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Füreder W, Sperr WR, Heibl S, Zebisch A, Pfeilstöcker M, Stefanzl G, Jäger E, Greiner G, Schwarzinger I, Kundi M, Keil F, Hoermann G, Bettelheim P, Valent P. Prognostic factors and follow-up parameters in patients with paroxysmal nocturnal hemoglobinuria (PNH): experience of the Austrian PNH network. Ann Hematol 2020; 99:2303-2313. [PMID: 32856141 DOI: 10.1007/s00277-020-04214-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 08/10/2020] [Indexed: 11/29/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematologic disease characterized by a deregulated complement system, chronic Coombs-negative, intravascular hemolysis, and a variable clinical course with substantial risk to develop thromboembolic events. We analyzed diagnostic and prognostic parameters as well as clinical endpoints in 59 adult patients suffering from PNH in 5 hematology centers in Austria (observation period: 1978-2015). Median follow-up time was 5.6 years. The median clone size at diagnosis amounted to 55% and was higher in patients with classical PNH (81%) compared to patients with PNH associated with aplastic anemia (AA) or myelodysplastic syndromes (MDS) (50%). The clone size also correlated with lactate dehydrogenase (LDH) levels. In one patient, anemia improved spontaneously and disappeared with complete normalization of LDH after 16 years. Seventeen patients received therapy with eculizumab. The rate of thromboembolic events was higher in the pre-eculizumab era compared with eculizumab-treated patients but did not correlate with the presence of age-related clonal hematopoiesis or any other clinical or laboratory parameters. Peripheral blood colony-forming progenitor cell counts were lower in PNH patients compared with healthy controls. Only two patients with classical PNH developed MDS. Overall, 7/59 patients died after 0.5-32 years. Causes of death were acute pulmonary hypertension, Budd-Chiari syndrome, and septicemia. Overall survival (OS) was mainly influenced by age and was similar to OS measured in an age-matched healthy Austrian control cohort. Together, compared with previous times, the clinical course and OS in PNH are favorable, which may be due to better diagnosis, early recognition, and eculizumab therapy.
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Affiliation(s)
- Wolfgang Füreder
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria. .,Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - W R Sperr
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - S Heibl
- Klinikum Wels-Grieskirchen, Wels, Austria
| | - A Zebisch
- Division of Hematology, Medical University of Graz, Graz, Austria.,Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, Graz, Austria
| | - M Pfeilstöcker
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Hanusch Hospital Vienna, Vienna, Austria
| | - G Stefanzl
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - E Jäger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - G Greiner
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - I Schwarzinger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - M Kundi
- Department of Environmental Health, Medical University of Vienna, Vienna, Austria
| | - F Keil
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Hanusch Hospital Vienna, Vienna, Austria
| | - G Hoermann
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria.,Central Institute of Medical and Chemical Laboratory Diagnostics, University Hospital Innsbruck, Innsbruck, Austria
| | - P Bettelheim
- Division of Hematology and Oncology, Elisabethinen Hospital Linz and Europa-Platz Labor Linz, Linz, Austria
| | - P Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Araten DJ, Boxer D, Zamechek L, Sherman E, Nardi M. Analysis of platelets by flow cytometry in patients with Paroxysmal Nocturnal Hemoglobinuria (PNH). Blood Cells Mol Dis 2020; 80:102372. [DOI: 10.1016/j.bcmd.2019.102372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/22/2019] [Indexed: 10/25/2022]
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Lobry C, Bains A, Zamechek LB, Ibrahim S, Aifantis I, Araten DJ. Analysis of TET2 mutations in paroxysmal nocturnal hemoglobinuria (PNH). Exp Hematol Oncol 2019; 8:17. [PMID: 31453016 PMCID: PMC6702710 DOI: 10.1186/s40164-019-0142-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/01/2019] [Indexed: 12/18/2022] Open
Abstract
Background Large clonal populations of cells bearing PIG-A mutations are the sine qua non of PNH, but the PIG-A mutation itself is insufficient for clonal expansion. The association between PNH and aplastic anemia supports the immune escape model, but not all PNH patients demonstrate a history of aplasia; therefore, second genetic hits driving clonal expansion have been postulated. Based on the previous identification of JAK2 mutations in patients with a myeloproliferative/PNH overlap syndrome, we considered TET2 as a candidate gene in which mutations might be contributing to clonal expansion. Methods Here we sequenced the TET2 and JAK2 genes in 19 patients with large PNH clones. Results We found one patient with a novel somatic nonsense mutation in TET2 in multiple hematopoietic lineages, which was detectable upon repeat testing. This patient has had severe thromboses and has relatively higher peripheral blood counts compared with the other patients—but does not have other features of a myeloproliferative neoplasm. Conclusions We conclude that mutations in TET2 may contribute to clonal expansion in exceptional cases of PNH.
