo Suzuki
- Department of Molecular Life Science, Tokai University School of Medicine, Isehara, Japan
| | - Kiyoshi Ando
- Department of Hematology/Oncology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
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9
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Jiang J, Cai Y, Wan L, Yang J, Wang C. Cord blood infusion-accelerated hematopoietic recovery after combined immunosuppressive therapy with fludarabine and rabbit ATG in severe aplastic anemia. Int J Hematol 2020; 111:360-368. [PMID: 31900878 DOI: 10.1007/s12185-019-02807-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 12/15/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022]
Abstract
Immunosuppressive therapy (IST) with anti-thymocyte globulin (ATG) and cyclosporine A (CsA) is currently the standard treatment for patients with severe aplastic anemia (SAA) who have no suitable donor or are ineligible for allogeneic stem cell transplantation. However, the delayed hematopoietic recovery, which accounts for most early deaths, remains a key problem. Thus, we designed an IST protocol with fludarabine, rabbit ATG, and CsA followed by unrelated cord blood (UCB) infusion to study whether hematopoiesis could be accelerated. Nineteen patients were enrolled in this study. The median neutrophil recovery time was 22 days and the treatment-related mortality within 3 months was 5.3%. The median platelet recovery time was 180 days. Six patients had transient or sustained UCB engraftment and the median platelet recovery time of these patients was significantly shorter than those who had no UCB engraftment (46 days vs 206 days, p = 0.006). The cumulative incidence of response rate at 12 months was up to 88.7% with CR rate of 72.2%. The overall survival at 2 years and 5 years was 94.7% and 78.9%, respectively. These results suggest that UCB infusion may play an important role in accelerating hematopoietic recovery in this protocol.
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Affiliation(s)
- Jieling Jiang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200080, China
| | - Yu Cai
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200080, China
| | - Liping Wan
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200080, China
| | - Jun Yang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200080, China
| | - Chun Wang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200080, China.
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10
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Clucas DB, Fox LC, Wood EM, Hong FS, Gibson J, Bajel A, Szer J, Blombery P, McQuilten ZK, Hiwase D, Firkin F, Cole-Sinclair MF. Revisiting acquired aplastic anaemia: current concepts in diagnosis and management. Intern Med J 2019; 49:152-159. [PMID: 30324755 DOI: 10.1111/imj.14140] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 07/26/2018] [Accepted: 09/30/2018] [Indexed: 12/24/2022]
Abstract
Acquired aplastic anaemia is a rare, serious, immunologically mediated bone marrow failure syndrome, characterised by marrow hypoplasia of varying severity and significant pancytopenia. Careful attention and investigation, including molecular testing, is required to confirm the diagnosis and exclude other mimicking conditions, such as inherited bone marrow failure syndromes. In a proportion of patients, the disease evolves to myelodysplasia or acute myeloid leukaemia and in some there is an association with paroxysmal nocturnal haemoglobinuria. The disease has a major impact on patient quality of life. Haemopoietic stem/progenitor cell transplantation for eligible patients with an available donor is the only current curative therapy. Other patients may receive immunosuppression, most commonly with anti-thymocyte globulin and cyclosporin. An initial response to immunosuppression is often encouraging, but relapse is common. Supportive care, including management of transfusion requirements and infections, is central to management. Promising new diagnostic tools and emerging therapies will likely transform approaches to this important, chronic and life-threatening condition.
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Affiliation(s)
- Danielle B Clucas
- Department of Clinical Haematology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Lucy C Fox
- Department of Clinical Haematology, Epworth Hospital, Monash University, Melbourne, Victoria, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Frank S Hong
- Department of Clinical Haematology, The Northern Hospital, Melbourne, Victoria, Australia.,Clinical Services and Research, Australian Red Cross Blood Service, Melbourne, Victoria, Australia
| | - John Gibson
- Institute of Haematology, Royal Prince Alfred Hospital, Adelaide, South Australia, Australia.,The University of Sydney, Sydney, South Australia, Australia
| | - Ashish Bajel
- Integrated Haematology Service, Victorian Comprehensive Cancer Centre (The Royal Melbourne Hospital/Peter MacCallum Cancer Centre), Melbourne, Victoria, Australia
| | - Jeff Szer
- Integrated Haematology Service, Victorian Comprehensive Cancer Centre (The Royal Melbourne Hospital/Peter MacCallum Cancer Centre), Melbourne, Victoria, Australia
| | - Piers Blombery
- Molecular Haematology Laboratory, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Zoe K McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Medical Centre, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Devendra Hiwase
- Department of Clinical Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,The University of Adelaide, Adelaide, South Australia, Australia
| | - Frank Firkin
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
| | - Merrole F Cole-Sinclair
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
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11
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Activity of eltrombopag in severe aplastic anemia. Blood Adv 2019; 2:3054-3062. [PMID: 30425070 DOI: 10.1182/bloodadvances.2018020248] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 09/24/2018] [Indexed: 12/22/2022] Open
Abstract
Since the approval of horse antithymocyte globulin (ATG) decades ago, there was a long hiatus in therapies with activity in severe aplastic anemia (SAA). This scenario changed in 2014 when eltrombopag, a thrombopoietin receptor agonist, was approved for SAA after an insufficient response to initial immunosuppressive therapy (IST). The basis for this approval was the observation of single-agent activity of eltrombopag in this patient population, where 40% to 50% recovered blood counts at times involving >1 lineage. The achievement of transfusion independence confirmed the clinical benefit of this approach. Increase in marrow cellularity and CD34+ cells suggested a recovery to a more functioning bone marrow. Further in its development, eltrombopag was associated with standard horse ATG plus cyclosporine in first line, producing increases in overall (at about 90%) and complete response rates (at about 40%) and leading to transfusion independence and excellent survival. Interestingly, best results were observed when all drugs were started simultaneously. The cumulative incidence of clonal cytogenetic abnormalities to date has compared favorably with the vast experience with IST alone in SAA. Longer follow-up will help in define these long-term risks. In this review, the development of eltrombopag in SAA will be discussed.
