Severe autoimmune thrombocytopenia after allogeneic bone marrow transplantation for aplastic anemia

Autoimmune thrombocytopenia (AITP) after bone marrow transplantation (BMT) was suggested to occur by immune dysregulation mainly in association with graft-versus-host disease (GVHD). Here we present a patient who developed severe AITP after BMT. A 40-year-old woman with severe aplastic anemia received a BMT from a partially HLA-matched brother. Despite myeloid and erythroid engraftments, platelet recovery was delayed. All bone marrow cells were 46,XY and were derived from the donor. Grade I acute GVHD involving skin developed from day 34 posttransplantation, but promptly responded to prednisolone in addition to a prophylactic dose of tacrolimus. With the tapering of prednisolone, thrombocytopenia progressed without substantial changes in the white blood cell count, hemoglobin concentration, or reticulocyte count. On day 188, the patient developed chronic GVHD involving skin and liver, which promptly responded to the readministration of prednisolone and increased tacrolimus. However, the patient's platelet count decreased to 9 x 10(9) cells/L on day 222. The platelet-associated immunoglobulin G (PAIgG) values were elevated. Bone marrow examination showed hypercellularity with plentiful megakaryocytes. The number of colony-forming units-megakaryocyte was within the normal range. The elevated PAIgG values and a correlation between thrombocytopenia and the intensity of the immunosuppressive agents strongly suggested a causative role of the autoimmune mechanisms for thrombocytopenia in this patient.     

Primary transplantation of allogeneic peripheral blood stem cell for severe aplastic anemia

 Primary allogeneic peripheral blood stem cell transplantation (allo-PBSCT) has not been previously described in the treatment of severe aplastic anemia (SAA). We report a patient with SAA who underwent primary allo-PBSCT with cells from her HLA-identical sibling and achieved rapid bone marrow reconstitution. The patient has been in complete remission with normal blood counts for 9 months following allo-PBSCT. This suggests that primary allo-PBSCT is a safe and effective alternative in the treatment of SAA. Received: 13 November 1996 / Accepted: 29 January 1997     

骨髓小粒对AA、MDS诊断及非典型再障、MDS、增生性贫血鉴别诊断的意义

目的 :探讨骨髓小粒对再生障碍性贫血 (AA )、骨髓增生异常综合征 (MDS)、增生性贫血 (简称增贫 )的鉴别诊断价值。方法 :对 10例 AA、5例 MDS、5例增贫及 10例正常人的骨髓小粒进行研究。结果 :AA患者的骨髓小粒中非造血细胞所占比例明显高于 MDS、增贫和正常人 ,差异有显著性 (P <0 .0 1)。 MDS患者的骨髓小粒中的原粒 早幼粒比例明显高于其他三组 (P <0 .0 1) ,并出现多个系统的病态造血。增生性贫血患者的骨髓小粒仅表现为红系的增生和红系的病态造血。结论 :骨髓小粒的观察对 AA、MDS、增贫的鉴别诊断有着重要的意义。     

Cyclophosphamide/antithymocyte globulin conditioning of patients with severe aplastic anemia for marrow transplantation from HLA-matched siblings: Preliminary results

Many approaches have been taken to reducing the rate of graft failure and the incidence of graft-versus-host disease (GVHD) in bone marrow transplantation (BMT) of patients with severe aplastic anemia (SAA). The combination of cyclophosphamide with irradiation has had unequivocal success in reconstituting a sustained engraftment, but this procedure has severe associated risks such as second malignancies. Recently, cyclophosphamide (CYC) plus antithymocyte globulin (ATG) has been shown to be an effective alternative to irradiation-based programs in retransplants. Based on these experiences, the current clinical trial was started to prepare patients suffering from SAA for marrow transplantation from HLA-identical siblings with ATG plus CYC. Nine patients have been enrolled into the study so far. They received a total dose of 200 mg/kg CYC and concomitantly 120 mg/kg or 90 mg/kg ATG, followed by cyclosporine plus methotrexate as post-transplantation GVHD prophylaxis. Eight of nine patients survived without any transplant-associated complications; i.e., they had a documented stable engraftment without rejection and without acute or chronic GVHD. One patient died due to anAsper-gillus sepsis prior to a definite engraftment. Although our data are preliminary because of the small number of patients enrolled and a follow-up of only 30 months, CYC plus ATG appears to be an effective preparative regimen for BMT in patients with SAA, resulting in a favorable outcome.     

