OBJECTIVETo evaluate the clinical characteristics and risk factors of clonal evolution after immunosuppressive therapy (IST) in children with severe/very severe aplastic anemia (SAA/VSAA).

METHODSThe clinical data of 231 children with newly-diagnosed SAA/VSAA who received IST were retrospectively studied. The incidence and risk factors of clonal evolution after IST were analyzed.

RESULTSThe 5-year overall survival rate of the 231 patients was 82.7%. Except for 18 cases of early deaths, 213 patients were evaluated for IST efficacy. Among the 231 patients, cytogenetic abnormalities for at least two chromosome metaphase were detectable in 14 (7.4%) patients, and PNH clones were detectable in either peripheral red blood cells or neutrophils for 95 patients. Among the 213 patients evaluated for IST efficacy, 15 patients experienced clonal evolution after IST. Five patients had PNH and trisomy 8 which were defined as favorable progressions, and ten patients experienced monosomy 7 and MDS/AML as unfavorable progressions. The 5-year accumulative incidence of favorable and unfavorable progression were (2.2±2.2)% and (4.8±3.3)%, respectively. Until the last follow-up, 100% (5/5) of patients with favorable progressions and 50% (5/10) of patients with unfavorable progressions survived. WBC>3.5×10/L, CD3T cell percentage>80%, dosage of antithymocyte globulin >3.0 mg/(kg·d) and no response to IST were related to unfavorable progressions by univariate analysis. Cox multivariate analysis revealed that an increased CD3T cell percentage (>80%) and no response to IST were independent risk factors for unfavorable progressions.

CONCLUSIONSThe children with SAA/VSAA who have an increased CD3T cell percentage at diagnosis or have no response to IST are in high risks of unfavorable progressions.

Adolescent ; Anemia, Aplastic ; drug therapy ; genetics ; immunology ; mortality ; Child ; Child, Preschool ; Chromosome Aberrations ; Clonal Evolution ; Female ; Humans ; Immunosuppressive Agents ; therapeutic use ; Infant ; Male ; Proportional Hazards Models ; Retrospective Studies

The defectiveness of bone marrow mesenchymal stem cells (BM-MSCs) in acquired aplastic anemia (AA) has been a frequent research topic in recent years. This review summarizes the defectiveness of BM-MSCs which is responsible for the mechanism of acquired AA and the prospective application of BM-MSCs in the treatment of acquired AA. An increasingly number of laboratory statistics has demonstrated that the defectiveness of BM-MSCs is more likely to play an important role in the pathogenesis of AA, namely, the apparently different biological characteristics and gene expression profiles, the decreased ability of supporting hematopoiesis as well as self-renewal and differentiation, and the exhaustion of regulating immune response of hematopoietic environment. Those abnormalities continuously prompt AA to become irreversible bone marrow failure along with the imbalanced immunity. With deepening research on MSCs, infusion of MSCs for the primary purpose of recovering hematopoietic microenvironment may become a new approach for the treatment of AA.
Anemia, Aplastic ; etiology ; immunology ; therapy ; Bone Marrow ; Cell Differentiation ; Cell Proliferation ; Cytokines ; analysis ; Humans ; Lymphocyte Activation ; Mesenchymal Stem Cell Transplantation ; Mesenchymal Stromal Cells ; physiology ; T-Lymphocytes, Regulatory ; immunology

OBJECTIVETo study the role of Th17/Treg imbalance in the immune pathogenesis and therapeutic significance in childhood aplastic anemia (AA).

METHODWe analyzed data from 43 children (male: female = 14: 29) with AA, all the cases were at the age of 2 to 14 years at diagnosis, and were hospitalized at our department of pediatrics between January 2012 and October 2013 in the Second Hospital of Anhui Medical University. All these patients were divided into 2 groups, severe AA (SAA) group (n = 25, male: female = 8: 17, 2-14 years old) and non-severe AA (NSAA) group (n = 18, male: female = 6: 12, 2-14 years old), depending on the severity at first diagnosis. As to the treatment, we analyzed data at 3 phases of treatment, diagnosis (n = 43, male: female = 14: 29, 2-14 years old), transfusion-indenpendence (n = 8, male: female = 5: 3, 2-11 years old), complete response (n = 6, male: female = 3: 3, 2-11 years old); at the same time, AA children who did not respond to the treatments were considered as failed treatment control (transfusion-indenpendence with failed treatment group, n = 5, male: female = 1: 4, 3-8 years old; complete response failed treatment group, n = 4, male: female = 2: 2, 4-11 years old). The ratio of Treg and Th17 cells in CD4(+) T cells were tested by flow cytometry. The levels of IL-6 and IL-17 in plasma were determined by ELISA. During the same period, 25 age-matched healthy children (male: female = 12: 13, 3-14 years old) were recruited as normal control, 9 cases (male: female = 5: 3, 2-11 years old) of AA children induced by chemotherapy as diagnosis control group. Differences in variables were analyzed using ANOVA and t-tests or the Kruskal-Wallis and Mann-Whitney U-tests, as appropriate. Correlation analysis was evaluated by the Spearman rank correlation test.

