1
|
Tu Y, Zhang J, Zhao M, He F. Nomogram establishment for short-term survival prediction in ICU patients with aplastic anemia based on the MIMIC-IV database. Hematology 2024; 29:2339778. [PMID: 38625693 DOI: 10.1080/16078454.2024.2339778] [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: 01/24/2024] [Accepted: 03/27/2024] [Indexed: 04/17/2024] Open
Abstract
OBJECTIVE To establish an efficient nomogram model to predict short-term survival in ICU patients with aplastic anemia (AA). METHODS The data of AA patients in the MIMIC-IV database were obtained and randomly assigned to the training set and testing set in a ratio of 7:3. Independent prognosis factors were identified through univariate and multivariate Cox regression analyses. The variance inflation factor was calculated to detect the correlation between variables. A nomogram model was built based on independent prognostic factors and risk scores for factors were generated. Model performance was tested using C-index, receiver operating characteristic (ROC) curve, calibration curve, decision curve analysis (DCA) and Kaplan-Meier curve. RESULTS A total of 1,963 AA patients were included. A nomogram model with 7 variables was built, including SAPS II, chronic pulmonary obstructive disease, body temperature, red cell distribution width, saturation of peripheral oxygen, age and mechanical ventilation. The C-indexes in the training set and testing set were 0.642 and 0.643 respectively, indicating certain accuracy of the model. ROC curve showed favorable classification performance of nomogram. The calibration curve reflected that its probabilistic prediction was reliable. DCA revealed good clinical practicability of the model. Moreover, the Kaplan-Meier curve showed that receiving mechanical ventilation could improve the survival status of AA patients in the short term but did not in the later period. CONCLUSION The nomogram model of the short-term survival rate of AA patients was built based on clinical characteristics, and early mechanical ventilation could help improve the short-term survival rate of patients.
Collapse
Affiliation(s)
- Yan Tu
- Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, People's Republic of China
| | - Jingcheng Zhang
- Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, People's Republic of China
| | - Mingzhe Zhao
- Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, People's Republic of China
| | - Fang He
- Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, People's Republic of China
| |
Collapse
|
2
|
Jaime-Pérez JC, González-Treviño M, Gómez-De León A, Campos-Bocardo MA, Barragán-Longoria RV, Cantú-Rodríguez OG, Gutiérrez-Aguirre CH, Gómez-Almaguer D. Outpatient ATG-free hematopoietic transplantation for aplastic anemia in limited-resource environments offers excellent results: Data from a single LATAM center. Blood Cells Mol Dis 2024; 109:102885. [PMID: 39182343 DOI: 10.1016/j.bcmd.2024.102885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 06/18/2024] [Accepted: 08/19/2024] [Indexed: 08/27/2024]
Abstract
OBJECTIVE To document the results of outpatient hematopoietic stem cell transplantation (HSCT) from the peripheral blood (PB) of sibling donors without anti-thymocyte globulin (ATG) in the conditioning regimen. MATERIAL AND METHODS Patients from a low-income population with severe AA who received a PB, unmanipulated sibling HLA-identical HSCT between 2000 and 2020 at a single institution were studied. Survival was the primary outcome. RESULTS Forty-one transplants were performed. Time between diagnosis and transplant was five months (1-104). Median age was 37 (range, 4-61) years; 25 (61 %) recipients were males and 32 (78 %) had treatment failure, 9 (22 %) have not received treatment. ATG was administered in 5 (12.2 %) cases; the graft source was PB in 38 (92.7 %) transplants. Twenty-six (63.4 %) transplants were carried out in the outpatient setting. Infections developed in 14 (34.1 %) patients. Primary graft failure (GF) occurred in 3 (7.3 %) patients. The 15-year OS was 81 %, EFS was 77.4 %. Patients with high pre-HSCT transfusion burden had lower OS (p = 0.035) and EFS (p = 0.026). Previous treatment failure and age were not associated with lower OS (p = 0.115, p = 0.069) or EFS (p = 0.088, p = 0.5, respectively). CONCLUSIONS HLA-identical T-cell replete outpatient HSCT from the PB of sibling donors for AA patients using ATG-free conditioning offers excellent long-term survival.
Collapse
Affiliation(s)
- José Carlos Jaime-Pérez
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico..
| | - Mariana González-Treviño
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Andrés Gómez-De León
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Miguel A Campos-Bocardo
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Renata V Barragán-Longoria
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Olga Graciela Cantú-Rodríguez
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - César Homero Gutiérrez-Aguirre
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - David Gómez-Almaguer
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| |
Collapse
|
3
|
Fu S, Du Y, Pan T, Ma F, He H, Li Y. Causal role of immune cells in aplastic anemia: Mendelian randomization (MR) study. Sci Rep 2024; 14:18010. [PMID: 39097629 PMCID: PMC11297992 DOI: 10.1038/s41598-024-69104-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 07/31/2024] [Indexed: 08/05/2024] Open
Abstract
Prior research has identified associations between immune cells and aplastic anaemia (AA); however, the causal relationships between them have not been conclusively established. A two-sample Mendelian randomisation analysis was conducted to investigate the causal link between 731 immune cell signatures and AA risk using publicly available genetic data. Four types of immune signatures, including relative cell, absolute cell (AC), median fluorescence intensities and morphological parameters, were considered sensitivity analyses were also performed to verify the robustness of the results and assess potential issues such as heterogeneity and horizontal pleiotropy. Following multiple test adjustments using the False Discovery Rate (FDR) method, no statistically significant impact of any immunophenotype on AA was observed. However, twelve immunophenotypes exhibited a significant correlation with AA without FDR correction (p of IVW < 0.01), of which eight were harmful to AA: CD127- CD8br %T cell (Treg panel), CD25 on IgD + CD38dim (B cell panel), CD38 on naive-mature B cell (B cell panel), CD39 + resting Treg % CD4 Treg (Treg panel), CD39 + secreting Treg AC (Treg panel), CD8 on CD28 + CD45RA- CD8br (Treg panel), HLA DR + NK AC (TBNK panel), Naive DN (CD4-CD8-) AC (Maturation stages of T cell panel); and four were protective to AA: CD86 on CD62L + myeloid DC (cDC panel), DC AC (cDC panel), DN (CD4-CD8-) NKT %T cell (TBNK panel), and TD CD4 + AC (Maturation stages of T cell panel). The results of this study demonstrate a close link between immune cells and AA by genetic means, thereby improving the current understanding of the interaction between immune cells and AA risk and providing guidance for future clinical research.
Collapse
Affiliation(s)
- Shaojie Fu
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Yazhe Du
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Tingting Pan
- Teaching Department, The First Hospital of Jilin University, Changchun, China
| | - Fuzhe Ma
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Hua He
- Department of Oncology, The First Hospital of Jilin University, Changchun, China
| | - Yuying Li
- Department of Hematology, The First Hospital of Jilin University, Changchun, China.
| |
Collapse
|
4
|
Eapen M. Choosing donors in clinical practice. Blood 2024; 144:248-249. [PMID: 39023876 DOI: 10.1182/blood.2024024970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024] Open
|
5
|
Sharathkumar A, Carr J, Claassen D, Syrbu S, Bhagavathi S, Al-Huniti A, Modi A, Bates M, Mott SL. Romiplostim for Treatment of Children and Young Adults With Severe Aplastic Anemia and Myelodysplastic Syndrome. J Pediatr Hematol Oncol 2024; 46:252-261. [PMID: 38787686 DOI: 10.1097/mph.0000000000002891] [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: 01/04/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024]
Abstract
Thrombopoietin receptor agonists (TPO-RAs) induce trilineage hematopoiesis under conditions with acquired hematopoietic failure. We evaluated safety, tolerability, and preliminary efficacy of a TPO-RA, romiplostim (Nplate), with or without standard-of-care immunosuppressive therapy (±IST) for children (ages < 21 y) with newly diagnosed and relapsed/refractory severe aplastic anemia (SAA) and myelodysplastic syndrome (MDS). Data were collected from an observational study and a single arm interventional pilot study. The safety outcome was treatment-related adverse events (AEs). Efficacy was evaluated by complete hematopoietic response (CHR) at week 24. Romiplostim was commenced at 5 µg/kg/week, with dose escalation of 2.5 µg/kg/week (maximum, 20 µg/kg/dose) based on platelet response. Romiplostim was continued until CHR was observed. Ten subjects (SAA, 9 [IST, 4; without IST, 5]; MDS, 1) completed the study (median age: 9.2 y). Median romiplostim dose was 10 µg/kg/week (range: 5 to 17.5 µg/kg/week). The cumulative incidence of CHR was 70.4% (95% CI, 20.2%-92.6%). Among 21 AEs (Grade 1 to 3), 3 were attributed to romiplostim. At a median posttherapy follow-up of 10.9 months (range: 0.7 to 77.5), no clonal evolution, bone marrow fibrosis or mortality was reported. This proof-of-concept study provides data about short-term safety, tolerability, and preliminary efficacy of romiplostim (±IST) for treatment of pediatric SAA/MDS.
Collapse
Affiliation(s)
- Anjali Sharathkumar
- Stead Family Department of Pediatrics, Carver College of Medicine
- Holden Comprehensive Cancer Center
| | - Jamie Carr
- Institute for Clinical and Translational Science
| | - David Claassen
- Stead Family Department of Pediatrics, Carver College of Medicine
| | - Sergei Syrbu
- Department of Pathology, University of Iowa, Iowa City, IA
| | | | - Ahmad Al-Huniti
- Department of Pediatrics, Mayo Clinic, Hematology, Rochester, MN
| | - Arunkumar Modi
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Melissa Bates
- Holden Comprehensive Cancer Center
- Department of Health and Human Physiology
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA
| | | |
Collapse
|
6
|
Vatsayan R, Jain A, Jandial A, Bose P, Sachdeva MUS, Varma N, Jain A, Prakash G, Khadwal A, Malhotra P. Aberrant baseline cytokine profile in patients with newly diagnosed acquired aplastic anaemia correlates with disease severity and the treatment response. Blood Cells Mol Dis 2024; 107:102857. [PMID: 38815307 DOI: 10.1016/j.bcmd.2024.102857] [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: 04/01/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Immune dysregulation is crucial in the pathogenesis of acquired aplastic anaemia (aAA). There is paucity of data regarding correlation of baseline cytokine profile with treatment response in aAA. OBJECTIVE Present prospective case-control study aimed to correlate the baseline cytokines in patients with aAA with the treatment response. METHODS Fifty-one patients with newly-diagnosed aAA > 13 years of either sex were enrolled over 1.5 years. Twenty age-and sex-matched healthy controls (HC) were also included. The cytokine profile (IL-2, 4, 6, 8, 10, 17, IFN-γ and TNF-α) in the peripheral blood plasma of aAA patients was performed at the baseline using cytometric bead analysis. The cytokine levels were compared with HC and correlated with response to immunosuppressive therapy (IST) at 3-months. RESULTS The median age of cases was 29 years (range,13-74). The cases had higher mean levels of IL2 (p = 0.326), IL4 (p = 0.038), IL6 (p = 0.000), IL10 (p = 0.002), TNF-α (p = 0.302), IFN-γ (p = 0.569) and IL-17 (p = 0.284) than the HC. The baseline levels of all the cytokines were higher (statistically non-significant) among responders (n = 13) than the non-responders (n = 14) to IST. CONCLUSIONS Baseline cytokine profile in patients with aAA might predict response to the IST. Larger studies are needed to validate our results.
Collapse
Affiliation(s)
- Rahul Vatsayan
- Department of Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur Jain
- Department of Haematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi 110029, India
| | - Aditya Jandial
- Department of Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Parveen Bose
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Man Updesh Singh Sachdeva
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelam Varma
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arihant Jain
- Department of Clinical Haematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Prakash
- Department of Clinical Haematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alka Khadwal
- Department of Clinical Haematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Haematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| |
Collapse
|
7
|
Ciangola G, Santinelli E, McLornan DP, Pagliuca S, Gurnari C. Diagnostic evaluation in bone marrow failure disorders: what have we learnt to help inform the transplant decision in 2024 and beyond? Bone Marrow Transplant 2024; 59:444-450. [PMID: 38291125 DOI: 10.1038/s41409-024-02213-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/01/2024]
Abstract
Aplastic anemia (AA) is the prototypical bone marrow failure syndrome. In the current era of readily available 'molecular annotation', application of comprehensive next-generation sequencing panels has generated novel insights into underlying pathogenetic mechanisms, potentially leading to improvements in personalized therapeutic approaches. New evidence has emerged as to the role of somatic loss of HLA class I allele expression in 'immune-mediated' AA, associated molecular aberrations, and risk of clonal evolution. A deeper understanding has emerged regarding the role of 'myeloid' gene mutations in this context, translating patho-mechanistic insights derived from wider clinical and translational research within the myeloid disorder arena. Here, we review contemporary 'tools' which aid in confirmation of a diagnosis of AA, with an additional focus on their potential in guiding therapeutic options. A specific emphasis is placed upon interpretation and integration of this detailed diagnostic information and how this may inform optimal transplantation strategies.
