More Related Content Similar to Non-Transplant Therapies Aplastic Anemia. (20) Non-Transplant Therapies Aplastic Anemia.1. Copyright © by ARTCOM PT All rights reserved.
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Company LogoZHONGHONG SHAO, MD
China
Head of Hematology, Department of Tianjin
Medical University General Hospital
Dr Shao is Vice President of Chinese Society of
Hematology (CSH); Head of Erythrocyte Disease
Working Group and Head of China PNH Registy
Working Group. At Present, Prof. Shao is the vice
President of Hematology Branch of Chinese Medical
Doctor Association; Vice-chairman of Hematology &
Immunology branch of Chinese Society of
Immunology; Head of Clinical Flow Cytometry
Assicuatuib. Standing Committee Member of CSCO;
President of Tianjin Hematology Association;
Associate Editor-in-chief of Chinese Journal of
Hematology; Editorial Broad Member of Chinese
Journal of Practice Internal Medicine, Journal of
Experimental Hematology, Journal of Clinical
Hematology.
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Aplastic Anemia in China
Tianjin Medical University General Hospital
SHAO Zong-Hong
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Company LogoAA
Epidemiology
Pathogenesis
Treatment
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Company LogoEpidemiology
1986~1989
24 Provinces
600,000
0.74/105
, higher incidence than Western
countries
No gender difference
At any age
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Company LogoAA
Epidemiology
Pathogenesis
Treatment
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High CD3+CD8+ Effector T Cells in BM
Chinese Journal of Hematology,2004,25(10):613-616.
0
10
20
30
40
50
60
%BMMNC
AA Group Control
Group
* P<0.01
*
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The expression of Linker for
Activations of Tcells (LAT)
in PB CD3+T cells of the SAA
patients was higher than
normal controls.
European Journal of Haematology. 2014.
High LAT in Peripheral Blood CD3+T cells
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Company LogoDentritic Cell (DC)
mDC : 0.29±0.10
pDC :
0.29±0.13
After IST, the percentage of mDC and pDC decreased
In 6 months, pDC returned to the pre-treatment level;
mDC was 50% of the pre-treatment level
Int J Hematol, 2011, 93(2):156-162.
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Different sources of mDCs and Lymphocyte 1:50 MLR
lymphocyte proliferation rates
Group mDCs source lymphocyte source lymphocyte proliferation
rates ( % )
1 SAA normal 322.13±171.07*
2 SAA SAA 320.25±161.90
3 normal normal 192.25±91.93
4 normal SAA 182.50±147.79
*Group 1 vs Group 3 P<0.05
mDCs in SAA patients enhanced lymphocyte proliferation
Chinese Journal of Medicine,2009, 48(12):1040-1043.
Dentritic Cell (DC)
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Company LogoEffector T Cell
n
CD8+
CD25+
T cell CD8+
HLA-DR+
T cell
in CD8+
Tcell in CD3+
T cell in CD8+
Tcell in CD3+
T cell
SAA 14 3.67±2.58 2.25±1.35 39.30±8.13*#
27.81±7.10*#
Remission
SAA
15 5.19±4.29 2.98±1.35 20.65±5.38 12.02±3.03#
Normal
Control
12 4.84±2.31 2.11±1.88 18.34±6.68 8.50±2.33
*SAA vs Remission Group p<0.05
#SAA / R-SAA vs Normal Control p<0.05
CD8+
HLA-DR+
T cell was high in SAA patient
CD8+
CD25+
T cell without significant difference
Chinese Journal of Hematology,2011,32(9):597-601.
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CD8+
CD25+
T cell
8. 51
1. 78
1. 86
96. 08
85. 2
82. 09
72. 11
34. 38
17. 92
94. 25
51. 2
32. 91
0
10
20
30
40
50
60
70
80
90
100
穿孔素 颗粒酶 Fas TNF- β
初治SAA
缓解SAA
正常对照
35. 42
7. 69
23. 34
93. 21
69. 2
68. 34
100
54 56. 85
100
65
50
0
10
20
30
40
50
60
70
80
90
100
穿孔素 颗粒酶 Fas TNF- β
CD8+
HLA-DR+
T cell function factors were high in SAA patients
CD8+
HLA-DR+
T cell
Chinese Journal of Hematology,2012,92(18):1240-1243.
