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Autoimmune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA) can be observed in Waldenström macroglobulinemia (WM). The autoimmune disorders are primarily mediated by autoimmune monoclonal gammopathy, but drug-induced hemolysis should also be considered. Herein, we presented the case of a 63-year-old female WM patient complicated with ITP, who was admitted to our department with a complaint of abdominal pain. After first half of bortezomib/dexamethasone/rituximab (BRD) chemotherapy, her platelet level recovered, but subsequently decreased to extremely low level (around 1–2×109/L), and the patient suffered from platelet transfusion refractoriness. During the management of refractory thrombocytopenia, the patient developed severe hemolytic anemia, and further tests confirmed warm AIHA. FcγRIIα polymorphism test showed that the patient had FcγRIIα-131RH, which implied that the AIHA may not be WM-related. Given the effects of ibrutinib in controlling WM, secondary AITP and AIHA, ibrutinib single treatment was started, which quickly corrected the thrombocytopenia within five days, but not hemolysis. With a relatively safe platelet level, eltrombopag was stopped, and the hemolysis relieved three days after eltrombopag withdrawal. This is the first report on eltrombopag-induced AIHA in the management of WM-associated ITP.

Monocytopenia and mycobacterial infection (MonoMAC) syndrome is a rare disease. Herein, we reported a 65-year-old Asian woman, previously diagnosed with myelodysplastic syndrome (MDS), suffering from recurrent pneumonia, intermittent fever, fatigue, and chest tightness lasting for five months. She was ultimately diagnosed with MonoMAC syndrome with Mycobacterium kansasii (M. kansasii) infection and GATA2 mutation through metagenomic generation sequencing (mNGS) of peripheral blood specimen, for which she was given anti-NTM therapy. Her situation significantly improved within 2 weeks of therapy. We discussed the clinical features, genetic characteristic, and prognosis of this disorder, aiming to further elucidate this rare syndrome. For MDS/AML patient with recurrent mixed infection and pancytopenia (especially with monocyte absence), MonoMAC syndrome should be highly suspected, and germline mutation and pathogen sequencing should be performed.

A 49-year-old male patient who had been diagnosed with variable hairy cell leukemia (HCL-V) was treated with interferon for half a year but exert no obvious effect. After two courses of chemotherapy with cladribine, he achieved remission, and splenomegaly significantly improved (the length in craniocaudal dimension decreased from 15.8cm to 11.8cm). Four years later, the patient got disease relapse and was recommended for another cycle of cladribine (6mg for 7 days). On the last day of cladribine, the patient developed fever with needle-like red rashes on the face, limbs, and trunk. At the very beginning, the rash was lighter in color, sparsely distributed, and without obvious itching. Three days later, the rash gradually darkened, expanded and merged, with itching. With the application of high dose gamma globulin and corticosteroids (prednisolone combined with dexamethasone), the rash finally faded, and the patient was discharged. Rash caused by cladribine is not uncommon, such serious and widespread drug-induced rash is rare, and there are few reports. This article reviewed relevant studies and treatments.

Huijin Hu,1,* Tao Chen,2,* Wenbin Liu,1 Yiping Shen,1 Qiushuang Li,3 Yuhong Zhou,1 Baodong Ye,1 Dijiong Wu1 1Department of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, People’s Republic of China; 2Department of Hematology, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang, People’s Republic of China; 3Center of Clinical Evaluation and Analysis, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, People’s Republic of China*These authors contributed equally to this workCorrespondence: Dijiong Wu; Baodong YeDepartment of Hematology, The First Affiliated Hospital of Zhejiang Chinese Medical University, #54 Youdian Road, Hangzhou, Zhejiang, 310006, People’s Republic of ChinaFax +8657187073569Email wudijiong@zcmu.edu.cn; 13588453501@163.comObjective: To better understanding and differentiation of traditional Chinese medicine (TCM) syndromes in severe aplastic anemia (SAA) patients undergoing hematopoietic stem cell transplantation (Allo-HSCT) and their correlation with iron metabolism, cAMP/cGMP, 17-OH-CS and thyroxine.Methods: Eighteen patients with SAA who underwent HSCT were enrolled. The syndrome was evaluated before conditioning and days after stem cell reinfusion (− 10d, − 1d, +7d, +30d, +60d, and +90d). The correlation of TCM syndrome (Yin, Yang, and stasis) to cyclic nucleotides, 17-OH-CS, thyroxine, and iron metabolism were analyzed and compared to data from normal subjects.Results: More “Yin deficiency” (n=11, 11/18) syndrome was observed before HSCT, and nearly 61% was complicated with “blood stasis”. After conditioning, the proportion of “kidney Yin and Yang deficiency” increased to 61.6%. Fourteen days after HSCT, the syndrome developed into “Spleen-Kidney Yang Deficiency,” and the stasis score decreased. On +90day, majority patients were diagnosed with “Kidney Yang Deficiency” (35.7%) or “Spleen-Kidney Yang Deficiency” (28.6%), and 88.9% were diagnosed without stasis. The correlation analysis showed that cGMP might represent “Deficient Yang” as well as low total triiodothyronine (T3) and free T3 (FT3). There was also a positive relation between labile plasma iron (LPI), hepcidin, soluble transferrin receptor (sTfR), and “Yin deficiency”, and the last two factors, along with marrow nitric oxide synthase were also positively related to “Stasis” syndrome.Conclusion: During HSCT, the syndrome evolved from “kidney Yin and Yang deficiency” to “kidney Yang deficiency” or “spleen–kidney Yang deficiency”, and the “stasis” along with “Yin deficiency” syndromes were quickly relieved within 90 days. The changes of cyclic nucleotides, 17-OH-CS, thyroxine, and iron metabolism indexes can be applied for better differentiation of TCM syndrome.Keywords: aplastic anemia, traditional Chinese medicine syndrome, iron metabolism, syndrome evolution, hematopoietic stem cell transplantation