RESULT(1) The ratio of Th17 cells in newly diagnosed AA patients were higher than that of normal group or diagnosis control group [1.63% (1.27%, 2.48%) vs. 0.4% (0.35%, 0.51%) or 0.50% (0.45%, 0.75%), both P < 0.01] while the ratio of Treg cells was lower [4.24% (3.10%, 5.29%) vs. 7.03% (6.56%, 7.48%) or 7.50% (6.60%, 8.30%), both P < 0.01] and the proportion of Th17/Treg were significantly higher [0.53(0.34, 0.69) vs. 0.06 (0.05, 0.07) or 0.09 (0.08,0.11), both P < 0.01]. (2) The levels of IL-6 and IL-17 in newly diagnosed AA patients were higher than in normal group [ (223 ± 92) vs. (116 ± 18) ng/L, (26.2 ± 12.0) ng/L vs. (10.6 ± 2.1) ng/L, P both < 0.01]. There was a positive correlation between Th17 cells and some Th17 cells related cytokines such as IL-17 and IL-6 (r = 0.62, 0.64, P both < 0.01). (3) The ratio of Th17, Th17/Treg, and the levels of IL-6 and IL-17 in children with SAA were also higher than in normal group [1.80% (1.25%, 2.61%) vs. 0.40% (0.35%, 0.51%), 0.57% (5.10%,0.82%) vs. 0.06% (0.05%, 0.07%), (225 ± 108) vs. (116 ± 18) ng/L, (25.9 ± 12.6) vs. (10.6 ± 2.1)ng/L, all P < 0.01]. NSAA also higher than normal group. The ratio of Treg in children with SAA and NSAA was less than that in normal group (P all < 0.01). However, the ratio of Th17, Treg, Th17/Treg, and the levels of IL-6 and IL-17 had no significant difference between SAA and NSAA (all P > 0.05). (4) In different stages of treatment, such as diagnosis, transfusion-indenpendence, complete response, there were significant differences in the ratio of Th17 and Th17/Treg (both P < 0.05) but not in Treg (P > 0.05).

CONCLUSIONThe imbalance of Th17/Treg cells and abnormally increased cytokines related to Th17 cells exist in peripheral blood of AA children, but did not significantly affect the severity of AA in preliminary diagnosis. After treatment with immunosuppression, AA was gradually relieved as the imbalance of Th17/Treg was corrected.

Adolescent ; Anemia, Aplastic ; immunology ; therapy ; Blood Transfusion ; Child ; Child, Preschool ; Cytokines ; Female ; Flow Cytometry ; Humans ; Interleukin-17 ; Interleukin-6 ; Male ; T-Lymphocytes, Regulatory ; immunology ; Th17 Cells ; immunology

OBJECTIVETo compare the efficacy and safety of four different regimens for pediatric severe aplastic anemia (SAA) with immuno-suppressive therapy (IST) with or without combined human granulocyte colony-stimulating factor (G-CSF).

METHODThe authors retrospectively analyzed 105 children with SAA treated with IST with or without G-CSF in the hospital from February 2000 to September 2010. Regimen A, without G-CSF in the whole treatment, was used to treat Group A patients, n = 27; Regimen B, G-CSF, was initiated in Group B, n = 24, before the IST until hematologic recovery; Regimen C, G-CSF, was used together with the IST for Group C patients, n = 24, until hematologic recovery; Regimen D,G-CSF was used for Group D, n = 30, after the end of IST until hematologic recovery. The response rate, relapse rate, mortality, infection rate, infection-related death rate, risk of evolving into MDS/AML, survival rate, factors affecting the time of event-free survival and so on.

