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Lv Q, Huiqin Z, Na X, Chunyan L, Zonghong S, Huaquan W. Treatment of Severe Aplastic Anemia with Porcine Anti-Human Lymphocyte Globulin. Curr Pharm Des 2020; 26:2661-2667. [PMID: 32183661 DOI: 10.2174/1381612826666200317131940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/09/2020] [Indexed: 11/22/2022]
Abstract
Aplastic anemia (AA) is a bone marrow failure syndrome characterized by pancytopenia. Decreased numbers of hematopoietic stem cells and impaired bone marrow microenvironment caused by abnormal immune function describe the major pathogenesis of AA. Hematopoietic stem cell transplantation and immunesuppressive therapy are the first-line treatments for AA. Porcine anti-lymphocyte globulin (p-ALG) is a new product developed in China. Several studies have shown that p-ALG exhibited good therapeutic effects in AA.
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Affiliation(s)
- Qi Lv
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Zhang Huiqin
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Xiao Na
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Liu Chunyan
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Shao Zonghong
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - Wang Huaquan
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
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Rabbit antithymocyte globulin dose does not affect response or survival as first-line therapy for acquired aplastic anemia: a multicenter retrospective study. Ann Hematol 2018; 97:2039-2046. [PMID: 29978284 DOI: 10.1007/s00277-018-3416-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/24/2018] [Indexed: 12/22/2022]
Abstract
In a prospective randomized study, treatment for aplastic anemia (AA) with rabbit antithymocyte globulin (r-ATG) and cyclosporine showed inferior hematological response and survival in comparison to horse antithymocyte globulin (h-ATG) and cyclosporine. However, h-ATG was discontinued in most Asian, South American, and European countries, where r-ATG became the only ATG formulation available. We retrospectively evaluated consecutive patients with acquired AA who received either rabbit (n = 170) or horse (n = 85) ATG and cyclosporine for first-line treatment from 1992 to 2014 in seven referral centers in Brazil and Argentina. Overall response at 3 months was 17% (95%CI, 11-23%) for r-ATG and 44% (95%CI, 33-55%) for h-ATG (p < 0.001). At 6 months, it was 31% (95%CI, 34-39%) for r-ATG and 59% (95%CI, 48-69%) for h-ATG (p < 0.001). Overall survival at 5 years was 57% (95%CI, 47-65%) for r-ATG and 80% (95%CI, 69-87%) for h-ATG (log-rank = 0.001). Relapse was significantly higher in patients receiving h-ATG (28%; 95%CI, 17-43%) as compared to r-ATG (9.4%; 95%CI, 4-21%; log-rank, p = 0.01). The type of ATG was the only factor associated with both response and survival. The r-ATG dose varied from 1 to 5 mg/kg/day, but it did not correlate with outcomes. In summary, this is the largest multicenter study comparing the two ATG formulations in AA. Our results indicate that the dose of r-ATG does not influence hematologic response or survival in first-line therapy for acquired AA. Considering the toxicity and costs of r-ATG, our findings challenge its aggregate benefit to cyclosporine therapy and further strengthen that h-ATG should remain standard therapy in AA.
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Schoettler ML, Nathan DG. The Pathophysiology of Acquired Aplastic Anemia: Current Concepts Revisited. Hematol Oncol Clin North Am 2018; 32:581-594. [PMID: 30047412 DOI: 10.1016/j.hoc.2018.03.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Idiopathic acquired aplastic anemia is a rare, life-threatening bone marrow failure syndrome characterized by cytopenias and hypocellular bone marrow. The pathophysiology is unknown; the most favored model is of a dysregulated immune system leading to autoreactive T-cell destruction of hematopoietic stem and progenitor cells in a genetically susceptible host. The authors review the literature and propose that the major driver of acquired aplastic anemia is a combination of hematopoietic stem and progenitor cells intrinsic defects and an inappropriately activated immune response in the setting of a viral infection. Alterations in bone marrow microenvironment may also contribute to the disease process.
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Affiliation(s)
- Michelle L Schoettler
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215-5450, USA; Division of Hematology/Oncology, Boston Children's Hospital, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Pediatrics, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA
| | - David G Nathan
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215-5450, USA; Division of Hematology/Oncology, Boston Children's Hospital, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Pediatrics, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA.
