Line Immunosuppressive Therapy Research Articles

Evaluating Effective Therapeutic Options for Inhibitor Eradication in Patients with Acquired Hemophilia a: A 10-Year Single Center Experience

Background Acquired hemophilia A (AHA) is a rare disorder characterized by emergence of neutralizing antibodies or inhibitors to factor VIII. The main treatment strategy for AHA involves control of bleeding with factor VIII bypassing agents and eradicating the autoantibodies using immunosuppressive therapy (IST) for restoration of normal hemostasis. Previous studies have demonstrated the effectiveness of both cyclophosphamide and rituximab in combination with steroids for treating AHA, however, clear guidelines for choosing between these agents for rapid inhibitor eradication are lacking. This retrospective study aimed to compare the effectiveness of cyclophosphamide and rituximab as first-line therapies for rapid antibody elimination and relapse prevention. Methods We queried our hospital electronic health record system using ICD 9/10 code to identify patients >18 years that had at least 2 inpatient or outpatient encounters for the diagnosis of AHA between 1 st July 2013 and 30 th June 2023. Variables collected included initial aPTT value, serial factor VIII activity & Bethesda inhibitor titer and immunosuppressive therapies used. Time to remission was defined when inhibitor titer was <1% along with improving factor VIII activity. At our institute, all patients received 1mg/kg of steroids initially, then either six cycles of 400mg/kg IV Cyclophosphamide every 28 days on day 1 along with 100mg of oral Prednisone days 1-5 or four cycles of IV Rituximab at a weekly dose of 375mg/m2 was used as 1 stline IST for patients with inhibitor titer >10%. Patients that did not achieve remission or those with persistently high inhibitor titers after 3 cycles of Cyclophosphamide were switched to 2 nd line therapy. In few patients oral Cyclophosphamide or Mycophenolate mofetil was used as maintenance therapy after 1 st or 2 nd line therapy. Bleeding control was achieved with use of rpFVIII or rFVII, FEIBA or emicizumab depending on product availability. Descriptive statistics (mean, SD) & openAI.ChatGPT-4 generated correlation coefficient was used for data analysis. Results A total of 11 male and 5 female patients were identified. The mean age at diagnosis was 69 years and the average length of follow up was 672 days. The mean aPTT value at diagnosis was 84.3 seconds. Inhibitor titer ranged from 1.5 to 329% with an average of 63.62%. Patients with low inhibitor titer of <10% received only steroids and all of them achieved remission without relapse. Rituximab as first-line therapy led to remission in 100% of cases, while only 28.5% of patients treated with cyclophosphamide achieved remission without needing second-line therapy. The time to remission was significantly shorter in patients treated with rituximab compared to cyclophosphamide (43.4vs148.7days). Additionally, none of the patients treated with rituximab experienced a relapse after 1 st remission, while 57% of patients treated with cyclophosphamide did and majority needed 2 nd line & maintenance therapy (Figure-1). Initial inhibitor titer had a moderate to strong positive correlation with the time to remission, the incidence of relapse, and the need for second line and maintenance therapy (Figure- 2). Conclusions Rituximab as first line IST appeared to be more effective than cyclophosphamide in achieving rapid remission and reducing incidence of relapse. Our analysis also revealed that initial inhibitor titer may serve as a useful predictor of disease course, potentially guiding therapeutic decision-making and eliminating need for cytotoxic medication or maintenance therapy. Future large prospective studies are needed to confirm these findings and further investigate other factors influencing therapeutic outcomes in patients with AHA.

Effectiveness of rituximab versus oral immunosuppressive therapies in neuromyelitis optica spectrum disorder in a racially diverse cohort of subjects: A single-center retrospective study.

Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune, inflammatory disorder characterized by severe relapses and high level of disability. In clinical trials of NMOSD, Black patients are under-represented, < 12%, compared to a relatively high prevalence of NMSOD in this population, 10/100,000. Despite the higher prevalence of NMOSD in Black and Asian patients, there is limited knowledge of the effectiveness of disease modifying treatments across racially diverse groups. To assess the effectiveness of rituximab and oral immunosuppressive agents in a cohort of NMOSD patients, the majority of whom are Black, in a real-world, clinical setting. A single-center retrospective study was conducted at the University of Chicago Medical Center. (1) diagnosis according to the 2015 International Panel for NMO Diagnosis (IPND) Criteria, (2) positive anti-aquaporin-4 antibodies on ELISA or cell-based tests, (3) initiation of immunosuppressant therapy within 5 years of disease onset, (4) first-line treatment with rituximab, mycophenolate (MMF), or azathioprine (AZA). Patients with negative anti-AQP4 titers were excluded. Kaplan-Meier survival analysis was used to estimate proportion of relapse-free patients following initiation of first line immunosuppressive therapy. A Cox proportional hazards regression model assessed the association of risk of relapsing with first-line immunosuppressive treatments with and without adjustments of pre-specified factors (age at disease onset, duration of disease, sex, race, CNS location of relapse). 7 of 29 patients (24%) receiving rituximab experienced a relapse within the first 3 years of treatment vs. 13 of 23 patients (57%) receiving either AZA or MMF. Within the first 6 months of treatment, 2 (6.9%) patients treated with rituximab experienced a relapse vs. 7 (30.4%) patients treated with either MMF or AZA. In the 29 patients treated with rituximab, the 1-year and 3-year proportion of relapse-free patients was 88.8% and 70.9%. For the 23 patients treated with either AZA or MMF, the 1-year and 3-year proportion of relapse-free patients was 69.5% and 38.7%. In the univariate analysis, the risk of relapse was significantly higher in patients treated with AZA or MMF compared to those treated with rituximab (hazard ratio [HR] of 2.48 [0.99 - 6.21]; p=0.046). In this real-world study involving a majority of Black NMOSD patients, rituximab was relatively more effective in preventing relapses within 3 years of therapy initiation than AZA and MMF. Rituximab remains an effective option for treating NMOSD, especially when there are delays in treatment due to access and economic issues associated with newer treatments.

