Iron overload (IO) is a pathological condition characterized by excessive iron accumulation, leading to systemic functional impairment. It frequently occurs in patients with congenital or acquired anemia, such as aplastic anemia, who require long-term transfusions. Iron chelation therapy (ICT) is the standard approach for managing transfusion-related IO. However, the currently available iron chelators are limited by their toxicity and administration challenges. Hetrombopag (HPAG), an oral small-molecule non-peptide thrombopoietin receptor agonist (TPO-RA), has been approved for the treatment of immune thrombocytopenia and aplastic anemia. HPAG contains an iron-scavenging moiety that functions independently of its TPO-RA activity; however, its role in ICT has not been clearly defined. In this study, we conducted a longitudinal evaluation of iron burden in clinical cohorts of patients with severe aplastic anemia treated with immunosuppressive therapy alone or in combination with HPAG therapy. Complementary preclinical models mimicking transfusion-induced IO have been used to elucidate the therapeutic potential and underlying mechanisms. Our findings identified HPAG as a potent iron-chelating agent with both prophylactic and therapeutic efficacy against systemic IO. Mechanistically, HPAG functions as a potential ferroptosis inhibitor by significantly reducing toxic iron accumulation, suppressing iron-induced lipid peroxidation at the cellular level, and alleviating systemic complications. These findings advance our understanding of transfusional IO and support the idea that targeting ferroptosis is a novel therapeutic strategy for systemic IO.

The addition of thrombopoietin receptor agonists (TPO-RAs) to immunosuppressive therapy (IST) improves the hematologic response rate and quality in patients with severe aplastic anemia (SAA). However, no studies have yet reported on whether there are differences in the efficacy of TPO-RAs. Here, we retrospectively analyzed the clinical data of SAA patients who received hetrombopag (HPAG) or eltrombopag (EPAG) as part of first-line standard IST to compare the efficacy. Sixty-seven patients were enrolled in the HPAG group and 42 patients in the EPAG group. The overall hematologic response (OR) rates of the HPAG group at 3 and 6 months after IST were 50.7% and 65.6%, respectively, close to that of the EPAG group (50%, p = 0.973; 73.8%, p = 0.494). The rates of complete response (CR) at 3 and 6 months were 13.4% and 31.3% in the HPAG group, respectively, which were like those in the EPAG group (11.9% and 28.6%), with no statistical difference (p = 1.00 and 0.59). The median time to first response (3.0 vs. 3.2 months, p = 0.79) was similar in HPAG and EPAG. The overall survival (OS) rates were 91.0% and 92.8% in the HPAG group and EPAG group (p = 0.53), respectively. Monosomy 7 was detected in one patient in the EPAG group and her disease transformed into acute myelocytic leukemia (AML) at 25 months after ATG treatment. One patient in HPAG had trisomy 8 at 9 months of ATG treatment, and bone marrow examination showed no disease progression. CONCLUSION: The addition of HPAG to standard IST in SAA patients showed similar response rates and response quality to that of EPAG. HPAG could be an alternative to EPAG for the first-line treatment of SAA patients.

Background Luspatercept, approved by the FDA and EMA for patients with transfusion-dependent lower-risk myelodysplastic syndrome (LR-MDS) unresponsive to erythropoiesis-stimulating agents (ESAs), lacks extensive real-world data, particularly in China.Methods We retrospectively analyzed 14 LR-MDS-SF3B1 patients treated with luspatercept for ≥12 weeks.Results Median age was 60 years (range 47-72); 42.9% were male. Before treatment, 78.6% were transfusion-dependent, and 42.9% had prior ESA therapy. At median 24-week follow-up (range 12-44), erythroid response rates were 71.43% (week 12), 75.00% (week 16), and 62.50% (week 24). Hemoglobin levels significantly improved at weeks 12 and 24 (P = 0.013, P = 0.005). No grade 3-4 adverse events occurred. Hematologic improvement-erythroid (HI-E) patients exhibited higher white blood cells, neutrophils, and reticulocytes at week 12 versus non-HI-E patients. Bone marrow analysis revealed erythroid hyperplasia in HI-E patients, with higher erythrocyte percentage (56.00% vs. 34.00%, P = 0.023), lower myeloid-to-erythroid ratio (0.60 vs. 1.59, P = 0.024), and increased polychromatic erythroblasts (19.50% vs. 10.00%, P = 0.034).Conclusions Luspatercept demonstrated efficacy and safety in Chinese LR-MDSSF3B1 patients. Greater erythroid hyperplasia correlated with better clinical response.

