再生障碍性贫血—阵发性睡眠性血红蛋白尿综合征78例临床分析

作者收治７８例再生障碍性贫血－阵发性睡眠性血红蛋白尿综合征（ＡＡ－ＰＮＨ综合征）患者，其中ＡＡ转化为ＰＮＨ４６例；ＰＮＨ伴ＡＡ特征１４例；ＡＡ伴ＰＮＨ特征１７例；ＰＮＨ转化为ＡＡ１例。各型之间在血象和骨髓象方面无明显区别，并就各型特点及两病之间的关系进行了讨论。     

再生障碍性贫血-阵发性睡眠性血红蛋白尿致急性肾功能衰竭

病例摘要 病史患者男性,32岁,"贫血18年,反复酱油色尿8年,少尿伴血肌酐升高1月"于2009-03-12入院.     

阵发性睡眠性血红蛋白尿和阵发性睡眠性血红蛋白尿/再生障碍性贫血综合征患者HLA-DR2出现频率增高

许多免疫性疾病与ＨＬＡ等位基因有关 ,有报道再生障碍性贫血 (ＡＡ)亦与ＨＬＡ等位基因有关 ,许多ＡＡ患者可发现存在糖基化磷酸肌醇锚蛋白 (ＧＰＩ ＡＰ)缺陷细胞存在。本研究旨在观察阵发性睡眠性血红蛋白尿 (ＰＮＨ)克隆扩增与ＨＬＡ等位基因的关系。方法　该研究含 2组人群 ,第 1组 41 5例 ,包括 2 60例ＡＡ(其中 48例伴ＰＮＨ克隆存在 ) ,1 3 9例骨髓增生异常综合征 (ＭＤＳ) ,1 6例原发性ＰＮＨ ;第 2组 3 0 8例 ,为ＡＡ或ＭＤＳ ,之前均接受了强化免疫抑制治疗。两组中有 2 51例患者相同。运用分子分型技术测定患者的ＨＬＡ基因型 ,…     

阵发性睡眠性血红蛋白尿症与再生障碍性贫血患者干细胞因子和FLT3配体及其受体表达的研究

目的:检测干细胞因子(SCF)与FLT3配体(FL)及其受体在阵发性睡眠性血红蛋白尿(PNH)与再生障碍性贫血(AA)的表达情况,探讨2者在PNH与AA发病中作用。方法:用ELISA法检测PNH与AA患者骨髓SCF和可溶性FL的含量,用流式细胞术对AA与PNH骨髓单个核细胞c kit与FLT3的表达进行分析。结果:PNH、慢性AA患者SCF含量分别为(456.8±115.2)、(372.6±111.5),与正常对照组(389.2±123.3)比较差异无统计学意义(P>0.05);PNH、慢性AA患者c kit表达分别为(48.8±15.6)、(39.6±11.5),低于正常对照组(75.2±23.3)。PNH患者FL水平为226.3±50.6,明显高于正常对照组(89.4±20.8),但低于慢性AA(658.2±125.5)(P<0.01);PNH、慢性AA患者FLT3表达分别为(13.2±5.8)、(8.5±2.7),与正常对照相比差异无统计学意义(P>0.05)。结论:干细胞因子、FLT3配体及其受体参与PNH与AA的发病,2者共同的发病机制可能为干细胞因子受体缺陷、免疫紊乱。     

