Li Y

Predicting early response to immunosuppressive therapy in severe aplastic anemia by soluble transferrin receptor assay

OBJECTIVE To evaluate the value of serum soluble transferrin receptor (sTfR) concentration in predicting early response to immunosuppressive therapy (IST) in severe aplastic anemia (SAA). METHODS Clinical data and hematologic responses of 140 SAA patients treated with rabbit antithymocyte globulin (rATG) combination with cyclosporine in our hospital were retrospectively analyzed. Correlation of pre-IST baseline of sTfR and IST responses was statistically analyzed and receiver operating characteristic (ROC) curve was used to estimate the sensitivity and specificity of sTfR in prediction of early responses. RESULTS Serum concentration of sTfR in very SAA (VSAA) patients were significantly lower than SAA and transfusion dependent non-SAA cases (P=0.001). The responders, especially at 3 months, had significantly higher pre- IST baseline of sTfR [median, 0.89 (range, 0.21-2.42) mg/L] than that [median, 0.58 (range, 0.13-1.88) mg/L] of non-responders (P=0.005). The cutoff level of 0.91 mg/L and 0.88 mg/L for predicting responses at 3 and 6 months were established based on the ROC curve, with the degree of accuracy of 65.0% and 60.7% respectively. Multivariate analysis showed that pre-IST baseline of sTfR was the independent factor of predicting response at 3 months (P=0.007) and at 6 months (P=0.021). CONCLUSION As a indicator of bone marrow failure severity, sTfR could predict early response to IST therapy in aplastic anemia.

[Impact of recombinant human thrombopoietin (rhTPO) on short-term response of immunosuppressive therapy in patients with newly diagnosed acquired severe aplastic anemia].

目的 评价重组人血小板生成素（rhTPO）对重型再生障碍性贫血（SAA）免疫抑制治疗（IST）近期疗效的影响。 方法 回顾性分析IST联合rhTPO治疗40例成人SAA患者，以同期单用标准IST方案的患者为对照组，比较两组患者血液学反应及血小板恢复情况，并分析影响近期疗效的相关因素。 结果 IST后3个月，rhTPO组患者血液学反应率及良好血液学反应率均明显高于对照组（75.0%对50.0%，P=0.022；17.5%对2.5%，P=0.025）。IST后6个月，rhTPO组与对照组患者血液学反应率分别为77.5%和57.5%，差异无统计学意义（P=0.058），但rhTPO组良好血液学反应率高于对照组（45.0%对22.5%，P=0.033）。rhTPO组患者脱离血小板输注时间较对照组短[33(0~90)d对53(0~75)d，P=0.019]，血小板输注中位量也明显低于对照组。IST后3个月rhTPO组患者PLT中位数为29(4~95)× 109/L，明显高于对照组的15(5~94)×109/L（P=0.006)。两组患者预期3年生存率比较差异无统计学意义（100.0%对91.0%，P=0.276）。 结论 rhTPO可提高SAA的IST血液学反应率，加快血小板恢复。OBJECTIVE To evaluate the impact of recombinant human thrombopoietin (rhTPO) on short-term response of immunosuppressive therapy (IST) in patients with newly diagnosed acquired severe aplastic anemia (SAA). METHODS The clinical data of forty adult acquired SAA patients, who treated with IST combined with rhTPO, were retrospective analyzed and the hematologic recovery were compared with patients by the IST alone during the same period. The factors affecting the short-term response were also analyzed. RESULTS At 3 months after IST, both the total response rate and CR+GPR rate in rhTPO group were much higher than those in control group (75.0% vs 50.0%, P=0.022; and 17.5% vs 2.5%, P=0.025). At 6 months after IST, there was no difference of total hematologic response rate in rhTPO group and control group (77.5% vs 57.5%, P=0.058), while the CR+GPR rate was still higher in rhTPO group (45.0% vs 22.5%, P=0.033). The median time of platelet transfusion independence was much shorter in rhTPO group [33(0-90) vs 53(0-75) d, P=0.019]. Patients in rhTPO group needed less platelets transfusion support. The median platelet count in rhTPO group was 29(4-95)×10⁹/L at 3 months after IST, which was much higher than that in control group [29(4-95)×10⁹/L, P=0.006]. There was no significant difference regarding overall survival between the two groups (100.0% vs 91.0%, P=0.276). CONCLUSION rhTPO is effective in promoting platelet recovery and improving the hematopoietic response for SAA patients with IST.