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12
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Evaluating the Efficacy and Anti-infective Effect of High-dose Intravenous Immunoglobulin Adjuvant Therapy for Acquired Aplastic Anemia Children. J Pediatr Hematol Oncol 2019; 41:129-132. [PMID: 30339655 DOI: 10.1097/mph.0000000000001333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The efficacy and anti-infective effect of high-dose intravenous immunoglobulin (HDIVIG) in severe or very severe aplastic anemia children were evaluated. PATIENTS AND METHODS In total, 61 patients who underwent immunosuppressive therapy were retrospectively reviewed. The non-IVIG group (30 cases) received rabbit-antithymocyte protein (R-ATG, 3 to 5 mg/kg/d, for 5 consecutive days)+cyclosporin A (CSA), and the HDIVIG group (31 cases) underwent R-ATG+CSA+immunoglobulin (1 g/kg/d, for 2 consecutive days, once a month, 6 times). RESULTS The early effective rate was higher in the HDIVIG group (P=0.020). However, the long-term effective rate and the 5-year overall survival rates difference were not statistically significant (P=0.717, 0.419). The infection rate and severe infection rate in the HDIVIG group were lower (P=0.003, 0.008). The infection-related mortality differences were not statistically significant after ATG application (P>0.05). In the HDIVIG group, 9 patients were nonresponders. Among the nonresponders, 8 patients' first-dose IVIG was given within 7 days before ATG. CONCLUSIONS HDIVIG may increase the early effective rate and reduce early infection and serious infection for aplastic anemia children, but failed to reduce the infection-related mortality.
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13
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Scheinberg P. Activity of eltrombopag in severe aplastic anemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:450-456. [PMID: 30504345 PMCID: PMC6245975 DOI: 10.1182/asheducation-2018.1.450] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Since the approval of horse antithymocyte globulin (ATG) decades ago, there was a long hiatus in therapies with activity in severe aplastic anemia (SAA). This scenario changed in 2014 when eltrombopag, a thrombopoietin receptor agonist, was approved for SAA after an insufficient response to initial immunosuppressive therapy (IST). The basis for this approval was the observation of single-agent activity of eltrombopag in this patient population, where 40% to 50% recovered blood counts at times involving >1 lineage. The achievement of transfusion independence confirmed the clinical benefit of this approach. Increase in marrow cellularity and CD34+ cells suggested a recovery to a more functioning bone marrow. Further in its development, eltrombopag was associated with standard horse ATG plus cyclosporine in first line, producing increases in overall (at about 90%) and complete response rates (at about 40%) and leading to transfusion independence and excellent survival. Interestingly, best results were observed when all drugs were started simultaneously. The cumulative incidence of clonal cytogenetic abnormalities to date has compared favorably with the vast experience with IST alone in SAA. Longer follow-up will help in define these long-term risks. In this review, the development of eltrombopag in SAA will be discussed.
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Affiliation(s)
- Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, Sao Paulo, Brazil
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14
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Deeg HJ. More than one angle to target aplastic anemia? Cancer 2018; 124:4165-4167. [PMID: 30307607 DOI: 10.1002/cncr.31656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/22/2016] [Accepted: 06/08/2018] [Indexed: 11/07/2022]
Affiliation(s)
- H Joachim Deeg
- Fred Hutchinson Cancer Research Center, University of Washington School of Medicine, Seattle, Washington
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15
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Saponins from Panax notoginseng leaves improve the symptoms of aplastic anemia and aberrant immunity in mice. Biomed Pharmacother 2018; 102:959-965. [PMID: 29710551 DOI: 10.1016/j.biopha.2018.03.175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/26/2018] [Accepted: 03/28/2018] [Indexed: 12/27/2022] Open
Abstract
Aplastic anemia (AA) is usually treated with immunosuppressive agents, but their efficacy and safety are not satisfactory. Panax notoginseng saponins (PNS) promote the proliferation of hematopoietic stem/progenitor cells. This study aimed to examine the effects of leaf PNS (LPNS) on hematopoiesis and T cells in mouse models of AA. The experiments were performed in normal mice and AA mice (controls, cyclosporine, and low, medium, and high doses of LPNS). Hematopoietic cells were counted using colony formation assays. The proportions of T cells were measured by flow cytometry. The ERK1/2, T-bet, GATA-3, FOXP3, and RORγ proteins were assessed by western blotting. Cytokines were measured using a cytometric bead array. AA mice showed impaired hematopoiesis, high activation of T cells, and decreased expression of T-bet, GATA-3, and FOXP3. LPNS attenuated the inflammation observed in AA mice, and significantly increased the number of hematopoietic progenitor cells. The proportions of Th2 and regulatory T cells and the protein levels of P-ERK1/2, GATA-3, and FOXP3 were increased in the AA + LPNS mice compared with the AA mice. In contrast, LPNS decreased the proportions of Th1 and Th17 cells and the protein expression of T-bet. LPNS and cyclosporine had similar effects, but of different amplitudes. These results suggest that LPNS have dual activities in AA: 1) promoting the proliferation of hematopoietic progenitor cells; and 2) modulating T cell immune functions, an activity similar to that of cyclosporine. Additional studies are necessary to confirm those results before clinical use.
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16
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Sun YX, Li H, Feng Q, Li X, Yu YY, Zhou LW, Gao Y, Li GS, Ren J, Ma CH, Gao CJ, Peng J. Dysregulated miR34a/diacylglycerol kinase ζ interaction enhances T-cell activation in acquired aplastic anemia. Oncotarget 2018; 8:6142-6154. [PMID: 28008152 PMCID: PMC5351619 DOI: 10.18632/oncotarget.14046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 12/13/2016] [Indexed: 01/07/2023] Open
Abstract
Acquired aplastic anemia is an idiopathic paradigm of human bone marrow failure syndrome, which involves active destruction of hematopoietic stem cells and progenitors by cytotoxic T cells in the bone marrow. Aberrant expression of microRNAs in T cells has been shown to lead to development of certain autoimmune diseases. In the present study, we performed a microarray analysis of miRNA expression in bone marrow CD3+ T cells from patients with aplastic anemia and healthy controls. Overexpression of miR34a and underexpression of its target gene diacylglycerol kinase (DGK) ζ in bone marrow mononuclear cells were validated in 41 patients and associated with the severity of aplastic anemia. Further, the level of miR34a was higher in naïve T cells from patients than from controls. The role of miR34a and DGKζ in aplastic anemia was investigated in a murine model of immune-mediated bone marrow failure using miR34a−/− mice. After T-cell receptor stimulation in vitro, lymph node T cells from miR34a−/− mice demonstrated reduced activation and proliferation accompanied with a less profound down-regulation of DGKζ expression and decreased ERK phosphorylation compared to those from wild-type C57BL6 control mice. Infusion of 5 × 106 miR34a−/− lymph node T cells into sublethally irradiated CB6F1 recipients led to increased Lin-Sca1+CD117+ cells and less vigorous expansion of CD8+ T cells than injection of same number of wild-type lymph node cells. Our study demonstrates that the miR34a/DGKζ dysregulation enhances T-cell activation in aplastic anemia and targeting miR34a may represent a novel molecular therapeutic approach for patients with aplastic anemia.