This study aimed to assess the prevalence of somatic mutations (SMs) in severe/very severe aplastic anemia (V/SAA) and transfusion-dependent nonsevere aplastic anemia (TD-NSAA) prior to immunosuppressive therapy (IST) and their impact on treatment efficacy. Next-generation sequencing was used to analyze 114 hematopoiesis-related genes at disease onset in 312 patients. SMs were detected in 17.9% of cases, involving 25 genes, most commonly DNMT3A (14, 20.9%) and BCOR (9, 13.4%). SMs were more frequent in patients over 40 years old, predominantly with a single mutation of low variant allele frequency (< 20%). Patients with SM were older and had lower lymphocyte counts. SMs did not significantly influence hematologic responses at 3, 6, or 12 months, relapse, progression, death, survival, or failure-free survival (p > 0.05). Grouping patients by mutated genes revealed no significant differences in IST efficacy, though Group I (PIGA or BCOR/BCORL1) showed higher hematologic response rates in patients over 40 years of age. The cumulative incidence of clonal evolution was higher in Group II (DNMT3A, TET2, ASXL1, FAT1, or RUNX1), though not statistically significant. SMs in V/SAA and TD-NSAA were infrequent and did not affect IST outcomes or treatment decisions. However, the higher clonal evolution incidence in certain mutations warrants further research.

Old individuals are at a high risk of developing aplastic anemia, and immunosuppressive therapy (IST) based on anti-human T-lymphocyte immunoglobulin (ATG) and cyclosporine (CsA) is recommended for treating severe aplastic anemia (SAA). Adding the thrombopoietin receptor agonist (TPO-RA) to IST could improve hematologic responses in patients with SAA; however, limited data exist for elder patients. Here, we report on the efficacy and prognostic factors associated with porcine ATG and CsA with or without TPO-RA as first-line therapy in elderly patients with SAA. Porcine ATG was administered intravenously at a dose of 20 mg/kg/d for 5 days. CsA was administered orally, maintaining plasma trough concentrations of 150–250 µg/L. Eltrombopag was administered at a dose of 75–150 mg/day, and hetrombopag was administered orally at a dose of 15 mg/day. One hundred and twenty-eight SAA patients, with a median age of 63 (60–73) years old, were included in this study, including 44 very severe aplastic anemia (VSAA) patients. All patients completed the porcine ATG treatment, and mild serum sicknesses were observed. Ten patients (2 SAA patients and 8 VSAA patients) died within 3 months of ATG initiation (early death), with severe infections being the main cause of death. Sixty-nine patients achieved a hematologic response at 6 months, with an overall response (OR) rate of 53.9

BACKGROUND Congenital sideroblastic anemia (CSA) is a rare and heterogeneous group of genetic disorders. Conventional treatment include pyridoxine (vitamin B6) and allogeneic hematopoietic stem cell transplantation (allo-HSCT), and can alleviate anemia in the majority of cases. Nevertheless, some CSA cases remain unresponsive to pyridoxine or are unable to undergo allo-HSCT. Novel management approaches is necessary to be developed. To explore the response of luspatercept in treating congenital sideroblastic anemia. CASE SUMMARY We share our experience in luspatercept in a 4-year-old male patient with CSA. Luspatercept was administered subcutaneously at doses of 1.0 mg/kg/dose to 1.25 mg/kg/dose every 3 wk, three consecutive doses, evaluating the hematological response. Luspatercept leading to a significant improvement in the patient's anemia. The median hemoglobin during the overall treatment with three doses of luspatercept was 90 (75-101) g/L, the median absolute reticulocyte count was 0.0593 (0.0277-0.1030) × 1012/L, the median serum ferritin was 304.3 (234.4-399) ng/mL, and the median lifespan of mature red blood cells was 80 (57-92) days. Notably, no adverse reactions, such as headaches, dizziness, vomiting, joint pain, or back pain, were observed during the treatment period. CONCLUSION We believe that luspatercept might emerge as a viable therapeutic option for the maintenance treatment of CSA or as a bridging treatment option before hematopoietic stem cell transplantation.