Advances in the Management of Primary Membranous Nephropathy and Rituximab-Refractory Membranous Nephropathy.

Primary membranous nephropathy (pMN) is an auto-immune disease characterized by auto-antibodies targeting podocyte antigens resulting in activation of complement and damage to the glomerular basement membrane. pMN is the most common cause of nephrotic syndrome in adults without diabetes. Despite a very heterogeneous course of the disease, the treatment of pMN has for many years been based on uniform management of all patients regardless of the severity of the disease. The identification of prognostic markers has radically changed the vision of pMN and allowed KDIGO guidelines to evolve in 2021 towards a more personalized management based on the assessment of the risk of progressive loss of kidney function. The recognition of pMN as an antibody-mediated autoimmune disease has rationalized the use immunosuppressive drugs such as rituximab. Rituximab is now a first line immunosuppressive therapy for patients with pMN with proven safety and efficacy achieving remission in 60-80% of patients. For the remaining 20-40% of patients, several mechanisms may explain rituximab resistance: (i) decreased rituximab bioavailability; (ii) immunization against rituximab; and (iii) chronic glomerular damage. The treatment of patients with rituximab-refractory pMN remains controversial and challenging. In this review, we provide an overview of recent advances in the management of pMN (according to the KDIGO 2021 guidelines), in the understanding of the pathophysiology of rituximab resistance, and in the management of rituximab-refractory pMN. We propose a treatment decision aid based on immunomonitoring to identify failures related to underdosing or immunization against rituximab to overcome treatment resistance.

Impact of TNFAIP3 Genetic Polymorphisms on Primary Immune Thrombocytopenia in Egyptian Adults: Case-control Study

BACKGROUND: Immune Thrombocytopenia (ITP) is a common acquired hematological disease. Genetic polymorphisms play an important role in ITP pathogenesis and prognosis. TNF-α-induced protein 3 (TNFAIP3) is a negative regulator of NF-kB in many signaling pathways. Several variants of TNFAIP3 have been associated with various inflammatory autoimmune disorders. AIM: Our study aimed to study the association of TNFAIP3 single nucleotide polymorphisms (SNPs); rs2230926 &amp; rs5029939 with ITP susceptibility, as well ITP prognosis by follow up the cases for 18 months. METHODS: One hundred and ten ITP patients as well 110 matched unrelated normal controls were enrolled in our study. The polymorphisms were assessed by real-time polymerase chain reaction (real time PCR). RESULTS: There were a significant difference between cases and control groups regarding rs2230926 T&gt;G and rs5029939 C&gt;G frequencies with p &lt; 0.05. Linkage disequilibrium (LD) analysis of the two variants revealed that there was a significant LD (p &lt; 0.001). Non-cutaneous bleeding manifestations were observed mainly in the mutant genotypes of rs2230926 and rs5029939. The ITP patients with mutant genotypes of rs5029939 showed more need to use 2nd line immunosuppressive therapy as well the mutant genotypes of rs2230926 showed more steroid dependence and less complete recovery. CONCLUSION: Our data concluded the presence of LD between rs5029939 and rs2230926. The mutant genotypes of both variants were associated with increase the susceptibility to ITP and accompanied by worse clinical manifestations and poor response to the treatment in the adult Egyptian patients.

Controversies in the Treatment of Cardiac Sarcoidosis.

There are many challenging aspects of the management of cardiac sarcoidosis (CS) with corticosteroids and other immunosuppressive therapy (IST). First, it is not always clear who will benefit from therapy or when to initiate treatment. Secondly, there are no randomized controlled trials or large prospective studies to guide what medications to use, at what doses, and for how long. The European Respiratory Society (ERS) clinical practice guidelines on the treatment of sarcoidosis makes a strong recommendation for the use of immuno-suppressive therapy in CS patients with functional cardiac abnormalities, including heart blocks, dysrhythmias, or cardiomyopathy where patients are considered at-risk of adverse outcomes. Corticosteroids are the first line immunosuppressive therapy in CS however, early initiation of second-line steroid sparing medications has been advocated and there is data to suggest that concomitant initiation of therapy may be more beneficial. The use of anti-tumor necrosis factor (anti-TNF) agents (including infliximab and adalimumab) considered beneficial third-line anti-sarcoidosis treatment agents in other severe refractory manifestations of disease remains controversial.

Transplant Outcome for Patients with Acquired Aplastic Anemia over the Age of 40: Mortality HAS NOT Been Reduced in 2015

