51
|
Young NS, Calado RT, Scheinberg P. Current concepts in the pathophysiology and treatment of aplastic anemia. Blood 2006; 108:2509-19. [PMID: 16778145 PMCID: PMC1895575 DOI: 10.1182/blood-2006-03-010777] [Citation(s) in RCA: 610] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Aplastic anemia, an unusual hematologic disease, is the paradigm of the human bone marrow failure syndromes. Almost universally fatal just a few decades ago, aplastic anemia can now be cured or ameliorated by stem-cell transplantation or immunosuppressive drug therapy. The pathophysiology is immune mediated in most cases, with activated type 1 cytotoxic T cells implicated. The molecular basis of the aberrant immune response and deficiencies in hematopoietic cells is now being defined genetically; examples are telomere repair gene mutations in the target cells and dysregulated T-cell activation pathways. Immunosuppression with antithymocyte globulins and cyclosporine is effective at restoring blood-cell production in the majority of patients, but relapse and especially evolution of clonal hematologic diseases remain problematic. Allogeneic stem-cell transplant from histocompatible sibling donors is curative in the great majority of young patients with severe aplastic anemia; the major challenges are extending the benefits of transplantation to patients who are older or who lack family donors. Recent results with alternative sources of stem cells and a variety of conditioning regimens to achieve their engraftment have been promising, with survival in small pediatric case series rivaling conventional transplantation results.
Collapse
Affiliation(s)
- Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute/NIH, 10 Center Drive, Bldg 10/CRC, Rm 3E-5140, Bethesda, MD 20892-1202, USA.
| | | | | |
Collapse
|
52
|
Killick SB, Cavenagh JD, Davies JK, Marsh JCW. Low dose antithymocyte globulin for the treatment of older patients with aplastic anaemia. Leuk Res 2006; 30:1517-20. [PMID: 16530266 DOI: 10.1016/j.leukres.2006.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 02/01/2006] [Accepted: 02/02/2006] [Indexed: 11/25/2022]
Abstract
We report 14 older patients with aplastic anaemia (AA) who were treated with 'low dose' antithymocyte globulin (ATG). The aims of the study were to assess the efficacy and safety of reduced dose ATG in patients over the age of 60 years. Median age was 71 years (range 62-74 years). At the study endpoint (response to treatment at 6 months) 12 patients were evaluable. All patients received lymphoglobuline (horse ATG; Genzyme) at a dose of 0.5vials/10kg/day for 5 days (5mg/kg/day, equivalent to one-third of the standard dose). There were no deaths attributed to ATG. Two patients died during follow-up, from sepsis and anaphylaxis following platelet transfusion, respectively. Only one of the 12 evaluable patients responded to treatment and remains transfusion independent at 14 months after ATG. These results suggest that this lower dose of ATG, though well tolerated, had low efficacy in the treatment of AA.
Collapse
Affiliation(s)
- S B Killick
- Department of Haematology, Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK.
| | | | | | | |
Collapse
|
53
|
Sugimori C, Chuhjo T, Feng X, Yamazaki H, Takami A, Teramura M, Mizoguchi H, Omine M, Nakao S. Minor population of CD55-CD59- blood cells predicts response to immunosuppressive therapy and prognosis in patients with aplastic anemia. Blood 2006; 107:1308-14. [PMID: 16179371 DOI: 10.1182/blood-2005-06-2485] [Citation(s) in RCA: 201] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We investigated the clinical significance of a minor population of paroxysmal nocturnal hemoglobinuria (PNH)-type blood cells in patients with acquired aplastic anemia (AA). We quantified CD55-CD59- granulocytes and red blood cells (RBCs) in peripheral blood from 122 patients with recently diagnosed AA and correlated numbers of PNH-type cells and responses to immunosuppressive therapy (IST). Flow cytometry detected 0.005% to 23.1% of GPI-AP- cells in 68% of patients with AA. Sixty-eight of 83 (91%) patients with an increased proportion of PNH-type cells (PNH+) responded to antithymocyte globulin (ATG) + cyclosporin (CsA) therapy, whereas 18 of 39 (48%) without such an increase (PNH-) responded. Failure-free survival rates were significantly higher (64%) among patients with PNH+ than patients with PNH- (12%) at 5 years, although overall survival rates were comparable between the groups. Numbers of PNH-type and normal-type cells increased in parallel among most patients with PNH+ who responded to IST, suggesting that these cells are equally sensitive to immune attack. These results indicate that a minor population of PNH-type cells represents a reliable marker of a positive IST response and a favorable prognosis among patients with AA. Furthermore, immune attack against hematopoietic stem cells that allows PNH clonal expansion might occur only at the onset of AA.