Immune thrombocytopenia (ITP) was defined using the International Consensus Guidelines as a platelet count

Background: Autoimmune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA) can be observed in Waldenström Macroglobulinemia (WM). The cause of AIHA should be carefully distinguished during the disease management. Case Presentation: A 63-year-old female WM patient complicated with thrombocytopenia, who was admitted to our department with a complaint of abdominal pain. After first half of bortezomib/dexamethasone/rituximab (BRD) chemotherapy, her platelet level recovered, but subsequently decreased to extremely low level (around 1-2×109/L), and the patient suffered from platelet transfusion refractoriness. During the management of refractory thrombocytopenia, the patient developed severe hemolytic anemia, and further tests confirmed warm AIHA. FcγRIIα polymorphism test showed that the patient had FcγRIIα-131RH, which implied that the AIHA may not be WM-related. Given the effects of ibrutinib in controlling WM, ibrutinib single treatment was started, which quickly corrected the thrombocytopenia within five days, but not hemolysis. With a relatively safe platelet level, eltrombopag was stopped, and the hemolysis alleviated within three days after eltrombopag withdrawal. Conclusion: This is the first report on eltrombopag-induced AIHA, and we should always keep in mind of the drug induced hemolysis even in disorders with autoimmune background.

Aplastic anemia (AA) is a common hematologic disease that is characterized by hematopoietic failure of the bone marrow and pancytopenia of the peripheral blood, which can be divided into severe and non-severe aplastic ane-mia, or acute and chronic aplastic anemia according to the severity of the disease and the progress of the clinical course. During the past years, the advantages of Traditional Chinese Medicine (TCM) on the treatment of AA have been well clarified and its theory system has been improved as well. This review is mainly on representing the pathogenesis, therapeutic principle and method, research progression, and advantages of TCM on AA.

Dijiong Wu,1 Xiaowen Wen,2 Wenbin Liu,1 Huijin Hu,1 Baodong Ye,1 Yuhong Zhou1 1Department of Hematology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, People’s Republic of China; 2Department of Internal Medicine, Central Hospital of Jinhua Affiliated to Zhejiang University, Jinhua, Zhejiang, People’s Republic of China Background and aim: Iron overload is commonly observed during the course of aplastic anemia (AA), which is believed to aggravate hematopoiesis, cause multiple organ dysfunction, lead to disease progression, and impair quality of life. Deferasirox (DFX) and deferoxamine (DFO) are among the most common iron chelation agents available in the clinical setting. The aim of this study was to investigate if the combination therapy with DFX and DFO is superior in hematopoietic recovery and iron chelation. Methods: Briefly, we developed a composite mouse model with AA and iron overload that was consequently treated with DFX, DFO, or with a combination of both agents. The changes in peripheral hemogram, marrow apoptosis, and its related protein expressions were compared during the process of iron chelation, while the iron depositions in liver and bone marrow and its regulator were also detected. Results: The obtained results showed that compared to DFX, DFO has a better effect in protecting the bone marrow from apoptosis-induced failure. The combination of DFO and DFX accelerated the chelation of iron, while their efficiency on further hemogram improvement appeared limited. Conclusion: To sum up, our data suggest that single treatment with DFO may be a better choice for improving the hematopoiesis during the gradual chelation treatment irrespective of the convenience of oral DFX, while the combination treatment should be considered for urgent reduction of the iron burden. Keywords: aplastic anemia, iron overload, mouse, animal model, deferasirox, deferoxamine