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Affiliation(s)
- Camille Lobry
- 1Institut National de la Santé et de la Recherche Medicale (INSERM) U1170, Institut Gustave Roussy, 94805 Villejuif, France
| | - Ashish Bains
- 2Pathology and Laboratory Medicine, Temple University, 3401 North Broad Street, Philadelphia, PA 19140 USA
| | - Leah B Zamechek
- 3Columbia University Medical Center, 1130 St. Nicholas Avenue, Room 901, New York City, USA
| | - Sherif Ibrahim
- Cairo Diagnostics, 244 Westchester Avenue, West Harrison, NY 10604 USA
| | - Iannis Aifantis
- 5Department of Pathology, NYU School of Medicine, 550 First Avenue, New York, NY 10016 USA
| | - David J Araten
- 6Division of Hematology, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health and the NYU School of Medicine, 240 East 38th Street, 19th Floor, New York, NY 10016 USA.,7Division of Hematology, New York VA Medical Center, 423 East 23rd Street, New York, NY 10010 USA
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Mannelli F, Bencini S, Peruzzi B, Cutini I, Sanna A, Benelli M, Magi A, Gianfaldoni G, Rotunno G, Carrai V, Gelli AMG, Valle V, Santini V, Notaro R, Luzzatto L, Bosi A. A systematic analysis of bone marrow cells by flow cytometry defines a specific phenotypic profile beyond GPI deficiency in paroxysmal nocturnal hemoglobinuria. CYTOMETRY PART B-CLINICAL CYTOMETRY 2012; 84:71-81. [PMID: 23281097 DOI: 10.1002/cyto.b.21064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 11/26/2012] [Accepted: 11/27/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Paroxysmal nocturnal hemoglobinuria (PNH) is a unique disorder caused by a PIG-A gene mutation in a stem cell clone. Its clinical picture can sometimes make challenging the distinction from other disorders, and especially from myelodysplastic syndromes (MDS), since both diseases correlate with cytopenias and morphological abnormalities of bone marrow (BM) cells. Recently, flow cytometry (FC) has been proposed to integrate the morphologic assessment of BM dysplasia, and thus to improve the diagnostics of MDS. METHODS In the present study, we have analyzed systematically FC data resulting from the study of BM cells from patients with PNH and MDS. RESULTS Our data demonstrated abnormalities in PNH beyond the deficiency of glycosylphosphatidylinositol-linked proteins and the application of a systematic approach allowed us to separate effectively MDS and PNH in a cluster analysis and to highlight disease-specific abnormalities. Indeed, the parallel evaluation of some key parameters, i.e. patterns of expression of CD45 and CD10, provided information with practical diagnostic usefulness in the distinction between PNH and MDS. Moreover, the hypo-expression of CD36 that we observed on monocytes might be related to the thrombotic tendency in PNH. CONCLUSIONS We investigated systematically the phenotypic profile of BM cells from patients with PNH; our data provide useful antigenic patterns to solve between PNH and MDS, sometimes morphologically overlapping. Moreover, some PNH-related phenotypic changes might be involved in the physiopathology of the disease and further studies addressing this issue are warranted.