Collapse
Affiliation(s)
- Chiharu Sugimori
- Cellular Transplantation Biology, Division of Cancer Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
54
|
Kojima S, Frickhofen N, Deeg HJ, Okamoto S, Marsh J, Teramura M, Bacigalupo A, Mizoguchi H. Aplastic Anemia. Int J Hematol 2005; 82:408-11. [PMID: 16533743 DOI: 10.1532/ijh97.05138] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Seiji Kojima
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
55
|
Abstract
Outcome of patients with aplastic anaemia (AA), whether treated with allogeneic BMT or immunosuppressive therapy has steadily increased over the last three decades. However, there is a difference in quality of outcome between these two therapeutic modalities. There is no plateau for survival after ATG as patients are at later risk of transformation to myelodysplasia (MDS) or acute myeloid leukaemia (AML), paroxysmal nocturnal haemoglobinuria and relapse of their aplasia. In contrast, AA patients are not at risk of these later complications if they have undergone successful bone marrow transplantation. Long term survival after HLA identical sibling BMT is 80-90%, but GVHD and graft rejection remain to be addressed. The results of unrelated donor BMT for AA have shown considerable improvement over the last five years. Difficulties remain for those patients who fail immunosuppressive therapy and in whom BMT is not possible, since alternative immunosuppressive agents have so far proven to be somewhat disappointing.
Collapse
Affiliation(s)
- Judith C W Marsh
- Department of Haematology, St George's Hospital Medical School, Cranmer Terrace, London SW17 ORE, UK.
| |
Collapse
|
56
|
Hamerschlak N, Maluf E, Pasquini R, Eluf-Neto J, Moreira FR, Cavalcanti AB, Okano IR, Falcão RP, Pita MT, Loggetto SR, Rosenfeld LG, Lorand-Metze IGH. Incidence of aplastic anemia and agranulocytosis in Latin America--the LATIN study. SAO PAULO MED J 2005; 123:101-4. [PMID: 16021270 DOI: 10.1590/s1516-31802005000300002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
CONTEXT AND OBJECTIVE Aplastic anemia and agranulocytosis are rare but life-threatening disorders, often caused by drugs and other environmental exposures. Reported incidence of these diseases seems to vary between different geographic regions, and few data on their incidence are available for Latin American countries. The aim of this work is to determine the incidence of agranulocytosis and aplastic anemia in Brazil. DESIGN AND SETTING Incidence study. Seven centers took part in the pilot phase, so as to represent all Brazilian regions. METHODS Each center conducted an active search for new cases in a defined region by means of regular contacts with all hematologists, main clinical laboratories and clinicians in hospitals of the region. RESULTS 74 patients with aplastic anemia and 16 with agranulocytosis were identified. Patients with agranulocytosis had a median age of 31 years (interquartile range, IQR: 12.5-48.2); 32.2% were male and 81.2% were white. The median age of aplastic anemia patients was 21 years (IQR 15.0-35.2); 62.2% were male, 50.0% were white and 39.2% mulatto. The incidence of agranulocytosis was estimated to be 0.5 cases per million individuals per year, ranging from 0.0 to 1.1 cases per million per year between regions. The incidence of aplastic anemia was 2.7 cases per million per year, ranging from 1.1 to 7.1 cases per million per year between regions. CONCLUSIONS Aplastic anemia and agranulocytosis are rare diseases in Brazil. However, there is considerable variability in their incidences between different regions.