Myelodysplastic syndrome (MDS) is a group of disorders involving hematopoietic dysfunction, with a leukemic transformation characteristic. The risk based therapeutic strategy was well applied in clinical. And for patients with IPSS low or intermediate risk-1, NCCN guideline recommended hematopoietic stimulation therapy, immune suppression therapy (IST), as well as demethylation therapy, along with best supportive care. Eltrombopag (EPAG) was firstly approved as the second line option for immune thrombocytopenia (ITP), and recently it was also investigated for treatment of aplastic anemia and MDS. In MDS, based on available reports, the EPAG was mostly used along with hypomethylating-agent, or as salvage treatment after treatment failure. However, there was study showed that the combination of EPAG to azacitidine (AZA) may worsen platelet recovery, with lower response rate and increased trend of leukemic transformation. The successful EPAG monotherapy for MDS case was report, with complete hematologic remission and blasts elimination. To date, limited study was focus on investigating the benefit of EPAG as initial monotherapy for transfusion dependent (TD) patients with low to intermediate risk-1 MDS, as well as its safety. Herein, we reviewed cases of elderly TD-MDS patients who received EPAG as front-line single treatment in our center, and 7 patients was enrolled from July, 2019 to September, 2020. Patients received EPAG 25mg to a maximum 75mg. The side effects, numbers of transfusion, improvement of peripheral blood and bone-marrow blast were recorded. The 12weeks overall response rate was 85.7%, with 2 robust response (RR), and 4 hematologic response. In patients got response, 66.7% (4/6) became platelet transfusion independent, with an answering period from 19 days to 55 days. No drug adverse events were observed within 12 week-treatment, and no obvious increased blasts as well as myelofibrosis were observed. 2 patients repeated the next-generation sequencing, and no new mutations were found. After the 12-week treatment, the 2 RR patients were still taking EPAG and got continued complete remission with a median follow up of two years. Two patient (No.3 and No.4) relapsed after EPAG withdrawn and became transfusion depend again. Patient No.1 and No.6 died of infection and cerebral hemorrhage during the follow up. In summary, EPAG may improve the hematopoiesis of TD-patient with low to intermediate risk-1 MDS, and was well tolerant with a dose of 25mg to 75mg for Asian population. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Immune thrombocytopenia (ITP) is an autoimmune disease characterized by decreased platelet (PLT) count in peripheral blood and marrow megakaryocyte dysfunction, which was induced by antiplatelet antibodies or cytotoxic T cells. Many ITP patient were previously full response to first-line treatment such as corticoids (CIS) or immunoglobulin (IVIG), but were intolerant or relapse during the maintenance treatment, and turn to receive recombinant human thrombopoietin (rhTPO), rituximab (RTX), splenectomy as well as immunosuppressive therapy (IST). Unfortunately, there still some patients failed to multiple treatments are faced with high bleeding risk. Eltrombopag, the first oral non-peptide thrombopoietin receptor agonist (TPO-RA) that approved by US FDA in 2008, is the second-line treatment option for chronic ITP based on guideline recommendation. As reported, the effective rate of eltrombopag in ITP ranges from 59% to 89.7%, and limited predictive factors were available to assess the efficiency for individual. The characteristic of marrow megakaryocyte (MK) in ITP was reported as normal or hyper megakaryocytosis on the initiation (before treatment), however there are also ITP patients with decreased marrow MK, and the response of eltrombopag to these patients have not been fully reported. Bone marrow aspiration is a routine examination in China for the diagnosis of ITP with severe thrombocytopenia. Therefore, we conducted a research tried to assess the efficiency of eltrombopag to patients with multi-line failed ITP, and analyzing the possible factors may contribute to the differences based on personal characteristic. Thirty-five multi-line failed ITP patients with PLT count bellow 30× 10 9/L who received eltrombopag treatment were enrolled, and divided into three groups, the hyper-MK (MK count>35, n=17), normal-MK (8-35, n=10) and hypo-MK (≤7, n=8) groups. The average PLT count was 10.63±6.30×10 9/L before eltrombopag treatment, and it increased significantly to 12 (2-65)×10 9/L, 39 (2-212)×10 9/L, 68 (2-453)×10 9/L, 60 (3-358)×10 9/L, and 75 (3-308)×10 9/L in the 1st, 2nd, 4th, 6th , and 8th weeks after treatment (all P=0.000, except 1st week). The median intervals time required for platelet to reach 30×10 9/L and 100×10 9/L for the first time were 11 (4-40) and 21 (10-65) days, respectively (Fig. A-C). We found the overall, complete (PLT count ≥100×10 9/L) and partial response (PLT count ≥30×10 9/L or at least twice the baseline value) rates were 54.3% (n=19), 48.6% (n=17), and 5.7% (n=2) respectively to eltrombopag in our center. The overall response rate of patient with decreased MK was 75%, which was unexpectedly higher than the patient with increased or normal MK count (52.9% and 40%, respectively) (Fig. D). To explain the underling mechanism, we detected the peripheral T lymphocyte, B lymphocytes and NK cells before eltrombopag. Results showed that the patient with decreased MK were characteristic with higher T helper (Th) cells (39.62±2.01%) and regulatory T (Tregs) cells (7.93±1.63%) when compared to the hyper-MK (30.44±10.95%, 4.23±1.67%) and normal-MK group (25.67±5.72%, 4.81±2.12%). For patient with poorer eltrombopag response group, more percentage and absolute number of NK cells (15.48±7.12%, 234.4±91.80×10 6/L) were found in peripheral blood (Fig. E-F). We also discovered that previous first-line (CIS or IVIG) treatment, rhTPO effectiveness, RTX splenectomy and IST had no influence on eltrombopag response (Fig. G). As for safety, nine eltrombopag related adverse events were reported, and most commonly were upper respiratory tract infection (8.6%), elevated ALT (5.7%), and venous thrombosis (5.7%). All the side effect was cured by symptomatic treatment, eltrombopag dose reduction or discontinue. In summary, ITP patients with decreased megakaryocyte respond well to eltrombopag, and the abnormality of NK cells may play a role in patients exert a poor response. In further clinical practice, we should considering the megakaryocytes count as well as peripheral NK population to better predicting eltrombopag response in ITP patients. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Hepatitis-associated aplastic anemia (HAAA) refers to aplastic anemia (AA) in which pancytopenia appears within 6 months after an acute attack of hepatitis. The incidence of HAAA in the Far East and West accounts for 4-10% and 2-5%, respectively, in all AA cases. HAAA frequently occurs in young men, with a median age of 19 (6-56) years, and the two-month mortality after the onset of HAAA can reach 78-88% if the disease was leaved untreated. To date, the underlying pathogenesis is not yet clarified, and no specific correlation has been established between HAAA and chemical toxicants, neither radiation. Based on available studies, the hyper-activation of T lymphocytes and abnormal humoral immunity were confirmed in HAAA, and a large number of infiltrated lymphocytes are also noted in liver at the early stage of the disease, which resulting in liver dysfunction. Some viruses, including hepatitis A, hepatitis B, hepatitis C, parvovirus B19, human herpesvirus (HHV), and Epstein-Barr virus were correlated to the development of HAAA. However, the clinical results of the serological tests for hepatitis-associated viruses of most patients are negative, i.e., serologically negative HAAA. The frontline treatments are agreed to be allogeneic hematopoietic stem cell transplantation (allo-HSCT) or immunosuppressive therapy (IST). Because of the relatively scattered clinical data, compared to other acquired AA, the basis of treatment decision-making is insufficient. Some studies speculated that both IST and HSCT are effective, while others believe that transplantation should be the first choice if suitable donors are available. Therefore, we conducted a retrospective study and meta-analysis for better understanding and choice of the treatment. Our retrospective cohort study enrolled 18 HAAA patients, including 12 males and 6 females. A total of 12 (66.7%) patients received IST treatment, in which 4(33.33%) achieved completed remission (CR), 1(8.33%) partial remission (PR), and 7(58.33%) no response (NR), with a total effective rate of 41.7%. 6 patients (33.3%) received HSCT treatment, in which, 2 achieved CR, 1 PR, and 3 NR, with an effective rate of 50% (Table 1). The one-year overall survival (OS) rate of the IST group was significantly higher than that of the HSCT group (P16-years-old was 0.86 (95% CI: 0.50-1.46)(Figure E). The effective rate of ATG/ALG combined with CSA was 51.35%, and that of CSA alone was 46.7%. Compared to the HSCT group, the efficacy of ATG/ALG + CSA group (RR=0.73, 95% CI: 0.51-1.04) was better than that of CSA alone (RR=0.59, 95% CI: 0.32-1.09) (Figure F). The result of comparing ATG/ALG + CSA with CSA showed that the pooled RR was 1.35(95% CI: 0.70, 2.59) (Figure G), and the difference was not significant. This phenomenon could be attributed to the small number of articles included and insufficient sample size after subgroup analysis according to the IST treatment. We speculated that ATG/ALG combined with CSA has advantages in the treatment of HAAA compared to CSA alone. In summary, HSCT is more effective than IST in the treatment of HAAA, especially for patients 16-years-old, there is no significant difference in the efficacy between the HSCT and ATG/ALG + CsA strategies. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