Collapse
Affiliation(s)
- Giulia Ciangola
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Enrico Santinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Simona Pagliuca
- Sérvice d'Hématologie Clinique, CHRU de Nancy, Nancy, France
- CNRS UMR 7365 IMoPa, Biopôle de l'Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Carmelo Gurnari
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
8
|
Famokunwa B, Gupta A, Thomas S, Griffin M, Kulasekararaj A. Mapping aplastic anaemia hospital activity in England. EJHAEM 2024; 5:414-417. [PMID: 38633129 PMCID: PMC11020100 DOI: 10.1002/jha2.869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 04/19/2024]
Affiliation(s)
| | | | | | - Morag Griffin
- St. James's Hospital, Leeds Teaching Hospitals NHS TrustLeedsUK
| | - Austin Kulasekararaj
- King's College Hospital NHS Foundation TrustLondonUK
- King's College LondonLondonUK
| |
Collapse
|
9
|
Kulasekararaj A, Cavenagh J, Dokal I, Foukaneli T, Gandhi S, Garg M, Griffin M, Hillmen P, Ireland R, Killick S, Mansour S, Mufti G, Potter V, Snowden J, Stanworth S, Zuha R, Marsh J. Guidelines for the diagnosis and management of adult aplastic anaemia: A British Society for Haematology Guideline. Br J Haematol 2024; 204:784-804. [PMID: 38247114 DOI: 10.1111/bjh.19236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/26/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024]
Abstract
Pancytopenia with hypocellular bone marrow is the hallmark of aplastic anaemia (AA) and the diagnosis is confirmed after careful evaluation, following exclusion of alternate diagnosis including hypoplastic myelodysplastic syndromes. Emerging use of molecular cyto-genomics is helpful in delineating immune mediated AA from inherited bone marrow failures (IBMF). Camitta criteria is used to assess disease severity, which along with age and availability of human leucocyte antigen compatible donor are determinants for therapeutic decisions. Supportive care with blood and platelet transfusion support, along with anti-microbial prophylaxis and prompt management of opportunistic infections remain key throughout the disease course. The standard first-line treatment for newly diagnosed acquired severe/very severe AA patients is horse anti-thymocyte globulin and ciclosporin-based immunosuppressive therapy (IST) with eltrombopag or allogeneic haemopoietic stem cell transplant (HSCT) from a matched sibling donor. Unrelated donor HSCT in adults should be considered after lack of response to IST, and up front for young adults with severe infections and a readily available matched unrelated donor. Management of IBMF, AA in pregnancy and in elderly require special attention. In view of the rarity of AA and complexity of management, appropriate discussion in multidisciplinary meetings and involvement of expert centres is strongly recommended to improve patient outcomes.
Collapse
Affiliation(s)
- Austin Kulasekararaj
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Jamie Cavenagh
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Inderjeet Dokal
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, UK
| | - Theodora Foukaneli
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- NHS Blood and Transplant, Bristol, UK
| | - Shreyans Gandhi
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
- British Society Haematology Task Force Representative, London, UK
| | | | | | - Robin Ireland
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Sally Killick
- University Hospitals Dorset NHS Foundation Trust, The Royal Bournemouth Hospital, Bournemouth, UK
| | - Sahar Mansour
- St George's Hospital/St George's University of London, London, UK
| | - Ghulam Mufti
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Victoria Potter
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - John Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Roslin Zuha
- James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, Norfolk, England
| | - Judith Marsh
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| |
Collapse
|
10
|
Foucar CE, Foley DH, Aldous J, Burke PW, Pettit KR, Benitez LL, Perissinotti AJ, Marini BL, Boonstra P, Bixby DL. Real-world outcomes with immunosuppressive therapy for aplastic anemia in patients treated at the University of Michigan. Eur J Haematol 2024; 112:424-432. [PMID: 37929654 DOI: 10.1111/ejh.14131] [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: 07/31/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
Aplastic anemia (AA) is a rare bone marrow failure disorder that is treated with either allogeneic stem cell transplant or immunosuppressive therapy (IST) consisting of antithymocyte globulin (ATG), cyclosporine (CSA), and eltrombopag. While outcomes are favorable in younger patients, older patients (>60) have significantly worse long-term survival. The dose of ATG is often reduced in older patients and those with multiple comorbidities given concerns for tolerability. The efficacy and safety of dose-attenuated IST in this population is largely undescribed. We performed a retrospective review of patients with AA treated with IST. Our analysis was confounded by changes in practice patterns and the introduction of eltrombopag. We identified 53 patients >60 years old, of which, 20 received dose-attenuated IST, with no statistically significant difference in overall survival between full and attenuated dose cohorts. Overall response rates in both cohorts were similar at 6 months at 71% and 68%. There were more documented infectious complications in the full dose cohort (13 vs. 3). This supports the consideration of dose-attenuated IST in older patients with concerns about tolerance of IST. Lastly, our data confirmed favorable outcomes of younger patients receiving IST, especially in combination with eltrombopag.
Collapse
Affiliation(s)
- Charles E Foucar
- Division of Hematology and Oncology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Daniel H Foley
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jessica Aldous
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Patrick W Burke
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Kristen R Pettit
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Lydia L Benitez
- Department of Pharmacy Services and Clinical Sciences, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Sciences, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Bernard L Marini
- Department of Pharmacy Services and Clinical Sciences, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Philip Boonstra
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Dale L Bixby
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| |
Collapse
|
11
|
Vallejo C, Rosell A, Xicoy B, García C, Albo C, Polo M, Jarque I, Esteban B, Codesido ML. A multicentre ambispective observational study into the incidence and clinical management of aplastic anaemia in Spain (IMAS study). Ann Hematol 2024; 103:705-713. [PMID: 38175253 DOI: 10.1007/s00277-023-05602-x] [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: 06/22/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024]
Abstract
Aplastic anemia (AA) is a rare, life-threatening hematological disease, with a poorly defined incidence. As the data available on AA varies substantially worldwide, a multicenter, ambispective, observational study was carried out between 2010 and 2019 to assess the incidence, clinical management and survival of AA at seven Spanish hospitals. The incidence of AA was 2.83 per million inhabitants per year, consistent with that reported previously in Europe, with a median age at diagnosis of 61 years-old (range 12-86), and a similar number of males and females. The initial diagnosis was severe or very severe AA in 55.8% of cases and 93.7% required transfusion. The most frequent first line therapy was anti-thymocyte globulin (ATG) plus cyclosporin A (CsA, 44.2%), followed by other CsA-based regimes (46.3%), with hematopoietic stem cell transplantation an infrequent 1st line therapy. The 6-month response rate was 68.2%, which then increased over a median follow-up of 3.9 years. The 5-year overall survival (5OS) was 73.6%, similar in severe (78.6%) and very severe AA patients (74.6%) but lower in moderate AA (MAA) patients (68.4%). The 5OS was 100% in 0-25 year-old patients but dropping to 58.3% in patients ≥ 60 years-old. At the last contact, 75.8% of the patients were alive. In conclusion, the incidence, characteristics and management of AA in our study are consistent with that reported previously. In terms of survival, although the global long-term OS rate was good, there is room for improvement, particularly in older patients. Finally, what appears to be a worse long-term survival of MAA patients, as reported previously, reinforces the importance of not underestimating this condition when diagnosed as MAA.
Collapse
Affiliation(s)
- Carlos Vallejo
- Complejo Asistencial Universitario de Salamanca, Salamanca, Spain.
- Hospital Universitario Donostia, San Sebastián, Spain.
- PETHEMA Cooperative Group, Madrid, Spain.
- Instituto de Investigación Sanitaria Biodonostia, Donostia-San Sebastián, Spain.
| | - Ana Rosell
- Hospital Universitario Virgen de La Victoria, Málaga, Spain
| | - Blanca Xicoy
- Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Carmen García
- Hospital General Universitario de Alicante, Alicante, Spain
| | - Carmen Albo
- Hospital Universitario Álvaro Cunqueiro, Vigo, Spain
| | - Marta Polo
- Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | - Brígida Esteban
- Instituto de Investigación Sanitaria Biodonostia, Donostia-San Sebastián, Spain
| | - M Lorena Codesido
- Instituto de Investigación Sanitaria Biodonostia, Donostia-San Sebastián, Spain
| |
Collapse
|
12
|
Sharma A, Suresh A, Pirruccello J, Sullivan M. Aplastic anaemia following antibiotic use for urinary tract infection. BMJ Case Rep 2024; 17:e254547. [PMID: 38423579 PMCID: PMC10910398 DOI: 10.1136/bcr-2022-254547] [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] [Indexed: 03/02/2024] Open
Abstract
Aplastic anaemia is often associated with recent viral illnesses to include EBV and parvovirus along with certain medications such as anticonvulsants and sulfa containing antibiotics. We describe a case report of a female patient in her 70s who presented with pancytopenia after being treated with nitrofurantoin and ciprofloxacin for suspected urinary tract infection. She underwent an extensive workup to rule out alternative aetiologies of her pancytopenia to include a broad viral, autoimmune and malignancy evaluation which were unrevealing. Given her recent exposure to ciprofloxacin and nitrofurantoin and marrow recovery following removal of these agents, it was presumed that antibiotic exposure was the underlying cause of her aplastic anaemia.
Collapse
Affiliation(s)
- Aditya Sharma
- Internal Medicine, Dartmouth Medical School, Hanover, New Hampshire, USA
| | - Arvind Suresh
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | | | - Matthew Sullivan
- Dartmouth-Hitchcock Norris Cotton Cancer Center, Lebanon, New Hampshire, USA
| |
Collapse
|
13
|
Abdalhadi A, Omar NE, Kohla S, Aakel H, Ekeibed Y, Mohsen R. Aplastic anemia secondary to adjuvant Osimertinib therapy: a case report and a review of literature. Front Oncol 2024; 14:1275275. [PMID: 38454933 PMCID: PMC10917982 DOI: 10.3389/fonc.2024.1275275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
Aplastic anemia is a rare hematological disorder characterized by suppressed hematopoiesis and pancytopenia. Although several drugs have been associated with aplastic anemia, its occurrence in response to Osimertinib, a third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), is extremely rare. We present a case report of a 63-year-old patient with locally advanced non-small cell lung cancer (NSCLC) who developed aplastic anemia following adjuvant treatment with Osimertinib. Extensive investigations ruled out infectious etiology, and the absence of bone marrow involvement or other identifiable causes suggested a drug-induced etiology, specifically Osimertinib. This case report emphasizes the importance of recognizing this adverse event and considering it as a potential complication of Osimertinib therapy. Vigilant monitoring and prompt management are essential for optimizing patient outcomes. Further studies are needed to better understand the risk factors, underlying mechanisms, and management strategies for Osimertinib-induced aplastic anemia in the adjuvant settings.
Collapse
Affiliation(s)
- Ahmed Abdalhadi
- Medical Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Nabil E. Omar
- Pharmacy Department, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
- Health Sciences Program, Clinical and Population Health Research, College of Pharmacy, Qatar University, Doha, Qatar
| | - Samah Kohla
- Lab Medicine and Pathology, Hematopathology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
- Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Hassan Aakel
- Medical Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Yeslem Ekeibed
- Clinical Hematology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Reyad Mohsen
- Medical Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| |
Collapse
|
14
|
McQuilten Z, Heritier S, Fox L, Fox V, Young L, Blombery P, Cunningham I, Curnow J, Higgins A, Hiwase DK, Filshie R, Firkin F, Lacaze P, Mason K, Mills AK, Pepperell D, Patil S, Stevenson W, Szer J, Waters N, Wilson K, Ting S, Wood E. Efficacy and safety of avatrombopag in combination with immunosuppressive therapy in treatment-naïve and relapsed/refractory severe aplastic anaemia: protocol for the DIAAMOND-Ava-FIRST and DIAAMOND-Ava-NEXT Bayesian Optimal Phase II trials. BMJ Open 2024; 14:e076246. [PMID: 38238183 PMCID: PMC10806710 DOI: 10.1136/bmjopen-2023-076246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/14/2023] [Indexed: 01/23/2024] Open
Abstract
INTRODUCTION Immunosuppressive therapy (IST) with antithymocyte globulin (ATG) and ciclosporin is standard of care for patients with severe aplastic anaemia (sAA) not eligible or suitable for allogeneic stem cell transplant. While patients respond to IST, few achieve complete responses and a significant proportion are refractory or relapse. The addition of eltrombopag, a thrombopoietin-receptor agonist (TPO-A), to IST has been shown to improve haematological responses in sAA. Avatrombopag is a second-generation TPO-A with potential advantages over eltrombopag. However, to date avatrombopag has not been studied in sAA. METHODS AND ANALYSIS Investigator-initiated, single-arm registry-based Bayesian Optimal Phase II trial of avatrombopag conducted in two cohorts, patients with untreated sAA (FIRST cohort) and in patients with sAA that has relapsed or is refractory to IST (NEXT cohort). In the FIRST cohort, participants receive IST (equine ATG and ciclosporin) plus avatrombopag from day 1 until day 180 at 60 mg oral daily, with dose adjusted according to platelet count. Participants in the NEXT cohort receive avatrombopag at 60 mg oral daily from day 1 until day 180, with or without additional IST at the discretion of the treating clinician.For each cohort, two primary endpoints (haematological response and acquired clonal evolution) are jointly monitored and the trial reviewed at each interim analysis where a 'go/no-go' decision is made by evaluating the posterior probability of the events of interests. ETHICS AND DISSEMINATION The trial has received ethics approval (Monash Health RES-18-0000707A). The trial conduct will comply with ICH-GCP and all applicable regulatory requirements. The results of the trial will be submitted to a peer-review journal for publication. TRIAL REGISTRATION NUMBER ACTRN12619001042134, ACTRN12619001043123.