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Affiliation(s)
- Francesco Mannelli
- Unità Funzionale di Ematologia, Università degli Studi, AOU Careggi, Florence, Italy.
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Rachidi S, Musallam KM, Taher AT. A closer look at paroxysmal nocturnal hemoglobinuria. Eur J Intern Med 2010; 21:260-7. [PMID: 20603032 DOI: 10.1016/j.ejim.2010.04.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 04/05/2010] [Indexed: 12/28/2022]
Abstract
Knowledge of the molecular mechanisms leading to the paroxysmal nocturnal hemoglobinuria (PNH) phenotypes has substantially increased in the past two decades. The associated intravascular hemolysis, hypercoagulablilty, and bone marrow failure result in a wide range of clinical sequlae. Although treatment has usually been symptomatic through several modalities and rarely curative through hematopoietic cell transplantation, recent development of the novel targeted therapeutic agent eculizumab has offered new promises for this highly morbid and fatal disease. This review summarizes current knowledge of the pathophysiology, diagnostic modalities, clinical implications, and treatment approaches of patients with PNH.
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MESH Headings
- Anemia, Hemolytic/etiology
- Anemia, Hemolytic/physiopathology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Blood Coagulation/physiology
- Blood Coagulation Disorders/etiology
- Blood Coagulation Disorders/physiopathology
- Hemoglobinuria, Paroxysmal/complications
- Hemoglobinuria, Paroxysmal/diagnosis
- Hemoglobinuria, Paroxysmal/genetics
- Hemoglobinuria, Paroxysmal/physiopathology
- Hemoglobinuria, Paroxysmal/therapy
- Hemolysis/physiology
- Humans
- Kidney Diseases/etiology
- Kidney Diseases/physiopathology
- Prognosis
- Thrombosis/etiology
- Thrombosis/physiopathology
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Affiliation(s)
- Saleh Rachidi
- Department of Internal Medicine, Division of Hematology & Oncology, American University of Beirut Medical Center, Beirut, Lebanon
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Stern M, Buser AS, Lohri A, Tichelli A, Nissen-Druey C. Autoimmunity and malignancy in hematology—More than an association. Crit Rev Oncol Hematol 2007; 63:100-10. [PMID: 17391977 DOI: 10.1016/j.critrevonc.2007.02.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Revised: 01/02/2007] [Accepted: 02/06/2007] [Indexed: 02/01/2023] Open
Abstract
Several associations between hematological malignancies and autoimmunity directed against hematopoietic cells exist. Antibody mediated elimination of mature blood cells such as autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP) are frequent complications of non-Hodgkin lymphomas, most prominently chronic lymphocytic leukemia. Autoimmunity directed against hematopoietic precursor cells is the hallmark of aplastic anemia, but many features of this disease are shared by two related disorders, paroxysmal nocturnal hemoglobinuria (PNH) and myelodysplastic syndrome (MDS). While the clinical associations between hematological malignancy and autoimmunity have been described many decades ago, only in the last several years have the common pathogenetic mechanisms been elucidated. We summarize the recent progress made in understanding how hematological malignancy gives rise to autoimmunity directed against blood cells and vice versa, and illustrate parallels in the etiology of malignant and autoimmune hematological disorders. Specifically, recent progress in the recognition of the association of lymphoproliferative disorders and autoimmunity against mature blood cells, and common pathogenetic background of aplastic anemia, paroxysmal nocturnal hemoglobinuria, and myelodysplastic syndrome are discussed.