ObjectiveTo compare the efficacy of modified treatments based on “kidney reinforcing” in the management of chronic aplastic anemia (CAA), and explore their advantages and specialties.MethodsOne hundred and eleven patients with CAA were randomly divided into three groups: kidney reinforcing alone (KA), “kidney reinforcing and Qi tonifying” (KQ), and “kidney reinforcing and blood circulation invigorating” (KC). Normal and positive control groups were also formed. All patients were treated for 6 months (two courses). Hemograms, Traditional Chinese Medicine (TCM) syndrome scores, and therapeutic effects were assessed, and changes in T-lymphocyte subsets, regulatory T cells and cytokines were detected.ResultsThe KQ and KC groups had lower TCM syndrome scores than the positive control group after 6 months (P < 0.05). The KQ group had a higher overall efficacy than the positive control group after 3 months (P < 0.05), while platelet counts increased in the KC group after 6 months (P < 0.05). CD3+T-lymphocyte ratios decreased only in the KQ group, while CD3 + CD4+ CD8− Tlymphocytes increased only in the KC group after 6 months (P < 0.05). Levels of interferon-γ, tumor necrosis factor-α, interleukin (IL)-2 and IL-6 decreased and levels of IL-4 and IL-10 increased in all treated groups after 6 months. Levels of IL-6 in the KQ and KC groups were lower than those in the positive control group (P < 0.05).ConclusionTreatments based on kidney reinforcing have a rebalancing effect on cytotoxic and T helper cells, and regulate expression of interferon-γ, IL-2, IL-6 and IL-4. KQ may be more effective in treating CAA, and KC may have an advantage in platelet recovery.

Introduction Polycythemia vera (PV) is one of the most common forms of myeloproliferative neoplasms. Acute myeloid leukemia secondary to PV is well reported, and the mechanism has been clarified to some extent. Only a limited number of cases have been reported about the development of acute lymphoblastic leukemia (ALL) in the course of PV, and the possible underlying mechanism has not been explored well.