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Affiliation(s)
- Yuan-Xin Sun
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Hui Li
- Department of Rheumatology, People's Hospital of Bao'an, Shenzhen, China
| | - Qi Feng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Xin Li
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Ying-Yi Yu
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Li-Wei Zhou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Yan Gao
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Guo-Sheng Li
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Shandong University, Jinan, China
| | - Juan Ren
- Department of Hematology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Chun-Hong Ma
- Department of Immunology, Shandong University School of Medicine, Jinan, China
| | - Cheng-Jiang Gao
- Department of Immunology, Shandong University School of Medicine, Jinan, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Jinan, China
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Gong D, Han SC, Iqbal A, Qian J, Cao T, Liu W, Liu W, Qin W, Guo H. Fast and Selective Two-Stage Ratiometric Fluorescent Probes for Imaging of Glutathione in Living Cells. Anal Chem 2017; 89:13112-13119. [PMID: 29160689 DOI: 10.1021/acs.analchem.7b02311] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Two fluorescent, m-nitrophenol-substituted difluoroboron dipyrromethene dyes have been designed by nucleophilic substitution reaction of 3,5-dichloro-4,4-difluoro-4-bora-3a,4a-diaza-s-indacene (BODIPY). Nonsymmetric and symmetric probes, that is. BODIPY 1 (with one nitrophenol group at the position 3) and BODIPY 2 (with two nitrophenol groups at the positions 3 and 5) were applied to ratiometric fluorescent glutathione detection. The detection is based on the two-step nucleophilic aromatic substitution of the nitrophenol groups of the probes by glutathione in buffer solution containing CTAB. In the first stage, probe 1 showed ratiometric fluorescent color change from green (λem = 530 nm) to yellow (λem = 561 nm) because of monosubstitution with glutathione (I561nm/I530nm). Addition of excess glutathione caused the second stage of ratiometric fluorescent color change from yellow to reddish orange (λem = 596 nm, I596nm/I561nm) due to disubstitution with glutathione. Therefore, different concentration ranges of glutathione (from less to excess) could be rapidly detected by the two-stage ratiometric fluorescent probe 1 in 5 min. While, probe 2 shows single-stage ratiometric fluorescent detection to GSH (from green to reddish orange, I596nm/I535nm). Probes 1 and 2 exhibit excellent properties with sensitive, specific colorimetric response and ratiometric fluorescent response to glutathione over other sulfur nucleophiles. Application to cellular ratiometric fluorescence imaging indicated that the probes were highly responsive to intracellular glutathione.
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Affiliation(s)
- Deyan Gong
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University , Lanzhou 730000, P. R. China
| | - Shi-Chong Han
- State Key Laboratory of Veterinary Etiological Biology and Key Laboratory of Animal Virology of Ministry of Agriculture, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Sciences , Xujiaping 1, Lanzhou, Gansu Province 730046, P. R. China
| | - Anam Iqbal
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University , Lanzhou 730000, P. R. China.,Chemistry Department, University of Balochistan , Quetta, Pakistan
| | - Jing Qian
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University , Lanzhou 730000, P. R. China
| | - Ting Cao
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University , Lanzhou 730000, P. R. China
| | - Wei Liu
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University , Lanzhou 730000, P. R. China
| | - Weisheng Liu
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University , Lanzhou 730000, P. R. China
| | - Wenwu Qin
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University , Lanzhou 730000, P. R. China
| | - Huichen Guo
- State Key Laboratory of Veterinary Etiological Biology and Key Laboratory of Animal Virology of Ministry of Agriculture, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Sciences , Xujiaping 1, Lanzhou, Gansu Province 730046, P. R. China
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18
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Boddu P, Garcia-Manero G, Ravandi F, Borthakur G, Jabbour E, DiNardo C, Jain N, Daver N, Pemmaraju N, Anderlini P, Parmar S, KC D, Akosile M, Pierce SA, Champlin R, Cortes J, Kantarjian H, Kadia T. Clinical outcomes in adult patients with aplastic anemia: A single institution experience. Am J Hematol 2017; 92:1295-1302. [PMID: 28850699 DOI: 10.1002/ajh.24897] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 08/21/2017] [Accepted: 08/24/2017] [Indexed: 11/08/2022]
Abstract
Newer treatment modalities are being investigated to improve upon historical outcomes with standard immunosuppressive therapy (IST) in aplastic anemia (AA). We analyzed outcomes of adult patients with AA treated with various combinatorial anti-thymoglobulin-based IST regimens in frontline and relapsed/refractory (R/R) settings. Pretreatment and on-treatment clinical characteristics were analyzed for relationships to response and outcome. Among 126 patients reviewed, 95 were treatment-naïve (TN) and 63, R/R (including 32 from the TN cohort); median ages were 49 and 50 years, respectively. Overall survival (OS) was superior in IST responders (P < .001). Partial response to IST was associated with shorter relapse-free survival (RFS), as compared with complete response (P = .03). By multivariate analysis, baseline platelet and lymphocyte count predicted for IST response at 3 and 6 months, respectively. While additional growth factor interventions led to faster count recovery, there were no statistically significant differences in RFS or OS across the various frontline IST regimens (i.e., with/without G-CSF or eltrombopag). While marrow cellularity did not correlate with peripheral-blood counts at 3 months, cytomorphological assessment revealed dyspoietic changes in all nonresponders with hypercellular-marrow indices. Covert dysplasia, identified through early bone marrow assessment, has implications on future therapy choices after IST failure. Salvage IST response depended upon prior response to ATG: prior responders (46%) vs. primary refractory (0%) (P < .01). In the R/R setting, there was no survival difference between IST and allogeneic stem cell transplant groups, with a trend toward superior OS in the former. Transplant benefits in the R/R setting may be underrealized due to transplant-related mortality.