Collapse
Affiliation(s)
- Zoe McQuilten
- Department of Haematology, Monash Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lucy Fox
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Vanessa Fox
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lauren Young
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Piers Blombery
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Ilona Cunningham
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Jennifer Curnow
- Department of Haematology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Alisa Higgins
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Devendra K Hiwase
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- South Australian Health & Medical Research Institute, Adelaide, South Australia, Australia
| | - Robin Filshie
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Frank Firkin
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Paul Lacaze
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kylie Mason
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Anthony K Mills
- University of Queensland, Brisbane, Queensland, Australia
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Dominic Pepperell
- Department of Haematology, Fiona Stanley Hospital, Murdoch, Perth, Australia
| | - Sushrut Patil
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
| | - William Stevenson
- Department of Haematology, Royal North Shore Hospital, St Leonards, Sydney, Australia
| | - Jeff Szer
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Neil Waters
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kate Wilson
- University of Sydney, Sydney, New South Wales, Australia
| | - Stephen Ting
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Haematology, Eastern Health, Melbourne, Victoria, Australia
| | - Erica Wood
- Department of Haematology, Monash Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
15
|
Nakamura R, Patel BA, Kim S, Wong FL, Armenian SH, Groarke EM, Keesler DA, Hebert KM, Heim M, Eapen M, Young NS. Conditional survival and standardized mortality ratios of patients with severe aplastic anemia surviving at least one year after hematopoietic cell transplantation or immunosuppressive therapy. Haematologica 2023; 108:3298-3307. [PMID: 37259612 PMCID: PMC10690917 DOI: 10.3324/haematol.2023.282781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 05/23/2023] [Indexed: 06/02/2023] Open
Abstract
Immunosuppressive treatment (IST) and hematopoietic cell transplant (HCT) are standard therapies for severe aplastic anemia (SAA). We report on conditional survival and standardized mortality ratios (SMR), which compare the mortality risk with the general population adjusted for age, gender, and race/ethnicity, in patients with SAA alive for at least 12 months after treatment with IST or HCT between 2000 and 2018. Given changes to treatment regimens and differences in length of follow-up, two treatment periods were defined a priori: 2000-2010 and 2011-2018. The SMR of patients treated during the period 2000-2010 and who survived one year were 3.50 (95% confidence interval [CI]: 2.62-4.58), 4.12 (95% CI: 3.20-5.21), and 8.62 (95% CI: 6.88-10.67) after IST, matched related donor HCT, and alternative donor HCT, respectively. For the period 2011-2018, the corresponding SMR were 2.89 (95% CI: 1.54-4.94), 3.12 (95% CI: 1.90-4.82), and 4.75 (95% CI: 3.45-6.38), respectively. For IST patients, their mortality risk decreased over time, and became comparable to the general population by five years. For patients who underwent HCT during 2000-2010 and 2011-2018, their mortality risk became comparable to the general population after ten years and after five years, respectively. Thus, 1-year survivors after IST or HCT can expect their longevity beyond five years to be comparable to that of the general US population.
Collapse
Affiliation(s)
- Ryotaro Nakamura
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Bhavisha A Patel
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Soyoung Kim
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI; Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - F Lennie Wong
- Department of Population Sciences, City of Hope National Medical Center, Duarte, CA
| | - Saro H Armenian
- Department of Population Sciences, City of Hope National Medical Center, Duarte, CA
| | - Emma M Groarke
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Daniel A Keesler
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Kyle M Hebert
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Michael Heim
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mary Eapen
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| |
Collapse
|
16
|
Wan Z, Chen M, Han B. Avatrombopag, a promising novel thrombopoietin receptor agonist for refractory/relapsed/intolerant non-severe aplastic anemia: a phase 2 single-arm clinical trial. Ann Med 2023; 55:2224044. [PMID: 37318085 DOI: 10.1080/07853890.2023.2224044] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 04/01/2023] [Accepted: 06/03/2023] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION The therapeutic options for thrombocytopenia in non-severe aplastic anaemia (NSAA) are limited. Avatrombopag (AVA) is prescribed for thrombocytopenic diseases but not for NSAA. METHODS Herein, we conducted a phase 2, non-randomized, single-arm trial to explore the efficacy and safety of AVA in refractory/relapsed/intolerant NSAA. AVA dose was initiated at 20 mg/d and titrated to a maximum of 60 mg/d. The primary endpoint was the haematological response at 3 months. RESULTS Twenty-five patients were analyzed. The overall response rate (ORR) at 3 months was 56% (14/25), with 12% (3/25) achieving a complete response (CR). At a median follow-up of 7 (3-10) months, the OR and CR rates were 52% and 20%, respectively. Responders had a shorter duration of diagnosis of AVA administration than non-responders (10 (6-80) vs 37 (6-480) months, p = 0.027) and belonged to the relapsed/intolerant NSAA type (71% vs 27%, p = 0.047); 44% (8/18) patients previously treated with eltrombopag before enrollment responded at 3 months, with an average prior eltrombopag dose of median 72.5 (50-100) mg/d and an average AVA dose for a response of median 43.5 (20-60) mg/d. 3-month ORR had no significant correlation with eltrombopag exposure (p = 0.09), prior eltrombopag length (R2=0.11), or cumulative eltrombopag dose (R2=0.30). Only one patient relapsed after stopping AVA for 1 month. No serious AVA-related side effects or clone evolution were detected. CONCLUSION AVA is effective and well-tolerated in NSAA patients who are refractory, relapsed, or intolerant to CsA/tacrolimus ± eltrombopag. Earlier treatment and relapsed/intolerant AA may show a better short-term response rate. More studies are needed to define the optimal dose and the long-term efficacy (NCT04728789).
Collapse
Affiliation(s)
- Ziqi Wan
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, P.R. China
- Peking Union Medical College, Beijing, P.R. China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, P.R. China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, P.R. China
| |
Collapse
|
17
|
Chatzikalil E, Kattamis A, Diamantopoulos P, Solomou EE. New-onset aplastic anemia after SARS-CoV-2 vaccination. Int J Hematol 2023; 118:667-681. [PMID: 37768509 DOI: 10.1007/s12185-023-03666-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 09/02/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023]
Abstract
Aplastic anemia (AA) is a rare autoimmune disease. Drugs, viruses, and radiation are among the most common etiologic factors, and most cases have immune pathophysiology. SARS-CoV-2 vaccines have been linked with rare side effects, including cases of acquired aplastic anemia. Here we review all the reported cases of new-onset AA after SARS-CoV-2 vaccination, and discuss their clinical characteristics and management. 18 patients in these case reports had a median age of 58 years. The time from vaccination to onset of aplastic anemia ranged from 1 day to 7 months, with a median of 2.5 weeks. Seventeen patients were diagnosed with severe or very severe aplastic anemia post-vaccination and all patients received standard treatments for acquired aplastic anemia. Seventeen patients achieved a complete or partial response and only 1 patient died. Aplastic anemia can be considered a very rare SARS-CoV-2 vaccine-related adverse event, although a causative relationship has not been proven. Reporting cases of such uncommon post-vaccination events could help clinicians to consider aplastic anemia when pancytopenia is observed after vaccination. The benefits of SARS-Cov-2 vaccination are established, and reports of rare events serve only to increase awareness in daily clinical practice.
Collapse
Affiliation(s)
- Elena Chatzikalil
- Department of Pediatrics, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Antonis Kattamis
- Department of Pediatrics, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Panagiotis Diamantopoulos
- First Department of Internal Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Elena E Solomou
- Internal Medicine-Hematology, University of Patras Medical School, 26500, Rion, Greece.
| |
Collapse
|
18
|
Koldej RM, Prabahran A, Tan CW, Ludford-Menting M, Morgan H, Holzwart N, Davis MJ, Ritchie DS. Spatial proteomics identifies a spectrum of immune dysregulation in acquired bone marrow failure syndromes. Front Immunol 2023; 14:1213560. [PMID: 37818364 PMCID: PMC10560754 DOI: 10.3389/fimmu.2023.1213560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/04/2023] [Indexed: 10/12/2023] Open
Abstract
Poor graft function (PGF), manifested by multilineage cytopenias and complete donor chimerism post-allogeneic stem cell transplantation (alloSCT), and acquired aplastic anaemia (AA) are immune-mediated acquired bone marrow (BM) failure syndromes with a similar clinical presentation. In this study, we used spatial proteomics to compare the immunobiology of the BM microenvironment and identify common mechanisms of immune dysregulation under these conditions. Archival BM trephines from patients exhibited downregulation of the immunoregulatory protein VISTA and the M2 macrophage marker and suppressor of T-cell activation ARG1 with increased expression of the immune checkpoint B7-H3 compared to normal controls. Increased CD163 and CD14 expression suggested monocyte/macrophage skewing, which, combined with dysregulation of STING and VISTA, is indicative of an environment of reduced immunoregulation resulting in the profound suppression of hematopoiesis in these two conditions. There were no changes in the immune microenvironment between paired diagnostic AA and secondary MDS/AML samples suggesting that leukaemic clones develop in the impaired immune microenvironment of AA without the need for further alterations. Of the eight proteins with dysregulated expression shared by diagnostic AA and PGF, the diagnostic AA samples had a greater fold change in expression than PGF, suggesting that these diseases represent a spectrum of immune dysregulation. Unexpectedly, analysis of samples from patients with good graft function post-alloSCT demonstrated significant changes in the immune microenvironment compared to normal controls, with downregulation of CD44, STING, VISTA, and ARG1, suggesting that recovery of multilineage haematopoiesis post-alloSCT does not reflect recovery of immune function and may prime patients for the development of PGF upon further inflammatory insult. The demonstrable similarities in the immunopathology of AA and PGF will allow the design of clinical interventions that include both patient cohorts to accelerate therapeutic discovery and translation.
Collapse
Affiliation(s)
- Rachel M. Koldej
- Australian Cancer Research Foundation (ACRF) Translational Research Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Ashvind Prabahran
- Australian Cancer Research Foundation (ACRF) Translational Research Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Chin Wee Tan
- Bioinformatics Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Department of Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Mandy Ludford-Menting
- Australian Cancer Research Foundation (ACRF) Translational Research Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Huw Morgan
- Australian Cancer Research Foundation (ACRF) Translational Research Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Nicholas Holzwart
- Australian Cancer Research Foundation (ACRF) Translational Research Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Melissa J. Davis
- Bioinformatics Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Department of Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Department of Clinical Pathology, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - David S. Ritchie
- Australian Cancer Research Foundation (ACRF) Translational Research Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
| |
Collapse
|
19
|
Dasari S, Tse W, Wang J. Real-world evidence of incidence and outcomes of aplastic anaemia following administration of immune checkpoint inhibitors. Br J Haematol 2023; 202:1205-1208. [PMID: 37455367 DOI: 10.1111/bjh.18985] [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: 02/27/2023] [Revised: 05/14/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
Aplastic anaemia (AA) is a rare immune-related adverse events (irAEs) after immune checkpoint inhibitors (ICIs) administration with poorly understood incidence and outcomes. We analysed an electronic health record database of 52 303 ICI-treated patients and found 77 (0.15%) cases of AA, with a median onset of 126 days (interquartile range, 58-363 days). The most used treatment for AA was systemic glucocorticoids 60 (77.9%) and 32 (41.6%) patients were able to resume ICI within 1 year. Patients diagnosed with AA had a steep decline in overall survival (OS) within the first 120 days; when compared to propensity score-matched patients without AA, they had a significantly worse OS (hazard ratio 1.72, 95% confidence interval 1.19-2.50; p = 0.003).
Collapse
Affiliation(s)
- Srilatha Dasari
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - William Tse
- Department of Hematology and Oncology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jiasheng Wang
- Department of Hematology and Oncology, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| |
Collapse
|
20
|
Dolai TK, Jain M, Mahapatra M. Idiopathic Aplastic anemia: Indian Perspective. Indian J Hematol Blood Transfus 2023; 39:357-370. [PMID: 37304471 PMCID: PMC10247658 DOI: 10.1007/s12288-022-01592-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/26/2022] [Indexed: 06/13/2023] Open
Abstract
Aplastic anemia (AA) is a rare immunologically mediated bone marrow failure syndrome, characterized by progressive loss of hematopoietic stem cells resulting in peripheral pancytopenia. Elaborative investigation including molecular tests is required to exclude inherited bone marrow failure syndrome (IMBFS) as the treatment and prognosis vary dramatically between them. Haematopoietic stem cell transplant with a fully matched sibling donor (MSD-HSCT) is still the only curative treatment. Management of AA is a real-time challenge in India, because of the delay in the diagnosis, lack of proper supportive care, limited availability of the expertise centre, and the patient's affordability. Recently, results with intensified immunosuppressive therapy that includes anti-thymocyte globulin with cyclosporine-A (CsA) and eltrombopag, are enough encouraging to consider it as treatment of choice in patients lacking MSD or who are not fit for HSCT. However, limitations in resource constraints settings including the cost of therapy limit its full utilization. Relapse of the disease or evolution to myelodysplasia or paroxysmal nocturnal haemoglobinuria (PNH) in a proportion of patients is another challenge with immunosuppressants. The majority of the AA patients still receive CsA with or without androgens in India, mostly because of increased cost and limited availability of HSCT and ATG. The use of the unrelated or alternative donor is still upcoming in India, with unavailable data in terms of response and survival. Therefore, there is an utmost need for novel agents for the better management of AA having a balanced efficacy and toxicity profile to improve the survival and quality of life.