Marrow transplantation for severe aplastic anemia associated with exposure to quinacrine

Summary Severe aplastic anemia developed in a patient after administration of quinacrine for treatment of discoid lupus erythematosus. Marrow transplantation was performed from an HLA genotypically identical sister after conditioning with cyclophosphamide. Quinacrine which was accumulated in the patient tissues did not interfere with engraftment, suggesting that the drug has no direct cytotoxic effect on hematopoietic stem cells. This study extends our previous observation that severe aplastic anemia acquired after exposure to drugs or toxins can be cured by marrow transplantation.     

Erythropoietin in aplastic anemia

Summary The level of erythropoietin (Ep) was measured in sera and urine from aplastic anemia patients. Increased levels of E_p were demonstrated in sera from all 25 patients studied. An elevated level of E_p was found in the urine of 17 of 23 patients in whom the urine was tested. No correlation between blood hemoglobin and E_p level was observed. A higher serum E_p level was noted in patients with aplastic anemia than in patients with sideropenic anemia of the same severity. To explain the discrepancy, diminished E_p consumption in bone marrow of aplastic anemia patients is discussed.This work was supported by a grant form the Medical Scientific Fund of Serbia     

Fatal outcome of a patient with severe aplastic anemia after treatment with metenolone acetate

Summary A 75-year-old man suffering from severe aplastic anemia was treated first with cyclosporin A, then with stereoid pulse therapy, and subsequently with metenolone acetate. Marked elevation of transaminases was detected following initiation of treatment with metenolone acetate. This was followed by hepatic failure and death. Histopathological findings in autopsy specimens were compatible with the diagnosis of drug-induced liver impairment, for which metenolone acetate was considered the most likely causative agent. Liver impairment as a side effect of the use of this drug has been thought to be mild, reversible and rather infrequent. However, as demonstrated in the case described here, it is apparent that extreme caution should be exercised when using this drug in debilitated patients.     

同种异体骨髓移植治疗10例重型再生障碍性贫血患者的远期随访资料分析

目的：提高重型再生障碍性贫血(SAA)患者的长期治愈率。方法：1980年5月一2001年12月采用同种异体骨髓移植(BMT)治疗SAA患者l0例，并对其临床及远期随访资料进行分析。结果：近期死亡4例，转入侵性再生障碍性贫血(CAA)3例，治愈3例。治愈的3例中，l例8年后出现骨髓增生异常综合征(MDS)，以后转变成急性单核细胞白血病。结论：同种异体BMT是治疗SAA的有效治疗方法。加强对感染的防治和移植物抗宿主病(GVHD)的控制是移植后早期阶段的治疗关键。SAA经BMT治疗后的随访结果提示，BMT中的预处理方案有必要加以改进，应作染色体及基因检测，以探讨基因突变是否是AA转化为AC的机制。     

Transformation of severe aplastic anemia into acute myeloblastic leukemia with monosomy 7

 A cytogenetically normal man with severe aplastic anemia was treated with granulocyte colony-stimulating factor (G-CSF), erythropoietin (EPO), cyclosporin A, anti-thymocyte globulin, and interleukin-6 (IL-6), which resulted in a gradual improvement in his neutrophil count and hemoglobin level. After 2 years of the therapy, monosomy 7 was detected during cytogenetic analysis of his bone marrow, which evolved during a period of 5 months into acute myeloblastic leukemia. An in vitro proliferation assay of cytokine responses showed that leukemic blasts were sensitive only to G-CSF, and not to EPO or IL-6. Although allogeneic bone marrow transplantation from an HLA-matched unrelated donor was carried out in the non-remission stage, the patient died of systemic fungal infection on day 25, without any evidence of hematological engraftment. As long-term use of cytokines and immunomosuppressants in patients with severe aplastic anemia may induce or hasten the onset of a malignant transformation, careful attention must be paid to clonal evolution. Due to the poor prognosis of secondary myelodysplasia and leukemia, allogeneic bone marrow transplantation for such patients must be carried out early in the course of the disease. Received: 27 September 1995 / Accepted: 19 December 1995     

环孢菌素A长程治疗重型再生障碍性贫血临床观察

目的　探讨环孢菌素A(CsA)长程治疗重型再生障碍性贫血 (SAA)的疗效。方法　采用CsA为主方案治疗SAA 3 9例。比较治疗 3个月、6个月、1年、2年时的疗效 ,评估药物的副作用。结果　总有效率为45 5 % ,3个月、6个月、1年、2年时的有效率分别为 19 1%、45 0 %、5 6 3 %、83 3 %。SAAⅠ患者的早期病死率明显高于SAAⅡ患者 (P <0 0 1)。主要副作用为牙龈增生、多毛、痤疮、手震颤及肝肾功能异常 ,调整用药剂量患者均能很好耐受。结论　延长CsA的治疗时间能明显提高疗效 ,而不增加副作用 ;CsA可作为中性粒细胞绝对值 (ANC) >0 2× 10 9/L的SAA特别是SAAⅡ病人的一线治疗药物     