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Affiliation(s)
- Prajwal Boddu
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Guillermo Garcia-Manero
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Farhad Ravandi
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Gautam Borthakur
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Elias Jabbour
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Courtney DiNardo
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Nitin Jain
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Naval Daver
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Naveen Pemmaraju
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Paolo Anderlini
- Stem Cell Transplant, The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Simrit Parmar
- Stem Cell Transplant, The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Devendra KC
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Mary Akosile
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Sherry A. Pierce
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Richard Champlin
- Stem Cell Transplant, The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Jorge Cortes
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Hagop Kantarjian
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
| | - Tapan Kadia
- Departments of Leukemia; The University of Texas, M. D. Anderson Cancer Center; Houston Texas
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19
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Boddu PC, Kadia TM. Updates on the pathophysiology and treatment of aplastic anemia: a comprehensive review. Expert Rev Hematol 2017; 10:433-448. [DOI: 10.1080/17474086.2017.1313700] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
| | - Tapan Mahendra Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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20
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Zhang H, Wang C, Wang G, Wang K, Jiang K. Thrombin-mediated ratiometric two-photon fluorescent probe for selective imaging of endogenous ultratrace glutathione in platelet. Biosens Bioelectron 2016; 78:344-350. [DOI: 10.1016/j.bios.2015.11.065] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/12/2015] [Accepted: 11/23/2015] [Indexed: 01/04/2023]
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21
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Prigge JR, Hoyt TR, Dobrinen E, Capecchi MR, Schmidt EE, Meissner N. Type I IFNs Act upon Hematopoietic Progenitors To Protect and Maintain Hematopoiesis during Pneumocystis Lung Infection in Mice. THE JOURNAL OF IMMUNOLOGY 2015; 195:5347-57. [PMID: 26519535 DOI: 10.4049/jimmunol.1501553] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 10/02/2015] [Indexed: 01/22/2023]
Abstract
Although acquired bone marrow failure (BMF) is considered a T cell-mediated autoimmune disease, few studies have considered contributing roles of innate immune deviations following otherwise innocuous infections as a cause underlying the immune defects that lead to BMF. Type I IFN signaling plays an important role in protecting hematopoiesis during systemic stress responses to the opportunistic fungal pathogen Pneumocystis. During Pneumocystis lung infection, mice deficient in both lymphocytes and type I IFN receptor (IFrag(-/-)) develop rapidly progressing BMF associated with accelerated hematopoietic cell apoptosis. However, the communication pathway eliciting the induction of BMF in response to this strictly pulmonary infection has been unclear. We developed a conditional-null allele of Ifnar1 and used tissue-specific induction of the IFrag(-/-) state and found that, following Pneumocystis lung infection, type I IFNs act not only in the lung to prevent systemic immune deviations, but also within the progenitor compartment of the bone marrow to protect hematopoiesis. In addition, transfer of sterile-filtered serum from Pneumocystis-infected mice as well as i.p. injection of Pneumocystis into uninfected IFrag(-/-) mice induced BMF. Although specific cytokine deviations contribute to induction of BMF, immune-suppressive treatment of infected IFrag(-/-) mice ameliorated its progression but did not prevent loss of hematopoietic progenitor functions. This suggested that additional, noncytokine factors also target and impair progenitor functions; and interestingly, fungal β-glucans were also detected in serum. In conclusion, our data demonstrate that type 1 IFN signaling protects hematopoiesis within the bone marrow compartment from the damaging effects of proinflammatory cytokines elicited by Pneumocystis in the lung and possibly at extrapulmonary sites via circulating fungal components.
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Affiliation(s)
- Justin R Prigge
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT 59718; and
| | - Teri R Hoyt
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT 59718; and
| | - Erin Dobrinen
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT 59718; and
| | - Mario R Capecchi
- Howard Hughes Medical Institute, University of Utah, Salt Lake City, UT 84112
| | - Edward E Schmidt
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT 59718; and
| | - Nicole Meissner
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT 59718; and
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22
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Dufour C, Veys P, Carraro E, Bhatnagar N, Pillon M, Wynn R, Gibson B, Vora AJ, Steward CG, Ewins AM, Hough RE, de la Fuente J, Velangi M, Amrolia PJ, Skinner R, Bacigalupo A, Risitano AM, Socie G, Peffault de Latour R, Passweg J, Rovo A, Tichelli A, Schrezenmeier H, Hochsmann B, Bader P, van Biezen A, Aljurf MD, Kulasekararaj A, Marsh JC, Samarasinghe S. Similar outcome of upfront-unrelated and matched sibling stem cell transplantation in idiopathic paediatric aplastic anaemia. A study on behalf of the UK Paediatric BMT Working Party, Paediatric Diseases Working Party and Severe Aplastic Anaemia Working Party of EBMT. Br J Haematol 2015. [PMID: 26223288 DOI: 10.1111/bjh.13614] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
We explored the feasibility of unrelated donor haematopoietic stem cell transplant (HSCT) upfront without prior immunosuppressive therapy (IST) in paediatric idiopathic severe aplastic anaemia (SAA). This cohort was then compared to matched historical controls who had undergone first-line therapy with a matched sibling/family donor (MSD) HSCT (n = 87) or IST with horse antithymocyte globulin and ciclosporin (n = 58) or second-line therapy with unrelated donor HSCT post-failed IST (n = 24). The 2-year overall survival in the upfront cohort was 96 ± 4% compared to 91 ± 3% in the MSD controls (P = 0·30) and 94 ± 3% in the IST controls (P = 0·68) and 74 ± 9% in the unrelated donor HSCT post-IST failure controls (P = 0·02).The 2-year event-free survival in the upfront cohort was 92 ± 5% compared to 87 ± 4% in MSD controls (P = 0·37), 40 ± 7% in IST controls (P = 0·0001) and 74 ± 9% in the unrelated donor HSCT post-IST failure controls (n = 24) (P = 0·02). Outcomes for upfront-unrelated donor HSCT in paediatric idiopathic SAA were similar to MSD HSCT and superior to IST and unrelated donor HSCT post-IST failure. Front-line therapy with matched unrelated donor HSCT is a novel treatment approach and could be considered as first-line therapy in selected paediatric patients who lack a MSD.