Collapse
Affiliation(s)
- Tuphan Kanti Dolai
- Department of Haematology, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| | - Manisha Jain
- Department of Medical oncology and Haematology, Medanta Medcity, India
| | - Manoranjan Mahapatra
- Department of Haematology, All India Institute of Medical science, New Delhi, India
| |
Collapse
|
21
|
Mathara Diddhenipothage SAD, Goindoo RJ, Bragg F, Orchard E, Shears D, Calanchini M, Turner HE. Tumour occurrence in women with Turner syndrome: A narrative review and single-centre case series. Clin Endocrinol (Oxf) 2023; 99:64-72. [PMID: 36905085 DOI: 10.1111/cen.14910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/15/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Population studies suggest cancer morbidity may be different in Turner syndrome (TS) compared to the background female population. However, significant variability is observed in cancer associations likely due to heterogeneity in patient cohorts. We explored the prevalence and patterns of cancer amongst a cohort of women with TS attending a dedicated TS clinic. METHODS Retrospective analysis of the patient database was performed to identify TS women who developed cancer. Population data (available before 2015) from the National Cancer Registration and Analysis Service database were used for comparison. RESULTS Out of 156 TS women, median age of 32 (range 18-73) years, 9 (5.8%) had a recorded cancer diagnosis. Types of cancers were, bilateral gonadoblastoma, type 1 gastric neuroendocrine tumour (NET), appendiceal-NET, gastrointestinal stromal tumour, plasma cell dyscrasia, synovial sarcoma, cervical cancer, medulloblastoma and aplastic anaemia. Median age at cancer diagnosis was 35 (range 7-58) years and two were detected incidentally. Five women had 45,X karyotype, three received growth hormone treatment and all except one received oestrogen replacement therapy. The cancer prevalence of the background age-matched female population was 4.4%. CONCLUSIONS We confirm the previous observations that women with TS do not appear to be at overall increased risk of common malignancies. Our small cohort showed a spectrum of rare malignancies that are not typically associated with TS, except for a single patient with a gonadoblastoma. The slightly higher prevalence of cancer in our cohort might simply represent increased cancer prevalence in the background population, or might be related to small sample size and regular monitoring of these women due to TS per se.
Collapse
Affiliation(s)
| | - Ryan J Goindoo
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Fiona Bragg
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth Orchard
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Deborah Shears
- Department of Clinical Genetics, Oxford Centre for Genomic Medicine, Oxford, UK
| | - Matilde Calanchini
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Helen E Turner
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Trust, Oxford, UK
| |
Collapse
|
22
|
Proskuriakova E, Jasaraj RB, San Hernandez AM, Sakhuja A, Khoury M, Khosla P. A Case of Severe Aplastic Anemia in a 35-Year-Old Male With a Good Response to Immunosuppressive Therapy. Cureus 2023; 15:e40210. [PMID: 37435252 PMCID: PMC10332331 DOI: 10.7759/cureus.40210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/09/2023] [Indexed: 07/13/2023] Open
Abstract
Aplastic anemia (AA) is a severe but rare hematologic condition associated with hematopoietic failure leading to decreased or total absent hematopoietic precursor cells in the bone marrow. AA presents at any age with equal distribution among gender and race. There are three known mechanisms of AA: direct injuries, immune-mediated disease, and bone marrow failure. The most common etiology of AA is considered to be idiopathic. Patients usually present with non-specific findings, such as easy fatigability, dyspnea on exertion, pallor, and mucosal bleeding. The primary treatment of AA is to remove the offending agent. In patients in whom the reversible cause was not found, patient management depends on age, disease severity, and donor availability. Here, we present a case of a 35-year-old male who presented to the emergency room with profuse bleeding after a deep dental cleaning. He was found to have pancytopenia on his laboratory panel and had an excellent response to immunosuppressive therapy.
Collapse
Affiliation(s)
| | | | | | | | - Mtanis Khoury
- Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | - Pam Khosla
- Hematology and Oncology, Mount Sinai Hospital, Chicago, USA
| |
Collapse
|
23
|
Pan P, Chen C, Hong J, Gu Y. Autoimmune pathogenesis, immunosuppressive therapy and pharmacological mechanism in aplastic anemia. Int Immunopharmacol 2023; 117:110036. [PMID: 36940553 DOI: 10.1016/j.intimp.2023.110036] [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: 12/28/2022] [Revised: 02/26/2023] [Accepted: 03/10/2023] [Indexed: 03/23/2023]
Abstract
Acquired aplastic anemia (AA) is an autoimmune disease of bone marrow failure mediated by abnormally activated T cells, manifested by severe depletion of hematopoietic stem and progenitor cells (HSPCs) and peripheral blood cells. Due to the limitation of donors for hematopoietic stem cell transplantation, immunosuppressive therapy (IST) is currently an effective first-line treatment. However, a significant proportion of AA patients remain ineligible for IST, relapse, and develop other hematologic malignancies, such as acute myeloid leukemia after IST. Therefore, it is important to elucidate the pathogenic mechanisms of AA and to identify treatable molecular targets, which is an attractive way to improve these outcomes. In this review, we summarize the immune-related pathogenesis of AA, pharmacological targets, and clinical effects of the current mainstream immunosuppressive agents. It provides new insight into the combination of immunosuppressive drugs with multiple targets, as well as the discovery of new druggable targets based on current intervention pathways.
Collapse
Affiliation(s)
- Pengpeng Pan
- Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Institute of Clinical Pharmacology, Anhui Medical University, Hefei 230032, PR China
| | - Congcong Chen
- Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Institute of Clinical Pharmacology, Anhui Medical University, Hefei 230032, PR China
| | - Jian Hong
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, PR China
| | - Yue Gu
- Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Institute of Clinical Pharmacology, Anhui Medical University, Hefei 230032, PR China.
| |
Collapse
|
24
|
Vaht K, Brenner J, Ednersson SB, Ljungman P, Brune M, Andersson PO. Bone marrow expression of CD68/CD163 macrophages, IL-17 and FOXP3 cells in aplastic anemia and their relation to prognosis. Eur J Haematol 2023; 110:313-321. [PMID: 36469034 PMCID: PMC10108308 DOI: 10.1111/ejh.13908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 11/26/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The primary mechanism for bone marrow failure in aplastic anemia (AA) is autoimmune hematopoietic stem cell destruction. AA can be cured with antithymocyte globulin (ATG) treatment, and some smaller studies have indicated that the number of regulatory T cells (Tregs) may be predictive of response. Additionally, AA patients appear to have elevated numbers of Th17 cells and bone marrow macrophages, but outcome data are missing. METHODS We performed immunohistochemistry on bone marrow biopsies from 121 ATG-treated AA patients and 14 healthy controls, using antibodies against FOXP3 (for Tregs), IL-17 (for Th17), CD68 (for pan-macrophages) and CD163 (for M2 type macrophages) to study their possible relation to ATG response and AA prognosis. RESULTS AA patients had significantly fewer Tregs and Th17 cells but significantly more macrophages compared with controls. Treg, Th17 and pan-macrophage cell numbers were not associated with ATG response or differences in survival. Patients with higher levels of M2 macrophages had improved 5-year overall survival: 79.6% versus 57.4% (p = .017), and this benefit was primarily seen in AA patients with non-severe disease. CONCLUSIONS We found that Treg and Th17 cell numbers did not predict ATG response or survival, whereas M2 macrophages may be associated with improved survival.
Collapse
Affiliation(s)
- Krista Vaht
- Section of Hematology and Coagulation, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Medicine, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Jonas Brenner
- Department of Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susanne Bram Ednersson
- Department of Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Per Ljungman
- Centre of Allogeneic Stem Cell Transplantation Unit (CAST), Karolinska University Hospital and Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Mats Brune
- Section of Hematology and Coagulation, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Medicine, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Per-Ola Andersson
- Section of Hematology and Coagulation, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Medicine, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| |
Collapse
|
25
|
Bänziger S, Weisshaar K, Arokoski R, Gerull S, Halter J, Rovó A, Bargetzi M, Goede JS, Senft Y, Valenta S, Passweg JR, Drexler B. Feasibility of electronic patient-reported outcome monitoring and self-management program in aplastic anemia and paroxysmal nocturnal hemoglobinuria-a pilot study (ePRO-AA-PNH). Ann Hematol 2023; 102:199-208. [PMID: 36326854 PMCID: PMC9631592 DOI: 10.1007/s00277-022-05012-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Electronic patient-reported outcomes (ePRO) are increasingly recognized in health care, as they have been demonstrated to improve patient outcomes in cancer, but have been less studied in rare hematological diseases. The aim of this study was to develop and test the feasibility of an ePRO system specifically customized for aplastic anemia (AA) and paroxysmal nocturnal hemoglobinuria (PNH). METHODS After performing a user-centered design evaluation an ePRO system for AA and PNH patients could be customized and the application was tested by patients and their medical teams for 6 months. Symptom-reporting triggered self-management advice for patients and prompts them to contact clinicians in case of severe symptoms, while the medical team received alerts of severe symptoms for patient care. RESULTS All nine included patients showed a high adherence rate to the weekly symptom-reporting (72%) and reported high satisfaction. The system was rated high for usage, comprehensibility, and integration into daily life. Most patients (78%) would continue and all would recommend the application to other AA/PNH patients. Technical performance was rarely a barrier and healthcare providers saw ePRO-AA-PNH as a useful supplement, but the lacking integration into the hospital information system was identified as a major barrier to usage. CONCLUSION An ePRO system customized for AA and PNH was feasible in terms of adherence, satisfaction, and performance, showing a high potential for these rare conditions in terms of data collection and patient guidance. However, the integration into clinical workflows is crucial for further routine use. TRIAL REGISTRATION ClinicalTrials.gov NCT04128943.
Collapse
Affiliation(s)
- Silas Bänziger
- grid.410567.1Division of Hematology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Kimmo Weisshaar
- grid.410567.1Division of Hematology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | | | - Sabine Gerull
- grid.410567.1Division of Hematology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Jörg Halter
- grid.410567.1Division of Hematology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Alicia Rovó
- grid.411656.10000 0004 0479 0855Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Mario Bargetzi
- grid.413357.70000 0000 8704 3732Division of Hematology, University Medical Clinic, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Jeroen S. Goede
- grid.452288.10000 0001 0697 1703Division of Oncology and Haematology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Yuliya Senft
- grid.410567.1Division of Hematology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Sabine Valenta
- grid.410567.1Division of Hematology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland ,grid.6612.30000 0004 1937 0642Nursing Science, Department Public Health, University of Basel, Basel, Switzerland
| | - Jakob R. Passweg
- grid.410567.1Division of Hematology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Beatrice Drexler
- grid.410567.1Division of Hematology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| |
Collapse
|
26
|
Gavriilaki E, Tragiannidis A, Papathanasiou M, Besikli S, Karvouni P, Douka V, Paphianou E, Hatzipantelis E, Papaioannou G, Athanasiadou A, Marvaki A, Panteliadou AK, Vardi A, Batsis I, Syrigou A, Mallouri D, Lalayanni C, Sakellari I. Aplastic anemia and paroxysmal nocturnal hemoglobinuria in children and adults in two centers of Northern Greece. Front Oncol 2022; 12:947410. [PMID: 36439498 PMCID: PMC9684709 DOI: 10.3389/fonc.2022.947410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 10/17/2022] [Indexed: 09/14/2023] Open
Abstract
Bone marrow failure (BMF) syndromes are a group of various hematological diseases with cytopenia as a main common characteristic. Given their rarity and continuous progress in the field, we aim to provide data considering the efficiency and safety of the therapeutic methods, focusing on the treatment of aplastic anemia(AA) and paroxysmal nocturnal hemoglobinuria (PNH). We enrolled consecutive patients diagnosed with BMF in two referral centers of Northern Greece from 2008 to 2020. We studied 43 patients with AA (37 adults and 6 children/adolescents) and 6 with classical PNH. Regarding classical PNH, 4 patients have received eculizumab treatment with 1/4 presenting extravascular hemolysis. Among 43 patients with aplastic anemia, PNH clones were detected in 11. Regarding patients that did not receive alloHCT (n=15), 14/15 were treated with ATG and cyclosporine as first line, with the addition of eltrombopag in patients treated after its approval (n=9). With a median follow-up of 16.7 (1.8-56.2) months from diagnosis, 12/14 (85.7%) are alive (4-year OS: 85.1%). AlloHCT was performed in 28 patients. Five patients developed TA-TMA which did not resolve in 3/5 (all with a pre-transplant PNH clone). With the follow-up among survivors reaching 86.3 (6.3-262.4) months, 10-year OS was 56.9%, independently associated with PNH clones after adjusting for age (p=0.024). In conclusion, our real-world experience confirms that novel treatments are changing the field of BMF syndromes. Nevertheless, there is still an unmet need to personalize algorithms in this field.
