scholarly journals Aplastic anemia: immunosuppressive therapy in 2010

2011 ◽  
Vol 3 (2s) ◽  
pp. 7 ◽  
Author(s):  
Antonio M. Risitano ◽  
Fabiana Perna

Acquired aplastic anemia (AA) is the typical bone marrow failure syndrome characterized by an empty bone marrow; an immune-mediated pathophysiology has been demonstrated by experimental works as well as by clinical observations. Immunusuppressive therapy (IST) is a key treatment strategy for aplastic anemia; since 20 years the standard IST for AA patients has been anti-thymocyte globuline (ATG) plus cyclosporine A (CyA), which results in response rates ranging between 50% and 70%, and even higher overall survival. However, primary and secondary failures after IST remain frequent, and to date all attempts aiming to overcome this problem have been unfruitful. Here we review the state of the art of IST for AA in 2010, focusing on possible strategies to improve current treatments. We also discuss very recent data which question the equality of different ATG preparations, leading to a possible reconsideration of the current standards of care for AA patients.

2009 ◽  
Vol 31 (11) ◽  
pp. 884-887 ◽  
Author(s):  
Vicky Rowena Breakey ◽  
Stephen Meyn ◽  
Vicky Ng ◽  
Christopher Allen ◽  
Inderjeet Dokal ◽  
...  

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 4215-4215
Author(s):  
Sandra van Bijnen ◽  
Konnie Hebeda ◽  
Petra Muus

Abstract Abstract 4215 Introduction Paroxysmal Nocturnal Hemoglobinuria (PNH) is a disease of the hematopoietic stem cell (HSC) resulting in a clone of hematopoietic cells deficient in glycosyl phosphatidyl inositol anchored proteins. The clinical spectrum of PNH is highly variable with classical hemolytic PNH at one end, and PNH in association with aplastic anemia (AA/PNH) or other bone marrow failure states at the other end. It is still largely unknown what is causing these highly variable clinical presentations. Immune-mediated marrow failure has been suggested to contribute to the development of a PNH clone by selective damage to normal HSC. However, in classic PNH patients with no or only mild cytopenias, a role for immune mediated marrow failure is less obvious. No series of trephine biopsies has been previously documented of patients with PNH and AA/PNH to investigate the similarities and differences in these patients. Methods We have reviewed a series of trephine biopsies of 41 PNH patients at the time the PNH clone was first detected. The histology was compared of 27 patients with aplastic anemia and a PNH clone was compared to that of 14 patients with classic PNH. Age related cellularity, the ratio between myeloid and erythroid cells (ME ratio), and the presence of inflammatory cells (mast cells, lymphoid nodules and plasma cells) were evaluated. The relation with clinical and other laboratory parameters of PNH was established. Results Classic PNH patients showed a normal or hypercellular marrow in 79% of patients, whereas all AA/PNH patients showed a hypocellular marrow. Interestingly, a decreased myelopoiesis was observed not only in AA/PNH patients but also in 93% of classic PNH patients, despite normal absolute neutrophil counts (ANC ≥ 1,5 × 109/l) in 79% of these patients. The number of megakaryocytes was decreased in 29% of classic PNH patients although thrombocytopenia (< 150 × 109/l) was only present in 14% of the patients. Median PNH granulocyte clone size was 70% (range 8-95%) in classic PNH patients, whereas in AA/PNH patients this was only 10% (range 0.5-90%). PNH clones below 5% were exclusively detected in the AA/PNH group. Clinical or laboratory evidence of hemolysis was present in all classical PNH patients and in 52% of AA/PNH patients and correlated with PNH granulocyte clone size. Bone marrow iron stores were decreased in 71% of classic PNH patients. In contrast, increased iron stores were present in 63% of AA/PNH patients, probably reflecting their transfusion history. AA/PNH patients showed increased plasma cells in 15% of patients and lymphoid nodules in 37%, versus 0% and 11% in classic PNH. Increased mast cells (>2/high power field) were three times more frequent in AA/PNH (67%) than in PNH (21%). Conclusion Classic PNH patients were characterized by a more cellular bone marrow, increased erythropoiesis, larger PNH clones and clinically by less pronounced or absent peripheral cytopenias and more overt hemolysis. Decreased myelopoiesis and/or megakaryopoiesis was observed in both AA/PNH and classic PNH patients, even in the presence of normal peripheral blood counts, suggesting a role for bone marrow failure in classic PNH as well. More prominent inflammatory infiltrates were observed in AA/PNH patients compared to classical PNH patients. Disclosures: No relevant conflicts of interest to declare.