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Affiliation(s)
- Carlo Dufour
- Clinical and Experimental Haematology Unit, Giannina Gaslini Children's Hospital, Genova, Italy
| | - Paul Veys
- Department of Haematology & Bone Marrow Transplantation, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Elisa Carraro
- Paediatric Haematology and Oncology, University of Padova, Padova, Italy
| | - Neha Bhatnagar
- Department of Haematology & Bone Marrow Transplantation, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marta Pillon
- Paediatric Haematology and Oncology, University of Padova, Padova, Italy
| | - Rob Wynn
- Blood and Marrow Transplant Unit, Royal Manchester Children's Hospital, Manchester, UK
| | - Brenda Gibson
- Department of Paediatric Haematology & Oncology, Royal Hospital for Sick Children, Glasgow, UK
| | - Ajay J Vora
- Department of Paediatric Haematology, The Children's Hospital, Sheffield, UK
| | | | - Anna M Ewins
- Department of Paediatric Haematology & Oncology, Royal Hospital for Sick Children, Glasgow, UK
| | | | - Josu de la Fuente
- Division of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
| | | | - Persis J Amrolia
- Department of Haematology & Bone Marrow Transplantation, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Roderick Skinner
- Department of Paediatric and Adolescent Haematology/Oncology and BMT, Great North Children's Hospital & Northern Institute for Cancer Research, Newcastle upon Tyne, UK
| | - Andrea Bacigalupo
- Haematology and Oncology Department, IRCCS A.O.U. San Martino Hospital, IST, Genoa, Italy
| | | | | | | | - Jakob Passweg
- Stem Cell Transplant Team, Division of Haematology, University Hospital Basel, Basel, Switzerland
| | - Alicia Rovo
- Haematology, University Hospital of Basel, Basel, Switzerland
| | - André Tichelli
- Haematology, University Hospital of Basel, Basel, Switzerland
| | - Hubert Schrezenmeier
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Transfusion Service Baden-Württemberg-Hessen und University Hospital Ulm, Ulm, Germany
| | - Britta Hochsmann
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Transfusion Service Baden-Württemberg-Hessen und University Hospital Ulm, Ulm, Germany
| | - Peter Bader
- Division for Stem Cell Transplantation and Immunology, Hospital for Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Anja van Biezen
- EBMT Data Office, University Medical Centre, Leiden, The Netherlands
| | - Mahmoud D Aljurf
- Adult Haematology/HSCT Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Austin Kulasekararaj
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Judith C Marsh
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Sujith Samarasinghe
- Department of Haematology & Bone Marrow Transplantation, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Zeng Y, Katsanis E. The complex pathophysiology of acquired aplastic anaemia. Clin Exp Immunol 2015; 180:361-70. [PMID: 25683099 DOI: 10.1111/cei.12605] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2015] [Indexed: 12/15/2022] Open
Abstract
Immune-mediated destruction of haematopoietic stem/progenitor cells (HSPCs) plays a central role in the pathophysiology of acquired aplastic anaemia (aAA). Dysregulated CD8(+) cytotoxic T cells, CD4(+) T cells including T helper type 1 (Th1), Th2, regulatory T cells and Th17 cells, natural killer (NK) cells and NK T cells, along with the abnormal production of cytokines including interferon (IFN)-γ, tumour necrosis factor (TNF)-α and transforming growth factor (TGF)-β, induce apoptosis of HSPCs, constituting a consistent and defining feature of severe aAA. Alterations in the polymorphisms of TGF-β, IFN-γ and TNF-α genes, as well as certain human leucocyte antigen (HLA) alleles, may account for the propensity to immune-mediated killing of HSPCs and/or ineffective haematopoiesis. Although the inciting autoantigens remain elusive, autoantibodies are often detected in the serum. In addition, recent studies provide genetic and molecular evidence that intrinsic and/or secondary deficits in HSPCs and bone marrow mesenchymal stem cells may underlie the development of bone marrow failure.
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Affiliation(s)
- Y Zeng
- Department of Pediatrics, Steele Children's Research Center, University of Arizona, Tucson, AZ, USA
| | - E Katsanis
- Department of Pediatrics, Steele Children's Research Center, University of Arizona, Tucson, AZ, USA
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Samarasinghe S, Marsh J, Dufour C. Immune suppression for childhood acquired aplastic anemia and myelodysplastic syndrome: where next? Haematologica 2015; 99:597-9. [PMID: 24688105 DOI: 10.3324/haematol.2014.105569] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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25
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Xie X, Shi W, Zhou X, Shao Y, Qiao X. Comparison of rabbit antithymocyte globulin and Jurkat cell-reactive anti-t lymphocyte globulin as a first-line treatment for children with aplastic anemia. Exp Hematol 2014; 42:431-8. [DOI: 10.1016/j.exphem.2014.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 12/05/2013] [Accepted: 02/07/2014] [Indexed: 01/13/2023]
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26
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Lu S, Qin X, Yuan S, Li Y, Wang L, Jin Y, Zeng G, Yen L, Hu J, Dang T, Song S, Hou Q, Rao J. Effect of Tianshengyuan-1 (TSY-1) on telomerase activity and hematopoietic recovery - in vitro, ex vivo, and in vivo studies. Int J Clin Exp Med 2014; 7:597-606. [PMID: 24753753 PMCID: PMC3992398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 02/18/2014] [Indexed: 06/03/2023]
Abstract
Aplastic anemia is a heterogeneous disorder of bone marrow failure syndrome. Accumulating evidence indicates that both acquired and congenital aplastic anemia is linked to telomerase activity and telomere length. Chinese herbal medicine Tianshengyuan-1 (TSY-1), a liquid extraction of multiple Chinese herbs, appears to stimulate hematopoiesis in patients with bone marrow deficiencies; however, the exact mechanism of action remains unclear. In this study, we investigated the effect of TSY-1 on telomere length and telomerase activity. We first investigated the effects of TSY on in vitro cultured cell lines including CD34+ hepatic stem cells and CD4+/CD8- Jurkat cells. An immune-mediated murine aplastic anemia model and human samples, including peripheral blood samples of 4 healthy donors and bone marrow hematopoietic cells from 4 patients with hypocellular myelodysplastic syndrome (MDS), were also used to test the efficacy of TSY on hematopoiesis, telomerase activity and telomere length. Our results indicated that TSY-1 increased the telomerase activity and telomere length in a dose-response manner in vitro, in vivo, and in human samples including 3 of 4 healthy individuals and 3 of 4 bone marrow samples from MDS patients. In immune-mediated murine aplastic anemia model, TSY-1 activity on Telomere length was parallel to the significant increasing of the RBC, hemoglobin, hematocrit, and platelet count in peripheral blood, increasing of CD34+ cell count and hematopoiesis, and decreasing of fatty infiltration in bone marrow samples. Our study demonstrated that TSY-1 may exert its effects by modulating telomerase activity of hematopoietic cells. Further studies are warranted to explore the precise molecular mechanisms of how TSY-1 regulates telomerase activity and telomere length, and also to test the TSY-1 in randomized control trials.