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Antithymocyte globulin treatment at the time of transplantation impairs donor hematopoietic stem cell engraftment. Cell Mol Immunol 2015; 14:443-450. [PMID: 26499257 DOI: 10.1038/cmi.2015.92] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 09/25/2015] [Accepted: 09/26/2015] [Indexed: 01/20/2023] Open
Abstract
Antithymocyte globulin (ATG) is often included in the conditioning regimen to prevent graft vs. host disease in allogeneic hematopoietic stem cell (HSC) transplantation. However, because ATG contains antibodies targeting a wide range of antigens on human cells, its potential off-target effects remain a concern. Here, we explored this question in humanized mice that permit the analysis of human cell depletion in tissues. We showed that ATG binds to almost all lineages of human hematopoietic cells including HSCs, and accordingly it is capable of depleting almost all human hematopoietic cells. Interestingly, the efficacy of ATG was highly variable depending on the tissue of residence, with human cells in bone marrow significantly less susceptible than those in the blood and spleen. Recovery of multilineage human lymphohematopoietic reconstitution in humanized mice that received ATG 3 weeks after HSC transplantation indicates that ATG had a minimal effect on human HSCs that have settled in bone marrow niches. However, efficient human HSC depletion and engraftment failure were seen in mice receiving ATG at the time of transplantation. Our data indicate that the efficacy of ATG is tissue-dependent, and suggest a potential risk of impairing donor hematopoietic engraftment when ATG is used in preparative conditioning regimens.
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Immunosuppressive therapies in the management of acquired immune-mediated marrow failures. Curr Opin Hematol 2012; 19:3-13. [PMID: 22143074 DOI: 10.1097/moh.0b013e32834da9a4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Immunosuppression is a key treatment strategy for patients suffering from aplastic anemia or related immune-mediated bone marrow failure syndromes. Several attempts have been performed to improve the standard immunosuppression regimen of horse antithymocyte globulin (h-ATG) and cyclosporine A (CyA). RECENT FINDINGS The addition of a third immunosuppression agent to h-ATG + CyA did not result in any improvement. Antilymphocyte agents other than h-ATG have been investigated. A rabbit-ATG preparation, which was known to be more immunosuppressive than h-ATG, resulted in markedly inferior outcome in a large randomized study from the National Institutes of Health. These data seem to be confirmed in additional experiences with rabbit-ATG from other groups. Cyclophosphamide and alemtuzumab have been proven to be biologically active in small studies, but available data suggest inferior outcomes when compared with h-ATG. All these alternative agents result in a more pronounced lymphocyte depletion, suggesting that the actual mechanisms of action of immunosuppressive therapy in aplastic anemia are not fully understood. SUMMARY Immunosuppression by h-ATG and CyA remains the standard of care for aplastic anemia patients lacking a low-risk transplant procedure, resulting in a 60-70% response rate. Rabbit-ATG, cyclophosphamide and alemtuzumab demonstrated a biological activity, but resulted in inferior outcome as compared with h-ATG; thus, they are not recommended as front-line therapy of aplastic anemia.
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Afable MG, Shaik M, Sugimoto Y, Elson P, Clemente M, Makishima H, Sekeres MA, Lichtin A, Advani A, Kalaycio M, Tiu RV, O'Keefe CL, Maciejewski JP. Efficacy of rabbit anti-thymocyte globulin in severe aplastic anemia. Haematologica 2011; 96:1269-75. [PMID: 21606164 DOI: 10.3324/haematol.2011.042622] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND A combination of horse anti-thymocyte globulin and cyclosporine produces responses in 60-70% of patients with severe aplastic anemia. We performed a phase II study of rabbit anti-thymocyte globulin and cyclosporine as first-line therapy for severe aplastic anemia. DESIGN AND METHODS Twenty patients with severe aplastic anemia treated with rabbit anti-thymocyte globulin were compared to 67 historical control cases with matched clinical characteristics treated with horse anti-thymocyte globulin. RESULTS Response rates at 3, 6 and 12 months were similar for patients treated with rabbit anti-thymocyte globulin or horse anti-thymocyte globulin: 40% versus 55% (P=0.43), 45% versus 58% (P=0.44) and 50% versus 58% (P=0.61), respectively. No differences in early mortality rates or overall survival were observed. We then performed multivariable analyses of response at 6 months and overall survival and identified the presence of a paroxysmal nocturnal hemoglobinuria clone (P=0.01) and a pretreatment absolute reticulocyte count greater than 30×10(9)/L (P=0.007) as independent predictors of response and younger age (P=0.003), higher pretreatment absolute neutrophil (P=0.02) and absolute lymphocyte counts (P=0.03) as independent predictors of overall survival. None of the immunogenetic polymorphisms studied was predictive of response to immunosupressive therapy. CONCLUSIONS Despite reports suggesting differences in biological activity of different anti-thymocyte globulin preparations, rabbit and horse anti-thymocyte globulin appear to have a similar efficacy for up-front treatment of severe aplastic anemia. Clinicaltrial.gov: NCT01231841).