To investigate the protective effects and mechanisms of Radix Astragali Injection on multiple organs of rats with obstructive jaundice (OJ).A total of 180 rats were randomly divided into the sham-operated, model control and treated groups (60 in each group). On 7, 14, 21 and 28 days after operation, the serum contents of alanine aminotransferase (ALT), aspartate aminotransferase (AST), r-glutamyl transpeptidase (r-GT), total bilirubin (TBil), direct bilirubin (DBil), blood urine nitrogen (BUN), and creatinine (CREA) were determined. And the pathological changes of livers, kidneys and lungs, and protein expressions of toll-like receptor-4 (TLR-4) of livers, intercellular adhesion molecule-1 (ICAM-1) of lungs, Bax and nuclear factor-kappa B (NF-κB), as well as apoptotic indexes of multiple organs were observed, respectively.The pathological severity scores of multiple organs (including livers on 7, 14, 21 and 28 days, kidneys on 14 and 28 days, and lungs on 14 days), serum contents of ALT (14 and 21 days), AST (14 days), TBil (7, 14, 21 and 28 days), DBil (14 and 21 days), BUN (28 days), protein expressions of TLR-4 (in livers, 28 days), Bax (in livers and kidneys, 21 days), and apoptotic indexes in livers (7 and 21 days) in the treated group were significantly lower than those in the model control group (P0.05 or P0.01).Radix Astragali Injection exerts protective effects on multiple organs of OJ rats by improving the pathological changes of lung, liver and kidney, decreasing the serum index of hepatic and renal function as well as inhibiting the protein expression of TLR-4 and Bax in the livers and Bax in the kidneys.

Bone marrow microvessel plays an important role in the onset and progression of hematologic diseases whose genesis is regulated by a variety of regulatory factors. Since abnormal angiogenesis has been found in a number of malignant and non-malignant hematologic diseases, microvessel density can be a valuable prognostic indicator, and also a stratifying factor in some of these diseases. In some cases, inhibiting or stimulating angiogenesis with certain treatments may be very important in improving therapeutic outcomes. However, mechanisms underlying these effects are yet to be further investigated.

Inv(16)(p13q22) or t(16;16)(p13.1;q22) [hereafter inv(16)], a chromosomal rearrangement occurred in 5-12% acute myeloid leukemia (AML) patients, disrupts the core-binding factor (CBF) transcription complex and creates a leukemogenic fusion gene CBFb-MYH11 (CM). Only about 50% inv(16) patients achieve long-term survival with standard chemotherapy. Therefore, more effective therapies are necessary to improve outcomes. MicroRNAs (miRNAs) are small non-coding RNA molecules that inhibit multiple target gene expression. High miR-126 expression is a miRNA hallmark of inv(16) AML. However, the function and mechanism of miR-126 dysregulation in inv(16) AML remains elusive. Our results indicate that miR-126 levels are significantly higher in inv(16) AML CD34+ and CD34- blasts compared to normal counterparts. We have previously generated a conditional Cbfb-MYH11 (CM) knock-in (KI) mouse model (Cbfb+/56M/Mx1-Cre), in which lethal AML develops in 4-6 months after CM induction. We observed an overtime-increased miR-126 in the peripheral blood relative to control (log fold change = 4.11; p< 0.0001) as well as in multiple progenitor subpopulations, including LSK, pre-megakaryocyte/erythrocyte (Pre-Meg/E), pre-granulocyte-macrophage (Pre-GM), and granulocyte-macrophage progenitors (GMP) in CM preleukemic and leukemic mice. Expression of CM in 32D cells significantly upregulated miR-126, pri-miR-126, pre-miR-26 and the host gene Egfl7 compared to vector control or WT CBFb, suggesting that transcriptional activation of miR-126 is induced by CM. But, is the aberrant expression of miR-126 necessary for leukemia growth in CM AML? To address this question, we crossed the conditional CM KI mice with a miR-126-floxed model (miR-126f/f). CM/miR-126△/△ mice showed significantly reduced AML incidence (3 out of 10) and prolonged disease-free survival compared to CM mice (p < 0.0001), indicating that high miR-126 promotes AML growth. Deletion of miR-126 significantly reduced the expansion of preleukemic (6 weeks after induction) stem/progenitor populations (LSK, Pre-GM, and Pre-Meg/E). In addition, we observed significantly increased radiation-induced apoptosis in LSK (CM 11.61±2.277% vs. CM/miR-126△/△16±1.386%, p=0.03) and Pre-Meg/E (CM 8.885±1.607% vs. CM/miR-126△/△25.5±3.961%, p=0.0081), which represent leukemia-initiating populations in CM mice (Cai et al, Blood 2016). Furthermore, miR-126 knockdown in human inv(16) AML patient samples led to significantly increased apoptosis in all AML stem/progenitor cell subsets (shCtrl 7.469±1.085% vs. shmiR-126 13.8±1.585% in CD34+, p=0.0045; shCtrl 11.59±1.723% vs. shmiR-126 17.97±1.461% in CD34-, p=0.0122) and reduced quiescence/increased cycling in more primitive subsets (e.g, CD34+CD38-, CD34+CD38+). These results indicate that high miR-126 contributes to CM leukemia initiation and maintenance by antagonizing stress-induced apoptosis and maintaining the quiescence of stem/progenitor cells. Thus, miR-126 may be a novel therapeutic target in this subtype AML. To target aberrantly expressed miR-126 in CM-AML, we designed a CpG-anti-miR-126 oligonucleotide (ODN) inhibitor (named miRisten, Bin Zhang et al, Nat Med 2018) that is efficiently (60-90%) taken up and achieved 50-80% reduction of miR-126 in AML LSK and blasts. Compared with a scramble ODN control (Ctrl), in vivo miRisten treatment (20 mg/kg i.v. daily for 3 weeks) significantly reduced CM-AML burden in spleen (Ctrl 71.23±3.756% vs. miRisten 51.91±5.788%, p=0.0103) and bone morrow (Ctrl 66.07±3.203% vs. miRisten 50.9±2.999%, p=0.0038), and reduced the frequency of LSK (Ctrl 1.72±0.6176% vs. miRisten 0.2316±0.03894%, p=0.0482). Importantly, miRisten treatment significantly reduced the leukemia-initiating capacity with prolonged survival in secondary transplants compared to Ctrl (median survival 95.5 days vs. 84.5 days; n=10, p=0.0004). When we combined miRisten with chemotherapy, adopting a regimen consisted of Cytarabine (Ara-C; 50 mg/kg i.p. daily for 5 days) and daunorubicin (DNR; 1.5 mg/kg i.v. every other day for 3 days), we observed a further reduction of AML burden and prolonged survival compared to chemotherapy alone (median survival 102 days vs. 84 days, n=10-11, p Disclosures No relevant conflicts of interest to declare.