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Affiliation(s)
- Su Lu
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los AngelesLos Angeles, CA, USA
- Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University and Tianjin Medical University Cancer Institute and HospitalTianjin, China
| | - Xiaotian Qin
- Beijing Tianyuyiming Biological Technology Co., Ltd (BTBTL)Beijing, China
| | - Shaopeng Yuan
- Institute of Materia Madica, Chinese Academy of Medical ScienceseBeijing, China
| | - Yawei Li
- Beijing Tianyuyiming Biological Technology Co., Ltd (BTBTL)Beijing, China
| | - Liming Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los AngelesLos Angeles, CA, USA
- Department of Surgery, Cancer Hospital, Chinese Academy of Medical ScienceBeijing, China
| | - Yusheng Jin
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los AngelesLos Angeles, CA, USA
| | - Gang Zeng
- Department of Urology, David Geffen School of Medicine, University of California at Los AngelesLos Angeles, CA, USA
| | - Lawrence Yen
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los AngelesLos Angeles, CA, USA
| | - Jenny Hu
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los AngelesLos Angeles, CA, USA
| | - Tracie Dang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los AngelesLos Angeles, CA, USA
| | - Sophie Song
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los AngelesLos Angeles, CA, USA
| | - Qi Hou
- Institute of Materia Madica, Chinese Academy of Medical ScienceseBeijing, China
| | - Jianyu Rao
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los AngelesLos Angeles, CA, USA
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Kulagin A, Lisukov I, Ivanova M, Golubovskaya I, Kruchkova I, Bondarenko S, Vavilov V, Stancheva N, Babenko E, Sipol A, Pronkina N, Kozlov V, Afanasyev B. Prognostic value of paroxysmal nocturnal haemoglobinuria clone presence in aplastic anaemia patients treated with combined immunosuppression: results of two-centre prospective study. Br J Haematol 2013; 164:546-54. [DOI: 10.1111/bjh.12661] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 10/09/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Alexander Kulagin
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Igor Lisukov
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Maria Ivanova
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Irina Golubovskaya
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | | | - Sergey Bondarenko
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Vladimir Vavilov
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Natalia Stancheva
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Elena Babenko
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | - Alexandra Sipol
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
| | | | | | - Boris Afanasyev
- First Pavlov State Medical University of St. Petersburg; St. Petersburg Novosibirsk Russia
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Shao Y, Li X, Shi J, Ge M, Huang J, Huang Z, Zhang J, Nie N, Zheng Y. Cyclosporin combined with levamisole for refractory or relapsed severe aplastic anaemia. Br J Haematol 2013; 162:552-5. [PMID: 23700976 DOI: 10.1111/bjh.12383] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Li X, Shao Y, Ge M, Shi J, Huang J, Huang Z, Zhang J, Nie N, Zheng Y. A promising immunosuppressive strategy of cyclosporine alternately combined with levamisole is highly effective for moderate aplastic anemia. Ann Hematol 2013; 92:1239-47. [PMID: 23620110 DOI: 10.1007/s00277-013-1764-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 04/15/2013] [Indexed: 10/26/2022]
Abstract
The appropriate management of patients with moderate aplastic anemia (mAA) remains to be unclear and controversial. A cohort of 118 patients with mAA received a novel immunosuppressive strategy of cyclosporine alternately combined with levamisole (CSA and LMS regimen), which included 42 newly diagnosed and 76 chronic (disease duration >6 months) cases. CSA and LMS regimen was orally administrated with the initial dose of CSA 3 mg/kg per day in adults or 5 mg/kg per day in children, and LMS 150 mg per day in adults or 2.5 mg/kg per day in children, continued for 12 more months after achieving maximal hematologic response, followed by a slow tapering. The overall response rates were of 100 and 86.8 % for newly diagnosed and chronic group, respectively. The 24-month progression-free survival were 95.2 % (95 % confidence intervals [CI], 85.9-100 %) and 93.6 % (95 % CI, 86.9-100 %) for newly diagnosed and chronic group, respectively (P = 0.50). The 2-year event-free survival for the patients in newly diagnosed group (86.6 %; 95 % CI, 70.4-100 %) was superior to that in chronic group (57.0 %; 95 % CI, 43.5-70.4 %, P = 0.001). To date, 11 patients relapsed and no patients evolved to clonal disorders. Thus, CSA and LMS regimen represents a promising immunosuppressive strategy for mAA.
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Affiliation(s)
- Xingxin Li
- Severe Aplastic Anemia Studying Program, State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 288 Nanjing Road, Tianjin, 300020, People's Republic of China
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Li X, Shi J, Ge M, Shao Y, Huang J, Huang Z, Zhang J, Nie N, Zheng Y. Outcomes of optimized over standard protocol of rabbit antithymocyte globulin for severe aplastic anemia: a single-center experience. PLoS One 2013; 8:e56648. [PMID: 23554855 PMCID: PMC3598903 DOI: 10.1371/journal.pone.0056648] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 01/11/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Previous reports showed that outcome of rabbit antithymocyte globulin (rATG) was not satisfactory as the first-line therapy for severe aplastic anemia (SAA). We explored a modifying schedule of administration of rATG. DESIGN AND METHODS Outcomes of a cohort of 175 SAA patients, including 51 patients administered with standard protocol (3.55 mg/kg/d for 5 days) and 124 cases with optimized protocol (1.97 mg/kg/d for 9 days) of rATG plus cyclosporine (CSA), were analyzed retrospectively. RESULTS Of all 175 patients, response rates at 3 and 6 months were 36.6% and 56.0%, respectively. 51 cases received standard protocol had poor responses at 3 (25.5%) and 6 months (41.2%). However, 124 patients received optimized protocol had better responses at 3 (41.1%, P = 0.14) and 6 (62.1%, P = 0.01). Higher incidences of infection (57.1% versus 37.9%, P = 0.02) and early mortality (17.9% versus 0.8%, P<0.001) occurred in patients received standard protocol compared with optimized protocol. The 5-year overall survival in favor of the optimized over standard rATG protocol (76.0% versus. 50.3%, P<0.001) was observed. By multivariate analysis, optimized protocol (RR = 2.21, P = 0.04), response at 3 months (RR = 10.31, P = 0.03) and shorter interval (<23 days) between diagnosis and initial dose of rATG (RR = 5.35, P = 0.002) were independent favorable predictors of overall survival. CONCLUSIONS Optimized instead of standard rATG protocol in combination with CSA remained efficacious as a first-line immunosuppressive regimen for SAA.