Mortality following HSCT in pts with SAA over the age of 40 is reported to be in the order of 50%; international guidelines recommend first line immunosuppressive therapy above the age of 40. The aim of this study is to assess whether this is still true in 2015.We used the Working Party for SAA (WPSAA) of the European Blood and Bone Marrow Transplantation Registry (EBMT), and identified 768 patients, aged 40 years or more, with acquired SAA , who underwent an allogeneic HSCT between 2001 and 2015.. Pts were divided in two transplant eras: 2001-2009 (n=329) and 2010-2015 (n=439). In the 2010-2015 period pts were older (52 vs 50 years, p<0.01), were more often grafted from alternative donors (ALT) (52% vs 28%, p<0.01), with a greater use of BM (53% vs 42%, p<0.01), and more often received a fludarabine containing regimen (60% vs 42%, p<0.01), and ATG or Campath (87% vs 67%, p<0.001).The 5 year OS of patients grafted in 2001-2009 was 61% , compared with 58% for pts grafted in 2010-2015 (p= 0.9). In multivariate analysis including the interval between diagnosis and transplant, the patient's age, donor type, stem cell source , the use of fludarabine and ATG or Campath, the lack of improved survival in 2010-2015 was confirmed (RR 0.9, 95%CI 0.7-1.19; p=0.5). A very strong age effect was shown both in univariate and multivariate analysis: 5 year OS of patients aged 40-49 years, 50-59 years and >60 years , was respectively 66%, 57%, 40% (p<0.0001). The second favorable predictive factor was the use of either ATG or Campath (RR 0,58- 95%CI 0.43-0.76, p=0.002)Regarding HSCT from HLA identical siblings, we could show identical 5 year survival for pts aged 40-49 years in 2010-2015 as compared to 2001-2009 (67% vs 70% p=0.8); for patients aged 50-59 years (59% vs 60%, p=0.9) and patients over 60 (47% vs 50%, p=0.9). For UD the 5 year survival in pts aged 40-49 was 64% in 2010-2015, vs 56% in the earlier period (p=0.1), and 53% vs 58% (p=0.6) for pts aged 50-59. The numbers were too small for comparison in patients over 60, with only 8 patients grafted in the 2001-2009 period; 61 patients were grafted in 2010-2015 with a 47% actuarial 5 year survival. (Figure 1).Combined primary and secondary graft failure was reduced from 16% to 12% in the two time periods (p=0.02), acute GvHD grade II-IV was reduced from 15% to 11% (p=0.1) and chronic GvHD was also reduced from 31% to 25% (p=0.01). Infections remain the leading cause of death in both transplant eras (18% and 22% respectively), followed by GvHD (5% and 4%) and graft failure (5% and 2%),whereas PTLD have been reduced from 3% to 0,5%.HSCT in pts with acquired SAA over the age of 40 years, continues to carry a significant risk of mortality , also in 2015, ranging from 30% in younger SIB transplants to over 50% in older pts. This study gives further support to current guidelines , suggesting first line therapy with ATG+CsA , in patients over the age of 40. Tailored protocols need to be devised to reduce transplant mortality in older SAA patients. [Display omitted] DisclosuresPeffault De Latour:Novartis: Consultancy, Honoraria, Research Funding; Alexion Pharmaceuticals, Inc.: Consultancy, Honoraria, Research Funding; Amgen: Research Funding; Pfizer: Consultancy, Honoraria, Research Funding.

Successful Treatment of Bleeding in Acquired Hemophilia A with Activated Prothrombin Complex Concentrate in Spain

INTRODUCTION. Acquired hemophilia A (AHA) is a rare autoimmune disorder characterized by development of autoantibodies against coagulation factor VIII (FVIII). Bypassing agents are recommended as first-line for the treatment of bleeding episodes in patients with AHA. Due to the low incidence of AHA, available clinical data on efficacy and safety of the activated prothrombin complex concentrate (aPCC) in patients with AHA are limited. The objective of this retrospective multicenter study was to detail AHA management in patients treated with aPCC in real life in Spain.METHODS. Data from patients with AHA, treated in any moment with aPCC, in five reference centers for coagulopathies disorders, between June 2012 and June 2017, have been collected.Bleedings were classified as initial (first episode after AHA diagnosis or relapse), concurrent (new bleeding at the same time but at a different anatomical location), subsequent (a new bleed recurring 72 hours after the resolution of the previous bleed) or re-bleed (same anatomical location within 72 hours of the resolution of the previous bleeding). Severity of the bleed was evaluated according the Word Health Organization scale. Hemostatic efficacy was assessed as bleeding cessation and pain control. Safety was evaluated during bypassing agent treatment and until 30 days after discontinuation.RESULTS . Ten patients (6 males), 40% idiopathic AHA, median aged 70 years (64-84, IQR) at diagnosis. Seven patients out of 10 had at least 1 thrombotic risk factor, but no history of thrombotic events previous AHA. The median baseline residual FVIII level was 1% (0-1%, IQR), the median inhibitor titer was 24 BU (9-40, IQR).In all cases the suspected diagnosis of AHA was precipitated by a bleeding event (combined with a prolonged aPTT in 7 patients). Suspected diagnosis came from hematology (80%), emergency room (10%) and internal medicine (10%). The diagnosis was made promptly by hematology after the suspicion at a median of 1 day (0-7, IQR). 10 patients presented 19 bleedings (13 initial, 4 subsequent, 1 concurrent, 1 re-bleed) (WHO severity: grade 1, n=1; grade 2, n=5; grade 3, n=12; grade 4, n=1) that were recorded. 84% of these bleedings arose spontaneously, 44% of them manifested primarily as muscle hematomas. There was emergency surgery because of acute abdominal surgey complication. Seventeen bleedings were treated with aPCC as first line (n=11) or second line after rFVIIa (n=6), achieved bleeding cessation and pain control in the 100% of the evaluated bleeding episodes. The mean initial dose per infusion was 54.4 (± 12.9 SD) U/kg, the median total dose was 48000 U (32000-68000 U, IQR), the initial dosing interval was 8 hours (8-12, IQR), the median duration of treatment was 5.5 days (3.5-10.5 days, IQR), and the median number of injections was 15 (7.5-21, IQR). No adverse events, including thromboembolic events, were described during aPCC treatment. A 75-years-old female patient died due to a severe respiratory insufficiency after 19 days of aPCC discontinuation. The reasons to change from rFVIIa to aPCC were non bleeding control in 2 patients and necessity to reduce the number of infusions per day for ambulatory management in the rest. All patients received first line immunosuppressive therapy: prednisone 1 patient, corticosteroids plus cyclophosphamide 7 patients, rituximab plus other immunosuppressive drug 2 patients. Patient with prednisone alone and one with rituximab plus esteroides needed a second line treatment for no response after more than 4 weeks. Median time to response in the group of corticosteroids plus cyclophosphamide was 56.5 days (40-108, IQR), rituximab plus other immunosuppressive drug 56.5 days (50-56.5 days, IQR).CONCLUSIONS . This is the first study providing information on the daily use of aPCC in the treatment of AHA in Spain. With a hemostatic efficacy rate of 100% and a good safety profile, in line with other published real-life data. This multicenter Spanish experience supports the role of aPCC as first-line treatment for bleedings in AHA. DisclosuresNo relevant conflicts of interest to declare.