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Affiliation(s)
- Manuel G Afable
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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Grüllich C, Ziegler C, Finke J. Rabbit Anti T-Lymphocyte Globulin Induces Apoptosis in Peripheral Blood Mononuclear Cell Compartments and Leukemia Cells, While Hematopoetic Stem Cells Are Apoptosis Resistant. Biol Blood Marrow Transplant 2009; 15:173-82. [DOI: 10.1016/j.bbmt.2008.11.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 11/09/2008] [Indexed: 11/27/2022]
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Barakat RK, Schmolck JP, Finkel KW, Foringer JR. Prolonged renal failure secondary to antithymocyte globulin treatment in severe aplastic anemia. Ann Pharmacother 2007; 41:895-8. [PMID: 17426071 DOI: 10.1345/aph.1k036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report a case of acute renal failure in a patient with severe aplastic anemia after administration of antithymocyte globulin (ATG). CASE SUMMARY A 41-year-old man diagnosed with severe aplastic anemia was treated with ATG and cyclosporine. After one dose of ATG (3012 mg, 40 mg/kg), the patient developed anuric acute renal failure, with serum creatinine 3.4 mg/dL (1.2 mg/dL at baseline) and blood urea nitrogen (BUN) 29 mg/dL (13 mg/dL at baseline), which required intermittent hemodialysis. Renal failure resolved with cessation of the drug, serum creatinine and BUN returned to baseline levels, and the patient no longer required hemodialysis. DISCUSSION ATG is a purified and concentrated gamma globulin, primarily a monomeric immunoglobulin G from hyperimmune serum of horses. It is widely used to treat severe aplastic anemia and to manage acute transplant rejection. This patient had no other confounding factors for the cause of the renal failure. An objective causality assessment using the Naranjo probability scale suggested that ATG was the probable cause of the acute renal failure. Primary glomerular disease was not excluded, as a renal biopsy was not performed. CONCLUSIONS The association between renal injury and administration of ATG remains unclear; therefore, we recommend that renal function be assessed and carefully monitored prior to and after administration of ATG.
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Affiliation(s)
- Ruchdi K Barakat
- Division of Renal Diseases and Hypertension, The University of Texas Medical School at Houston, Houston, TX 77030, USA
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Zheng Y, Liu Y, Chu Y. Immunosuppressive therapy for acquired severe aplastic anemia (SAA): a prospective comparison of four different regimens. Exp Hematol 2006; 34:826-31. [PMID: 16797409 DOI: 10.1016/j.exphem.2006.03.017] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2005] [Revised: 03/30/2006] [Accepted: 03/30/2006] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This study was designed to investigate four different immunosuppressive therapy (IST) regimens as treatment of acquired severe aplastic anemia (SAA). PATIENTS AND METHODS 142 consecutive SAA patients were randomized to receive one of the following IST regimens: equine anti-human thymocyte immunoglobulin (E-ATG) alone (IST regimen I); E-ATG and cyclosporine A (CSA) (IST regimen II); E-ATG, CSA plus recombinant human granulocyte-macrophage colony-stimulating factor (rhuGM-CSF) and rhu erythropoietin (rhuEPO) (IST regimen III); or rabbit ATG (ATG-F), CSA, rhuGM-CSF, and rhuEPO (IST regimen IV). No repeated courses of E-ATG or ATG-F were given for nonresponders. All patients also received stanozolol or testosteron propionate. RESULTS The overall response rate to IST regimen I was 58%. The response to IST regimen II (79%) was significantly higher (p = 0.04), more rapid and complete than after IST regimen I. The response rate to IST regimen IV (53%) was significantly lower than that of IST regimen III (73%, p = 0.039). The additional use of growth factors did not reduce early deaths and did not accelerate hematopoietic recovery after IST. Of the 142 patients enrolled in this trial, 92 (65%) are alive at a median follow-up time of 102 months (range, 54-166 months). The 5-year actuarial survival for IST regimens I, II, III, and IV was 58%, 81%, 80%, and 66%, respectively. CONCLUSION The combination of E-ATG and CSA remains the best combination for the treatment of SAA patients, producing a survival advantage at 5 years. The addition of growth factors did not improve these results. Rabbit ATG-F appeared less effective than E-ATG.
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Affiliation(s)
- Yizhou Zheng
- Severe Aplastic Anemia Studying Program, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, People's Republic of China.