中性粒细胞为0的成人重型再生障碍性贫血强化免疫抑制治疗研究

目的评价兔抗人胸腺细胞免疫球蛋白(anti-thymocyte globulin,ATG)联合环孢素A(cyclosporine,CsA)强化免疫抑制治疗(intensive immunosuppressive therapy,IIST)中性粒细胞为0的成人再生障碍性贫血的疗效。方法回顾性分析2014年1月至2018年3月国内三家医院86例接受IIST的重型再生障碍性贫血(severe aplastic anemia,SAA)临床资料。将免疫抑制治疗前中性粒细胞为0的SAA定义为暴发型再生障碍性贫血(fulminant aplastic anemia,FAA),与SAA、极重型再生障碍性贫血(very SAA,vSAA)比较对IIST的疗效。结果 86例患者中,FAA 19例,vSAA 23例,SAA 44例。3个月总有效率分别为21.1%,56.5%和54.5%,6个月总有效率分别为42.1%,60.9%和72.7%。FAA组患者3个月的有效率明显低于vSAA和SAA组(21.1%vs. 56.5%,P=0.032;21.1%vs. 54.5%,P=0.023),6个月的有效率明显低于SAA组(42.1%vs. 72.7%,P=0.028),疗效与中性粒细胞计数显著相关(P=0.019)。三组的中位起效时间分别为17.0个月,4.0个月和3.0个月,FAA组慢于vSAA组、SAA组(P=0.031,P=0.001)。FAA组患者总生存率明显低于vSAA和SAA组(63.2%, 91.3%和95.5%,P=0.001),生存率与中性粒细胞计数及疗效显著相关(P=0.026,P=0.010)。结论中性粒细胞为0的成人FAA临床预后严重不良,需要探索新的治疗方案。     

再生障碍性贫血-阵发性睡眠性血红蛋白尿综合征与典型阵发性睡眠性血红蛋白尿症的临床对照研究

目的　研究再生障碍性贫血 -阵发性睡眠性血红蛋白尿综合征 (AA PNH综合征 )与典型阵发性睡眠性血红蛋白尿症 (PNH)临床特征的异同 ,加深对AA PNH综合征的认识。方法　回顾分析了 2 8例AA PNH综合征和 5 1例典型PNH的临床表现、实验室检查及治疗反应 ,并进行了对照研究。结果　AA PNH综合征与典型PNH相比 :①血栓形成、黄疸、肝脾肿大等临床表现均较轻。②网织红细胞虽较低 ,但仍高于正常 ;骨髓涂片及活检多表现为增生减低 ,但红系比例不低 ;③各溶血指标检查阳性率均较低 ,但CD5 5、CD5 9表达异常的检出率为10 0 % ,且其在红细胞、粒细胞、淋巴细胞中表达的百分率在两组患者中无明显差异。④免疫球蛋白、T细胞亚群的检测 ,两组患者均无异常。⑤两组患者对肾上腺糖皮质激素为主的治疗均反应良好。结论　AA PNH综合征虽临床表现有别于典型PNH ,但与典型PNH无本质区别 ;CD5 5、CD5 9的检测有助于提高AA PNH综合征的检出率     

慢性再生障碍性贫血-阵发性睡眠性血红蛋白尿症-急性白血病一例

患者男 ,18岁。 1978年 6月 3日因头晕、乏力 1年余住院。入院检查 :贫血貌 ,巩膜无黄染 ,浅表淋巴不大 ,皮肤黏膜无出血点。胸骨无压痛 ,心肺 (- ) ,肝脾未扪及。Hb 5 0g/L ,WBC 2 4× 10 9/L ,中性粒 0 4 6 ,淋巴 0 5 2 ,单核 0 0 2。网织红细胞 (Ret) 0 0 0 2。尿检查 :尿胆原 (+) ,总胆红素 2 0μmol/L ,肝肾功能正常。中性粒细胞碱性磷酸酶反应(N ALP)阳性率 70 % ,积分 180。多部位骨髓检查示增生度减低 ,粒系统 0 2 4 ,红系统 0 18,淋巴系统 0 5 8。诊断 :慢性再生障碍性贫血 (CAA)。应用泼尼松、丙酸睾丸酮、中药大菟…     