Chromosomal rearrangements involving the mixed lineage leukemia (MLL) gene at the 11q23 locus are found in a subset of acute myeloid leukemia (AML) generally associated with intermediate to poor prognosis. MLL-AF9 resulting from t(9;11)(p22;q23) is the most common in MLL-rearranged (MLL-r) AML. Chemotherapy is the current standard of care for AML and the overall 5-year survival rate is only 25%. We previously reported that HDAC8 functions to control p53 activity in hematopoietic stem cells via deacetylation of p53 protein (Hua et al, Blood 2017). Here, we investigated the contribution of HDAC8 in MLL-r AML pathogenesis and maintenance. We have previously generated a conditional Hdac8 floxed (f) allele and combined with Mx1-Cre (Mx1-Cre/Hdac8f/f(y)) to generate HDAC8△/△ mice upon induction with poly (I:C). To examine the role of HDAC8 in MLL-AF9-AML, we transduced Hdac8△/△ or control LSK (Lin-Sca1+cKit+) with a MSCV-ires-GFP (MIG)-MLL-AF9 (MA9) vector and sorted GFP+ cells for CFC assay. Hdac8△/△/MA9 cells generated significantly less CFC colonies compared to control, suggesting that HDAC8 promotes MA9 clonogenic activity. To assess their leukemogenic potential in vivo, we transplanted GFP+ control MA9 or Hdac8△/△/MA9 cells (5x103-104) into sublethally irradiated (6 Gy) wild-type (WT) recipients. All MA9 recipients (n=4) developed lethal AML with a median survival of 69 days while none of the Hdac8△/△/MA9 recipients (n=4) developed AML up to 4 months. To examine the contribution of HDAC8 in established AML, we transduced LSK from uninduced Hdac8f/f(y)/Mx1-Cre mice with MIG-MA9 and transplanted into WT recipients. Upon development of moribund leukemia, AML cells (5x 103) were transplanted into a cohort of recipients (n=16), which were treated with poly (I:C) (n=8; 14 mg/kg/dose) or PBS every other day for 2 weeks starting at day 10 (5-10% GFP+ in blood). Mice induced with poly (I:C) to delete Hdac8 showed dramatically lower white blood count [9.0 (103 /ul) vs. 109.7 (103 /ul); n=8, P We further evaluated the effect of HDAC8i in human AML cell lines and primary MLL-r AML patient cells. HDAC8i treatment increased p53 acetylation and enhanced p53-dependent apoptosis in MOLM-13 AML cells (22d: 50.8% vs. vehicle: 11.89%). Knock-down of p53 rescued the apoptosis induced by HDAC8i, indicating that HDAC8i induced apoptosis is mediated by p53. Similarly, HDAC8i (22d) treatment significantly increased apoptosis accompanied by elevated levels of p53 acetylation and p53 target gene expression in MLL-r AML CD34+ cells compared to normal (NL) CD34+ cells. Thus, HDAC8 inhibition targets human MLL-r AML cells and AML CD34+ cells by restoring p53 acetylation and inducing apoptosis. In conclusion, this study reveals a critical role of HDAC8 in promoting initiation and maintenance of MLL-AF9 AML and highlights HDAC8 inhibition as a promising approach to target MLL-r AML. Disclosures No relevant conflicts of interest to declare.