Collapse
Affiliation(s)
- Eleni Gavriilaki
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Athanasios Tragiannidis
- 2Paediatric Department, American Hellenic Educational Progressive Association (AHEPA) Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Papathanasiou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Sotiria Besikli
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | | | - Vassiliki Douka
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Eleni Paphianou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Emmanuel Hatzipantelis
- 2Paediatric Department, American Hellenic Educational Progressive Association (AHEPA) Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Giorgos Papaioannou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Anastasia Athanasiadou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Anastasia Marvaki
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Alkistis-Kira Panteliadou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Anna Vardi
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Ioannis Batsis
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Antonia Syrigou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Despina Mallouri
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Chrysavgi Lalayanni
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Ioanna Sakellari
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| |
Collapse
|
27
|
Aplastic Anemia as a Roadmap for Bone Marrow Failure: An Overview and a Clinical Workflow. Int J Mol Sci 2022; 23:ijms231911765. [PMID: 36233062 PMCID: PMC9569739 DOI: 10.3390/ijms231911765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/27/2022] Open
Abstract
In recent years, it has become increasingly apparent that bone marrow (BM) failures and myeloid malignancy predisposition syndromes are characterized by a wide phenotypic spectrum and that these diseases must be considered in the differential diagnosis of children and adults with unexplained hematopoiesis defects. Clinically, hypocellular BM failure still represents a challenge in pathobiology-guided treatment. There are three fundamental topics that emerged from our review of the existing data. An exogenous stressor, an immune defect, and a constitutional genetic defect fuel a vicious cycle of hematopoietic stem cells, immune niches, and stroma compartments. A wide phenotypic spectrum exists for inherited and acquired BM failures and predispositions to myeloid malignancies. In order to effectively manage patients, it is crucial to establish the right diagnosis. New theragnostic windows can be revealed by exploring BM failure pathomechanisms.
Collapse
|
28
|
Kelkka T, Tyster M, Lundgren S, Feng X, Kerr C, Hosokawa K, Huuhtanen J, Keränen M, Patel B, Kawakami T, Maeda Y, Nieminen O, Kasanen T, Aronen P, Yadav B, Rajala H, Nakazawa H, Jaatinen T, Hellström-Lindberg E, Ogawa S, Ishida F, Nishikawa H, Nakao S, Maciejewski J, Young NS, Mustjoki S. Anti-COX-2 autoantibody is a novel biomarker of immune aplastic anemia. Leukemia 2022; 36:2317-2327. [PMID: 35927326 PMCID: PMC9417997 DOI: 10.1038/s41375-022-01654-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 11/09/2022]
Abstract
In immune aplastic anemia (IAA), severe pancytopenia results from the immune-mediated destruction of hematopoietic stem cells. Several autoantibodies have been reported, but no clinically applicable autoantibody tests are available for IAA. We screened autoantibodies using a microarray containing >9000 proteins and validated the findings in a large international cohort of IAA patients (n = 405) and controls (n = 815). We identified a novel autoantibody that binds to the C-terminal end of cyclooxygenase 2 (COX-2, aCOX-2 Ab). In total, 37% of all adult IAA patients tested positive for aCOX-2 Ab, while only 1.7% of the controls were aCOX-2 Ab positive. Sporadic non-IAA aCOX-2 Ab positive cases were observed among patients with related bone marrow failure diseases, multiple sclerosis, and type I diabetes, whereas no aCOX-2 Ab seropositivity was detected in the healthy controls, in patients with non-autoinflammatory diseases or rheumatoid arthritis. In IAA, anti-COX-2 Ab positivity correlated with age and the HLA-DRB1*15:01 genotype. 83% of the >40 years old IAA patients with HLA-DRB1*15:01 were anti-COX-2 Ab positive, indicating an excellent sensitivity in this group. aCOX-2 Ab positive IAA patients also presented lower platelet counts. Our results suggest that aCOX-2 Ab defines a distinct subgroup of IAA and may serve as a valuable disease biomarker.
Collapse
Affiliation(s)
- Tiina Kelkka
- Hematology Research Unit Helsinki, University of Helsinki and Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland.,Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
| | - Mikko Tyster
- Hematology Research Unit Helsinki, University of Helsinki and Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland.,Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
| | - Sofie Lundgren
- Hematology Research Unit Helsinki, University of Helsinki and Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland.,Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
| | - Xingmin Feng
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Cassandra Kerr
- Department of Translational Hematology and Oncology Research and Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kohei Hosokawa
- Department of Hematology, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Jani Huuhtanen
- Hematology Research Unit Helsinki, University of Helsinki and Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland.,Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
| | - Mikko Keränen
- Hematology Research Unit Helsinki, University of Helsinki and Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland.,Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
| | - Bhavisha Patel
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Toru Kawakami
- Division of Hematology, Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuka Maeda
- Division of Cancer Immunology, Research Institute/Exploratory Oncology Research and Clinical Trial Center, National Cancer Center Japan, Tokyo, Japan
| | - Otso Nieminen
- Hematology Research Unit Helsinki, University of Helsinki and Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland.,Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
| | - Tiina Kasanen
- Hematology Research Unit Helsinki, University of Helsinki and Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland.,Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
| | - Pasi Aronen
- Biostatistics Unit, Faculty of Medicine, University of Helsinki and Helsinki-Uusimaa Hospital District, Helsinki, Finland
| | - Bhagwan Yadav
- Hematology Research Unit Helsinki, University of Helsinki and Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland.,Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
| | - Hanna Rajala
- Hematology Research Unit Helsinki, University of Helsinki and Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland.,Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
| | - Hideyuki Nakazawa
- Department of Hematology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Taina Jaatinen
- Histocompatibility Testing Laboratory, Finnish Red Cross Blood Service, Helsinki, Finland
| | - Eva Hellström-Lindberg
- Division of Hematology, Department of Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Seishi Ogawa
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Fumihiro Ishida
- Department of Biomedical Laboratory Sciences, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroyoshi Nishikawa
- Division of Cancer Immunology, Research Institute/Exploratory Oncology Research and Clinical Trial Center, National Cancer Center Japan, Tokyo, Japan
| | - Shinji Nakao
- Department of Hematology, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Jaroslaw Maciejewski
- Department of Translational Hematology and Oncology Research and Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Satu Mustjoki
- Hematology Research Unit Helsinki, University of Helsinki and Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland. .,Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland. .,iCAN Digital Precision Cancer Medicine Flagship, Helsinki, Finland.
| |
Collapse
|
29
|
Matsui K, Kamata W, Mochida Y, Ishioka K, Moriya H, Hidaka S, Ohtake T, Tamai Y, Kobayashi S. Acquired aplastic anemia complicated with anti-glomerular basement membrane disease successfully treated with immunosuppressive therapy: a case report. BMC Nephrol 2022; 23:136. [PMID: 35392836 PMCID: PMC8991481 DOI: 10.1186/s12882-022-02772-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Aplastic anemia (AA) is a rare but fatal disorder characterized by pancytopenia due to bone marrow hypoplasia. Anti-glomerular basement membrane disease (anti-GBM disease) is an immune complex small-vessel vasculitis that presents as rapidly progressive glomerulonephritis and/or pulmonary hemorrhage. Although both involve autoreactive T cells that are partially triggered by human leukocyte antigen (HLA)-DR15, there have been no reports of their co-existence and the treatment strategy is not well understood. CASE PRESENTATION A 67-year-old woman presented with fever, malaise, and acute kidney injury with proteinuria and hematuria requiring hemodialysis. She was diagnosed with anti-GBM antibody disease based on high serum anti-GBM antibody titer and crescentic glomerulonephritis on a renal biopsy. Pulse administration of methylprednisolone (MP), oral prednisolone (PSL), and plasmapheresis were performed. Only 2 weeks after the diagnosis of anti-GBM disease, the patient developed pancytopenia requiring frequent blood transfusions. The blood cell count did not recover even 1 month after discontinuing the drugs that could cause pancytopenia. Bone marrow examination showed hypocellularity without abnormal infiltrates or fibrosis, which led to the diagnosis of severe acquired AA. Further HLA phenotyping revealed that she had HLA-DR15. Increased dose of PSL with the secondary MP pulse and the addition of cyclosporine improved pancytopenia. Although she remained dialysis-dependent, anti-GBM disease and pancytopenia did not recur for more than 2 years. CONCLUSIONS We report the first case of acquired AA complicated with anti-GBM disease in an elderly woman with HLA-DR15, which was successfully treated with immunosuppressive therapy (IST). This report is valuable not only because it shows they may co-occur, but also because it provides a therapeutic option for this complex condition. It was also suggested that pancytopenia in patients with anti-GBM disease recalls serious hematologic diseases including AA that require immediate treatment based on bone marrow examination.
Collapse
Affiliation(s)
- Kenji Matsui
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, Kanawaga, 247-8533, Japan.
| | - Wataru Kamata
- Division of Hematology, Shonan Kamakura General Hospital, Kamakura, Kanawaga, Japan
| | - Yasuhiro Mochida
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, Kanawaga, 247-8533, Japan
| | - Kunihiro Ishioka
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, Kanawaga, 247-8533, Japan
| | - Hidekazu Moriya
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, Kanawaga, 247-8533, Japan
| | - Sumi Hidaka
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, Kanawaga, 247-8533, Japan
| | - Takayasu Ohtake
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, Kanawaga, 247-8533, Japan
| | - Yotaro Tamai
- Division of Hematology, Shonan Kamakura General Hospital, Kamakura, Kanawaga, Japan
| | - Shuzo Kobayashi
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, Kanawaga, 247-8533, Japan
| |
Collapse
|
30
|
Rossiello F, Jurk D, Passos JF, d'Adda di Fagagna F. Telomere dysfunction in ageing and age-related diseases. Nat Cell Biol 2022; 24:135-147. [PMID: 35165420 PMCID: PMC8985209 DOI: 10.1038/s41556-022-00842-x] [Citation(s) in RCA: 216] [Impact Index Per Article: 108.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 01/06/2022] [Indexed: 12/11/2022]
Abstract
Ageing organisms accumulate senescent cells that are thought to contribute to body dysfunction. Telomere shortening and damage are recognized causes of cellular senescence and ageing. Several human conditions associated with normal ageing are precipitated by accelerated telomere dysfunction. Here, we systematize a large body of evidence and propose a coherent perspective to recognize the broad contribution of telomeric dysfunction to human pathologies.
Collapse
Affiliation(s)
- Francesca Rossiello
- IFOM Foundation-FIRC Institute of Molecular Oncology Foundation, Milan, Italy
| | - Diana Jurk
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA
| | - João F Passos
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA.
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA.
| | - Fabrizio d'Adda di Fagagna
- IFOM Foundation-FIRC Institute of Molecular Oncology Foundation, Milan, Italy.
- Istituto di Genetica Molecolare, Consiglio Nazionale delle Ricerche (IGM-CNR), Pavia, Italy.
| |
Collapse
|
31
|
Necrotizing Bacterial Myositis as the Initial Presentation of Severe Aplastic Anaemia. Case Rep Hematol 2022; 2021:8276937. [PMID: 34970463 PMCID: PMC8714340 DOI: 10.1155/2021/8276937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 11/17/2021] [Accepted: 12/14/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Necrotizing soft tissue infections are rapidly progressing infections associated with severe inflammation and cytokine release. Early recognition and surgical intervention are key factors to secure survival. The current case presents a patient with multifocal necrotizing soft tissue infection as the initial presentation of severe aplastic anaemia. Case Presentation. A man in his fifties was admitted with septic shock with multiorgan failure and severe pancytopenia, after two days of malaise with high fever and right flank pain. The diagnosis streptococcal necrotizing myositis was significantly delayed due to atypical clinical findings. After initial surgical exploration, the decision was made to defer from surgical debridement due to extensive involvement of several muscle groups, grave pancytopenia, and suspected dismal prognosis. Surprisingly, the patient stabilized after antibiotics and intensive care treatment. Based on severe pancytopenia and hypocellular bone marrow, with no evidence of other bone marrow disorders, the patient was diagnosed with aplastic anaemia. Treatment for aplastic anaemia with antithymocyte globulin, cyclosporine, and eltrombopaq was started, and 2 months later, a partial haematological recovery was observed. The patient could be discharged from hospital without antibiotic treatment. Conclusions This case illustrates the crucial role of a multidisciplinary approach on admission and further during the clinical course. Clinical improvement despite severe neutropenia and stabilization during immunosuppressive therapy suggest that immunological factors modulate clinical course in necrotizing soft tissue infections.