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Affiliation(s)
- Martin Stern
- Division of Experimental Hematology and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Perugia, Policlinico Monteluce, Perugia, Italy
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Araten DJ, Luzzatto L. The mutation rate in PIG-A is normal in patients with paroxysmal nocturnal hemoglobinuria (PNH). Blood 2006; 108:734-6. [PMID: 16543465 PMCID: PMC1895494 DOI: 10.1182/blood-2006-01-0256] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Accepted: 02/26/2006] [Indexed: 12/20/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by the presence in the patient's hematopoietic system of a large cell population with a mutation in the X-linked PIG-A gene. Although this abnormal cell population is often found to be monoclonal, it is not unusual that 2 or even several PIG-A mutant clones coexist in the same patient. Therefore, it has been suggested that the PIG-A gene may be hypermutable in PNH. By a method we have recently developed for measuring the intrinsic rate of somatic mutations (mu) in humans, in which PIG-A itself is used as a sentinel gene, we have found that in 5 patients with PNH, mu ranged from 1.24 x 10(-7) to 11.2 x 10(-7), against a normal range of 2.4 x 10(-7) to 29.6 x 10(-7) mutations per cell division. We conclude that genetic instability of the PIG-A gene is not a factor in the pathogenesis of PNH.
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Affiliation(s)
- David J Araten
- Division of Hematology, New York University School of Medicine and the New York Veterans Administration Medical Center, 10016, USA.
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Marsh JCW, Elebute MO. Stem cells in paroxysmal nocturnal haemoglobinuria and aplastic anaemia: increasing evidence for overlap of haemopoietic defect. Transfus Med 2004; 13:377-86. [PMID: 14651743 DOI: 10.1111/j.1365-3148.2003.00465.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The clinical association between paroxysmal nocturnal haemoglobinuria (PNH) and aplastic anaemia (AA) has long been recognized. Haemolytic PNH, as confirmed by a positive Ham's test, can occur in the setting of AA, and conversely AA can be a late complication of PNH. With the development of sensitive flow cytometry to quantify the expression of phosphatidylinositolglycan (PIG)-anchored proteins on blood cells, a small PNH clone can now be detected in a large number of patients with AA at diagnosis. PIG-A gene mutations can also be demonstrated in some AA patients. In haemolytic PNH, there is always marrow suppression despite a morphologically cellular marrow. In vitro cultures show markedly diminished proliferative capacity in both short-term and long-term marrow cultures, similar to that seen in AA. A similar autoimmune process, through the T-cell cytotoxic repertoire, is probably responsible for the pathogenesis of both AA and PNH. PIG-deficient cells may be resistant to immunological attack by autoreactive cytotoxic T cells, because they lack PIG. They are also more resistant to apoptosis than the PIG-normal cell population. This results in the selection of the PIG-deficient clone, in contrast to the PIG-normal stem cells which possess the PIG anchor and hence are targeted and depleted by the autoreactive T cells.
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Affiliation(s)
- J C W Marsh
- Department of Haematology, St George's Hospital Medical School, London, UK.
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Plasilova M, Risitano AM, O'Keefe CL, Rodriguez A, Wlodarski M, Young NS, Maciejewski J. Shared and individual specificities of immunodominant cytotoxic T-cell clones in paroxysmal nocturnal hemoglobinuria as determined by molecular analysis. Exp Hematol 2004; 32:261-9. [PMID: 15003311 DOI: 10.1016/j.exphem.2003.11.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2003] [Revised: 09/23/2003] [Accepted: 11/20/2003] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Similar immune mechanisms have been suggested to operate in aplastic anemia (AA) and paroxysmal nocturnal hemoglobinuria (PNH), and the presence of PNH clones in AA may indicate that an immune reaction directed against hematopoietic stem cells may be responsible for the immune selection pressure leading to PNH evolution. We previously described expansions of selective cytotoxic T-lymphocyte (CTL) clones in AA patients. MATERIALS AND METHODS We applied a molecular analysis of the T-cell receptor repertoire to study the characteristics of CTL response in patients with various forms of PNH. Immunodominant T-cell clones were detected using combined flow cytometric and molecular analysis of the variable beta (VB) chain and CDR3 representation, followed by determination of the frequency of individual CDR3 clonotypes. Clonotypic polymerase chain reaction (PCR) was performed to establish clonotypic utilization pattern. RESULTS In patients with a past history of AA, and when subgrouped by current blood counts as "hypoproliferative" PNH patients (in contrast to purely hemolytic form of PNH), more pronounced skewing of VB family utilization was found, consistent with T-cell responses involving several immunodominant CTL clones. Sequences of the PNH-derived clonotypes were used to design PCR-based assays for the utilization analysis of individual clones in PNH patients. The clonotypic distribution pattern established by this PCR method indicated that immunodominant T-cell specificities were shared between some patients but also may be found at low frequencies in controls. CONCLUSION Analysis of the CDR3 sequence pattern as a marker for expanded immunodominant clonotypes may have an application in the study of T-cell responses in PNH.