This study aimed to review and quantitatively analyze (1) the association of aplastic anemia (AA) with human leukocyte antigen (HLA)-DRB1*15 and HLA-DRB1*15:01 polymorphisms and (2) the association of HLA-DRB1*15 and HLA-DRB1*15:01 polymorphisms with response to immunosuppressive therapy (IST) in AA. Published studies have reported conflicting and heterogeneous results regarding the association of HLA-DRB1*15 and HLA-DRB1*15:01 polymorphisms with response to IST in AA. The PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese BioMedical Literature, Wangfang and Chinese Social Sciences Citation Index databases were searched. All relevant publications were searched through December 2015. Odds ratio (OR), risk ratio (RR), and 95% confidence intervals (CI) for the comparison between case-control or cohort studies were evaluated. Finally, 24 articles were identified. For HLA-DRB1*15 and HLA-DRB1*15:01, the OR (95% CI) was 2.24(1.33-3.77), P < 0.01 and 2.50(1.73-3.62), P < 0.01, respectively; and the overall pooled RR was 1.72 (1.30-2.29), P < 0.01 and 1.59 (1.29-1.96), P < 0.01, respectively. Statistical evidence showed no publication bias (P > 0.05). Sensitivity analyses revealed that the results were statistically robust. The meta-analysis suggested that HLA-DRB1*15 and HLA-DRB1*15:01 polymorphisms might be associated with increased AA risk in Asians. IST might be more effective in HLA-DRB1*15+ and HLA-DRB1*15:01+ Asian patients with AA than in HLA-DRB1*15- and HLA-DRB1*15:01- Asian patients with AA. Future studies with adequate methodological quality on gene-gene and gene-environment interactions and gene treatment may yield valid results.

To determine the effect of combined treatment with Chinese medicine (CM) and allogeneic hematopoietic stem cell transplantation (allo-HSCT) on patients with severe aplastic anemia (SAA).Eleven patients were treated with CM plus allo-HSCT. Nine patients received a conditioning regimen consisting of fludarabine (Flu), anti-thymocyte globulin (pig ALG), or anti-lymphocyte globulin (Rabbit ATG) and cyclophosphamide (CY), and two patients received pig ALG and CY. All patients were treated with Kidney (Shen)-reinforcing, blood-activating, and stasis-removing (KBS) herbal preparation beginning at 1 week before transplantation and ending at 8 weeks after transplantation. Chimerism status was assessed by analyzing short tandem repeat (STR) polymorphisms.All patients recovered hematopoietic function and none had graft failure. The median number of days required for the absolute neutrophil count (ANC) increased to0.5×10(9)/L was 15 days (12-22 days) and for spontaneous platelet recovery to20×10(9)/L without post-transplantation transfusion was 17 days (15-27 days). Nine patients were long-term survivors and achieved full donor chimerism. The overall cumulative incidence of acute graft versus host disease (GVHD) grades I-II and III-IV was 18.2% (2/11) and 9.1% (1/11), respectively. The overall accumulated incidence of chronic GVHD was 27.3% and all patients had limited chronic GVHD. At a median follow-up time of 32 months (range: 12-97 months), 9 patients were still alive. The estimated 5-year overall survival (OS) rate was 81.8%. The incidence of treatment-related mortality, 2-year post-transplantation, was 18.2%. Two patients died from GVHD after transplantation.Treatment with the KBS formulation may reduce the rate of graft failure and treatment-related mortality and improve the rate of OS in SAA patients with allo-HSCT.

To explore differences in bone marrow angiogenesis seen in aplastic anemia (AA) patients presenting with differential Chinese medicine (CM) syndrome, and to correlate these differences with clinical pathology.Thirty-five patients were enrolled, including 18 with "yang deficiency syndrome" and 17 with "yin deficiency syndrome." Bone marrow biopsies and serum were collected. Microvessel density (MVD) and positive expression of vascular endothelial-derived growth factor (VEGF) were detected by immunohistochemisty. Hypoxia inducible factor -1α (HIF-1α), and VEGF expression were assayed by enzyme-linked immunoabsorbent assay (ELISA), serum lactate dehydrogenase (LDH) was tested by enzyme method and liquid chip technology was used to detected the expression of interleukin (IL)-2, IL-4, IL-6, IL-10, interferon (IFN)-γ and tumor necrosis factor (TNF)-α.Counts for leukocytes, absolute neutrophils and platelets in "yin deficiency syndrome" were lower than those found in "yang deficiency syndrome" (P0.05). MVD and VEGF expression, and the positive rate of CD34 and VEGF in bone marrow were lower in AA, especially in "yin deficiency syndrome" (P0.01 or P0.05). "Yin deficiency syndrome" displayed decreased VEGF and LDH expression, and enhanced expression of HIF-1α as compared to "yang deficiency syndrome" (P0.05). Levels of IL-4 and IL-6 were higher in AA (P0.01), but IL-10 was decreased (P0.05). High TNF-α expression was seen in "yang deficiency syndrome" and IFN-γ expression was decreased in "yin deficiency syndrome" as compared with normals (P0.01 and P0.05, respectively).AA patients have lower MVD than normals, especially in "yin deficiency syndrome." MVD might differentially correlate to disease severity, and could be dependent on bone marrow or serum VEGF expression and LDH. Additionally, IL-2, IL-10, IL-4 and IFN-γ were negatively associated while IL-6 and TNF-α were positively associated with MVD.