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Affiliation(s)
- Xingxin Li
- Severe Aplastic Anemia Studying Program, State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, P.R. China
| | - Jun Shi
- Severe Aplastic Anemia Studying Program, State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, P.R. China
| | - Meili Ge
- Severe Aplastic Anemia Studying Program, State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, P.R. China
| | - Yingqi Shao
- Severe Aplastic Anemia Studying Program, State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, P.R. China
| | - Jinbo Huang
- Severe Aplastic Anemia Studying Program, State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, P.R. China
| | - Zhendong Huang
- Severe Aplastic Anemia Studying Program, State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, P.R. China
| | - Jing Zhang
- Severe Aplastic Anemia Studying Program, State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, P.R. China
| | - Neng Nie
- Severe Aplastic Anemia Studying Program, State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, P.R. China
| | - Yizhou Zheng
- Severe Aplastic Anemia Studying Program, State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, P.R. China
- * E-mail:
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31
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Gerds AT, Scott BL. Last marrow standing: bone marrow transplantation for acquired bone marrow failure conditions. Curr Hematol Malig Rep 2012; 7:292-9. [PMID: 23065408 DOI: 10.1007/s11899-012-0138-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Paroxysmal nocturnal hemoglobinuria, aplastic anemia, and myelodysplastic syndrome are a spectrum of acquired marrow failure, having a common pathologic thread of both immune dysregulation and the development of abnormal hematopoiesis. Allogeneic hematopoietic cell transplantation plays a critical role in the treatment of these disorders and, for many patients, is the only treatment modality with demonstrated curative potential. In recent years, there have been many breakthroughs in the understanding of the pathogenesis of these uncommon disorders. The subsequent advances in non-transplant therapies, along with concurrent improvement in outcomes after hematopoietic cell transplantation, necessitate continual appraisal of the indications, timing, and approaches to transplantation for acquired marrow failure syndromes. We review here contemporary and critical new findings driving current treatment decisions.
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Affiliation(s)
- Aaron T Gerds
- Fred Hutchinson Cancer Research Center and the University of Washington School of Medicine, 1100 Fairview Avenue N, D1-100, Seattle, WA, 98109-1024, USA.
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32
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Samarasinghe S, Webb DKH. How I manage aplastic anaemia in children. Br J Haematol 2012; 157:26-40. [PMID: 22348483 DOI: 10.1111/j.1365-2141.2012.09058.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 01/09/2012] [Indexed: 01/09/2023]
Abstract
Aplastic anaemia (AA) is a rare heterogeneous condition in children. 15-20% of cases are constitutional and correct diagnosis of these inherited causes of AA is important for appropriate management. For idiopathic severe aplastic anaemia, a matched sibling donor (MSD) haematopoietic stem cell transplant (HSCT) is the treatment of choice. If a MSD is not available, the options include immunosuppressive therapy (IST) or unrelated donor HSCT. IST with horse anti-thymocyte globulin (ATG) is superior to rabbit ATG and has good long-term results. In contrast, IST with rabbit ATG has an overall response of only 30-40%. Due to improvements in outcome over the last two decades in matched unrelated donor (MUD) HSCT, results are now similar to that of MSD HSCT. The decision to proceed with IST with ATG or MUD HSCT will depend on the likelihood of finding a MUD and the differing risks and benefits that each therapy provides.
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Affiliation(s)
- Sujith Samarasinghe
- Paediatric Haematopoietic Stem Cell Transplant Unit, Department of Adolescent and Paediatric Haematology and Oncology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle Upon Tyne, UK.
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Gómez-Almaguer D, Jaime-Pérez JC, Ruiz-Arguelles GJ. Antibodies in the treatment of aplastic anemia. Arch Immunol Ther Exp (Warsz) 2012; 60:99-106. [PMID: 22307362 DOI: 10.1007/s00005-012-0164-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 11/28/2011] [Indexed: 11/30/2022]
Abstract
Antibodies have been the cornerstone of treatment of acquired aplastic anemia for more than 25 years. Treatment with antithymocyte globulin (ATG) is considered pivotal and the addition of cyclosporine improves the overall response rate. This antibody is heterogeneous and horse ATG is apparently more effective than rabbit ATG. Several issues remain unsolved in relation to the combination of ATG and cyclosporine: cost, toxicity and late clonal disorders. In recent years, alternative immunosuppressive therapy has been proposed and new antibodies have emerged: porcine ATG, alemtuzumab, daclizumab, and rituximab. Experience with these antibodies is limited to a few studies with alemtuzumab being the most promising, but the results are interesting and provocative. More studies are needed to find the perfect antibody.
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Affiliation(s)
- David Gómez-Almaguer
- Hematology Service, Hospital Universitario, UANL, Paris 3029 Col. Cumbres, 64610, Monterrey, N.L., Mexico.
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Immunosuppressive therapies in the management of acquired immune-mediated marrow failures. Curr Opin Hematol 2012; 19:3-13. [PMID: 22143074 DOI: 10.1097/moh.0b013e32834da9a4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Immunosuppression is a key treatment strategy for patients suffering from aplastic anemia or related immune-mediated bone marrow failure syndromes. Several attempts have been performed to improve the standard immunosuppression regimen of horse antithymocyte globulin (h-ATG) and cyclosporine A (CyA). RECENT FINDINGS The addition of a third immunosuppression agent to h-ATG + CyA did not result in any improvement. Antilymphocyte agents other than h-ATG have been investigated. A rabbit-ATG preparation, which was known to be more immunosuppressive than h-ATG, resulted in markedly inferior outcome in a large randomized study from the National Institutes of Health. These data seem to be confirmed in additional experiences with rabbit-ATG from other groups. Cyclophosphamide and alemtuzumab have been proven to be biologically active in small studies, but available data suggest inferior outcomes when compared with h-ATG. All these alternative agents result in a more pronounced lymphocyte depletion, suggesting that the actual mechanisms of action of immunosuppressive therapy in aplastic anemia are not fully understood. SUMMARY Immunosuppression by h-ATG and CyA remains the standard of care for aplastic anemia patients lacking a low-risk transplant procedure, resulting in a 60-70% response rate. Rabbit-ATG, cyclophosphamide and alemtuzumab demonstrated a biological activity, but resulted in inferior outcome as compared with h-ATG; thus, they are not recommended as front-line therapy of aplastic anemia.