Collapse
Affiliation(s)
- Nelson Hamerschlak
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, São Paulo, Brazil.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
57
|
Abstract
Abstract
The primary therapeutic approach to acquired aplastic anemia (AA) in older adults differs from the primary approach used in children and younger adults because in the former group, the results of allogeneic bone marrow transplantation (BMT) are less favorable. With increasing age of the patients, immunosuppressive therapy with antithymocyte globulin (ATG) and cyclosporine (CsA) constitutes the primary treatment option and may be better than BMT. There are very few clinical clues as to the selection of patients likely to respond to immunosuppression. Repeated ATG/CsA cycles are often used as salvage regimens, but in refractory patients BMT may be the best treatment option, as the prognosis for non-responders is poor without definitive treatment. Conservative therapy such as intense immunosuppression is associated with a high relapse rate but does not impact the survival and overall prognosis. The inability to eliminate autoimmune T cell clones using current therapeutic strategies suggests that prolonged immunosuppressive maintenance therapy may be needed for a substantial proportion of patients. Late clonal complications of conservatively treated patients include evolution to myelodysplasia and paroxysmal nocturnal hemoglobinuria and may develop in 20% of the patients. However, BMT also has several sequelae including an increased frequency of solid tumors. Novel immunosuppressive and immunomodulatory agents and constantly improving results of allogeneic BMT will further improve the survival rate of adult patients with AA.
Collapse
Affiliation(s)
- Jaroslaw P Maciejewski
- The Cleveland Clinic Foundation, Taussig Cancer Center, Cleveland Clinic College of Medicine of the Case Western Reserve University, Cleveland, Ohio 44195, USA.
| | | |
Collapse
|
58
|
Torres HA, Bodey GP, Rolston KVI, Kantarjian HM, Raad II, Kontoyiannis DP. Infections in patients with aplastic anemia: experience at a tertiary care cancer center. Cancer 2003; 98:86-93. [PMID: 12833460 DOI: 10.1002/cncr.11478] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Infection is a significant cause of death in patients with aplastic anemia (AA). However, few recent studies have examined infectious complications in patients with AA. METHODS The authors retrospectively evaluated the type of infections, associated pathogens, and outcome of infectious episodes (IEs) in patients with AA who were treated at The University of Texas M. D. Anderson Cancer Center between July 1994 and June 2000. RESULTS Fifty-two patients with a median age of 37 years (range, 3-83 years) were identified. Overall, 104 IEs were documented in 42 patients (81%). The most common microbiologically documented infections were bacteremias (38%) followed by pneumonias (16%). Most patients (55%) had bacterial infections, mainly caused by gram-positive cocci. Multidrug-resistant, gram-negative bacilli also were not uncommon in this patient population. Five of 12 patients who died during the study period died of infection. All of these patients had invasive fungal infections, mostly due to molds. All five patients had prolonged and severe neutropenia. CONCLUSIONS Infections remain a major cause of death in patients with AA. Bacterial infections, especially those caused by gram-positive cocci, constitute the main cause of IE. Invasive mold infections, however, are the major cause of death in this patient population.
Collapse
Affiliation(s)
- Harrys A Torres
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
| | | | | | | | | | | |
Collapse
|
59
|
Rosenfeld S, Follmann D, Nunez O, Young NS. Antithymocyte globulin and cyclosporine for severe aplastic anemia: association between hematologic response and long-term outcome. JAMA 2003; 289:1130-5. [PMID: 12622583 DOI: 10.1001/jama.289.9.1130] [Citation(s) in RCA: 305] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
CONTEXT In most patients, aplastic anemia results from T-cell-mediated immune destruction of bone marrow. Aplastic anemia can be effectively treated by stem cell transplantation or immunosuppression. OBJECTIVE To assess long-term outcomes after immunosuppressive therapy. DESIGN, SETTING, AND PATIENTS Cohort of 122 patients (31 were < or =18 years and 91 were >18 years) with severe aplastic anemia, as determined by bone marrow cellularity and blood cell count criteria, were enrolled in a single-arm interventional research protocol from 1991 to 1998 at a federal government research hospital. INTERVENTIONS A dose of 40 mg/kg per day of antithymocyte globulin administered for 4 days, 10 to 12 mg/kg per day of cyclosporine for 6 months (adjusted for blood levels), and a short course of corticosteroids (1 mg/d of methylprednisolone for about 2 weeks). MAIN OUTCOME MEASURES Survival, improvement of pancytopenia and transfusion-independence, relapse, and evolution to other hematologic diseases. RESULTS Response rates were 60% at 3 months after initiation of treatment, 61% at 6 months, and 58% at 1 year. The blood cell counts of patients who responded no longer satisfied severity criteria and they were transfusion-independent. Overall actuarial survival at 7 years was 55%. Survival was associated with early satisfaction of response criteria (86% vs 40% at 5 years; P<.001) and by blood counts at 3 months (reticulocyte count or platelet count of >50 x 10(3)/ microL predicted survival at 5 years of 90% [64/71] vs 42% [12/34] for patients with less robust recovery [P<.001 by log-rank test]). There were no deaths among responders more than 3 years after treatment. Relapse was common, but severe pancytopenia usually did not recur. Relapse did not influence survival. Thirteen patients showed evolution to other hematologic diseases, including monosomy 7. CONCLUSIONS Approximately half of patients with severe aplastic anemia treated with antithymocyte globulin and cyclosporine have durable recovery and excellent long-term survival. These outcomes were related to the quality of hematologic recovery.