Caspr 2 antibody associated disease–An unusual presentation

Introduction: Antibodies to Voltage Gated Potassium Channels (VGKC) are directed against Leucine-rich Glioma- Inactivated1 (LGI1) and Contactin Associated Protein like 2 (Caspr2). Common presentations of Caspr2 antibody associated diseases include limbic encephalitis, Morvan’s syndrome and acquired neuromyotonia. New clinical phenotypes are being considered to the spectrum of Caspr2 antibody associated disease. Here we report a case of Caspr2 antibody associated disease with an unusual clinical presentation. Case Report: 40 year old male presented with distal symmetrical sensorimotor neuropathy of 4 months duration. Subsequently he had developed neurobehavioral symptoms in the form of irritability, episodic memory impairment and seizures. After medical evaluation he was diagnosed to have anti Caspr2 antibody associated disease. Patient showed improvement with an immunosuppressive therapy, but had recurrence of autoimmune encephalitis 1 month later. Along with that, he had also developed right vocal cord palsy, for which no other cause was identified. Patient improved with second line immunosuppressive therapy. He had no further recurrence and is under follow up. Keywords: Voltage gated potassium channels, Leucine-rich Glioma-inactivated 1, Contactin associated protein, Limbic encephalitis, Neuromyotonia.

PS1121 ABSENCE OF GPI‐NEGATIVE CELLS AT DIAGNOSIS AND LOW NEUTROPHIL COUNT 2 MONTHS AFTER ATGAM BASED TREATMENT ARE ASSOCIATED WITH LOWER 6‐MONTH RESPONSE RATE IN ADULTS WITH (VERY) SEVERE APLASTIC ANEMIA

Background:In aplastic anemia (AA), allogeneic stem cell transplantation (AlloSCT) is proposed as first line treatment for young patients with a sibling donor. For all other patients, ATGAM‐based immunosuppressive therapy (IST) is the treatment of choice. After IST, recovery of blood counts can take up to 6 months. Patients with (very) severe AA ((V)SAA), with a neutrophil count &lt;0.2 or &lt;0.5 x 109/L respectively, remain at risk for infectious complications until blood count recovery. Timely identification of patients less likely to respond to IST could lead to earlier selection for second line treatment (either alloSCT or second line IST) in order to prevent prolonged neutropenia. In AA, the presence of glycophosphatidylinositol (GPI) negative cell clones at diagnosis is associated with a better response to IST in some studies. We hypothesized that the absence of GPI negative cells (&lt;0.1%) before IST and low neutrophil count 2 months after start of treatment are associated with a lower response rate 6 months after IST in (V)SAA patients.Aims:To Determine whether the presence of GPI negative cell clones before IST and a neutrophil count &lt;0.2 x 109/L 2 months after IST can predict for treatment refractoriness at 6 months in adult (V)SAA patients.Methods:The Dutch registry of adults with acquired aplastic anemia receiving ATGAM (40 mg/kg for 4 days intravenously) and ciclosporin as first‐line treatment contains data on all consecutive patients treated in 8 major hospitals (LUMC, A‐UMC, UMCG, R‐UMC, UMCN, EMC, MST and AZN) including baseline and monthly follow‐up data. Response at 6 months was defined as transfusion independency and neutrophil count &gt;0.5 x 109/L. Overall survival (OS) was evaluated with the Kaplan‐Meier method.Results:Between 2012 and February 2019, 73 patients, 47 with SAA and 26 with VSAA were registered. Median age at start of IST was 58 years (18–79) and the median follow up time was 21 months. The 6‐month OS probability was 96% for SAA and VSAA combined (88% for VSAA and 100% for SAA). 62 patients were evaluable for response 6 months after start of IST. Response was seen in 35 patients (56% (CI 44–68%)). At diagnosis, 36 patients had a detectable GPI negative cell clone. In 25 patients, GPI‐negative cells were not detected and in 12 patients the presence of GPI‐negative cells was not tested. The response rate 6 months after start of IST for patients with a GPI‐negative clone at diagnosis was 63% (CI 47–80%) versus 40% (CI 20–60%) for patients without a GPI‐negative clone. Median neutrophil count 2 months after start of IST was available for 57 patients. The majority of the patients (53) had a neutrophil count ≥ 0.2 x 109/L and in this group the response rate at 6 months was 58% (CI 45–71%). In contrast, of the 4 patients with neutrophil counts &lt;0.2 x 109/L at 2 months after IST, 1 died 3 months after IST and the remaining 3 patients were alive but non‐responding to IST at 6 months.Summary/Conclusion:Our analysis of a relatively old (V)SAA patient cohort treated with ATGAM based IST suggests that presence of GPI negative cells at diagnosis and the neutrophil count at 2 months could be used to predict response to first line IST. This knowledge could aid in the decision to start second line treatment (alloSCT or second‐line IST) in this vulnerable patient group.