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Jia L, Yu J, He L, Wang H, Jiang L, Miao X, Wu W, Yang P. Nutritional support in the treatment of aplastic anemia. Nutrition 2011; 27:1194-201. [DOI: 10.1016/j.nut.2011.01.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 01/09/2011] [Accepted: 01/31/2011] [Indexed: 11/26/2022]
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Scheinberg P, Nunez O, Weinstein B, Scheinberg P, Biancotto A, Wu CO, Young NS. Horse versus rabbit antithymocyte globulin in acquired aplastic anemia. N Engl J Med 2011; 365:430-8. [PMID: 21812672 PMCID: PMC3721503 DOI: 10.1056/nejmoa1103975] [Citation(s) in RCA: 339] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In severe acquired aplastic anemia, hematopoietic failure is the result of immune-mediated destruction of bone marrow stem and progenitor cells. Immunosuppressive therapy with antithymocyte globulin (ATG) plus cyclosporine is an effective alternative to stem-cell transplantation and improves blood counts and survival. Although horse ATG is the standard therapy, rabbit ATG is more potent in depleting peripheral-blood lymphocytes and is preferred in other clinical circumstances. METHODS From December 2005 through July 2010, we performed a randomized trial comparing these two ATG formulations in conventional regimens. Patients were treated at a single facility. The primary outcome was hematologic response at 6 months, as determined by blood counts. The study was designed to enroll 60 patients each for the rabbit-ATG and horse-ATG groups and was powered to detect a difference of 25 percentage points in the response rate. RESULTS A large, unexpected difference was observed in the rate of hematologic response at 6 months in favor of horse ATG (68%; 95% confidence interval [CI], 56 to 80) as compared with rabbit ATG (37%; 95% CI, 24 to 49; P<0.001). Overall survival at 3 years also differed, with a survival rate of 96% (95% CI, 90 to 100) in the horse-ATG group as compared with 76% (95% CI, 61 to 95) in the rabbit-ATG group (P=0.04) when data were censored at the time of stem-cell transplantation, and 94% (95% CI, 88 to 100) as compared with 70% (95% CI, 56 to 86; P=0.008) in the respective groups when stem-cell-transplantation events were not censored. CONCLUSIONS In a randomized study, rabbit ATG was inferior to horse ATG as a first treatment for severe aplastic anemia, as indicated by hematologic response and survival. (Funded by the Intramural Research Program of the National Institutes of Health; ClinicalTrials.gov number, NCT00260689.).
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Affiliation(s)
- Phillip Scheinberg
- Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, MD, USA.
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Long-term follow-up of clonal evolutions in 802 aplastic anemia patients: a single-center experience. Ann Hematol 2011; 90:529-37. [DOI: 10.1007/s00277-010-1140-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2009] [Accepted: 12/14/2010] [Indexed: 10/18/2022]
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38
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Pulsipher MA, Young NS, Tolar J, Risitano AM, Deeg HJ, Anderlini P, Calado R, Kojima S, Eapen M, Harris R, Scheinberg P, Savage S, Maciejewski JP, Tiu RV, DiFronzo N, Horowitz MM, Antin JH. Optimization of therapy for severe aplastic anemia based on clinical, biologic, and treatment response parameters: conclusions of an international working group on severe aplastic anemia convened by the Blood and Marrow Transplant Clinical Trials Network, March 2010. Biol Blood Marrow Transplant 2010; 17:291-9. [PMID: 21034841 DOI: 10.1016/j.bbmt.2010.10.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 10/20/2010] [Indexed: 12/21/2022]
Abstract
Although recent advances in therapy offer the promise for improving survival in patients with severe aplastic anemia (SAA), the small size of the patient population, lack of a mechanism in North America for longitudinal follow-up of patients, and inadequate cooperation among hematologists, scientists, and transplant physicians remain obstacles to conducting large studies that would advance the field. To address this issue, the Blood and Marrow Transplant Clinical Trials Network (BMT CTN) convened a group of international experts in March 2010 to define the most important questions in the basic science, immunosuppressive therapy (IST), and bone marrow transplantation (BMT) of SAA and propose initiatives to facilitate clinical and biologic research. Key conclusions of the working group were: (1) new patients should obtain accurate, expert diagnosis and early identification of biologic risk; (2) a population-based SAA outcomes registry should be established in North America to collect data on patients longitudinally from diagnosis through and after treatment; (3) a repository of biologic samples linked to the clinical data in the outcomes registry should be developed; (4) innovative approaches to unrelated donor BMT that decrease graft-versus-host disease are needed; and (5) alternative donor transplantation approaches for patients lacking HLA-matched unrelated donors must be improved. A partnership of BMT, IST, and basic science researchers will develop initiatives and partner with advocacy and funding organizations to address these challenges. Collaboration with similar study groups in Europe and Asia will be pursued.
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Affiliation(s)
- Michael A Pulsipher
- Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City, Utah 84113, USA.
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Abstract
An immune basis for most patients with aplastic anemia (AA) provides a rationale for immunosuppressive therapy (IST), using antithmyocyte globulin and cyclosporine as one therapeutic modality; hematologic response is observed in up to 75% of patients. Recent advances in understanding the pathogenesis of AA have identified defective telomere maintenance as an important explanation for the onset of marrow failure, relapse and clonal evolution after IST, in some patients with AA. The finding of inherited mutations in the telomerase gene complex in patients with apparent acquired AA has important implications for clinical management. Hematopoietic stem cell transplantation (HSCT) for acquired AA, whether from an HLA identical sibling or an unrelated donor, provides an excellent chance of long term cure. Current issues with HSCT include graft rejection, chronic GVHD and poor outcome in older patients. The lack of a suitable bone marrow donor for all patients who need a transplant, illustrates the need for novel transplant procedures, such as cord blood transplantation.
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Affiliation(s)
- Neal S Young
- Hematology Branch, NHLBI, NIH, Bethesda, Maryland, USA
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