Blood ◽  
2003 ◽  
Vol 102 (10) ◽  
pp. 3584-3586 ◽  
Author(s):  
Jaroslaw P. Maciejewski ◽  
Elaine M. Sloand ◽  
Olga Nunez ◽  
Carol Boss ◽  
Neal S. Young

AbstractIn contrast to severe aplastic anemia (sAA), the appropriate management of patients with moderate pancytopenia is unclear. In this study, we examined the efficacy of a humanized monoclonal antibody recognizing interleukin-2 receptor (daclizumab), which has proven to be a successful immunosuppressive agent in solid organ and bone marrow transplantation. We treated 17 patients with moderate aplastic anemia (mAA) with 1 mg/kg every 2 weeks for 3 months. mAA was defined as depression of 2 of the 3 blood counts: absolute neutrophil count 1200/mm3 or less, platelet count 70 000/mm3 or less, hemoglobin level 8.5 g/dL or lower, and absolute reticulocyte count 60 000/mm3 or less. The primary end point of our protocol was a hematologic response in at least one affected peripheral blood value. Daclizumab had little toxicity. Six of the 16 (38%) evaluable patients responded to treatment. Two patients with previously chronic disease showed complete return of normal counts, which were sustained for more than 2 years following treatment. Four patients had single-lineage responses. Two previously transfusion-dependent patients became transfusion independent; one patient with many neutropenia-related infections had a normal neutrophil count following treatment. Daclizumab appears safe; its efficacy in this pilot protocol suggests that expanded study of this monoclonal antibody in immune-mediated bone marrow failure syndrome is warranted. (Blood. 2003; 102:3584-3586)


Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 3736-3736
Author(s):  
Joshua J. Field ◽  
Philip J. Mason ◽  
Yvonne J. Barnes ◽  
Allison A. King ◽  
Monica Bessler ◽  
...  

Abstract Mutations in TERC, the RNA component of telomerase, result in autosomal dominant dyskeratosis congenita (DC), a rare bone marrow failure syndrome. DC is clinically heterogeneous and TERC mutations have been detected in a subset of patients previously diagnosed with idiopathic aplastic anemia (AA) and myelodysplastic syndrome (MDS). Unrecognized TERC mutations are clinically relevant as patients with DC respond poorly to immunotherapy and have an increased risk of complications following conventional conditioning for stem cell transplant (SCT). We aimed to determine the frequency of TERC mutations in pediatric patients with AA and MDS who require a SCT. We obtained 315 blood or bone marrow samples from the National Donor Marrow Program Registry from children under age 18 with bone marrow failure who underwent an unrelated stem cell transplant. We screened these samples for mutations in the TERC gene using direct DNA sequencing. To exclude polymorphisms, we also screened 537 racially diverse healthy controls. The study group was composed of patients with MDS (n=151), AA (n=123), and juvenile myelomonocytic leukemia (JMML) (n=41), which may be difficult to distinguish from MDS. The mean age at the time of transplant was 9 years. We found sequence alterations in the promoter region of TERC in 2 patients. A 2 base pair deletion (-240delCT) was identified in a 4 year-old child with MDS and a 1 year-old child with JMML was found to have a point mutation (-99C→G), which was identified previously in an 18 year-old patient with paroxysmal nocturnal hemoglobinuria and is known to affect the Sp1 binding site. The pathogenicity of this mutation is unclear. In summary, our findings suggest that screening for TERC gene mutations is unlikely to diagnose occult DC in children with severe bone marrow failure who require a stem cell transplant but have no clinical features or history to suggest a familial bone marrow failure syndrome.


Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 1047-1047
Author(s):  
Bing Han ◽  
Bo Liu ◽  
Yongqiang Zhao

Abstract Background Acquired bone marrow failure syndrome (BMF) is a group of diseases include aplastic anemia(AA), melodysplastic syndrome (MDS) and paraoxymal nocturnal hemoglobinuria (PNH). Some BMF patients have short telomeres in their peripheral nucleated cells. The length of telomere is maintained by a group of enzymes called telomerase complex. The core components of this complex are a RNA template and a reverse transcriptase, called TERC and TERT, respectively. Recently several studies in the west and Japan have disclosed the presence of telomerase complex gene mutation in a small group of patients with acquired bone marrow failure. They speculated that this small group of patients might represent a subset of cryptogenic Dyskeratosis Congenita (DKC), in which the premature exhaustion of hematopoietic reservoir is caused by mutations in the telomerase gene. This group of patients, though very small in number, would benefit from early bone marrow transplantation instead of traditional immunosuppressive therapy. The incidence of aplastic anemia in Chinese people is relatively high compared with that in the western country. But there has so far been no study in China about the incidence of telomerase gene mutation in acquired bone marrow failure and its relationship with telomere length. Objectives To study the incidence of telomerase gene (namely TERC and TERT ) mutation in Chinese patients with acquired bone marrow failure and explore its relationship with telomere shortening. Methods Blood samples from 90 patients with AA, MDS, and PNH in northern China were collected and performed TERC and TERT mutation analysis. Telomere length was measured by Southern blotting and compared with their normal counterparts. Results 2 TERC mutations (n37 A→G, reported previously ; n66G→C) and 2 TERT mutations (n1870G→T (E/*); n1780G→T (S/I) ) were identified in 90 BMF patients. Among them, 3 mutations are reported first time. 1 patient with TERT mutation, however, was finally diagnosed as DKC instead of acquired AA, making the incidence of telomerase gene mutation in Chinese people with acquired bone marrow failure 3.4%, similar to that of the western people. Southern Blot analysis showed the small group of patients carrying TERC and TERT mutations has very short telomeres, compared with normal controls and with their aplastic counterparts. Conclusions The incidence of telomerase gene mutation in Chinese people with acquired bone marrow failure is 3.4%, similar to that of the western people. This small group of patients has very short telomeres, it is thus clinically important to screen for this small group of patients.


Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 180-180
Author(s):  
Gloria T Shan ◽  
Ivy Tran ◽  
Ashley R Sandy ◽  
Ann Friedman ◽  
Yi Zhang ◽  
...  

Abstract Abstract 180 Aplastic anemia is a severe bone marrow disorder characterized by the loss of hematopoietic stem cells (HSC). HSC destruction is thought to be T cell-mediated in a majority of patients with aplastic anemia. Global immunosuppression and HSC transplantation can induce disease remission, but these treatments are not effective in all patients and can promote life-threatening complications. Thus, novel immunomodulatory approaches are needed in this disorder. Notch is a conserved cell-cell communication pathway that can regulate T cell differentiation and function with context-dependent effects. To study the role of Notch signaling in pathogenic T cells causing immune-mediated bone marrow failure, we inhibited canonical Notch signaling in mature T cells through conditional expression of the pan-Notch inhibitor DNMAML (ROSA-DNMAMLf × Cd4-Cre mice). We used two complementary mouse models of immune-mediated bone marrow failure that mimic features of aplastic anemia: administration of C57BL/6 (B6) T cells into sublethally irradiated (500 rads) minor histocompatibility antigen mismatched BALB/b recipients (Chen et al., J Immunol 2007; 178:4159), or infusion of B6 lymphocytes into unirradiated MHC-mismatched B6×DBA F1 recipients. In contrast to control B6 T cells which led to lethal bone marrow failure in virtually all recipients, DNMAML-expressing Notch-deprived T cells were profoundly deficient at inducing HSC loss in both disease models, leading to markedly improved long-term survival (>90%). Notch-deficient T cells showed a modest decrease in overall expansion within secondary lymphoid organs, but their accumulation in the target bone marrow was preserved. Upon restimulation with anti-CD3 and anti-CD28 antibodies, DNMAML T cells had decreased production of IL-2 and interferon gamma. Activated CD4+ and CD8+ DNMAML T cells had reduced interferon gamma, granzyme B, and perforin transcripts despite preserved induction of the master transcription factors Tb×21 (encoding T-bet) and Eomes. In vivo infusion of CFSE-labeled host-type target cells revealed a decreased cytotoxicity in DNMAML as compared to control B6 T cell recipients. These observations point to a novel spectrum and mechanism of Notch action in mature T cells. Since we have shown recently that canonical Notch signaling is dispensable for the maintenance of adult HSCs (Maillard et al., Cell Stem Cell 2008, 2:356), our findings suggest that Notch inhibition could represent a novel therapeutic modality to target the T cell response and reverse immune-mediated HSC destruction in aplastic anemia. Disclosures: Shan: American Society of Hematology: Research Funding. Zhang:University of Michigan Comprehensive Cancer Center: Research Funding; Damon Runyon Cancer Research Foundation: Research Funding. Maillard:Damon Runyon Cancer Research Foundation: Research Funding; American Society of Hematology: Research Funding; University of Michigan Comprehensive Cancer Center: Research Funding.