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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.
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Affiliation(s)
- S B Killick
- Department of Haematology, Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK.
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Fang JP, Xu HG, Huang SL, Chen C, Huang K. Immunosuppressive treatment of aplastic anemia in Chinese children with antithymocyte globulin and cyclosporine. Pediatr Hematol Oncol 2006; 23:45-50. [PMID: 16326412 DOI: 10.1080/08880010500313389] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Fifty-one children with aplastic anemia (AA) from 1993 to 2004 in the authors' institution were treated by 3 therapies: 11 patients in group 1 received the SSL-6 protocol; 16 patients in group 2 had CsA alone, where the dose of CsA began from 9-12 mg/kg in the initial 2 weeks and tapered off to 5 mg/kg later; 24 patients in group 3 were treated combining rabbit ATG (Pasteur, Merieux) 2.5 mg/kg for 5 days with CsA, which was the same dose as in group 2. The response was 27, 50, and 79%, respectively. The statistical analysis showed that the protocol of intensive immunosuppressive treatment (IST) was the most effective one and CsA was better than that of SSL-6. None of our patients developed clone diseases although the follow-up was as long as more than to 9 years. The data suggest that children with AA should receive IST as first-line therapy in developing countries. Hematopoietic stem cell transplantation (HSCT) is effective treatment for patients with aplastic anemia (AA). However, HSCT is not widely used in China for economic reasons and lack of donors. Immunosuppressive therapy (IST) is now the mainstay treatment for AA. To evaluate the effect of immunosuppressive therapy, combining antithymocyte globulin (ATG) with cyclosporine (CsA), a retrospective study on 51 children with AA from January 1993 to December 2004 treated in the authors' department was performed.
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Affiliation(s)
- Jian-Pei Fang
- Department of Pediatrics, The Second Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
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Beiras-Fernandez A, Thein E, Chappel D, Gallego R, Fernandez-Roel D, Kemming G, Hammer C. Polyclonal anti-thymocyte globulins influence apoptosis in reperfused tissues after ischaemia in a non-human primate model. Transpl Int 2004. [DOI: 10.1111/j.1432-2277.2004.tb00469.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Beiras-Fernandez A, Thein E, Chappel D, Gallego R, Fernandez-Roel D, Kemming G, Hammer C. Polyclonal anti-thymocyte globulins influence apoptosis in reperfused tissues after ischaemia in a non-human primate model. Transpl Int 2004; 17:453-7. [PMID: 15338119 DOI: 10.1007/s00147-004-0736-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2003] [Revised: 12/01/2003] [Accepted: 05/05/2004] [Indexed: 12/19/2022]
Abstract
Reperfusion triggers the expression of inflammatory cytokines and adhesion molecules that increase the rate of apoptosis in the reperfused tissues after ischaemia, thus worsening the outcome of the grafts. Polyclonal anti-thymocyte globulins (pATGs) are able to reduce the number of lymphocytes as well as block adhesion molecules and induce apoptosis in T-lymphocytes through Fas-ligand. The aims of this study were to investigate the influence of pATGs on the prevention of apoptosis of reperfused tissues after ischaemia and to monitor their capability to enhance lymphocyte apoptosis thus decreasing the deleterious effects of ischaemia/reperfusion injury (IRI). Extremities of cynomolgus monkeys ( n=8) were flushed via either the femoral or the brachial artery. After 60 min of ischaemia the limbs were reperfused with human blood. ATG was added to the blood in a therapeutic dose 20 min prior to reperfusion of the extremities. Surgically available limbs ( n=20) were assigned to the following groups: ATG group ( n=10) and control group (without ATG; n=10). DNA fragmentation analysis was performed in situ to detect apoptosis at the single-cell level. Our study shows an increased rate of muscle and connective tissue apoptosis in the control group compared with the ATG-treated group. Cells found in the vascular areas present different rates of apoptosis, with enhanced cellular death of endothelium and connective perivascular areas being observed in the control group. The group treated with ATG shows an increased rate of white blood cell (WBC) apoptosis in vascular and perivascular areas. Previous studies have shown that pATGs are able to induce apoptosis as well as complement-mediated cell death in peripheral T-lymphocytes in vitro. Our results confirm that pATGs not only increase the rate of apoptosis of WBCs in vivo but also have a protective effect on the reperfused tissue. This may alleviate the damage after reperfusion of solid-organ transplantation.
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Affiliation(s)
- Andres Beiras-Fernandez
- Institute for Surgical Research, LM University, Marchioninistrasse 27, 81377 Munich, Germany.
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