RESULT(1) The response (CR+PR) rates 4, 6, 12 and 24 months after IST of the whole series of 105 SAA children were 50.5% (7.6%+42.9%) , 60.0% (21.9%+38.1%) , 67.6% (38.1%+29.5%) and 69.5% (40.0%+29.5%) respectively. The 2-year survival rate was 90.5%; the follow-up of the patients for 13 years showed that the whole survival rate was 87.6%. (2) The differences of the response rates 4, 6, 12 and 24 months after IST of the 4 groups were not significant (P > 0.05). (3) No significant differences were found in the mortalities 4, 6, 12 and 24 months among the 4 groups (P > 0.05). (4) Of the 105 patients, 4 children had relapsed disease in the period of time from 6 to 24 months after IST. All the four patients belonged to the groups with G-CSF. (5) The use of G-CSF could not decrease the infection period before IST (day) (P = 0.273), and it had no impact on the infection rate after IST (P = 0.066). It did not reduce the rates of septicemia and infectious shock. And to the infection-related death rate no significant conclusion can be made. (6) Follow up of the patients for 13 years, showed that 2 had the evolution to MDS/AML in the 105 patients and the two children belonged to the groups with G-CSF. (7) Kaplan-meier curve analysis did not show any differences in the survival rates of the four groups. (8) Cox regression analysis showed that the use of G-CSF had no benefit to the patients' long term survival. While the age of diagnosis and the infection history before IST were significantly related to the patients' long term survival.

CONCLUSIONThe use of G-CSF did not contribute to the early response and could not reduce the infection rate, infection-related death rate and the patients' long term survival. There were no significant differences in the survival rates of the four groups. Attention should be paid to the risk of the evolution to MDS/AML.

Adolescent ; Anemia, Aplastic ; drug therapy ; immunology ; mortality ; Antilymphocyte Serum ; administration & dosage ; therapeutic use ; Child ; Child, Preschool ; Cyclosporine ; administration & dosage ; therapeutic use ; Drug Therapy, Combination ; Female ; Follow-Up Studies ; Granulocyte Colony-Stimulating Factor ; administration & dosage ; therapeutic use ; Humans ; Immunosuppressive Agents ; adverse effects ; therapeutic use ; Infant ; Male ; Retrospective Studies ; Risk Factors ; Severity of Illness Index ; Survival Rate ; Treatment Outcome

Anemia, Aplastic ; drug therapy ; immunology ; Animals ; Antilymphocyte Serum ; immunology ; therapeutic use ; Calcineurin Inhibitors ; immunology ; therapeutic use ; Humans ; Immunoglobulins ; immunology ; therapeutic use ; Lymphocytes ; drug effects ; immunology ; Swine

Aplastic anemia(AA) is mostly considered as an immune-mediated bone marrow failure syndrome, characterized by pancytopenia and bone marrow hypoplasia. The pathogenesis of AA is complicated, until now it is not fully understood. Further study on the pathological mechanism will be helpful for the diagnosis and treatment of AA. CD8(+) T cells and their secreted cytokines play important roles in the abnormal immunity during the process of AA. Thus, this review focuses on the role of CD8(+) T cells and their secreted cytokines in the pathogenesis of AA.
Anemia, Aplastic ; immunology ; metabolism ; pathology ; CD8-Positive T-Lymphocytes ; immunology ; metabolism ; secretion ; Cytokines ; metabolism ; Humans ; Immunity, Cellular

This study was aimed to investigate the changes of CD34(+) and CD71(+)CD45(-) cell levels in MDS and AA patients. A total of 25 cases MDS and 43 cases of AA (18 cases SAA and 25 cases of NSAA) from January 2010 to October 2013 in the Department of Hematology, affiliated hospital of Hebei United University were enrolled in this study. The complete blood count, bone marrow smears, bone marrow biopsy, karyotype analysis and bone marrow blood cell immune genotyping (mainly the proportion of CD34(+) cells, CD71(+)CD45(-) cells in nucleated cells) were carried out for all patients; the changes of CD34(+) and CD71(+)CD45(-) cell levels in patients with MDS and AA (SAA NSAA) were compared; the differences of white blood cell count, platelet count and hemoglobin concentration in patients with count of CD71(+)CD45(-) ≥ 15% or <15% were analyzed. The results showed that the count of CD34(+) in MDS group was higher than that in AA (NSAA and SAA) group (P < 0.05). The count of CD71(+)CD45(-) cells in MDS group was higher than that in SAA (P < 0.05), there was no significant difference between NSAA group and MDS group. In MDS group with CD71(+)CD45(-) ≥ 15%, the platelet count was significantly higher than that in NSAA group (P < 0.05); and there was no statistical difference for leukocyte, platelet count and hemoglobin level between MDS and NSAA group with CD71(+)CD45(-) <15% (P > 0.05). It is concluded that the count of CD34(+) cells in MDS patients is significantly higher than that in AA and SAA patients. The count of CD71(+)CD45(-) cells in MDS group is significantly higher than that of SAA group. The platelet count in MDS patients with CD71(+)CD45(-) cells ≥ 15% is significantly higher than that of the NSAA group.
Adolescent ; Adult ; Aged ; Aged, 80 and over ; Anemia, Aplastic ; pathology ; Antigens, CD ; immunology ; Antigens, CD34 ; immunology ; Blood Cell Count ; Bone Marrow ; Bone Marrow Cells ; cytology ; immunology ; Female ; Flow Cytometry ; Humans ; Leukocyte Common Antigens ; immunology ; Male ; Middle Aged ; Myelodysplastic Syndromes ; pathology ; Receptors, Transferrin ; immunology ; Young Adult