Collapse
Affiliation(s)
- Stephen Rosenfeld
- Hematology Branch, Bldg 10, National Heart, Lung, and Blood Institute, Bethesda, Md, USA
| | | | | | | |
Collapse
|
60
|
Derossi SS, Raghavendra S. Anemia. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 2003; 95:131-41. [PMID: 12582350 DOI: 10.1067/moe.2003.13] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Scott S Derossi
- University of Pennsylvania School of Dental Medicine, Pennsylvania, USA
| | | |
Collapse
|
61
|
Killick SB, Mufti G, Cavenagh JD, Mijovic A, Peacock JL, Gordon-Smith EC, Bowen DT, Marsh JCW. A pilot study of antithymocyte globulin (ATG) in the treatment of patients with 'low-risk' myelodysplasia. Br J Haematol 2003; 120:679-84. [PMID: 12588356 DOI: 10.1046/j.1365-2141.2003.04136.x] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report 30 'low-risk' patients with myelodysplasia (MDS) (defined as < 10% bone marrow blasts) who were treated with antithymocyte globulin (ATG). In total, 20 patients were evaluable at the study end-point (response to treatment at 6 months). The diagnosis in these 20 patients was refractory anaemia (RA) in 13, RA with excess blasts in four, and RA with ringed sideroblasts in three. Median age was 54.5 years (range, 31-73 years). There were two cases of secondary MDS. The bone marrow was hypocellular in eight cases and cytogenetics were abnormal in four cases. All patients received lymphoglobuline (horse ATG; Sangstat, France) at a dose of 1.5 vials/10 kg/day for 5 d. The treatment was well tolerated. Three patients in the study died (disease progression, invasive aspergillosis and lung carcinoma respectively); 10 out of 20 evaluable patients (50%) responded to treatment and became transfusion independent; eight out of 13 (62%) patients with RA responded. The median duration of response was 15.5 months (2-42+ months) at the time of analysis.
Collapse
Affiliation(s)
- Sally B Killick
- Department of Haematology, St George's Hospital, London, UK.
| | | | | | | | | | | | | | | |
Collapse
|
62
|
Gluckman E, Rokicka-Milewska R, Hann I, Nikiforakis E, Tavakoli F, Cohen-Scali S, Bacigalupo A. Results and follow-up of a phase III randomized study of recombinant human-granulocyte stimulating factor as support for immunosuppressive therapy in patients with severe aplastic anaemia. Br J Haematol 2002; 119:1075-82. [PMID: 12472591 DOI: 10.1046/j.1365-2141.2002.03947.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In patients with idiopathic severe aplastic anaemia who are treated with immunosuppressive agents to combat T lymphocyte-mediated destruction of haematopoietic progenitor cells, neutropenia is a major cause of infections and toxicity. Evidence from preliminary studies suggests that recombinant human glycosylated granulocyte colony-stimulating factor (lenograstim) increases the number and functionality of neutrophils in patients with severe aplastic anaemia. This randomized, parallel-group, multicentre study was conducted to evaluate the efficacy and safety of subcutaneous lenograstim during the first 12 weeks of standard immunosuppressive therapy in 102 patients with de novo severe aplastic anaemia. The addition of lenograstim to standard therapy resulted in an increase in the proportion of patients showing complete neutrophil response (83.0%vs 44.9%; P < 0.0001). This was seen even among patients with very severe aplastic anaemia (69.2%vs 31.6%; P = 0.012). In patients receiving lenograstim, median time to complete neutrophil response was shorter (6.3 vs 16.1 weeks; P = 0.0001) and mean duration of first neutrophil response was longer (P = 0.0248) than in the control group. At a median follow-up of 5 years, no difference was observed between the groups in term of survival, haematological response and occurrence of secondary leukaemia (one patient in each group). We conclude that lenograstim support of immunosuppressive therapy might be used for patients with severe aplastic anaemia as it significantly enhances neutrophil recovery but does not modify the overall response and survival.