强化免疫抑制治疗重型再生障碍性贫血后血小板输注21例疗效观察

血小板输注是临床治疗因血小板数量减少或血小板功能障碍所致的出血性疾病的重要手段。联合应用抗胸腺细胞球蛋白(ATG)及环孢素A(CsA)是目前公认的重型再生障碍性贫血(SAA)标准免疫抑制治疗(IST)方案。但应用ATG后仍有较长时间的白细胞及血小板减少的过程,输注血小板及红细     

两种免疫抑制疗法治疗重型再生障碍性贫血比较研究

目的 :探讨重型再生障碍性贫血的适宜治疗方案。方法 :回顾性比较猪 -抗胸腺细胞球蛋白( P- ATG)单用 ( IST方案 )与联合方案兔 -抗人 T淋巴细胞球蛋白 ( R- ATL G)、环孢霉素 A( Cs A)、重组人粒 -巨噬细胞集落刺激因子 ( rhu GM- G- CSF) /重组人粒细胞集落刺激因子 ( rhu- G-CSF)及重组人红细胞生成素 ( rhu EPO) ( IST方案 )治疗 SAA疗效。结果 :IST方案 组不仅疗效高于 IST方案 组 ,且其有效者造血功能恢复更为迅速及良好。结论 :SAA患者更适宜于 IST方案 。     

阵发性睡眠性血红蛋白尿并自身免疫性溶血性贫血l例

患者男 ,1 5岁。以乏力、尿黄、全身发黄 3月余入院。患者 3个月前受凉后出现四肢乏力 ,小便色黄如浓茶样 ,伴发热 ,最高达 38.5℃ ,咳嗽 ,咳白色黏痰 ,全身皮肤发黄。在当地医院检查网织红细胞0 .2 85 ,骨髓穿刺提示为增生性贫血 ,Coomb试验阳性 ,阵发性睡眠性血红蛋白尿 (PNH)相关检查阴性 ,诊断为自身免疫性溶血性贫血 (AIHA)。给予泼尼松 40mg/d及对症治疗后 ,症状好转并减量 ,减至2 0mg/d时 ,血清总胆红素又升高 ,遂增至 30mg/d来我院复查。体检 :体温 37.3℃ ,脉搏 80次 /min ,血压 1 2 0 / 80mmHg( 1mmHg=0 .1 33kPa)。神清 ,皮…     

Natural history of paroxysmal nocturnal hemoglobinuria clones in patients presenting as aplastic anemia

Objective: To investigate the natural history of paroxysmal nocturnal hemoglobinuria (PNH) clones in patients with acquired aplastic anemia (AA). Patients and Methods: Twenty‐seven patients with AA and a detectable PNH clone were monitored for a median of 5.7 years (range1.5–11.5 years). Twenty‐two patients received high‐dose cyclophosphamide (HiCy) therapy. The erythrocyte and granulocyte PNH clone sizes were measured using flow cytometry and analyzed via CellQuest software. PE‐conjugated anti‐glycophorin A, anti‐CD15, FITC‐conjugated anti‐CD59, and FLAER staining were used to define glycosylphosphatidylinositol‐AP‐deficient cells. Results: We found a linear relationship between PNH clone size and the development of intravascular hemolysis, assessed by lactate dehydrogenase (LDH) values (Pearson correlation coefficient = 0.80, P < 0.001 for erythrocyte PNH clones; and Pearson correlation coefficient = 0.73, P < 0.0001 for granulocyte PNH clones). An erythrocyte PNH size of 3–5% and granulocyte PNH size of 23% were the thresholds to predict hemolysis as measured by an elevated LDH (receiver operating characteristic analyses with AUC = 0.96 for erythrocyte PNH clone sizes and AUC = 0.88 for granulocyte PNH clone sizes). Patients with small (≤15%) initial PNH clone sizes were less likely to develop an elevated LDH (mean ± SD: 236.9 ± 109.9 vs. 423.1 ± 248.8; P = 0.02). Over time, the PNH clone sizes remained stable in 25.9% of patients; 48.1% experienced a rise in the PNH clone size; and 25.9% experienced a decrease. Conclusion: The risk of developing clinically significant PNH after HiCy therapy appears to be low in AA patients with PNH clones, especially for those with small initial PNH clones and for those who respond to HiCy therapy.     