Long-Term Follow-up of the Randomized Controlled Study in Patients with Newly Diagnosed Severe Aplastic Anemia Treated with ATG, Cyclosporine, with or without G-CSF: On Behalf of the SAA Working Party of the EBMT

Long-Term Follow-up of the Randomized Controlled Study in Patients with Newly Diagnosed Severe Aplastic Anemia Treated with ATG, Cyclosporine, with or without G-CSF: On Behalf of the SAA Working Party of the EBMT

Traitement de la glomérulonéphrite extramembraneuse

Membranous nephropathy is one of the leading causes of nephrotic syndrome in adults, evolving to 30 % end-stage renal disease after 10 years, in the absence of specific treatment. In 2009, the M-type phospholipase A2 receptor (PLA2R), a podocyte membrane glycoprotein, was identified as the first autoantigen involved in more than 70 % of primitive membranous nephropathy. Many studies have reported that high titers of PLA2R antibodies are correlated with a lower risk of spontaneous or immunosuppressant-induced remission, a higher risk of nephrotic syndrome and of progression to end-stage renal disease. Treatment is still challenging and controversial because of potential toxicity and lack of a reliable prognosis marker. In the past, the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines recommended immunosuppressive therapies as steroids and alkylating agents or cyclosporine in patients with persistent nephrotic syndrome or impaired renal function. Recent studies and one multicentric randomised controlled trial brought clear evidence to support the use of rituximab in these patients: rituximab regimen induces immunological and clinical remission in patients with membranous nephropathy, with a high safety profile. However, they have provided important data on the impact of PLA2R antibodies assessment as a prognostic biomarker in patients with membranous nephropathy. The next step will be the integration of this biomarker in KDIGO guidelines and the recommendation of rituximab as a first line immunosuppressive therapy in patient with persistent nephrotic syndrome due to membranous nephropathy.

Early intensified intravenous cyclosporine therapy predicts favorable response to immunosuppressive therapy with rabbit antithymocyte globulin in patients with severe aplastic anemia

Because of relapse after horse ATG (hATG) therapy, rabbit ATG (rATG) would be a realistic alternative as second line immunosuppressive therapy (IST) in severe aplastic anemia (SAA) patients. We investigated whether intensified intravenous (IV) CsA therapy with rATG would increase the response of IST in SAA patients.Sixty-one of the 123 patients received IV CsA therapy with rATG during initial 2 weeks then changed to oral form (IV CsA group), while other 62 patients just received oral CsA therapy with rATG (oral CsA group).Hematologic response rates at 3 and 6 months were not different between IV CsA group and oral CsA group (p=0.795, p=0.079). However, CsA levels during initial 15 days were higher in response-achieved group than response-not-achieved group. Intensive IV CsA group maintained CsA level ≥300ng/ml during 15 days had higher responses at 6 months than non-intensive IV CsA group and oral CsA group (p=0.009, p=0.021). Intensive IV CsA group (HR=3.239, 95% CI=1.095–8.997, p=0.013) independently predicted favorable the hematologic response at 6 months of IST.Early intensified CsA therapy was important to achieve favorable outcomes in IST including rATG.

Burst-Forming Unit-Erythroid Assays (BFU-E) Can Help Distinguish Cellular Bone Marrow Failure Disorders

AbstractAbstract 3475Cytopenias in the context of cellular marrows cause significant morbidity for patients and are challenging for clinicians to diagnose and treat. Often the differential diagnosis includes pure red cell aplasia (PRCA), large granular lymphocyte leukemia (LGL), marrow suppression associated with systemic inflammation, and clonal bone marrow failure disorders such as myelodysplastic syndrome (MDS) or paroxysmal nocturnal hemoglobinuria (PNH). Unfortunately, it can be difficult to differentiate between these possibilities, and correct treatment depends on accurate diagnosis.The diagnostic algorithm for these patients includes multiple studies: cytogenetics, fluorescence in situ hybridization, T cell gene rearrangements, and flow cytometry. These multiple tests rarely provide a definitive diagnosis and do not consistently predict response to therapy. Functional tests of effective hematopoiesis are lacking. Colony growth assays quantifying BFU-E in bursts per 105 marrow mononuclear nuclear cells (MMNC) have been shown to predict response to immunosuppressive therapy (IST) for the bone marrow failure disorder of PRCA. (Charles et al. Blood 1996) However, these data were from an era before it was recognized that PRCA had several etiologies, one of which was LGL.We hypothesize that colony growth assays might provide diagnostic and therapeutic information in the evaluation of patients with bone marrow failure disorders. As part of an IRB-approved study, we performed a retrospective analysis on patients presenting for evaluation of cytopenias in the context of cellular marrows from January 2007-June 2012. Inclusion criteria were a recorded BFU-E assay performed prior to therapy, established diagnosis for the cytopenias and at least 6 months of follow up after treatment initiated. Response was defined as transfusion independence and ANC >1000/μL. For comparison, BFU-E in healthy controls was used.Thirty-six patients meeting the above criteria had BFU-E assessed over the study. All patients’ marrows were cellular or hypercellular for age, with a median cellularity of 60% (range 20–100). The diagnoses included 13 patients with LGL (8 of which had red cell aplasia only); 9 patients with PRCA (non-LGL in etiology); 8 patients with MDS; and 6 patients with cytopenias from systemic inflammation. The median follow up was 10.5 months (range 1–42). There were 8 deaths. There were 25 normal controls for comparison of BFU-E growth. The median growth in the normal controls was 40.3 BFU-E/105 MMNC (range 23.7–87).The eight patients with MDS had the lowest median growth of all categories at 5 BFU-E/105 MMNC (range 0–38). Four of these patients with MDS died from progression to acute leukemia in less than 9 months after initiation of therapy. The 4 patients still alive remain red cell transfusion dependent despite therapy with demethylating agents. Two have increased blasts on restaging marrows.The 13 patients with LGL grew a median of 61.3 BFU-E/105 MMNC (range 24.7–101). Nine patients (69%) responded to first or second line IST with durable remissions of 9 months or greater. One of the nonresponders died at 31 months from infection after multiple relapses and treatments.The 9 non-LGL PRCA patients grew a median of 23 BFU-E/105 MMNC (range 4.5–49). Only three patients (33%) of these patients responded to IST. The etiologies of the PRCA included 2 associated with thymoma, 2 with anti-erythropoietin antibodies (2 deaths at 1 and 11 months), 2 with ABO-incompatible transplants, and 3 idiopathic PRCA patients (1 death at 15 months).The 6 patients with cytopenias from systemic inflammation had documented autoimmunity (4 with Evan’s syndrome and 2 with systemic lupus erythematosus) and grew a median of 105.5 BFU-E/105 MMNC (range 33–137). All 6 (100%) patients responded to IST.In conclusion, patients with cellular marrows and cytopenias can be distinguished by BFU-E growth as seen in Figure 1. MDS patients have very low to undetectable growth. LGL and PRCA associated with LGL have high BFU-E growth, similar to other autoimmune processes, whereas non-LGL PRCA has low BFU-E growth. BFU-E predicts for response to IST in PRCA, as it seems to predict for LGL. In this cohort, nonmalignant diseases are well distinguished from MDS by BFU-E growth. Prospective studies of colony growth assays as part of the diagnostic algorithm for bone marrow failure disorders appear warranted. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