2012 ◽  
Vol 2012 ◽  
pp. 1-7 ◽  
Author(s):  
Irene Mavroudi ◽  
Helen A. Papadaki

Increasing interest on the field of autoimmune diseases has unveiled a plethora of genetic factors that predispose to these diseases. However, in immune-mediated bone marrow failure syndromes, such as acquired aplastic anemia and chronic idiopathic neutropenia, in which the pathophysiology results from a myelosuppressive bone marrow microenvironment mainly due to the presence of activated T lymphocytes, leading to the accelerated apoptotic death of the hematopoietic stem and progenitor cells, such genetic associations have been very limited. Various alleles and haplotypes of human leucocyte antigen (HLA) molecules have been implicated in the predisposition of developing the above diseases, as well as polymorphisms of inhibitory cytokines such as interferon-γ, tumor necrosis factor-α, and transforming growth factor-β1 along with polymorphisms on molecules of the immune system including the T-bet transcription factor and signal transducers and activators of transcription. In some cases, specific polymorphisms have been implicated in the outcome of treatment on those patients.


Hematology ◽  
2009 ◽  
Vol 2009 (1) ◽  
pp. 329-337 ◽  
Author(s):  
Akiko Shimamura

Abstract The treatment and medical management of aplastic anemia fundamentally differ between patients with inherited versus acquired marrow failure; however, the diagnosis of an inherited bone marrow failure syndrome is frequently obscure. Recent exciting advances in our understanding of the molecular pathophysiology of the inherited bone marrow failure syndromes have resulted in a profusion of new tests to aid in diagnosis. This in turn has raised questions regarding the appropriate choice of testing for the patient presenting with aplastic anemia. Important clues to the diagnosis of an inherited marrow failure syndrome may be gleaned from careful attention to the clinical history, physical exam, and laboratory workup.


Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 3483-3483
Author(s):  
Kazuya Sato ◽  
Xingmin Feng ◽  
Jichun Chen ◽  
Marie J. Desierto ◽  
Keyvan Keyvanfar ◽  
...  