[Effects of peri-immunosupressive therapy period infection on hematologic response and survival of severe aplastic anemia].

目的 探索围免疫抑制治疗(IST)期(IST前1个月至IST后3个月)感染对重型／极重型再生障碍性贫血(SAA/VSAA)患者IST疗效的影响。 方法 回顾性分析一线行IST的105例SAA/VSAA患者临床资料，研究围IST期感染特征及其对IST疗效的影响。 结果 全部105例患者中，97例(92.4%)发生270例次围IST期感染，中位感染2(1~7)次，中位发热7(1~47) d，发病部位以呼吸道最为常见，占35.1%。致病微生物明确的感染96例次(35.6%)，共检出169株病原菌，以细菌为主，占88.2%。IST前1个月感染与未感染患者IST后6个月血液学反应率比较差异有统计学意义(50.8％对80.0%，P=0.004)。ROC曲线优化IST后6个月能否获得血液学反应的感染次数界限值为3次，发热时间界限值为4 d。全部105例患者5年总生存(OS)率为76%，感染3次及以上患者5年OS率为(59.6±7.2)%，明显低于感染少于3次患者[(89.5±4.0)%] (P<0.01)；发热时间≥4 d患者5年OS率为(63.4±5.8)%，明显低于发热时间<4 d患者(100.0%)(P<0.01)。 结论 IST前1个月感染对IST疗效有影响，围IST期感染3次及以上、发热时间≥4 d患者IST血液学反应率低，生存时间短。OBJECTIVE To explore the effects of peri-immunosuppressive treatment（IST）infection on outcomes of severe and very severe aplastic anemia（SAA/VSAA）patients. METHODS Medical record and follow-up data of 105 SAA/VSAA who underwent first-line IST were retrospectively analyzed to find out the characters of infections（1 month before to 3 months after IST）, and its effects on hematologic response and survival. RESULTS Of 105 patients, a total of 270 febrile episodes were recorded in 97 patients（92.4%）during their peri- IST periods, with the median infections of 2（1-7）episodes in each patient with the median febrile duration of 7（1-47）days. Respiratory system（35.1%）was the primary anatomic site of infection. Bacteria（88.2%）were common causes of total 169 pathogenic bacteria in 96 clear pathogenic bacteria episodes. And patients who got infection 1 month before IST had much lower 6- month hematologic response rate than their counterpart ones（50.8% vs 80.0%, P=0.004）. Multiple febrile episodes （ ≥3 times） and the total febrile duration ≥4 days showed the best sensitivity and specificity according to the ROC curve analysis. The 5-year overall survival of the 105 patients was 76%. The 5- year OS of patients with multiple febrile episodes （ ≥3 times） were much lower than their counterpart ones［（59.6±7.2）% vs（89.5±4.0）%］（P＜0.01）. The 5-year OS of the total febrile duration ≥4 days was much lower than their counterpart ones［（63.4±5.8）% vs 100.0%］（P＜0.01）. CONCLUSION Infections 1 month before IST were associated with hematologic response. Multiple febrile episodes（≥3 times） and infections with the febrile duration ≥4 days presented inferior hematologic response and survival.

[CD4⁺/CD8⁻ T- cell large granular lymphocytic leukemia: one case report and literatures reviews].

OBJECTIVE Presenting the clinical features of one patient with CD4⁺/CD8⁻ T-cell large granular lymphocytic leukemia, to improve the understanding of the disease. METHODS Clinical data of one patient hospitalized for skin rush and leukocytosis were analyzed, and the related literatures were reviewed. RESULTS The patient was hospitalized for skin rush and leukocytosis. Routine blood test showed remarkable elevated white blood cell counts and mild anemia. Subsequent hematological examination led to a diagnosis of T- cell large granular lymphocytic leukemia with CD4⁺/CD8⁻ immunophenontype. CONCLUSION CD3⁺/CD4⁺/CD8⁻ T- cell large granular lymphocytic leukemia is a kind of variant subtype, and is relatively rare, it has different clinical features with classic CD3⁺/CD4⁻/CD8⁺/TCRαβ⁺T- cell large granular lymphocytic leukemia, so differentiating diagnosis is of great importance.