1095 - Aplastic Anemia: A Single Institution Experience

ABSTRACT Background Aplastic anemia (AA) is an extremely rare disease characterized by pancytopenia and hypocellular bone marrow (BM). Diagnosis is difficult and requires high degree of suspicion. Bone marrow transplantation (BMT) and Immunosuppressive Therapy (IST) are the only therapeutic options with a curative aim. Objectives Analysis of clinical and pathological features, therapeutic approach and overall survival of patients diagnosed with idiopathic AA in IPO-Porto. Methods Retrospective analysis of idiopathic AA patients from September/1995 to October/2011. The overall survival (OS) analysis was performed by Kaplan Meier method. Results During this period, 12 patients were identified with a median age of 31 years (16-49), 75% were younger than 40 years. 50% were female. The main symptom at diagnosis was asthenia (58.3%), followed by ecchymosis (16.7%) and fever (16.7%). At diagnosis, 33.3% had neutrophil counts less than 1.5x109/L and 41.7% had platelet counts less than 20.0x109/L. All patients had BM cellularity less than 25%. Only one patient had BMT as 1st line treatment; this patient is in complete remission with a follow-up of 15 years. The remaining patients underwent IST with anti-thymocyte immunoglobulin, cyclosporine and methylprednisolone; three patients had complete remission but relapsed, with a disease-free interval of 55 months. As a 2nd line treatment, three patients received unrelated BMT and two had complete remission. Of the seven patients who underwent 2nd line IST, three had complete remission, two underwent BMT on the 3rd line, and two patients were treated, respectively, with alemtuzumab and cyclosporine. Patients receiving IST had a median follow-up of 56 months. Three deaths occurred and OS at 15 years is 70%. Patients with neutrophil counts less than 1.5x109/L had a lower OS (P = 0.01). There was no secondary myelodysplastic syndromes or acute leukemias. Conclusion BMT is considered to be the most appropriate treatment in young patients with a compatible donor. However, IST is also a valid treatment for those without a donor, with a good survival. Disclosure All authors have declared no conflicts of interest.

Prospective Phase II Pilot Study of Rabbit Antithymocyte Globulin (ATG, Thymoglobuline) with Ciclosporin for Patients with Acquired Aplastic Anemia and Matched Pair Analysis with Patients Treated with Horse ATG (Lymphoglobuline) and Ciclosporin: A Study From the EBMT Severe Aplastic Anemia Working Party (RATGAA07)