Idiopathic aplastic anemia is a primary bone marrow failure disease that manifests with pancytopenia. To now, standard IST combined with eltrombopag is recommended as a first-line regimen for severe aplastic anemia patients who are ineligible for HSCT. Several previous studies have shown that IST combined with recombinant human thrombopoietin (rhTPO) or eltrombopag/ hetrombopag can improve the early hematologic response of SAA patients, especially the proportion of good hematologic response (GHR) in the early stage. RhTPO and thrombopoietin receptor agonist (TPO-RA) have different binding sites with thrombopoietin receptor and do not have competitive binding, which may produce a synergistic effect. A retrospective study showed that eltrombopag combined with rhTPO increased the hematologic response rate of IST and improved the quality of hematologic response in SAA with mild adverse effects. Therefore, the combination of TPO-RA and rhTPO in SAA patients undergoing IST treatment may result in faster and higher HR rates. Clinical studies have confirmed that hetrombopag, acts similarly to eltrombopag in SAA, but there are no clinical studies of hetrombopag in combination with rhTPO in SAA. Here, we report a single-center prospective study of 39 patients with naïve severe aplastic anemia treated with porcine ATG and cyclosporine plus hetrombopag combined with rhTPO between March 2023 and April 2024 and evaluate the early outcome of this treatment regimen. Patients received hetrombopag orally at the dose of 15mg daily, as 2.5mg tablets, starting from day+1 of IST and rhTPO with hypodermic injection for 90 days, starting from day+15 of IST. The primary endpoint was to observe the good hematologic response rate, blood product transfusion, and safety profile of the study regimen at 3 months. The median age of 39 patients in the hetrombopag group was 42 years (range from 16 to 70 years), with 22 male and 17 female, with 25 SAA and 14 VSAA. The median follow-up time was 220 days (range: from 100 to 458 days) in the hetrombopag group. No patients experienced death within 3 months after this regimen. The overall hematologic response rate (OR) at 3 months was 75.0% (27/36) in 36 patients who can access the hematologic response. The complete hematologic response rate (CR) at 3 months was 25% (9/36) and the GPR rate was 22.2% (8/36). The overall good hematologic response rate (CR+GPR) was 47.2% (17/36) at 3 months. At 6 months, the overall response was 76.9% (20/26) in 26 patients with accessible response. The complete response rate was 34.6% (9/26) and the GPR rate was 19.2% (5/26) at 6 months. The overall good hematologic response rate (CR+GPR) was 53.8% (14/26) at 6 months. No patients discontinued hetrombopag and rh-TPO due to adverse events. There was no clonal evolution and no death by the last follow-up time point. But the relapse rate was 5.5% (2/36). The two patients were dependent on the platelet transfusion. In conclusion, adding rh-TPO to standard IST combined with hetrombopag had efficacy in treatment-naïve severe aplastic anemia and significantly improved the rapidity and strength of hematologic response.