A cohort study of the nature of paroxysmal nocturnal hemoglobinuria clones and PIG-A mutations in patients with aplastic anemia

Abstract:  Background:  Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by the clonal expansion of blood cells, which are deficient in glycosylphosphatidylinositol anchored proteins (GPI-APs). As PNH frequently occurs during the clinical course of acquired aplastic anemia (AA), it is likely that a process inducing bone marrow failure in AA is responsible for the selection of GPI-AP deficient blood cells or PNH clone. Objective:  To explore the nature and mutation of a PNH clone in AA. Methods:  We performed regular repeated flow cytometric analyses of CD59 expression on peripheral blood cells from a cohort of 32 patients with AA. Mutation of phosphatidylinositol glycan class A (PIG-A) was also studied. Results:  Fifty-one episodes of occurrences of CD59 negative granulocytes out of a total cohort 167 flow cytometric analyses (31%) were observed in 22 patients (69%). CD59 negative erythrocytes were less apparent than the granulocytes. Repeated occurrences of PNH clones were observed in 16 patients. Most of the emerging PNH clones were transient in nature. They were more frequently detected during episodes of lower white blood cell and platelet counts. Persistence and expansion of the GPI-AP deficient blood cell populations to the level of clinical PNH were seen in only four patients (12.5%). Analysis of PIG-A gene demonstrated eight mutations among the four patients, with two and four independent mutations in two patients. Conclusions:  Our study indicates that PIG-A mutations of hematopoietic stem cells with resultant PNH clones, are relatively common among AA patients. It also supports the hypothesis of selection of the PNH clone by a process or condition associated with or responsible for bone marrow failure in AA. However, there must be an additional factor favoring expansion or growth of the clone to the level of clinical or florid PNH.     

On the lysis of paroxysmal nocturnal hemoglobinuria erythrocytes by complement: Dual role of C3b

Summary The efficiency of cytolysis by the terminal complement proteins C5b-9 can be markedly enhanced by C3b molecules bound on the target cell membrane (Hammer et al. 1976). This enhancement was shown to be proportional to the number of C3b molecules on the cell membrane. The present experiments have shown that the hemolytic efficiency of the complement membrane attack system is two to five times greater on paroxysmal nocturnal hemoglobulinuria erythrocytes (PNHE) than on normal human E. This difference is attribut to a derivative of C3, probably C3b, on PNHE since it was abolished by anti-C3 but not by anti-C2. The efficiency of C5b-9 to lyse PNHE was only partially decreased by C3b inactivator and 1H, indicating that the C3b on PNHE is not readily inactivated by its regulatory proteins. Furthermore, cells from a single severely affected patient consumed 3-fold more C5b6 than normal human E yet concommitantly measured membrane fluidity was normal. From these observations we conclude that cell-bound C3b on PNHE serves two functions: (a) it increases the hemolytic efficiency of membrane attack components of the complement system; and (b) it provides sites for assembly of the alternative pathway convertases.     

Paroxysmal nocturnal hemoglobinuria clones in severe aplastic anemia patients treated with horse anti-thymocyte globulin plus cyclosporine

Background

Clones of glycosylphosphatidylinositol-anchor protein-deficient cells are characteristic in paroxysmal nocturnal hemoglobinuria and are present in about 40–50% of patients with severe aplastic anemia. Flow cytometry has allowed for sensitive and precise measurement of glycosylphosphatidylinositol-anchor protein-deficient red blood cells and neutrophils in severe aplastic anemia.

Design and Methods

We conducted a retrospective analysis of paroxysmal nocturnal hemoglobinuria clones measured by flow cytometry in 207 consecutive severe aplastic anemia patients who received immunosuppressive therapy with a horse anti-thymocyte globulin plus cyclosporine regimen from 2000 to 2008.