Significance of p53 overexpression in bone marrow biopsies from patients with bone marrow failure: aplastic anemia, hypocellular refractory anemia, and hypercellular refractory anemia

 Among patients with bone marrow failure, differentiating acquired aplastic anemia (AA) from hypocellular refractory anemia (hypo RA) can be a difficult and challenging task. Morphological, cytochemical, immunocytochemical, and cytogenetic studies may provide tools for discriminating between both entities. In addition, differences in the pattern of proliferation and apoptosis of bone marrow cells in AA and in the myelodysplastic syndrome have been reported. Because of the correlation between p53 and apoptosis, we examined the overexpression of p53 on bone marrow biopsies in RA and AA. Our study included 14 patients with hypo RA, 14 patients with hypercellular (hyper) RA, ten patients with classic acquired AA, and 37 hematologically normal individuals. p53 was overexpressed in eight (57%) hypo RA patients and 11 (79%) hyper RA patients. All normal individuals and patients with AA showed no overexpression of p53 in their marrow. These results were statistically significant:p<0.01 (AA vs hypo RA),p<0.001 (AA vs hyper RA), while the difference between hypo RA and hyper RA was not statistically significant. We conclude that p53 overexpression in bone marrow biopsies is a valuable tool for studying bone marrow failure and may provide additional information to help differentiate hypo RA from acquired AA. Received: March 13, 1998 / Accepted: August 13, 1998     

Prognostic aspects of aplastic anemia in pregnancy

Summary Our recent experience on six cases of aplastic anemia complicated with pregnancy is described. In addition, 43 similar cases were collected from the literature and reviewed to analyze some prognostic aspects of this relatively rare but potentially serious complication. Clinical and hematological data were treated to extract some clinically meaningful factors in relation to the success and failure of pregnancy.Among initial hematological parameters, no significant difference was found between successful and unsuccessful cases with an exception of hemoglobin concentration. The patients diagnosed as aplastic anemia prior to conception demonstrated an better outcome of pregnancy as well as survival rate of mother when compared with those diagnosed during pregnancy. Mortality has apparently improved after the late 1950's. Success rate of pregnancy before 1958 was 21% while it was 67% and 71% in the era of 1959–1969 and after 1970, respectively. However, hemorrhage and infection remained to be two major causes of maternal death in both eras.Based on these observations, the currently recommendable attitude to this complication is discussed.     

Outcome of adult severe or very severe aplastic anemia treated with immunosuppressive therapy compared with bone marrow transplantation: multicenter trial

To compare survival rates and long-term complications after bone marrow transplantation (BMT) or treatment with immunosuppressive agents (ISA) in the management of adult aplastic anemia (AA) and to identify prognostic factors associated with improved survival, we evaluated 229 adult AA patients treated with ISA from 1990 to 2001 and compared the results with those for 64 BMT recipients. Of 156 patients with severe aplastic anemia (SAA) or very severe AA treated with ISA (antithymocyte globulin [ATG] or ATG plus cyclosporine), 46.8% showed complete or partial response and 7.1% had relapses. After long-term follow-up, 1 case each of acute leukemia, myelodysplastic syndrome, and paroxysmal nocturnal hemoglobinuria developed. The 6-year survival rate was 69%. Response to ISA, disease severity, and low absolute neutrophil count (ANC) (< or = 200/mm3) were associated with poor survival. Patient age, sex, initial platelet count, etiology, or treatment regimen did not significantly affect survival. Cox regression analysis showed low ANC to be the only pretreatment variable significantly associated with poor survival (P = .000). Of 64 BMT recipients, 82.8% had sustained engraftment, and 12.5% experienced graft failure. Twenty (31.3%) of the patients developed grade II to IV acute graft-versus-host disease (GVHD), and 12 (18.8%) of the patients developed chronic GVHD. The 6-year survival rate was 79%. Patient age and sex, disease severity, etiology, ANC, initial platelet count, and treatment regimen did not affect survival. Survival of 83 AA patients, aged 14 to 40 years, treated with ISA was not statistically significant from that of 61 adult AA patients who underwent BMT (6-year survival rate, 65% and 79%, respectively). However, BMT in adult AA achieved long-term engraftment and a lower relapse rate than ISA. These results suggest that ISA can achieve a high response rate and long-term survival among patients with adult AA, regardless of disease severity. Further studies with larger numbers of patients and long-term follow-up are needed.     