Collapse
|
63
|
Young NS. Immunosuppressive treatment of acquired aplastic anemia and immune-mediated bone marrow failure syndromes. Int J Hematol 2002; 75:129-40. [PMID: 11939258 DOI: 10.1007/bf02982017] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Modern therapeutic strategies for the treatment of acquired aplastic anemia are based on the current understanding of its pathophysiology as well as empiric observations. Most cases of aplastic anemia appear to be the result of immune-mediated destruction of hematopoietic cells, which can be approached by stem cell transplantation in younger patients with appropriate histocompatible donors or by immunosuppression to reduce T-cell activity. Popular treatment regimens combine antithymocyte globulin with cyclosporine. Although a majority of patients respond with improved blood counts and achieve transfusion-independence, late clonal complications of myelodysplasia and cytogenetic abnormalities occur in a substantial minority of cases. Additionally, there is no clear algorithm for the treatment of refractory disease. Newer methods of treatment, including high-dose cyclophosphamide and the development of potentially tolerizing combinations of drugs. are under study. Effective therapies for aplastic anemia might also be applied to other T-cell mediated, organ-specific human diseases.
Collapse
Affiliation(s)
- Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda. MD 20892-1652, USA
| |
Collapse
|
64
|
Mollee P, Woodward N, Durrant S, Lockwood L, Gillett EA, Morton J, Rowell J. Single institution outcomes of treatment of severe aplastic anaemia. Intern Med J 2001; 31:337-42. [PMID: 11529587 DOI: 10.1046/j.1445-5994.2001.00078.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND In severe aplastic anaemia, the treatment of choice for young patients with a human leucocyte antigen-matched sibling is now established as allogeneic bone marrow transplantation (BMT). In older patients and in those without a matched sibling donor, immunosuppressive therapy is the usual first option. 'Alternative' marrow donors are emerging as an option for those without a matched sibling donor. AIMS To review 10 years of local experience in treating severe aplastic anaemia with BMT and immunosuppressive therapy with emphasis on long-term outcomes. METHODS A retrospective analysis was performed of all patients with severe aplastic anaemia presenting to the Royal Brisbane and Royal Children's Hospitals between 1989 and 1999. Data were abstracted regarding patient demographics, pretreatment characteristics and outcome measures, including response rates, overall survival and long-term complications. RESULTS Twenty-seven consecutive patients were identified, 12 treated with immunosuppression alone and 15 with BMT. In these two groups, transfusion independence was attained in 25% and 100%, respectively, with overall survival being 36% and 100%, respectively. Those treated with immunosuppression were significantly older (median 41.5 versus 22 years, P = 0.008). Long-term survivors of either treatment had extremely low morbidity. Three patients carried pregnancies to term post-transplant. Three patients received alternative donor BMT with correspondingly excellent survival. CONCLUSIONS Patients treated with allogeneic BMT for severe aplastic anaemia enjoyed extremely good long-term survival and minimal morbidity. Patients treated with immunosuppressive therapy had a poorer outcome reflecting their older age and different usage of therapies over the past decade. Optimal treatment strategies for severe aplastic anaemia remain to be determined.