Abstract 2408 BackgroundPreviously, horse antithymocyte globulin (hATG) with ciclosporin (CSA) was the standard immunosuppressive therapy (IST) for patients with aplastic anemia (AA) ineligible for HSCT, with response rates of 60–75% within 3–4 months. Rabbit ATG (rATG, Thymoglobuline, Genzyme) was reserved for non-response or relapse after a course of hATG. Following the withdrawal of hATG (Lymphoglobuline) from the market, the use of rATG as first line IST has been evaluated prospectively with hATG (ATGAM, Pfizer) in a randomised study from NIH (Scheinberg et al, NEJM, 2011), reporting significantly lower response rate and worse outcome after rATG. We report here the results of a multicenter, EBMT, phase II pilot study of 35 patients with AA enrolled between August 2008 and August 2010 at 10 centres (EUdraCT number 2007–000902–55). Patients enrolled were ineligible for matched sibling HSCT, had not received prior ATG or CSA and included both severe AA (SAA) and transfusion dependent non-severe AA (NSAA). The median age was 36 years (range 17–75). Six (17%) patients had very severe AA, 20 (57%) SAA and 9 (26%) had NSAA. Primary endpoint was response at 6 months. Dose of rATG was 3.75mg/kg daily for 5 days. CSA dose was 5mg/kg daily from day +1. For prevention of serum sickness, prednisolone was given at 1–2mg/kg daily from day 1–5, then the dose halved every 5 days. Results were compared in a 3: 1 ratio with 105 historical patients from the EBMT registry, matched for categorised age and disease severity, and who had been treated with hATG (Lymphoglobuline, Genzyme) and CSA. The study was designed to demonstrate a 25% difference in total response to rATG, with 80% power at a 5% level of significance. The median follow up for all patients treated with rATG is 285 days (6–781). ResultsAt 3 months, no patients had achieved a complete response (CR). Partial response (PR) occurred in 11 (34%). Two patients died, on day +6 and +9, and one was lost to follow up. At 6 months, CR rate was 7% (n=2) and PR rate 32% (n=11). One patient relapsed at 59 days. Five patients underwent unrelated donor HSCT for non-response to rATG, at day +153, 168, 321, 322 and 460 post rATG. Infections occurred in 22 (63%), elevated liver function in 10 (29%), rash in 8 (23%), haemorrhage in 7 (20%), hypertension in 6 (17%), abnormal renal function in 6 (17%), arthralgia in 5 (14%), avascular bone necrosis in one. There were 10 deaths after rATG (28.5%) and one following subsequent HSCT. Infections were the main cause of death in 9/10 patients. For rATG, overall survival at 2 yr was 56%, compared to 78% for hATG, p=0.001. Overall survival after censoring HSCT patients was 39% for rATG and 72% for hATG, p=0.0005. On multivariate analysis, rATG (RR = 3.4, p=0.003) and age > 37 years (RR = 3.8, p=0.002), were independent adverse risk factors for survival. Disease severity and time from diagnosis to treatment were not significant risk factors. CR at a given time was 11% for rATG and 44% for hATG, and PR for rATG was 43% and 23% for hATG. There were 19/105 (18%) deaths after hATG.Changes in CD4+ T-cells were analysed in a subset of 5 patients from a single center, prior to rATG (n=5) and post rATG (n=8). The relevant (preliminary) findings are:pre-ATG therapy, number of Tregs was significantly lower in AA compared to healthy age-matched controls (p=0.009), while Th17 (p=0.014), Th1 cells (p=0.014) and Th2/Tregs ratio (p=0.025) were higher in AA patients. Following treatment with ATG, the frequency of Th1 (p=0.002) and B-cells (p=0.007) was reduced but there was no significant change in the frequency of Tregs, Th17/Tregs or T-helpers/Tregs ratios. However, the frequency of cytokine secreting non-Tregs (CD4+ CD25high CD45 RA− Foxp3low) studied in 5 patients was significantly increased in post treatment samples (p=0.02) and there was a trend for a higher frequency in non-responders compared to responders. ConclusionsWe report significantly inferior response and survival with rATG (Thymoglobuline) compared to hATG (Lymphoglobuline), and a high incidence of serious infections with rATG, in association with significant changes in CD4+ T-cell subsets. These results have major implications for future treatment algorithms for AA and improve further our understanding of the mechanism of action of rATG in AA. Disclosures:Marsh:Genzyme: Consultancy, Research Funding. Off Label Use: ATG used in treatment of aplastic anemia. Schrezenmeier:Genzyme: Research Funding. Risitano:Genzyme: Honoraria. Dufour:Pfizer: Research Funding. Elebute:Alexion: Honoraria. Mufti:Celgene: Consultancy, Research Funding; Genzyme: Research Funding. Bacigalupo:Genzyme: Speakers Bureau; Pfizer: Research Funding.

Thymoglobuline Is As Effective As Lymphoglobuline in Japanese Patients with Aplastic Anemia Possessing Increased Glycosylphosphatidylinositol-Anchored Protein (GPI-AP) Deficient Cells

Abstract 1339 Background:Thymoglobuline (TG), a rabbit anti-thymocyte globulin (ATG) preparation which has more potent immunosuppressive effects than horse ATG Lymphoglobuline (LG), has been shown to be as effective as LG as both first and second line immunosuppressive therapy (IST) for aplastic anemia (AA) by several retrospective studies. However, recent prospective studies from the U.S. and Europe have shown a lower effectiveness of TG compared to horse anti-thymocyte globulin (ATG). The conflicting results may be due to the heterogeneity in the pathophysiology of AA or in the ethnic backgrounds of the patients evaluated. Small populations of glycosylphosphatidylinositol-anchored protein (GPI-AP)-deficient (GPI-AP−) blood cells are detectable in approximately 60% of patients with newly-diagnosed AA, and are associated with a good response to LG (Blood, 107: 1308, 2006). TG may have comparable effects on LG if the study subjects are limited to AA patients possessing GPI-AP− blood cells. Objectives/Methods: To evaluate the effectiveness of TG in Japanese patients with AA, we retrospectively analyzed the outcomes of TG therapy in 57 patients (25 males and 32 females) with AA (40 with severe AA and 17 with non-severe AA) aged from 17 to 84 (median 58) years. Peripheral blood obtained before therapy was examined for the presence of GPI-AP− cells using flow cytometry with liquid fluorescent aerolysin, which can accurately determine the percentage of GPI-AP− granulocytes, erythrocytes, and monocytes at percentages of less than 0.01%. The cut-off values were defined as >0.003% for granulocytes, >0.005% for erythrocytes, and >0.01% for monocytes based on the analytical results of 57 healthy individuals. Results: The cumulative rate of response after 6 months of TG therapy was 59%. Significant increases in the GPI-AP− cell percentages in at least one of the three lineages were detected in 38 (67%) of the 57 patients before therapy. The response rate in patients with increased GPI-AP− cells (PNH+ patients, 69%) was significantly higher than that in patients without GPI-AP− cells (PNH− patients, 35%, P=0.016). Seventeen percent of PNH+ patients achieved complete remission (CR) within 1 year, while only 12% of PNH− patients achieved a CR. 97% of PNH+ and 84% of PNH− patients were alive at the median time of 1 year after the therapy. The response rate in PNH+ patients was comparable to that in PNH+ patients treated with LG (70%) in our recent prospective study. Conclusions: TG is therefore considered to be as effective as LG in Japanese adult patients with AA, particularly in PNH+ AA patients where immune pathophysiology is definitely involved. Alternative therapies may thus need to be considered for PNH− patients. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Efficacité du rituximab dans les hémophilies acquises: à propos de deux cas et revue de la littérature

Acquired hemophilia due to an inhibitor of factor VIII is a rare clinical situation. Rituximab is now used in the treatment of acquired hemophilia. We report two cases of acquired hemophilia treated by rituximab with efficiency. Rituximab appears to be a first line immunosuppressive therapy in acquired hemophilia, especially in post-partum hemophilia.