Abstract Abstract 3483 In aplastic anemia (AA), the marrow is not “empty” but replaced by fat; the increase in adipocytes number and size is most obvious on three dimensional reconstructions of the marrow in human and murine (Takaku T, Blood. 2008). A reciprocal relationship exists between adipogenesis and osteogenesis, and osteoblasts constitute the hematopoietic niche and play an active role in the regulation of stem cells and progenitors. Fat in the marrow has been considered an epiphenomenon in AA. However, a recent report suggested that bone marrow (BM) adipocytes negatively regulated hematopoiesis in mouse models (Naveiras O, Nature. 2009). Peroxisome proliferator-activated receptor-g (PPAR-g) is a key transcription factor for adipogenesis, and blocking PPAR-g signaling inhibited adipogenesis in vitro (Wright HM, J Biol Chem. 2000). To examine the role of BM adipocytes, we investigated the effects of PPAR-g antagonists, bisphenol A diglycidyl ether (BADGE, 30 mg/kg/day) and GW9662 (1 mg/kg/day), on hematopoiesis in a mouse model of immune-mediated BM failure (Chen J, J Immunol. 2007). We induced BM failure by infusion of lymph node (LN) cells from C57BL/6 mice into sublethally irradiated C.B10-H2(b)/LilMcd (C.B10) recipient mice that were matched at major histocompatibility antigens but differed in multiple minor histocompatibility antigens. In adaptation of the “runt” disease model, mice uniformly develop progressive and fatal pancytopenia, closely resembling human BM failure, without other evidence of graft-versus-host disease. We treated recipient mice with BADGE, GW9662, or control vehicle from day -1 to day 14. On day 14, mice were sacrificed and evaluated by peripheral blood (PB) cell counting and BM cellularity, as well as morphology of marrow adipocytes. Mice in the BADGE- and GW9662-treated groups showed higher numbers of leukocytes, neutrophils, and platelets in PB and higher total nucleated cells and Lin- Sca1+ c-kit+ stem cells in BM than did animals in the control group. Both confocal microscopic imaging and hematoxylin and eosin staining of BM also showed significantly higher numbers of nucleated cells and many fewer and smaller adipocytes in the treated groups (Figure 1). We also investigated dose response of BADGE in the treatment of AA mice. Low dose of BADGE (15 mg/kg/day) had no effect while high dose of BADGE (60 mg/kg/day) seemed to have no extra benefit for the BM hematopoiesis compared with the medium dose (30 mg/kg/day). However, we also noted in PPAR-g antagonist-treated groups that there was significantly less CD8+ T cell infiltration of BM, as determined by flow cytometry. We speculated that PPAR- g antagonists might also negatively affect activation of cytotoxic T cells. By magnetic beads-based multiplex assay, we found the concentrations of inflammation-related cytokines in the plasma, including Interleukin-6, tumor necrosis factor alpha, monocyte chemotactic protein-1 were markedly decreased in PPAR- g antagonist-treated groups. When we performed PCR arrays focusing on adipogenesis and inflammasome pathways, we found that expression of adipogenesis genes was greatly decreased in the treated groups, including Agt (−149 folds), Cebpa (−4.7 folds), Acacb (−11.7 folds), Fabp4 (−3.2 folds), Adig (−14.2 folds), and Bmp2 (−12.9 folds). The expression of inflammation- or inflammasome-related genes including Nlrc4 (−11.3 folds), Mapk12 (−4.8 folds), Ptgs2 (−8.7 folds), and Rela (−5.9 folds) was also decreased while apoptosis inhibitor genes including Xiap (+17.5 folds), Mapk1 (+6.6 folds), and Bcl2l1 (+3.9 folds) were increased in the treated groups. In vitro, BADGE and GW9662 inhibited activation and proliferation of T cells stimulated with anti-CD3/CD28 or phorbol myristate acetate/ionomycin. These data suggested that BADGE and GW9662 inhibition was not specific for adipogenesis but affected T cell activation. Indeed, PPAR-g antagonists failed to ameliorate pancytopenia and BM hypoplasia in the mice exposed to either a lethal or sublethal dose of total body irradiation. PPAR-g antagonists may act to attenuate murine immune mediated marrow failure by mechanism of inhibition of T-cell activation. Figure 1. Histology of femurs from untreated bone marrow failure mice and PPAR-g antagonists treated mice. Both BADGE and GW9662 inhibited adipogenesis and increased cellularity in the bone marrow of AA mice. Figure 1. Histology of femurs from untreated bone marrow failure mice and PPAR-g antagonists treated mice. Both BADGE and GW9662 inhibited adipogenesis and increased cellularity in the bone marrow of AA mice. Disclosures: No relevant conflicts of interest to declare.


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