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MESH Headings
- Adult
- Aged
- Anemia, Aplastic/complications
- Anemia, Aplastic/immunology
- Autoimmune Diseases/immunology
- Clone Cells/immunology
- Complementarity Determining Regions/genetics
- DNA, Complementary/genetics
- Disease Progression
- Female
- Gene Rearrangement, beta-Chain T-Cell Antigen Receptor
- Glycosylphosphatidylinositols/deficiency
- Hemoglobinuria, Paroxysmal/complications
- Hemoglobinuria, Paroxysmal/genetics
- Hemoglobinuria, Paroxysmal/immunology
- Humans
- Immunodominant Epitopes/immunology
- Male
- Membrane Proteins/genetics
- Middle Aged
- Polymerase Chain Reaction
- Receptors, Antigen, T-Cell, alpha-beta/genetics
- T-Lymphocytes, Cytotoxic/immunology
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Affiliation(s)
- Magdalena Plasilova
- Experimental Hematology and Hematopoiesis Section, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Ismail MM, Tooze JA, Flynn JA, Gordon-Smith EC, Gibson FM, Rutherford TR, Elebute MO. Differential apoptosis and Fas expression on GPI-negative and GPI-positive stem cells: a mechanism for the evolution of paroxysmal nocturnal haemoglobinuria*. Br J Haematol 2003; 123:545-51. [PMID: 14617023 DOI: 10.1046/j.1365-2141.2003.04643.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Paroxysmal nocturnal haemoglobinuria (PNH) has a dual pathogenesis. PIG-A mutations generate clones of haemopoietic stem cells (HSC) lacking glycosylphosphatidylinositol (GPI)-anchored proteins and, secondly, these clones expand because of a selective advantage related to bone marrow failure. The first aspect has been elucidated in detail, but the mechanisms leading to clonal expansion are not well understood. We have previously shown that apoptosis and Fas expression in HSC play a role in bone marrow failure during aplastic anaemia. We have now investigated apoptosis in PNH. Ten patients were studied. Apoptosis, measured by flow cytometry, was significantly higher among CD34+ cells from patients compared with healthy controls. Fas expression was also increased. Cells that were stained for CD34, CD59 and apoptosis showed a significantly lower apoptosis in CD34+/CD59- compared with CD34+/CD59+ cells from the same patient. In three patients, staining for CD34, CD59 and Fas revealed lower Fas expression on CD34+/CD59- cells. Differential apoptosis of CD34+/CD59- HSC may be sufficient in itself to explain the expansion of PNH clones in the context of aplastic anaemia. In addition to demonstrating a basic mechanism underlying PNH clonal expansion, these results suggest further hypotheses for the evolution of PNH, based on the direct or indirect resistance of GPI-negative HSC to pro-inflammatory cytokines.
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Affiliation(s)
- Medhat M Ismail
- Department of Cellular and Molecular Medicine, St George's Hospital Medical School, London, UK
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