During the past few years, a novel family of CD4⁺T cell lineage was detected and named as Th17 cells because of its unique ability expressing IL-17, which also can produce IL-17A, IL-17F, IL-21, IL-22 and IL-26. Some cytokines, such as TGF-β, IL-6, L-23 may promote the differentiation of Th17 subset, whereas some cytokines, such as IL-21, IL-2, IFN-γ, may have inhibitory effects. Th17 cells serving as immune effectors play an important role in autoimmune diseases caused by chronic inflammation injury. More and more studies confirmed that Th17 cells have closely correlations with the development of aplastic anemia, and may be a new target in the diagnosis, therapy, prognosis and prophylaxis of aplastic anemia.
Anemia, Aplastic ; immunology ; Autoimmune Diseases ; Cell Differentiation ; Cytokines ; Humans ; Inflammation ; Th17 Cells ; cytology ; immunology

BACKGROUNDCyclosporine A (CsA) has been widely used in the treatment of aplastic anemia (AA), but the application of CsA was limited in patients who had liver diseases or abnormal liver function due to its liver toxicity. Glycyrrhizin has long been used in China in the treatment of various liver diseases to lower transaminases. In this study, we observed the efficacy and safety of glycyrrhizic acid combined with CsA in the treatment of newly diagnosed patients with non-severe AA (NSAA).

METHODSA total number of 76 patients with newly diagnosed NSAA were enrolled into the study at our hospital between July 2005 and June 2010. The patients were divided randomly into two groups: the glycyrrhizin-treatment group (group A) and the control group (group B) with 38 patients in each group. All patients received 3 - 5 mg×kg(-1)×d(-1) CsA for at least 4 months and were treated either with or without glycyrrhizin for 4 months.

RESULTSsixty-eight patients were eligible for evaluation. In the control group, 9.09% patients (n = 3) achieved a complete response while 51.52% (n = 17) attained a partial response. The overall response rate was 60.61% (n = 20). The remaining 13 patients (39.39%) did not have any response. In the glycyrrhizin-treatment group, complete response rate was 20% (n = 7) and partial response rate was 62.86% (n = 22). The overall response rate was 82.86% (n = 29) and the non-response rate was 17.14% (n = 6). Response rate was significantly increased with the addition of glycyrrhizin to CsA compared with CsA alone (P < 0.05).

CONCLUSIONThe combination of glycyrrhizin and cyclosporine regimen was an effective treatment for NSAA in terms of improvement of response rate, reduction in CsA-related liver injury, and attenuation of severity of nausea and other adverse events in the treatment of patients with NSAA.

Adolescent ; Adult ; Aged ; Anemia, Aplastic ; drug therapy ; immunology ; Cyclosporine ; administration & dosage ; adverse effects ; Drug Therapy, Combination ; Female ; Glycyrrhizic Acid ; administration & dosage ; adverse effects ; Humans ; Interferon-gamma ; blood ; Interleukin-2 ; blood ; Male ; Middle Aged

Aplastic anemia (AA) is a bone marrow failure disease caused by abnormal activation of T lymphocytes, resulting in the apoptosis of hematopoietic cells and bone marrow failure. Currently, hematopoietic stem cell transplantation (HSCT), immunosuppressive - therapy (IST), and supportive care (e.g. transfusion adjuvant therapy, hematopoietic growth factors, and prevention of infection) are the main treatments of AA. Granulocyte transfusion has recently been accepted as an useful adjuvant therapy of HSCT and intensive IST. This article reported a severe AA patient who failed to respond to IST, but achieved spontaneous remission three times after granulocyte transfusions from related donors. Such cases have rarely been reported. Existence of human leukocyte antigen (HLA) cross between the patient and his relatives may influence the T cell-mediated immunity, which might explain this patient's recovery.
Adult ; Anemia, Aplastic ; immunology ; physiopathology ; therapy ; Granulocytes ; transplantation ; Humans ; Leukocyte Transfusion ; Male ; Remission, Spontaneous