[Increasing peripheral blood neutrophils after G-CSF treatment is a predictor of early response to immunosuppressive therapy in severe aplastic anemia].

OBJECTIVE To testify whether absolute neutrophil count (ANC) response to preimmunosuppressive-therapy (pre-IST) granulocyte-stimulating factor (G-CSF) treatment could predict early response to IST in severe aplastic anemia (SAA). METHODS Clinical data and hematologic response of 125 SAA patients treated with antithymocyte globulin (r-ATG) combined with cyclosporine were retrospectively analyzed. Correlation of ANC response to pre-IST G-CSF treatment and early response to IST were statistically analyzed, and receiver operating characteristic (ROC) curve was used to estimate the value of increased ANC (∆ANC) in predicting early IST response. RESULTS The hematologic response (HR) rate to IST in ANC reponded patients was significantly higher than non-responded group (3-month HR 49.0% vs 28.9%, P=0.023; 6-month HR 61.2% vs 40.8%, P=0.026). With ∆ANC≥0.5×10⁹/L as cutoff level, the best point to predict early IST response was 10 days after G-CSF (d 10). Response of ANC to pre-IST G-CSF treatment at d 10 was among the independent factors of predicting 3-month (P=0.004), but not for 6-month response to IST. The overall 5-year survival rate was 92.8% and 69.5% in ANC responded and non-responed groups, respectively (P=0.025). CONCLUSION Responding to pre-IST G-CSF treatment reflected the residual bone marrow hematopoiesis, and could act as a convenient and practical predictor to early IST response as well as long-term survival in SAA.

Identification and characterization of clinical features and gene mutation in a patient with iron refractory iron deficiency anemia (IRIDA)

OBJECTIVE To report the clinical data of a case of iron-refractory iron deficiency anemia (IRIDA), so as to improve the understanding of IRIDA. METHODS The IRIDA patients hematological characteristics were summarized and analyzed. The hepcidin levels were tested by ELISA kit. The TMPRSS6 gene was amplified by PCR reaction and its mutation was analyzed by sequencing. The effect of TMPRSS6 gene mutation on TMPRSS6 protein tertiary structure was predicted by Swiss-Model. RESULTS The patient was characterized by typical microcytic hypochromic anemia, low transferrin saturation, more reduction of intracellular iron than exocellular iron. The plasma hepcidin level was 213.77 μg/L which was significantly higher than that of IDA patients [5.19(3.31-12.02) μg/L]. The patient also carried a homozygous missense mutation of K253E in exon 7 of TMPRSS6. CONCLUSION In children and younger IDA patients with no reason for iron deficiency but unresponsiveness to routine iron treatment, the diagnosis of IRIDA needs to be considered. Serum hepcidin level and TMPRSS6 gene mutation should be detected.

[Chronic natural killer cell lymphocytosis: eight cases report and literature review].

OBJECTIVE To identify the characteristics of chronic natural killer cell lymphocytosis (CNKL). METHODS The clinical data of eight cases defined by the World Health Organization classification was retrospectively analyzed and related literatures were reviewed. RESULTS Half of the 8 patients were asymptomatic. Among them, the most common abnormalities were leukocytosis with the median of 11.8(4.5-20.0)×10⁹/L and high proportion of lymphocytes [0.78(0.51-0.89)], while anemia and thrombocytopenia only in 1 patient respectively. The absolute CD3⁻CD16⁺ NK cell count with the median of 5.7(2.4-9.6)×10⁹/L increased in peripheral blood. By the end of follow-up, except one case was lost, the other seven patients were in stable condition,including four cases without any medications and three patients receiving chlorambucil or glucocorticoid. CONCLUSION As an indolent chronic lymphoproliferative disease, CNKL was presented with mild clinical symptoms and increased number of CD3⁻CD16⁺ NK cells in peripheral blood. Patients with symptoms could be treated with immunosuppressive therapy while those asymptomatic could be followed up without intervention.