Collapse
|
32
|
Zhang XT, Wang X, Cao J, Chen W, Qi KM, Qi N, Liang F, Dong XY, Tang GF, Li DP, Sang W, Li ZY, Cheng H, Xu KL. Treatment outcome of 301 aplastic anemia patients in China: a 10-year follow-up and real-world data from single institute experience. Hematology 2021; 26:1025-1030. [PMID: 34895103 DOI: 10.1080/16078454.2021.2009646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE This study was carried out to explore clinical treatment and prognosis of patients with AA with different economic status. Methods: We retrospectively analyzed the clinical outcome of 301 patients with AA in our center from April 2008 to November 2017. RESULTS Treatments included anti-thymocyte globulin (ATG) or anti-lymphocyte globulin (ALG) combined with cyclosporineA (CsA) (9%), allogeneic hematopoietic stem cell transplantation (allo-HSCT) (7%), CsA combined with androgen or CsA alone (hereinafter referred to as CsA group) (77%), no specific therapy (7%). The 5-year overall survival (OS) was higher in patients with non-severe AA (94.6%) compared with those with severe AA (SAA) (66.6%, P <.001), very severe AA (VSAA) (41.3%, P <.001). The 5-year OS was 76.5% in patients with SAA/VSAA treated with ATG/ALG combined with CsA, 75% in allo-HSCT group(P =.936), 63.6% in CsA group (P =.557), which was significantly higher than no specific therapy group (21.8%, P =.002). For those who responded to CsA , the duration of CsA (median follow-up time: 27 months, 1-101 months) was positively correlated with progression-free survival (r=0.603, P <.001). Multivariate analysis revealed that 36-65 years of age, SAA/VSAA, and no specific therapy were independent risk factors for inferior survival. CONCLUSION The treatment of elderly patients with AA still faces challenges. CsA is benefit to the survival of SAA/VSAA patients. AA patients, who responded to initialy CsA treatment, may benefit from prolonged CsA treatment. In view of the side effects of CsA, the timing of withdrawal is worth further exploration.
Collapse
Affiliation(s)
- Xiao-Tian Zhang
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Xue Wang
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Jiang Cao
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Wei Chen
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Kun-Ming Qi
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Na Qi
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Fei Liang
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Xue-Yan Dong
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Guo-Feng Tang
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - De-Peng Li
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Wei Sang
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Zhen-Yu Li
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Hai Cheng
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Kai-Lin Xu
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China.,Institute of Hematology, Xuzhou Medical University, Xuzhou, People's Republic of China.,Key Laboratory of Bone Marrow Stem Cell, Xuzhou, People's Republic of China
| |
Collapse
|
33
|
Syed MA, Rahman AAU, Ghani A, Shah Syed MN, Siddiqui MI, Riaz H, Khidri FF, Baloch NN. An Investigation of Selected Socio-Demographic Factors with Aplastic Anemia in Pakistan: A Case-Control Study. Int J Gen Med 2021; 14:8929-8934. [PMID: 34876834 PMCID: PMC8642121 DOI: 10.2147/ijgm.s335961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/28/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction In Pakistan, the incidence rate of aplastic anemia is 3.5 cases/million. The associated risk factors are exposure to pesticides, chemicals, and some drugs. The link between aplastic anemia and socio-demographic factors is debatable. Purpose We conducted this study to investigate the role of socio-economic and -demographic factors with aplastic anemia. Methodology A total of 191 lab-confirmed incident cases of aplastic anemia were identified from the tertiary hospital of Karachi-Pakistan in between 2015 and 2018. Age and gender-matched 694 controls were randomly selected from the same institute admitted or visited for other non-neoplastic conditions. Socio-demographic and exposure information was gathered using a data collection form. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were computed for selected socio-demographic factors. Results Among socio-demographic factors, significant associations of aplastic anemia risk emerged for illiteracy (aOR: 2.3; 1.5; 3.5) occupation (any type) (aOR: 2.1; 1.7; 2.5), living in rural environments (aOR: 2.9; 1.9; 4.2). The odds of aplastic anemia increased with the age group 31–50 years (aOR: 1.8; 1.7; 3.5) and >50 years (aOR: 2.5; 2.1; 4.2). We observed no association of income with the risk of aplastic anemia. Conclusion This study highlights the importance of socio-demographic factors as a risk factor for the development of aplastic anemia in the population of Pakistan. In order to reduce disease incidence, health education program and use of personal protective equipment and organization of screening camps in high-risk population is warranted.
Collapse
Affiliation(s)
- Muhammad Asif Syed
- Field Epidemiology Laboratory Training Program (FELTP), Karachi, Pakistan
| | - Aneela Atta Ur Rahman
- Department of Community Medicine & Public Health Sciences, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan
| | - Abdul Ghani
- Department of Health, Jam Ghulam Qadir Government Teaching Hospital, Hub, Pakistan
| | - Muhammad Nadeem Shah Syed
- National Emergency Operation Center, National Stop Transmission of Polio (N-STOP), Islamabad, Pakistan
| | - Muhammad Ilyas Siddiqui
- Department of Community Medicine & Public Health Sciences, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan
| | - Hina Riaz
- Department of Physiology/Medical Research Centre, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan
| | | | | |
Collapse
|
34
|
Eapen M. Since everyone has a donor, why are some eligible patients still not transplanted? Best Pract Res Clin Haematol 2021; 34:101321. [PMID: 34865693 DOI: 10.1016/j.beha.2021.101321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Hematopoietic cell transplantation is an important treatment option for malignant and non-malignant hematologic diseases. Despite increasing the potential donor pool for hematopoietic cell transplantation there are many patients who are unable to access this treatment. There are several biologic and non-biologic factors that may explain lower utilization of transplantation. Biologic factors associated with lower utilization include older age, multiple comorbidities, persons of African American descent and high-risk disease that may not respond optimally to hematopoietic cell transplantation. Non-biologic factors associated with lower utilization include lower educational (without a high school diploma) or social status, uninsured, Medicaid or Medicare insurance and in persons aged ≥60 years, when the distance between their residence and hospital was greater than 37 miles. The decision to proceed to hematopoietic cell transplantation is a dialogue between the patient and the treating physician. While some patients may be considered poor candidates for continued treatment including hematopoietic cell transplantation others may be offered novel pharmacologic and cellular therapies with a capacity to deliver specific immunologic antitumor responses. Pharmacologic and cellular therapies are relatively recent, and it is not known whether the biologic and non-biologic factors that limit access to transplantation will limit access to these newer treatments.
Collapse
Affiliation(s)
- Mary Eapen
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, 9200 W Wisconsin Ave, WI, 53226, USA.
| |
Collapse
|
35
|
Chiu ML, Hsu YL, Chen CJ, Li TM, Chiou JS, Tsai FJ, Lin TH, Liao CC, Huang SM, Chou CH, Liang WM, Lin YJ. Chinese Herbal Medicine Therapy Reduces the Risks of Overall and Anemia-Related Mortalities in Patients With Aplastic Anemia: A Nationwide Retrospective Study in Taiwan. Front Pharmacol 2021; 12:730776. [PMID: 34690769 PMCID: PMC8531749 DOI: 10.3389/fphar.2021.730776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/27/2021] [Indexed: 12/14/2022] Open
Abstract
Aplastic Anemia (AA) is a rare but fatal hematologic disease that may occur at any age and especially higher in Asia. We investigated whether Chinese herbal medicine (CHM) is beneficial to AA patients as a complementary therapy using a nationwide population-based database in Taiwan between 2000-2016. Patient survival was estimated by Kaplan‒Meier survival analyses and Cox proportional-hazard model. CHM-users presented lower risks of overall and anemia-related mortalities when compared to non-users. The risk of overall mortality for CHM-users in AA patients was 0.70-fold [adjusted hazard ratio (aHR): 0.70, 95% confidence interval (CI): 0.66-0.74, p < 0.001). The risk of anemia-related mortality was lower in CHM-users when compared to non-users (aHR: 0.46, 95% CI: 0.32-0.67, p < 0.001). The association rule analysis revealed that CHM pairs were Ban-Zhi-Lian (BZL; Scutellaria barbata D. Don)→Bai-Hua-She-She-Cao (BHSSC; Oldenlandia diffusa (Willd.) Roxb.), followed by Dang-Gui (DG; Angelica sinensis (Oliv.) Diels)→Huang-Qi (HQi; Astragalus membranaceus (Fisch.) Bunge), and Xian-He-Cao (XHC; Agrimonia pilosa f. borealis (Kitag.) Chu)→Gui-Pi-Tang (GPT). Network analysis showed that BZL, BHSSC, DG, HQi, XHC, GPT, and Dan-Shen (DanS; Salvia miltiorrhiza var. charbonnelii (H.Lév.) C.Y.Wu) were commonly used CHMs for AA patients. Therefore, further studies for these commonly prescribed herbs are needed in functional investigations in hematopoiesis-stimulating effect and large-scale randomized controlled trials (RCT) in bone marrow failure related diseases.
Collapse
Affiliation(s)
- Mu-Lin Chiu
- School of Chinese Medicine, China Medical University, Taichung, Taiwan.,Proteomics Core Laboratory, Department of Medical Research, Genetic Center, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Lung Hsu
- China Medical University Children's Hospital, China Medical University, Taichung, Taiwan
| | - Chao-Jung Chen
- Proteomics Core Laboratory, Department of Medical Research, Genetic Center, China Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - Te-Mao Li
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Jian-Shiun Chiou
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Fuu-Jen Tsai
- School of Chinese Medicine, China Medical University, Taichung, Taiwan.,Proteomics Core Laboratory, Department of Medical Research, Genetic Center, China Medical University Hospital, Taichung, Taiwan.,China Medical University Children's Hospital, China Medical University, Taichung, Taiwan.,Department of Biotechnology and Bioinformatics, Asia University, Taichung, Taiwan
| | - Ting-Hsu Lin
- Proteomics Core Laboratory, Department of Medical Research, Genetic Center, China Medical University Hospital, Taichung, Taiwan
| | - Chiu-Chu Liao
- Proteomics Core Laboratory, Department of Medical Research, Genetic Center, China Medical University Hospital, Taichung, Taiwan
| | - Shao-Mei Huang
- Proteomics Core Laboratory, Department of Medical Research, Genetic Center, China Medical University Hospital, Taichung, Taiwan
| | - Chen-Hsing Chou
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Wen-Miin Liang
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Ying-Ju Lin
- School of Chinese Medicine, China Medical University, Taichung, Taiwan.,Proteomics Core Laboratory, Department of Medical Research, Genetic Center, China Medical University Hospital, Taichung, Taiwan
| |
Collapse
|
36
|
Richards SJ, Painter D, Dickinson AJ, Griffin M, Munir T, Arnold L, Payne D, Pike A, Muus P, Hill A, Newton DJ, McKinley C, Jones R, Kelly R, Smith A, Roman E, Hillmen P. The incidence and prevalence of patients with paroxysmal nocturnal haemoglobinuria and aplastic anaemia PNH syndrome: A retrospective analysis of the UK's population-based haematological malignancy research network 2004-2018. Eur J Haematol 2021; 107:211-218. [PMID: 34060690 DOI: 10.1111/ejh.13640] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES A retrospective population-based study to determine the incidence and prevalence of patients with the rare blood disease paroxysmal nocturnal haemoglobinuria (PNH). METHODS All patients were identified by flow cytometric detection of blood cells deficient in glycosylphosphatidylinositol (GPI) linked proteins at a single diagnostic reference laboratory that serves the Yorkshire based, Haematological Malignancy Research Network (HMRN) with a population of 3.8 million. RESULTS One hundred and ninety-seven patients with detectable PNH clones at a level of >0.01% in at least two lineages of cells (neutrophils, monocytes and/or red cells) were identified over a 15-year period (2004-2018). Of these, 88% had aplastic anaemia (AA), 8% classical PNH and 3% myelodysplastic syndrome. The overall incidence rate was estimated at 0.35 cases per 100 000 people per year. This equates to 220 cases newly diagnosed in the United Kingdom each year. The overall prevalence rate was 3.81 per 100 000, this equates to an estimated 2400 prevalent cases in the UK. The overall and relative 5-year survival rates were 72% and 82.7%, respectively. CONCLUSIONS This study showed that classical haemolytic PNH is a rare disease and represents only a small proportion overall of patients with detectable PNH cells, the majority of which have aplastic anaemia.