Unrelated Donor Umbilical Cord Blood Transplantation in Children with Acquired Aplastic Anemia. Korean Experience of 12 Cases.

Matched unrelated donor transplants have been reserved for patients with severe aplastic anemia (SAA) who fail a round of immunosuppressive therapy (IST). Despite the general acceptance of cord blood as an alternative stem cell source, unrelated donor cord blood transplantation (CBT) has not yet been recommended for SAA because of the high risk of graft failure and infectious complications. Only a few cases of successful CBT in SAA have been reported in the literature. From July, 2003 to Dec., 2005, twelve cases of unrelated donor CBTs in Korean children with acquired SAA were performed, and enrolled in this retrospective study. Two of them received double unit CBT. One patient who rejected a CBT received the second transplant with double unit CBT. All patients had no matched family donors. The median age and weight at the time of transplant were 7.0 years (2.8–18.8 years) and 23.3 kg (12.1–49.4 kg), respectively. Seven patients received previous IST including ATG/ALG plus cyclosporine (CyA). The median interval from the diagnosis to transplant was 20.5 months. The HLA discrepancy between the single unit umbilical cord blood and the patient was 0/6 in 1, 1/6 in 8, and 3/6 in 1. The conditioning regimen was heterogeneous, but included radiation in 3, and fludarabine in 3. The median infused nucleated cell dose was 3.3 × 107/kg (0.3–9.4 × 107/kg), and median CD34+ cell dose was 1.7 × 105/kg (0.4–6.6 × 105/kg) of recipient weight. Graft-versus-host disease (GvHD) prophylaxis was CyA plus methylprednisolone in 9 cases. Primary engraft failure was encountered in 3. The absolute neutrophil count ≥500/μL was achieved at 17.0 days (15–34 days), and platelet count ≥20,000/μL at 57.0 days (32–122 days), respectively. Complete donor chimerism was promptly observed in 8, with transient mixed chimerism in another patient. Acute GvHD ≥ II was observed in 5 cases, and extensive chronic GvHD was found in 2 among 8 evaluable cases. The 3-year overall survival was 74.1%, and 3-year estimated failure-free survival was 58.3%. The causes of death were sepsis, cytomegloviral pneumonitis, and chronic GvHD with intracranial hemorrhage in each patient. Cytomegaloviral disease was found in 3 cases. These results are comparable with those from unrelated donor BMT in refractory SAA. Considering the better tolerability of HLA mismatching, CBT should be considered as an alternative source of transplants. A randomized, prospective study comparing the 2nd-line IST, unrelated bone marrow transplants, or CBT is warranted to answer the best option for those who fail to 1st line IST without matched siblings.

Prospective Multicenter Trial Comparing Repeated Immunosuppressive Therapy (IST) with Stem Cell Transplantation (SCT) from an Alternative Donor as a Second-Line Treatment for Children with Acquired Aplastic Anemia (AA).

Immunosuppressive therapy (IST) has been shown to be an effective therapy for aplastic anemia (AA) patients without HLA-matched family donors. However, a significant proportion of patients are refractory to IST. Although the efficacy of repeated IST and stem cell transplantation (SCT) from an alternative donor has been confirmed, a direct comparison between these two procedures has not yet been conducted. In this study, we prospectively compared the efficacy of these two treatments. Between Oct. 1997 and Apr. 2003, 231 patients (125 male, 106 female; median age, 9 y; range, 0 to 17 y) were enrolled in the AA-97 study. Analysis was performed in April 2004. A total of 103 very severe AA and 74 severe AA patients received first-line IST consisting of antithymocyte globulin (ATG; Lymphoglobulin), Cyclosporin (CyA) and methylprednisolone (Mepred), while 54 non-severe AA patients received IST consisting of ATG and Mepred with or without CyA. G-CSF was administered only to patients with very severe AA. Sixty patients (26%) were non-responders to first-line IST and were eligible for 2 nd -line therapies. Of these, 29 patients lacking suitable donors received 2 nd-line IST with ATG (Lymphoglobulin), CyA and Mepred. Four developed severe anaphylactoid reactions and could not complete the 2 nd-line treatment. Twenty-nine patients received SCT as follows: BMT from an unrelated donor (n=22), BMT from an HLA-mismatched family donor (n=4) and cord blood SCT from an unrelated donor (n=3). Two patients did not receive any 2 nd-line treatment. Median interval between 1 st -line IST and 2 nd-line treatment was 8 mo for the SCT group (range: 4–20 mo) and 7 mo for the IST group (range: 5–14 mo). One patient receiving 2 nd-line IST and 5 patients receiving SCT died of infections. The overall probability of survival at 5 y from the start of 2 nd-line treatment was 82 ± 10% in the SCT group and 97 ± 5% in the IST group (p:0.08 ). However, trilineage response to a 2 nd course of IST was seen in only 3 of 25 evaluable patients (12%), and 10 non-responders to 2 nd-line IST later received BMT from an unrelated donor as a 3 rd -line therapy. Blood counts normalized in all patients following SCT. Failure-free survival (FFS) was defined as survival with treatment response. The estimated FFS at 5 y was significantly better (p <0.01) in the SCT group (81 ± 15%) than in the IST group (13 ± 12%). The probability of survival at 6 y from the start of 1 st treatments was 90 ± 6% in the 103 very severe AA patients, 97 ± 3% in the 74 severe AA patients and 95±4% in the non-severe 54 AA patients.Conclusion: SCT from alternative donors offers a better chance of FFS than 2 nd-line IST in non-responders to 1 st -line IST. However, overall survival rate is not different between two approaches.