再生障碍性贫血瘦素水平的测定

目的 :通过对再生障碍性贫血 (再障 )患者体内瘦素水平的测定 ,了解再障骨髓造血微环境异常与瘦素的关系。方法 :按正常人、再障、其他类型贫血分为三组 ,每位受试者均抽取骨髓液、外周血 ,用放射免疫分析法分别测定其瘦素含量。结果 :再障组骨髓液和外周血瘦素水平分别与正常人及其他类型贫血组比较 ,差异均有统计学意义 (P <0 .0 1) ,其他类型贫血组与正常人比较 ,差异无统计学意义 (P >0 .0 5 ) ,但三组的骨髓液与外周血瘦素含量差异均有统计学意义 (P <0 .0 1) ,但三组相关系数差异无统计学意义 (P >0 .0 5 )。结论 :再障患者骨髓液、外周血瘦素含量明显高于正常人及其他类型贫血 ,可能与再障骨髓脂肪细胞明显增多 ,脂肪细胞分泌瘦素增多有关。瘦素受体的不完整及造血干 /祖细胞对干细胞因子 (SCF)的反应性降低 ,破坏了瘦素与SCF协同刺激原始造血祖细胞增殖的作用 ,可能是造成再障瘦素水平高 ,而造血干 /祖细胞数量减少的一方面原因。     

非亲缘HLA不相合脐血移植治疗再生障碍性贫血

目的 :观察HLA位点不相合的非亲缘脐血细胞移植治疗重型再生障碍性贫血 (SAA)的疗效。方法 :采用 5～ 6个HLA位点相合的非亲缘脐血移植治疗SAA患者 1例。输入脐血单个核细胞数为 4.72× 10 7/kg。预处理方案为环磷酰胺 (5 0mg/kg·d-1× 4)、抗淋巴细胞球蛋白 (2 0mg/kg·d-1× 4)和全身照射 (3Gy)。用环胞素、骁悉和泼尼松预防移植物抗宿主病 (GVHD)。结果 :移植后白细胞下降至零 ,持续 12d ,中性粒细胞分别于移植后第 2 4天和第 2 6天恢复至 0 .5× 10 9/L和 1.0× 10 9/L ,血小板分别于移植后第 2 8天和第 82天达到 2 0× 10 9/L和 5 0× 10 9/L ,DNA短串重复序列PCR检测证实为持续稳定的供者造血。随访 12个月未发生急慢性GVHD。结论 :非亲缘脐血移植是治疗重型再障的一种有效的方法。     

Remission induction in a patient with severe aplastic anemia and renal failure by immunosuppressive treatment including antithymocyte globulin

Summary The pathogenesis of severe aplastic anemia (SAA) is still unclear. Based on clinical and experimental data the hypothesis has been put forward that autoimmune mechanisms may be involved. Encouraging results have been presented with various immunosuppressive drugs including antithymocyte globulin (ATG). We report the successful treatment of SAA with bolus methylprednisolone and ATG in a patient with high-grade renal failure. ATG was tolerated without side effects.     

抗人CD3单克隆抗体体外对再生障碍性贫血造血恢复的机制研究

目的:探讨抗人CD3单克隆抗体(CD3单抗)治疗再生障碍性贫血(再障)的机制。方法:建立再障患者骨髓单个核细胞(BMMNC)中造血细胞液态及半固体培养体系,加入多种造血生长因子进行扩增,并加入CD3单抗药物干预,以ELISA法测定培养上清中肿瘤坏死因子-α(TNF-α)、γ干扰素(IFN-γ)、白细胞介素-2(IL-2)3种细胞因子的含量,以流式细胞技术分析扩增前后的细胞表面标志,检测CD34 细胞的比例,并观察粒-巨噬细胞集落(CFU-GM)、红系爆式集落(BFU-E)的形成能力,从而研究CD3单抗对再障BMMNC中造血干/祖细胞体外扩增的影响。结果:加CD3单抗组与未加CD3单抗组相比较:体外液态培养7d时,培养上清中TNF-α、IFN-γ、IL-2细胞因子水平明显降低,CD34 细胞的扩增倍数升高,体外半固体培养10d时CFU-GM、BFU-E的产率增加。结论:CD3单抗可明显抑制T细胞介导的异常免疫激活,改善再障患者骨髓中造血细胞的体外扩增效应。     