Collapse
MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Anemia, Aplastic/complications
- Anemia, Aplastic/diagnosis
- Anemia, Aplastic/epidemiology
- Anemia, Aplastic/history
- Biomarkers
- Child
- Child, Preschool
- Female
- Hemoglobinuria, Paroxysmal/complications
- Hemoglobinuria, Paroxysmal/diagnosis
- Hemoglobinuria, Paroxysmal/epidemiology
- Hemoglobinuria, Paroxysmal/history
- History, 21st Century
- Humans
- Immunophenotyping
- Incidence
- Male
- Middle Aged
- Population Surveillance
- Prevalence
- Retrospective Studies
- Syndrome
- United Kingdom/epidemiology
- Young Adult
Collapse
Affiliation(s)
- Stephen J Richards
- Division of Haematology and Immunology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Daniel Painter
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Anita J Dickinson
- Haematological Malignancy Diagnostic Service, Leeds Teaching Hospitals NHS Trust, St. James's University Hospital, Leeds, UK
| | - Morag Griffin
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Talha Munir
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Louise Arnold
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Daniel Payne
- Haematological Malignancy Diagnostic Service, Leeds Teaching Hospitals NHS Trust, St. James's University Hospital, Leeds, UK
| | - Alexandra Pike
- Division of Haematology and Immunology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Petra Muus
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Alexion Pharmaceuticals Inc., Leeds, UK
| | - Darren J Newton
- Division of Haematology and Immunology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Claire McKinley
- Division of Haematology and Immunology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Rachael Jones
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Richard Kelly
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alex Smith
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Eve Roman
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Peter Hillmen
- Division of Haematology and Immunology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
37
|
Feurstein S, Churpek JE, Walsh T, Keel S, Hakkarainen M, Schroeder T, Germing U, Geyh S, Heuser M, Thol F, Pohlkamp C, Haferlach T, Gao J, Owen C, Goehring G, Schlegelberger B, Verma D, Krause DS, Gao G, Cronin T, Gulsuner S, Lee M, Pritchard CC, Subramanian HP, Del Gaudio D, Li Z, Das S, Kilpivaara O, Wartiovaara-Kautto U, Wang ES, Griffiths EA, Döhner K, Döhner H, King MC, Godley LA. Germline variants drive myelodysplastic syndrome in young adults. Leukemia 2021; 35:2439-2444. [PMID: 33510405 PMCID: PMC8725861 DOI: 10.1038/s41375-021-01137-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/17/2020] [Accepted: 01/11/2021] [Indexed: 01/29/2023]
Affiliation(s)
- Simone Feurstein
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago Comprehensive Cancer Center, The University of Chicago, Chicago, IL, USA
| | - Jane E Churpek
- Division of Hematology, Medical Oncology, and Palliative Care, Department of Medicine, The University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Tom Walsh
- Department of Medicine, Division of Medical Genetics, University of Washington, Seattle, WA, USA
| | - Sioban Keel
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Marja Hakkarainen
- Applied Tumor Genomics Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, University of Helsinki, Helsinki, Finland
| | - Thomas Schroeder
- Department of Hematology, Oncology and Clinical Immunology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Stefanie Geyh
- Department of Hematology, Oncology and Clinical Immunology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Felicitas Thol
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | | | - Juehua Gao
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Carolyn Owen
- Division of Hematology and Hematological Malignancies, University of Calgary, Calgary, AB, Canada
| | - Gudrun Goehring
- Department of Human Genetics, Hannover Medical School, Hannover, Germany
| | | | - Divij Verma
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Medicine, Frankfurt, Germany
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, USA
| | - Daniela S Krause
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Medicine, Frankfurt, Germany
| | - Guimin Gao
- Department of Public Health Sciences, The University of Chicago, Chicago, IL, USA
| | - Tara Cronin
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Suleyman Gulsuner
- Department of Genome Sciences, University of Washington, Seattle, WA, USA
| | - Ming Lee
- Department of Genome Sciences, University of Washington, Seattle, WA, USA
| | - Colin C Pritchard
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | | | - Daniela Del Gaudio
- Department of Human Genetics, The University of Chicago, Chicago, IL, USA
| | - Zejuan Li
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute and Houston Methodist Hospital, Houston, TX, USA
| | - Soma Das
- Department of Human Genetics, The University of Chicago, Chicago, IL, USA
| | - Outi Kilpivaara
- Applied Tumor Genomics Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Medical and Clinical Genetics/Medicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Ulla Wartiovaara-Kautto
- Applied Tumor Genomics Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, University of Helsinki, Helsinki, Finland
| | - Eunice S Wang
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | | | - Konstanze Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Hartmut Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Mary-Claire King
- Department of Genome Sciences, University of Washington, Seattle, WA, USA
| | - Lucy A Godley
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago Comprehensive Cancer Center, The University of Chicago, Chicago, IL, USA.
| |
Collapse
|
38
|
Adult aplastic anemia in Thailand: incidence and treatment outcome from a prospective nationwide population-based study. Ann Hematol 2021; 100:2443-2452. [PMID: 34269837 PMCID: PMC8440252 DOI: 10.1007/s00277-021-04566-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 06/04/2021] [Indexed: 11/20/2022]
Abstract
The incidence and outcomes of aplastic anemia (AA) in Asia remain limited. This study aimed to explore the incidence and outcomes of patients with adult AA across the country of Thailand. This is a prospective multi-center nationwide population-based observational study of AA patients aged at least 15 years old, diagnosed from August 2014 to July 2016, with a longitudinal follow-up period over 2 years. There were 348 newly diagnosed adult AA patients during the enrollment period, giving an annual incidence of 4.6 per million. The incidence of severe (SAA) and very severe aplastic anemia (VSAA) (3.8 per million) was higher than non-severe AA (NSAA, 0.8 per million). The peak incidence was observed in the patients aged from 80 to 89 years old (14.4 per million). The 2-year overall survival (OS) in NSAA, SAA, and VSAA were 65.5%, 49.3%, and 20.1%, respectively (P < 0.001). With regard to the response to immunosuppressive therapy, the overall response rate (ORR) in SAA/VSAA treated with rabbit anti-thymocyte globulin with/without cyclosporin A (rATG ± CsA) were significantly superior to those treated with CsA alone, or anabolic steroids (44.4% vs 36.4% and 31.2%, respectively, P < 0.001). The 2-year OS in SAA/VSAA treated with rATG ± CsA, CsA, and anabolic steroids were 54.8%, 54.5%, and 37.6% (P = 0.037), respectively. The incidence of adult AA in Thailand is higher than those in Western countries, and the peak incidence is in the elderly. rATG ± CsA provided a better response than anabolic steroids, translating to the superior survival in SAA/VSAA treated with rATG ± CsA.
Collapse
|
39
|
Outcomes of haploidentical bone marrow transplantation in patients with severe aplastic anemia-II that progressed from non-severe acquired aplastic anemia. Front Med 2021; 15:718-727. [PMID: 34170455 DOI: 10.1007/s11684-020-0807-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/29/2020] [Indexed: 10/21/2022]
Abstract
Severe aplastic anemia II (SAA-II) progresses from non-severe aplastic anemia (NSAA). The unavailability of efficacious treatment has prompted the need for haploidentical bone marrow transplantation (haplo-BMT) in patients lacking a human leukocyte antigen (HLA)-matched donor. This study aimed to investigate the efficacy of haplo-BMT for patients with SAA-II. Twenty-two patients were included and followed up, and FLU/BU/CY/ATG was used as conditioning regimen. Among these patients, 21 were successfully engrafted, 19 of whom survived after haplo-BMT. Four patients experienced grade II-IV aGvHD, including two with grade III-IV aGvHD. Six patients experienced chronic GvHD, among whom four were mild and two were moderate. Twelve patients experienced infections during BMT. One was diagnosed with post-transplant lymphoproliferative disorder and one with probable EBV disease, and both recovered after rituximab infusion. Haplo-BMT achieved 3-year overall survival and disease-free survival rate of 86.4% ± 0.73% after a median follow-up of 42 months, indicating its effectiveness as a salvage therapy. These promising outcomes may support haplo-BMT as an alternative treatment strategy for patients with SAA-II lacking HLA-matched donors.
Collapse
|
40
|
Wang WH, Wu JF, Chang HH, Lu MY, Yang YL, Chou SW, Lin DT, Lin KH, Jou ST. The Impact of Hepatitis on Clinical Outcomes for Pediatric Patients with Aplastic Anemia. J Pediatr 2020; 227:87-93.e2. [PMID: 32805258 DOI: 10.1016/j.jpeds.2020.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/24/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To assess the prognostic role of hepatitis in pediatric patients with aplastic anemia and the incidence of hepatitis B among patients with hepatitis-associated aplastic anemia in an area with a previously high prevalence of hepatitis B after nationwide hepatitis B vaccination for 30 years. STUDY DESIGN Pediatric patients (n = 78) with aplastic anemia were enrolled in this study, including 9 with hepatitis-associated aplastic anemia. We collected the clinical characteristics, etiologies of the aplastic anemia, hepatitis B virus serology and serum hepatitis B viral load, response to the treatments, and survival outcome from the participants. We applied univariate and multivariate Cox regression analysis to evaluate the correlations between clinical features and survival outcome. Survival analysis was done using Cox regression model and Kaplan-Meier curves. RESULTS Patients with hepatitis-associated aplastic anemia were related to significantly worse survival prognosis when compared with patients with non-hepatitis-associated aplastic anemia, and hepatitis-associated aplastic anemia was the only independent prognostic factor to predict a poor survival outcome in our patients with aplastic anemia by multivariable analysis. In none of the total 78 patients was aplastic anemia related to hepatitis B virus infection. CONCLUSIONS Patients with hepatitis-associated aplastic anemia had a significantly worse prognosis when compared with patients whose aplastic anemia was not hepatitis-associated. This study demonstrates the potential benefit of hepatitis B vaccination in decreasing the incidence of hepatitis-associated aplastic anemia in children.
Collapse
Affiliation(s)
- Wei-Hao Wang
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Pediatrics, Changhua Christian Hospital, Changhua, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsiu-Hao Chang
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Meng-Yao Lu
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yung-Li Yang
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shu-Wei Chou
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Dong-Tsamn Lin
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kai-Hsin Lin
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
41
|
Drexler B, Zurbriggen F, Diesch T, Viollier R, Halter JP, Heim D, Holbro A, Infanti L, Buser A, Gerull S, Medinger M, Tichelli A, Passweg JR. Very long-term follow-up of aplastic anemia treated with immunosuppressive therapy or allogeneic hematopoietic cell transplantation. Ann Hematol 2020; 99:2529-2538. [PMID: 32948913 PMCID: PMC7536165 DOI: 10.1007/s00277-020-04271-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 09/09/2020] [Indexed: 11/28/2022]
Abstract
Introduction Since the 1970s outcome of aplastic anemia (AA) patients has improved significantly due to the introduction of immunosuppressive therapy (IST) and allogeneic hematopoietic transplantation (HCT). However, patients may suffer from persistent disease, relapse, clonal evolution, graft-versus-host disease and other late effects. Here, we analyse very long-term outcome of all AA patients at our institution comparing not only survival, but also response status and complications. Methods Patient charts of all 302 AA patients treated between 1973 and 2017 at the University Hospital Basel, Switzerland, were retrospectively analysed. Results First line treatment was IST in 226 (75%) and HCT in 76 (25%) patients. Overall survival at 30 years was similar in patients treated initially by HCT and IST (44% (±14%), and 40% (± 9%) respectively, with better results in more recent years. Partial and no response occurred more frequently after IST, relapse incidence after IST was 24 %, whereas non-engraftment and graft failure was documented in 15 patients (19 %) after HCT. Clonal evolution to myelodysplastic syndrome / acute myeloid leukemia was 16 % at 25 years in IST patients, 1.3 % in HCT patients, iron overload (18 versus 4 %, p = 0.002) and cardiovascular events (11 versus 1 %, p=0.011) occured significantly more often in IST than HCT treated patients. The majority of long-term survivors, 96% of those alive at 25 years, were in complete remission at last follow up, irrespective of the initial treatment modality. Conclusion Very long term survivors after AA are those with stable hematopoietic recovery.
Collapse
Affiliation(s)
- Beatrice Drexler
- Division of Hematology, University Hospital, Basel, Switzerland.
| | | | - Tamara Diesch
- Division of Pediatric Oncology/Hematology, University Children's Hospital Basel UKBB, Basel, Switzerland
| | | | - Joerg P Halter
- Division of Hematology, University Hospital, Basel, Switzerland
| | - Dominik Heim
- Division of Hematology, University Hospital, Basel, Switzerland
| | - Andreas Holbro
- Division of Hematology, University Hospital, Basel, Switzerland
- Blood Transfusion Center, Swiss Red Cross, Basel, Switzerland
| | - Laura Infanti
- Division of Hematology, University Hospital, Basel, Switzerland
- Blood Transfusion Center, Swiss Red Cross, Basel, Switzerland
| | - Andreas Buser
- Division of Hematology, University Hospital, Basel, Switzerland
- Blood Transfusion Center, Swiss Red Cross, Basel, Switzerland
| | - Sabine Gerull
- Division of Hematology, University Hospital, Basel, Switzerland
| | | | - André Tichelli
- Division of Hematology, University Hospital, Basel, Switzerland
| | - Jakob R Passweg
- Division of Hematology, University Hospital, Basel, Switzerland
| |
Collapse
|
42
|
Chattopadhyay S, Law S. Morphogen signaling by Wnt/β-catenin pathway and microenvironmental alteration in the bone marrow of agricultural pesticide exposure-induced experimental aplastic anemia. J Biochem Mol Toxicol 2020; 34:e22523. [PMID: 32410290 DOI: 10.1002/jbt.22523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 03/14/2020] [Accepted: 04/27/2020] [Indexed: 11/08/2022]
Abstract
The etiologic link between pesticide toxicity and aplastic anemia in agricultural and agro-industrial setting has been frequently reported in epidemiological studies conducted worldwide. Chronic pesticide toxicity causes long-term bone marrow injury and perturbs the normal hematopoietic physiology, including survival of hematopoietic progenitor cells and bone marrow's blood cell forming ability. The purpose of this study is to understand the mechanism of pesticide toxicity-mediated bone marrow aplasia by studying Wnt/β-catenin signaling pathway and microenvironmental stromal components. An agricultural pesticide formulation comprising of cypermethrin, chlorpyriphos, and hexaconazole was used to induce bone marrow aplasia in inbred Swiss albino mice. Marrow failure followed by the onset of aplastic condition was confirmed by pancytopenic peripheral blood and hypocellular bone marrow filled with adipocytes. Significant downregulation of canonical Wnt/β-catenin signaling was identified by expression analysis of Wnt3a, β-catenin, and telomerase reverse transcriptase in the aplastic bone marrow hematopoietic stem/progenitor compartment. Along with signaling deregulation, disruption in both the osteoblastic and vascular stromal components was observed in the pesticide-exposed bone marrow microenvironment when compared to control. In this study, we tried to establish the correlation among disease pathophysiology, signaling deregulation in the hematopoietic cells, and bone marrow microenvironmental alteration during environmental exposure-mediated aplastic hematopoietic catastrophe, which may shed light on the unexplored mechanistic perspective of this fatal blood disease.