Because the mechanism underlying the development of acute pancreatitis (AP) has not yet been fully clarified, it has been a hot but difficult topic in basic and clinical research for a long time. Currently, the dominant hypothesis for the pathogenesis of AP is that it is a disease of self-digestive acute chemical inflammation induced by trypsin activation. As proteins to trigger the inflammatory response cascade, Toll-like receptors (TLRs), especially TLR4, provide a new clue for studying the pathogenesis of AP from the source. Some studies have found that when TLR4 is activated by certain factors, it can amplify an inflammatory effect and aggravate the body's inflammatory response through a series of signal transduction. Toll-like receptor 4 may play an important role in the synthesis and release of proinflammatory cytokines, and the up-regulation of the TLR4 gene may be related with the development and progression of multiple organ injury during AP. As the "gate" of inflammatory response, TLR4 may be closely associated with the development and progression of multiple organ injury during AP. Understanding the roles of TLR4 in AP will help to further clarify the pathogenesis of AP and to search a new target for the treatment of AP.

Aplastic anemia (AA) is a common hematologic disease characterized by hematopoietic failure of the bone marrow and pancytopenia of the peripheral blood. Some patients with AA suffer from transfusion-induced iron overload secondary to long-term blood transfusions due to moderate and severe anemia. Topics related to iron overload and chelation therapy have recently become important in hematologic diseases, especially in hematopoietic failure. However, no animal model of AA complicated by iron overload has been developed, which affects drug research and development. The purpose of our study is to establish a mouse model of aplastic anemia complicated by iron overload. We firstly controlled the total dose of iron supplements (2.0 *103 mg/kg) and compared how serum iron and ferritin levels varied among different dosage regimens to determine the best dosage and duration for the development of an iron overload model in mice (we finally chose the 200 mg/w/kg * 10 weeks). A composite model of AA was successfully established on the principle of immune-mediated bone marrow failure: DBA/2 mice were euthanized by cervical dislocation and the thymuses were taken out using aseptic techniques for the preparation of cell suspensions of 5 * 106/mL; Balb/c mouse were given whole-body irradiation with 60Co 6.0 Gy at 1 Gy/min, after which 0.2 mL of the prepared cell suspensions was injected into each mouse via the caudal vein within 4 h. We then compared the differences in liver volume, peripheral hemogram, bone marrow pathology, serum iron, serum ferritin, pathological iron deposition in multiple organs (liver, bone marrow, spleen), liver hepcidin, bone morphogenetic protein 6 (BMP6), SMAD family member 4 (SMAD4), transferrin receptor 2 (TfR2) protein, and mRNA expression levels among the Normal Control, AA, Iron Overload, and Composite Model groups to validate the composite model and to explore the pathogenesis and features of iron overload in the composite model. The results indicated significant abnormalities in iron metabolism parameters in mice with AA, which was reflected in the significant decrease of hepcidin expression in the liver (P < 0.01) that basically paralleled the changes in BMP6, SMAD4, and TfR2. Iron Overload Group had a suppressed hepcidin, BMP6, and SMAD4 mRNA expressions in liver, but these parameters were higher than in the AA group (P < 0.01). Association with iron overload would not further downregulate the negative parameters of iron deposition in mice with AA, and SMAD4 and TfR2 protein levels and hepcidin and SMAD4 mRNA expression levels were lower in the AA group than in the Composite Model group (P < 0.01 or P < 0.05). (see Fig.1 and Fig.2) The established model is basically consistent with the clinical manifestations and pathogenesis of AA complicated by transfusion-induced iron overload. This successful establishment will help in the screening of iron chelation drugs and studies on pharmacological mechanisms. Figure 1. Western-blot a nalysis of hepcidin, BMP6, SMAD4 and TfR2 expression among groups Figure 1. Western-blot a nalysis of hepcidin, BMP6, SMAD4 and TfR2 expression among groups Figure 2. Analysis of hepcidin, BMP6, SMAD4 and TfR2 mRNA expression levels among different groups Figure 2. Analysis of hepcidin, BMP6, SMAD4 and TfR2 mRNA expression levels among different groups Disclosures No relevant conflicts of interest to declare.

ObjectiveTo explore the effect of kidney-reinforcing, blood-activating and stasis-removing recipes on adhesion molecule expression of bone marrow mesenchymal stem cells (MSCs) from patients with chronic aplastic anemia (CAA).MethodsWe used three Traditional Chinese Medicine recipes, namely a kidney-reinforcing recipe (KRR), blood-activating and stasis-removing recipe (BASRR), and kidney-reinforcing, blood-activating and stasis-removing recipe (KRBASRR), and a normal saline control to prepare herbal medicine serum in Sprague Dawley rats. Thirty CAA patients were enrolled in the experimental group, including 17 kidney-Yang deficient patients and 13 kidney-Yin deficient patients. Ten healthy individuals were included in the control group. MSCs were isolated from bone marrow samples, and the cell density was observed to measure their proliferation ability by microscopy on days 2, 7, and 14 after isolation. In addition, the expression of adhesion molecules of bone marrow MSCs (CD106, CD49d, CD31 and CD44) were detected by flow cytometry after 48 h of treatment with the four different herbal medicine serums.ResultsThe proliferation of MSCs from kidney-Yang deficient and kidney-Yin deficient patients was weaker than that of MSCs from the control group. The expression of all adhesion molecules of bone marrow MSCs from CAA patients was obviously lower than that in the control group (P