Results

The presence of a glycosylphosphatidylinositol-anchor protein-deficient clone was detected in 83 (40%) patients pre-treatment, and the median clone size was 9.7% (interquartile range 3.5–29). In patients without a detectable clone pre-treatment, the appearance of a clone after immunosuppressive therapy was infrequent, and in most with a clone pre-treatment, clone size often decreased after immunosuppressive therapy. However, in 30 patients, an increase in clone size was observed after immunosuppressive therapy. The majority of patients with a paroxysmal nocturnal hemoglobinuria clone detected after immunosuppressive therapy did not have an elevated lactate dehydrogenase, nor did they experience hemolysis or thrombosis, and they did not require specific interventions with anticoagulation and/or eculizumab. Of the 7 patients who did require therapy for clinical paroxysmal nocturnal hemoglobinuria symptoms and signs, all had an elevated lactate dehydrogenase and a clone size greater than 50%. In all, 18 (8.6%) patients had a clone greater than 50% at any given time of sampling.

Conclusions

The presence of a paroxysmal nocturnal hemoglobinuria clone in severe aplastic anemia is associated with low morbidity and mortality, and specific measures to address clinical paroxysmal nocturnal hemoglobinuria are seldom required.     

阵发性睡眠性血红蛋白尿症患者粒细胞及血浆尿激酶受体的检测

目的了解阵发性睡眠性血红蛋白尿症(PNH)患者体内尿激酶受体(uPAR)的表达水平,并探讨uPAR检测在PNH诊断中的临床意义.方法用流式细胞仪检测20例PNH患者粒细胞表面uPAR、CD55、CD59的表达水平,并与21例正常人、59例其他贫血患者(18例自身免疫溶血性贫血、6例其他溶血性贫血、26例慢性再生障碍性贫血、9例缺铁性贫血)比较;同时采用免疫放射分析(IRMA)测定PNH患者与正常人血浆可溶性uPAR(suPAR)的水平.结果 20例PNH患者中uPAR 、CD55、CD59表达水平显著降低,且与正常人uPAR表达下限不重叠.在PNH患者中还存在峰型异常[双峰和(或)峰拖尾].而57例其他贫血患者中粒细胞表面uPAR的表达水平无改变.PNH患者血浆suPAR水平为(4.04±2.47 )μg/L,明显高于正常人的(1.73±0.96 )μg/L水平(P＜0.01).PNH患者血浆suPAR水平与粒细胞表面uPAR的表达呈负相关(r=-0.79,P＜0.01).结论 PNH患者粒细胞表面uPAR表达水平降低,而血浆suPAR水平增高,这一变化可作为诊断PNH新的特异性指标.     

阵发性睡眠性血红蛋白尿患者红细胞及血浆中乙酰胆碱酯酶的测定

目的 通过阵发性睡眠性血红蛋白尿(PNH)患者红细胞(RBC)及血浆中乙酰胆碱酯酶(AChE)的测定,研究糖化肌醇磷脂(GPI)锚链蛋白中酶的活性对PNH发病机制的影响.方法 2007年1月至3月在哈尔滨医科大学附属第一医院测定30例PNH患者及14名健康对照者血浆及红细胞中AChE的活性.结果 (1)PNH患者红细胞AChE(E-AChE)活性较健康对照组高,差异有显著性意义(t=2.325,P＜0.05).(2)PNH患者血浆中AChE活性较健康对照组明显降低,差异有显著性意义(t=5.346,P＜0.01).PNH患者红细胞及血浆中AChE活性比较差异无显著性意义.(3)健康对照组中血浆AChE活性明显高于红细胞中AChE活性(t=8.705,P＜0.01).结论 PNH患者血浆和红细胞中AChE活性处于平衡状态,反映了可溶性AChE在外周血中分布存在差异,通过AChE活性的动态变化,可以指导临床治疗和估计预后.