Collapse
Affiliation(s)
- Sukalpa Chattopadhyay
- Stem Cell Research and Application Unit, Department of Biochemistry and Medical Biotechnology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
| | - Sujata Law
- Stem Cell Research and Application Unit, Department of Biochemistry and Medical Biotechnology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
| |
Collapse
|
43
|
Choice of conditioning regimens for bone marrow transplantation in severe aplastic anemia. Blood Adv 2020; 3:3123-3131. [PMID: 31648332 DOI: 10.1182/bloodadvances.2019000722] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/22/2019] [Indexed: 11/20/2022] Open
Abstract
Allogeneic bone marrow transplantation (BMT) is curative therapy for the treatment of patients with severe aplastic anemia (SAA). However, several conditioning regimens can be used for BMT. We evaluated transplant conditioning regimens for BMT in SAA after HLA-matched sibling and unrelated donor BMT. For recipients of HLA-matched sibling donor transplantation (n = 955), fludarabine (Flu)/cyclophosphamide (Cy)/antithymocyte globulin (ATG) or Cy/ATG led to the best survival. The 5-year probabilities of survival with Flu/Cy/ATG, Cy/ATG, Cy ± Flu, and busulfan/Cy were 91%, 91%, 80%, and 84%, respectively (P = .001). For recipients of 8/8 and 7/8 HLA allele-matched unrelated donor transplantation (n = 409), there were no differences in survival between regimens. The 5-year probabilities of survival with Cy/ATG/total body irradiation 200 cGy, Flu/Cy/ATG/total body irradiation 200 cGy, Flu/Cy/ATG, and Cy/ATG were 77%, 80%, 75%, and 72%, respectively (P = .61). Rabbit-derived ATG compared with equine-derived ATG was associated with a lower risk of grade II to IV acute graft-versus-host disease (GVHD) (hazard ratio [HR], 0.39; P < .001) but not chronic GVHD. Independent of conditioning regimen, survival was lower in patients aged >30 years after HLA-matched sibling (HR, 2.74; P < .001) or unrelated donor (HR, 1.98; P = .001) transplantation. These data support Flu/Cy/ATG and Cy/ATG as optimal regimens for HLA-matched sibling BMT. Although survival after an unrelated donor BMT did not differ between regimens, use of rabbit-derived ATG may be preferred because of lower risks of acute GVHD.
Collapse
|
44
|
Similar outcomes of alemtuzumab-based hematopoietic cell transplantation for SAA patients older or younger than 50 years. Blood Adv 2020; 3:3070-3079. [PMID: 31648330 DOI: 10.1182/bloodadvances.2019000480] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022] Open
Abstract
Survival after allogeneic hematopoietic cell transplantation (HSCT) for severe aplastic anemia (SAA) among older patients remains poor and associated with increased risk for graft-versus-host disease (GVHD). In this retrospective study of 65 consecutive patients with acquired SAA who were transplanted using fludarabine, low-dose cyclophosphamide, and alemtuzumab (FCC), outcomes of 27 patients aged at least 50 years were compared with those of 38 patients younger than 50 years. The median age of the older cohort was 61 years (range, 51-71 years); 21 (78%) patients were transplanted from unrelated donors (3 of 21 from HLA 9/10 mismatch donors) and 6 from matched sibling donors. One-year GVHD-free, relapse-free survival (GRFS) was comparable to that of patients younger than 50 years (84% vs 94%, respectively; P = .23). Both groups showed low rates of acute (5% vs 4%) and chronic (18% vs 14%) GVHD, with no cases of severe GVHD among matched donor transplants, and similar 1-year transplant-related mortality (14% vs 5.4%, older vs younger; P = .23). HSCT comorbidity index (HTC-CI) scores were similar between the groups, but overall survival with an HCT-CI of at least 3 was lower compared with a score less than 3 (76% vs 98%; P = .005). Median donor T-cell chimerism among older patients was 64% and 60% at 1 and 3 years, respectively, and was similar to that of younger patients. Increased B regulatory cells potentially contributed to low alloreactivity and mutual donor-recipient tolerance in older patients. Effect of comorbidities rather than age alone may be a more important determinant of suitability for FCC HSCT in older patients.
Collapse
|
45
|
Fox LC, Ritchie DS. Pediatric aplastic anemia treatment patterns and responses; power in the numbers. Haematologica 2020; 104:1909-1912. [PMID: 31575670 DOI: 10.3324/haematol.2019.225870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Lucy C Fox
- Diagnostic Haematology, Peter MacCallum Cancer Centre.,University of Melbourne
| | - David S Ritchie
- University of Melbourne.,Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia
| |
Collapse
|
46
|
Božić Ozretić D, Piplović Vuković T, Vuković J, Madunić S, Podrug K, Puljiz Ž. Fatal Hepatitis-Associated Aplastic Anemia in a Young Male. Case Rep Gastroenterol 2020; 14:383-390. [PMID: 32884515 PMCID: PMC7443668 DOI: 10.1159/000508438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/01/2020] [Indexed: 11/19/2022] Open
Abstract
Hepatitis-associated aplastic anemia is a rare syndrome in which bone marrow failure occurs within weeks to 1 year after attack of acute hepatitis. Studies suggest that cytotoxic T lymphocytes play a central role in bone marrow destruction, but the exact etiology remains unknown. Bone marrow transplantation or immunosuppressive therapy are primary curative options. We present a case of a young male who was admitted to the Department of Gastroenterology and Hepatology for acute hepatitis of an unknown cause. Liver biopsy revealed extensive inflammatory process with hepatocyte necrosis. Forty days later, new onset pancytopenia was identified. Bone marrow biopsy showed severe hypocellularity, and he was diagnosed with severe hepatitis-associated aplastic anemia. Treatment with cyclosporine was initiated, but with inadequate response, and pretransplant evaluation was started. Due to severe neutropenia, following alveotomy procedure, the patient developed deep neck infection with consequent airway obstruction. Despite urgent treatment, his condition deteriorated to sepsis with lethal outcome.
Collapse
Affiliation(s)
- Dorotea Božić Ozretić
- Department of Gastroenterology and Hepatology, University Hospital of Split, Split, Croatia
| | - Tonka Piplović Vuković
- Department of Gastroenterology and Hepatology, University Hospital of Split, Split, Croatia
| | - Jonatan Vuković
- Department of Gastroenterology and Hepatology, University Hospital of Split, Split, Croatia.,University of Split, School of Medicine, Split, Croatia
| | - Sanja Madunić
- Department of Haematology, University Hospital of Split, Split, Croatia
| | - Kristian Podrug
- Department of Gastroenterology and Hepatology, University Hospital of Split, Split, Croatia
| | - Željko Puljiz
- Department of Gastroenterology and Hepatology, University Hospital of Split, Split, Croatia.,University of Split, School of Medicine, Split, Croatia
| |
Collapse
|
47
|
Haploidentical hematopoietic stem cell transplantation in aplastic anemia: a systematic review and meta-analysis of clinical outcome on behalf of the severe aplastic anemia working party of the European group for blood and marrow transplantation (SAAWP of EBMT). Bone Marrow Transplant 2020; 55:1906-1917. [PMID: 32346079 DOI: 10.1038/s41409-020-0897-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/15/2020] [Accepted: 03/31/2020] [Indexed: 11/08/2022]
Abstract
Aplastic anemia (AA) is a serious hematological disorder, which is solely cured by hematopoietic stem cell transplantation (HSCT). Haploidentical HSCT is an emerging modality with encouraging outcomes in several blood conditions. The present study aims to comprehensively assess the feasibility and safety of haploidentical HSCT in patients with severe and very severe AA. It is a systematic review and meta-analysis of studies related to haploidentical stem cell transplantation in idiopathic AA investigating rates of successful engraftment, acute graft-versus-host disease (aGvHD), chronic GvHD (cGvHD), transplant-related mortality (TRM), and posttransplantation viral infections (including cytomegalovirus [CMV]) in patients with AA. The effects of reduced-intensity conditioning (RIC) and nonmyeloablative conditioning (NMA), as well as various GvHD prophylaxis regimens on these outcomes were evaluated. In total 15 studies were identified, (577 patients, 58.9% males), successful engraftment was observed in 97.3% of patients (95% CI, 95.9-98.7) while grades II-IV aGvHD and cGvHD were reported in 26.6% and 25.0%, respectively. The pooled incidence of TRM was 6.7% per year (95% CI, 4.0-9.4). RIC regimens were associated with higher proportions of successful engraftment (97.7% vs 91.7%, P = 0.03) and aGvHD (29.5% vs 18.7%, P = 0.008) when compared with NMA regimens with no differences in cGvHD or mortality incidence. When compared with methotrexate-containing regimens and other regimens, posttransplant cyclophosphamide-containing regimens reduced the rates of aGvHD (28.6%, 27.8%, and 12.8%, respectively, P = 0.02), CMV viremia (55.7%, 38.6%, and 10.4%, respectively, P < 0.001), and CMV disease in initially viremic patients (2.1%, 33.0%, and 0%, respectively, P < 0.001). We have concluded that Haploidentical HSCT was associated with promising outcomes in terms of successful engraftment and reduced complications. Future prospective trials are needed to identify the preferred conditioning regimen, GvHD prophylaxis, and graft source in the setting of haploidentical transplant for AA.
Collapse
|
48
|
Qi WW, Fu R. [Progress in diagnosis and treatment in the elderly patients with aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:80-83. [PMID: 32023761 PMCID: PMC7357911 DOI: 10.3760/cma.j.issn.0253-2727.2020.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Indexed: 11/30/2022]
Affiliation(s)
- W W Qi
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - R Fu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| |
Collapse
|
49
|
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.
Collapse
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
| | | |
Collapse
|
50
|
Fattizzo B, Levati G, Cassin R, Barcellini W. Eltrombopag in Immune Thrombocytopenia, Aplastic Anemia, and Myelodysplastic Syndrome: From Megakaryopoiesis to Immunomodulation. Drugs 2019; 79:1305-1319. [PMID: 31292909 DOI: 10.1007/s40265-019-01159-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Eltrombopag is an orally available thrombopoietin receptor agonist indicated for the treatment of immune thrombocytopenia (ITP). Beyond the effect on megakaryopoiesis, the drug also showed a stimulating effect on the hematopoietic stem cell with consistent clinical efficacy in aplastic anemia (AA) and myelodysplastic syndromes (MDS). Eltrombopag is highly effective in ITP and less so in AA and MDS. This observation underlines the importance of residual normal hematopoiesis, which is maximal in ITP, minimal/absent in AA, and dysregulated in MDS. In ITP, the drug at 50-75 mg daily induced up to 85% responses both in clinical trials and real-life studies, with the possibility of tapering and discontinuation. In AA, eltrombopag at 150 mg daily was effective in about 40% of cases relapsed/refractory to standard immunosuppression or ineligible for bone marrow transplant. In MDS, the drug seems less effective, with responses in about a quarter of patients at various schedules. The efficacy of eltrombopag in ITP, AA, and MDS suggests the existence of common immune-pathological mechanisms in these diseases, including autoimmunity against peripheral blood cells and bone marrow precursors, as well as a possible evolution of one condition into the other. Additional mechanisms of action emerging from the clinical use of eltrombopag include modulation of T-regulatory cells, restoration of Fc-γ receptor balance in phagocytes, and an iron-mobilizing effect. In this review, we analyzed the most recent literature on eltrombopag use and efficacy in patients with ITP, AA, and MDS, exploring the basis for different dosing, combined treatments, and discontinuation in each context.
Collapse
Affiliation(s)
- Bruno Fattizzo
- UO Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giorgia Levati
- UO Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,University of Milan, Milan, Italy
| | - Ramona Cassin
- UO Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- UO Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|