Treatment of severe aplastic anemia with antilymphocyte globulin and androgens: A report on 33 patients

Summary Thirty-three patients with severe aplastic anemia were treated with antilymphocyte globulin (ALG, Mérieux) and androgens (with or without corticosteroids) between 1981 and 1989; 24 patients (72.7%) were responders after one course of ALG, eight were nonresponders, and only one patient had an early death. Eighteen of the 24 responses occurred within 2 months of ALG treatment. Of note is the good response rate we obtained for very severe aplastic anemia (four responders of five evaluable patients). With a median follow-up of 36 months (range 1–97), a survival rate of 77.6%±1.2% was obtained at 30 months. No predictive factor of survival could be identified except response to treatment (p=0.0001). The duration of the disease before treatment was inversely related to survival, although this difference did not reach statistical significance (p=0.06). Four initial responders relapsed after 14, 24, 38, and 57 months. Three of these patients received a second course of ALG and two responded. In contrast, four of the nonresponders received a second course of ALG, with only one response. Toxicity of androgens was mild. No patient developed a PNH clone or myelodysplastic syndrome. Major toxicity of corticosteroids was femoral osteonecrosis in three patients. In our experience, the combination of ALG and androgens in SAA, with or without corticosteroids, was associated with a higher response rate and better survival than in many previously published reports. This could have been due to the intensive supportive care during the initial weeks of treatment. We suggest that it may also result from the addition of androgens to ALG, although this issue may only be resolved in a randomized study.     

HLA配型相合的造血干细胞移植治疗重型再生障碍性贫血的临床研究

目的 评价HLA配型相合的异基因造血干细胞移植(allo-HSCT)治疗重型再生障碍性贫血(SAA)的疗效.方法 2000年1月至2008年11月采用allo-HSCT治疗SAA患者20例,其中同胞相合移植17例,非血缘关系移植3例.预处理采用环磷酰胺(Cy)50 mg·kg~(-1)·d~(-1)4 d加抗淋巴细胞免疫球蛋白(ATG)2.5 mg·kg~(-1)·d~(-1)或20 mg·kg~(-1)·d~(-1) d.移植物抗宿主病(GVHD)的预防方案为经典的环孢素A(CsA)联合短程甲氨蝶呤(MTX)及霉酚酸酯(MMF).同胞供者采集经重组人粒细胞集落刺激因子(G-CSF)动员的骨髓及外周血干细胞,非血缘供者单纯采集外周血干细胞.结果 回输单个核细胞中位数为7.89(4.00-14.21)×10~(8)/kg,所有患者均获供者造血重建,粒细胞植活中位时间14(11～20)d;血小板植活中位时间12(8～108)d.但1例患者发生晚期排斥,行另一供者二次移植后植活.21例次移植后共发生6例次急性GVHD(I度3例,Ⅱ度皮肤3例),发生率16%.19例生存期>100 d的患者中有7例发生慢性GVHD,其中4例为局限型,3例为广泛型.截至2009年2月28 日,经过中位18(2.0～106.8)个月的随访,共有17例患者无病生存,总生存率为82.5%.结论 采用Cy+ATG的预处理方案对SAA患者进行HLA配型相合HSCT,植活率高,可以获得良好的疗效.     

再生障碍性贫血85例临床分析

目的：总结85例再生障碍性贫血（再障）患者临床发病特点及治疗效果。方法：采用统一的调查表登记我院10年间确诊的再障患者,用回顾性方法进行资料分析。结果：85例再障患者中15－＜45岁的患者占67．1％。再障患者中AB血型比较较少。43．5％再障患者有CD4／CD8倒置。慢性再障的治疗有效率为68．2％,重型再障为53．1％,纯红再障为77．8％。慢性再障中CSA和雄激素联合应用的有效率为72．7％,单用雄性激素有效率为65．5％;重型再障中CSA和雄激素联合应用的有效率为58．8％,单用雄激素有效率为33．3％。慢性和急性再障2年生存率分别为88．0％和38．2％。院内死亡20例中,60％死于颅内出血。结论：雄激素是治疗慢性再障的主要药物,雄激素和CSA联合应用可提高疗效。雄激素治疗重型再障效果不佳,目前主张用CSA、ATG治疗,或CSA、ATG、大剂量甲泼尼龙、造血细胞因子联合应用。