Collapse
Affiliation(s)
- P Mollee
- Bone Marrow Transplant Unit, Royal Brisbane Hospital, Queensland, Herston, Australia
| | | | | | | | | | | | | |
Collapse
|
65
|
Abstract
Acquired, idiosyncratic aplastic anaemia (AA) is a rare but potentially fatal haematological disorder. Severe AA constitutes an acute medical emergency, and supportive therapy is needed to prevent overwhelming sepsis or a life threatening haemorrhage. Specific therapy for the disease includes the choice between allogeneic stem cell transplantation (SCT) from an HLA-identical sibling or immunosuppressive therapy with anti-thymocyte globulin (ATG) and cyclosporin A (CSA). Long-term cure rates of 75-90% are now achieved following HLA (human leukocyte antigen) identical sibling bone marrow transplant. The use of donors other than HLA-id siblings for transplantation in AA remains experimental. Transplantation offers the patient a chance of cure, whilst treatment with immunosuppressive therapy carries a long-term risk of relapse and clonal transformation. The haemopoietic growth factors, apart from granulocyte colony stimulating factor (G-CSF), have been shown to be potentially toxic when given to patients with AA. A short course of G-CSF may be useful to help treat severe infection, but its longer-term use with ATG and CSA remains controversial. Results from immunosuppressive treatment continue to improve with time, as a result of the additional use of CSA with ATG, the use of repeat courses of ATG for non-responders and improvements in the supportive care of patients.
Collapse
Affiliation(s)
- S B Killick
- Department of Haematology, St George's Hospital Medical School, Cranmer Terrace, London, SW17 ORE, UK
| | | |
Collapse
|
66
|
Affiliation(s)
- S E Ball
- Department of Haematology, St George's Hospital Medical School, Cranmer Terrace, London, UK.
| |
Collapse
|
67
|
Bacigalupo A, Brand R, Oneto R, Bruno B, Socié G, Passweg J, Locasciulli A, Van Lint MT, Tichelli A, McCann S, Marsh J, Ljungman P, Hows J, Marin P, Schrezenmeier H. Treatment of acquired severe aplastic anemia: bone marrow transplantation compared with immunosuppressive therapy--The European Group for Blood and Marrow Transplantation experience. Semin Hematol 2000; 37:69-80. [PMID: 10676912 DOI: 10.1016/s0037-1963(00)90031-3] [Citation(s) in RCA: 198] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patients with severe aplastic anemia (SAA) can be successfully treated with bone marrow transplantation (BMT) or immunosuppressive therapy (IS). The current outcome using both forms of therapy among 3,669 patients treated in Europe between 1976 and 1998 is reviewed. Significant progress has been made and the overall risk of failure is now low, with survival rates greater than 80% for both treatments. Chronic graft-versus-host disease (GvHD) remains a problem for BMT patients, and carries a high risk of lethal complications. On the other hand, IS patients are exposed to late failure due to relapse or clonal/malignant diseases. First-line BMT from identical siblings is compared with IS therapy in an intent-to-treat analysis of 1,765 patients, regardless of subsequent transplant status. The outcome of SAA patients has improved considerably over time and is influenced by patient variables such as severity of the disease and age, but also by the choice of the initial treatment.
Collapse
Affiliation(s)
- A Bacigalupo
- Working Party on Severe Aplastic Anemia of the European Blood and Marrow Transplantation Group and the Medical Statistical Department, University of Leiden, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
68
|
|
69
|
Frickhofen N, Rosenfeld SJ. Immunosuppressive treatment of aplastic anemia with antithymocyte globulin and cyclosporine. Semin Hematol 2000; 37:56-68. [PMID: 10676911 DOI: 10.1016/s0037-1963(00)90030-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Immunosuppression is the treatment modality for the majority of patients with aplastic anemia, most of whom are not candidates for allogeneic stem-cell transplantation. Antithymocyte globulin (ATG) or antilymphocyte globulin (ALG) have proven to be essential components of all regimens. Initial response rates can be improved by the addition of cyclosporine A (CsA), and this combination has become the standard of care for appropriate patients. Several new approaches to immunosuppression are being studied, including the optimal timing of administration of these drugs, the use of novel immunosuppressive agents, and the addition of early- and late-acting hematopoietic growth factors.
Collapse
Affiliation(s)
- N Frickhofen
- Department of Medicine III (Hematology/Oncology), Dr.-Horst-Schmidt-Kliniken GmbH, Wiesbaden, Germany
| | | |
Collapse
|
70
|
Kami M, Machida U, Hirai H. Late clonal complications in older patients receiving immunosuppressive therapy for aplastic anemia. Ann Intern Med 1999; 131:633-4. [PMID: 10523237 DOI: 10.7326/0003-4819-131-8-199910190-00029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|