Effector T Cell
Granzyme PerforinPerforin Granzyme
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0.11 0.68 0.53
0.37 0.79 0.41
9.62% 13.81% 18.21%
NK cell
SAA Remission SAA Normal Control
The percentage of NK cell was low in PB lymphocyte of SAA patients
R3 : CD56bright
; R4 : CD56dim
; R5 : CD3-
CD56-
CD16+
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PF
63.23% 70.62% 11.17%
PF
63.23% 70.62% 11.17%63.23% 70.62% 11.17%
NK cell express compensated high level of perforin in SAA patient
Chinese Jouranl of Hematology,2011,16:1084-1087.
NK cell
SAA Remission SAA Normal Control
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Company LogoPathogenesis of AA
Perforin
Granzyme
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Company LogoAA
Epidemiology
Pathogenesis
Treatment
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Company LogoExpert Consensus
IST HSCT
Lack of a matched donorATG Plus CSA
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IST HSCT
Lack of a matched donorATG Plus CSA
Expert Consensus
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Company LogoExpert Consensus
IST HSCT
Lack of a matched donorATG Plus CSA
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Other countries
Response rate 7O %~ 8O%
China
Response rate 76.7%
Chinese Journal of Hematology,2001,22(4):177-181.
Effect of IST
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• Horse ATG plus
cyclosporine
10-year EFS: 95%
10-year survival with
events : 65%
(including relapse and
clonal evolution )
Hematology Am Soc Hematol Educ Program. 2013;2013:76-81.
Fig. Survival after response to
immunosuppression in severe aplastic anemia
Effect of IST
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Br J Haematol. 2011 Jan;152(2):127-40.
For the last 10 years the standard regimen of horse ATG
for SAA results in overall survival rates ranging between
55% and 95%
Effect of IST
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Ann Hematol. 2013 Dec 14.
FAA (fulminant aplastic anemia):
ANC=0 before and after IST
for at least 2 weeks
Overall survival
5-year overall survival
FAA :88.5 %
vSAA:95.8 %
SAA:96.8 %
Effect of IST
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Tr eat ment ef f ect
40%
23%
21%
16%
完全缓解 部分缓解 稍有效 无效
Overall response rate : 83.9%
Complete
responders
Partial
responders
Minor
Recovery
No Response
Effect of IST in Our
Hospital
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Granulocyte Transfusion
Combined with Granulocyte Colony Stimulating Factor
PLoS ONE 9(2): e88148. doi:10.1371/journal.pone.0088148
Efficacy
Granulocyte transfusions + G-CSF = an adjunctive therapy for treating
severe infections of patients with SAA
•Survival Rate
Fig.Survival of SAA patients received granulocytes and G-CSF therapy.
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Granulocyte Transfusion
Combined with Granulocyte Colony Stimulating Factor
PLoS ONE 9(2): e88148.
Fig.Response of SAA patients receiving granulocytes and G-CSF therapy.
Efficacy
Granulocyte transfusions + G-CSF = an adjunctive therapy for treating
severe infections of patients with SAA
•Response Rate
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Granulocyte Transfusion
Combined with Granulocyte Colony Stimulating Factor
PLoS ONE 9(2): e88148.
Fig.Adverse effects of SAA patients received
granulocytes and G-CSF therapy.
Safety
•Chills and fever were mild or moderate and successfully treated and prevented in
the follow transfusions by
antipyretics or corticosteroids.
•Dyspnea
•Allergy reaction
•Heart failure
old patients
relative quick speed of transfusion,
cured by digoxin and furosemide.
There was no other severe
adverse event associated with
granulocytemtransfusions.
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Company LogoHematopoietic Growth Factors (HGFs)
With HGFs
• Higher response rate higher
(89 .2% vs 63 .9%),
• Lower rates of early infection
(24.3 % vs 55 .3%)
• Lower mortality
(4.0 % vs 16 .7%)
• Shorter duration of
cytopenia and blood
transfusion dependence
• Faster recovery of BM
hematopoiesis.
Without HGFs
With HGFs
The use of HGFs could reduce early infection and mortality rates and improve
the response rates in SAA patients.
Chinese Journal of Hematology,1996,17(4):176-178.
Chinese Journal of Hematology,2001,22(4):177-181.
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Company LogoComplication of Infection
Chinese Journal of Hematology,2003,24(10):530-533.