Residual hematopoiesis is an important prognostic factor of immunosuppressive therapy in severe aplastic anemia

OBJECTIVE To evaluate the prognostic value of residual bone marrow hematopoiesis in severe aplastic anemia (SAA) patients with immunosuppressive therapy (IST). METHODS Clinical data and hematologic responses of 38 SAA patients treated with IST regimen (antithymocyte globulin combined with cyclosporine) in our hospital were retrospectively analyzed. Correlation of pre-IST baseline reticulocyte (Ret), absolute neutrophils count (ANC), soluble transferrin receptor (sTfR) concentration, corrected TPO value and hematologic response rate were statistically analyzed and receiver operating characteristic (ROC) curve was used to estimate the value of Ret, ANC, sTfR, and corrected TPO in predicting early IST response. RESULTS Responders to IST had significantly higher pre-IST baseline Ret, ANC, sTfR concentration [19.9(2.7-84.4)×10⁹/L, 0.59(0.12-2.67)×10⁹/L, 0.82(0.22-1.58) mg/L] and lower corrected TPO value [142.9(31.8-1 035.0)] than non-responders [5.1(1.5-23.1)×10⁹/L, 0.20(0.04-1.33)×10⁹/L, 0.45(0.19-0.72)mg/L and 2 335.0(1 308.3-7 771.2)](P<0.05). Optimizing parameter cutoff levels obtained from ROC curve was Ret 6.75×109/L, ANC 0.30×109/L, sTfR 0.76 mg/L and corrected TPO 148.6, respectively. Combining the four parameters to predict 6 month hemotologic response showed that all the 7 patients with high Ret, ANC, sTfR and low corrected TPO, while only 1 among those 9 with low Ret, ANC, sTfR and high corrected TPO. CONCLUSION Such parameters evaluating residual bone marrow hematopoiesis as Ret, ANC, sTfR, corrected TPO are practical in predicting early IST response in SAA.

[High-dose cyclophosphamide for severe aplastic anemia associated with β-thalassemia: a case report and literatures review].

OBJECTIVE To investigate the clinical features and therapeutic method for severe aplastic anemia (SAA) associated with β-thalassemia, and to improve the recognition of the disease. METHODS One patient hospitalized for pancytopenia was reported and the related literatures were reviewed. RESULTS A 14-years old girl who presented with anemia from her childhood was hospitalized for acute onset of pancytopenia. Routine blood test showed that WBC count was 1.28×10⁹/L, hemoglobin 65 g/L, platelet count 18×10⁹/L, reticulocyte count 2×10⁹/L, neutrophil count 0.03×10⁹/L and mean corpuscular volume 59.6 fl, respectively. Both bone marrow aspiration and biopsy showed hypoplasia. Her red blood cells presented as microcytic hypochromic and target erythrocytes were common on peripheral blood smear. DNA analysis of the patient and her mother showed exon 17 heterozygous β-thalassemia (c.52 A>T). A diagnosis of SAA associated with β-thalassemia was clarified and high-dose cyclophosphamide (HD-CTX, 1.2 g/d×4 d) plus cyclosporine were offeved, which eventually led to a complete hematologic remission 12 months later. CONCLUSION This was the first report of SAA associated with β-thalassemia, and the regimen of HD-CTX led to a complete hematologic remission.

[Pure red cell aplasia with thymoma/T-cell large granular lymphocyte leukemia: two cases report and literatures review].

OBJECTIVE To investigate the clinical and laboratory features of 2 cases of pure red cell aplasia (PRCA) with thymoma/T-cell large granular lymphocyte leukemia (T-LGLL), and to improve the recognition of the disease and the role of lymphocyte in its mechanism. METHODS Two cases of PRCA with thymoma/T-LGLL were reported and the related literatures were reviewed. RESULTS Case 1 was a 63-years old male with hemoglobin level of 54 g/L at admission. Case 2 was a 52-years old female with hemoglobin level of 79 g/L at admission. They were both diagnosed as PRCA with thymoma before admission to our hospital and had no benefit from their thymectomy. Further examinations in our hospital showed that CD3⁺CD4⁻CD8⁺CD57⁺ large granular lymphocytes amplified with clonal TCR rearrangement in their peripheral blood. The diagnosis of PRCA with thymoma/T-LGLL was clarified. Case 1 did not respond to any of the frontline therapies while case 2 responded completely to cyclosporine. CONCLUSION Both thymoma and T-LGLL could be the cause of secondary PRCA, lymphocyte proliferation may play critical role in the pathogenesis.