The prevalence of infection in SAA patients was 86.0%
54.2 %was infected with gram-positive organisms,
40 .0% with gram-negative bacilli
5.8% with fungal infections
The total mortality of SAA patients with infection was 23.1%.
Pulmonary infection and septicemia increased mortality.
GM-CSF/G-CSF therapy reduce mortality.
GM-CSF or G-CSF therapy exerts an assistant role to
antibiotics in controlling the infections.
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Company LogoConclusion
Critical Diagnostic criteria
Prompt, adequate, fully, rational combination IST
Active prevention and control of infections
Improve response rate, decrease relapse
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Editor's Notes 这一观念,也得到了大部分国内专家的共识。
Neal S. Young在《再障病理生理学和治疗方面的现有观念》中也提到,ATG联合环孢素仍作为标准的一线免疫抑制治疗 。
免疫抑制治疗和造血干细胞移植是目前再障主要的治疗方法,英国再障诊断和治疗指南中指出,对于缺少匹配供者的患者,ATG联合环孢素的免疫抑制疗法是首选治疗。
关于免疫抑制治疗的疗效,国内外的报道不尽相同,但大约都在70-80%之间。右图显示在一个大样本的研究中,应用马ATG联合环孢素的标准免疫抑制治疗重再患者的生存率,没有并发症的患者10年生存率为95%,而发生并发症事件的10年生存率则为65%。
A large cohort (N=243) of NIH patients who responded to treatment with the standard regimen of horse ATG plus cyclosporine was analyzed. Shown are long-term outcomes including the negative impact of a complicating event. Events were defined as relapse (need for further immunosuppression after protocol treatment) and clonal evolution (myelodysplasia/acute myeloid leukemia; almost always accompanied by a new cytogenetic abnormality in the BM). Approximately half of the patients did not experience a clonal event and poor survival was largely a consequence of disease progression. Data were censored for transplantation.
关于免疫抑制治疗的疗效,国内外的报道不尽相同,但大约都在70-80%之间。右图显示在一个大样本的研究中,应用马ATG联合环孢素的标准免疫抑制治疗重再患者的生存率,没有并发症的患者10年生存率为95%,而发生并发症事件的10年生存率则为65%。
A large cohort (N=243) of NIH patients who responded to treatment with the standard regimen of horse ATG plus cyclosporine was analyzed. Shown are long-term outcomes including the negative impact of a complicating event. Events were defined as relapse (need for further immunosuppression after protocol treatment) and clonal evolution (myelodysplasia/acute myeloid leukemia; almost always accompanied by a new cytogenetic abnormality in the BM). Approximately half of the patients did not experience a clonal event and poor survival was largely a consequence of disease progression. Data were censored for transplantation.
近十年基于马ATG的免疫抑制治疗SAA的疗效结果,最右侧显示了这些研究的总体生存率。
PRCT, prospective randomized clinical trial, POLCT, prospective open-label clinical trial, RETR, retrospective study; GITMO, Gruppo Italiano Trapianto di Midollo Osseo; EBMT, European Group for Blood and Marrow Transplantation; NIH, National Institutes of Health; ATG, antithymocyte globulin; CyA, ciclosporin A; G-CSF, granulocyte colony-stimulating factor. Age: median age (years). Response: overall response rate. Clonal evol.: evolution to myelodysplastic syndrome/acute myeloid leukaemia (paroxysmal nocturnal haemoglobinuria). Survival: overall survival rate.
*PRCT ATG ± CyA; only data from the CyA arm are included.
Twenty-seven of patients received more than one course of ATG.
PRCT ATG + CyA ± G-CSF: data from both arms are included (No G-CSF/Yes G-CSF).
§PRCT ATG + CyA ± MMF: data from both arms are merged.
–PRCT ATG + CyA ± RAPA: data from both arms are merged.
FAA: fulminant aplastic anemia; vSAA: very severe aplastic anemia; SAA: severe aplastic anemia; FFS: Failure-free survival; OS: Overall survival.
The 5-year FFS (a) and the 5-year OS (b) according to the severity of AA. The 5-year FFS was 48.2 % in the FAA group, 65.1 % in the vSAA group, and 68.1 % in the SAA group, respectively. However, no significant difference was demonstrated (p=0.206). The 5-year OS
was comparable among the three groups: 88.5 % in the FAA group, 95.8 % in the vSAA group, and 96.8 % in the SAA group, respectively