Background: Hepatitis-associated aplastic anemia (HAAA) is a rare variant of severe aplastic anemia (SAA) characterized with a syndrome of bone marrow failure that traditionally occurs within 6 months of an acute attack of hepatitis. HAAA is potentially lethal if left untreated. Management includes immunosuppression with antithymocyte globulin and cyclosporine and allogeneic hematopoietic stem cell transplantation. Addition of thrombopoietin receptor agonist (TPO-RA) improves both the overall response rate and complete response rate of SAA patients. Here, we tried to investigate the effect and adverse events of TPO-RA added to standard immunosuppressive therapy for HAAA. Methods: A total of 17 HAAA patients who received ATG, cyclosporine and TPO-RA as first-line treatment between April 2019 and January 2024 were enrolled. 6 patients were SAA and 11 patients were very severe aplastic anemia (VSAA) according to the criteria of the International Aplastic Anemia Study Group. All TPO-RAs were added within 1 months after ATG initiation at dose of their standard administration respectively. Results: Of all the patients, 8 received avatrombopag (2 with SAA and 6 with VSAA), 5 received eltrombopag (1 with SAA and 4 with VSAA), and 4 received hatrombopag (3 with SAA and 1 with VSAA). The median neutrophil count was 0.23 (range 0.01-0.78) ×109/L, median reticulocyte count was 11 (range 1-40) ×109/L, and median platelet count was 5 (range 1-12) ×109/L. All patients achieved the end-point of 3 months and 16 patients achieved the end-point of 6 months. The rate of complete response was 11.8% and rate of overall response was 52.9% at 3 months. The rate of complete response at 6 months was 41.2% and rate of overall response was 70.6%. The overall response rate of patients treated with avatrombopag, eltrombopag and hatrombopag were 37.5% vs 40% vs 100%, and 62.5% vs 60% vs 100% at 3, 6 months after IST, respectively. The overall response rate at 3 months and 6 months were both higher than historical results of standard IST (ATG and cyclosporine, 34.1% at 3 months and 56.1% at 6 months). All TPO-RAs were safe, and there was no drug-related liver dysfunction. No patient discontinued TPO-RA due to adverse events. Conclusions: In conclusion, the addition of TPO-RA to IST was safe and associated with higher overall response rate among patients with HAAA.

Severe aplastic anemia (SAA) is a life-threatening bone marrow failure disease. The addition of eltrombopag to immunosuppressive therapy (IST) improves the response rate, but its hepatotoxicity is concerning. Avatrombopag (AVA), a small-molecule thrombopoietin-receptor agonist without hepatotoxicity, has unknown efficacy in SAA treatment. This retrospective study assessed the efficacy and safety of AVA added to IST 42 SAA patients compared to a historical cohort of 84 patients receiving IST alone, using propensity score matching. The median age was 31.5 (6.0-67.0 years) years old in group A and 26 (16.0-45.0 years) years old in group B. At 3 months, group A showed higher complete response (CR) and overall response (OR) rates than group B (CR: 19.0% vs. 4.8%, p = 0.024; OR: 54.8% vs. 39.3%, p = 0.145). Higher CR and OR rates were also found at 6 months in group A than in group B (CR: 31.0% vs. 14.3%, p = 0.145; OR 71.4% vs. 51.2%, p = 0.048). In multivariate analysis of group A, a shorter interval from disease onset to antithymocyte globulin (ATG) treatment (≤6 months) (p = 0.005) predicted better responses rate at 6 months. Event-free survival was also improved in group A (60.7% vs. 49.6%). AVA was well-tolerated, with no hepatic injury observed during treatment, even in those with pre-existing hepatic impairment. The addition of AVA to IST improves both the response rate and response quality in patients with SAA while ensuring safety.

Objective: To analyze the diagnostic value of cell-free plasma metagenomic next-generation sequencing (mNGS) pathogen identification for severe aplastic anemia (SAA) bloodstream infection. Methods: From February 2021 to February 2022, mNGS and conventional detection methods (blood culture, etc.) were used to detect 33 samples from 29 consecutive AA patients admitted to the Anemia Diagnosis and Treatment Center of the Hematology Hospital of the Chinese Academy of Medical Sciences to assess the diagnostic consistency of mNGS and conventional detection, as well as the impact on clinical treatment benefits and clinical accuracy. Results: ①Among the 33 samples evaluated by mNGS and conventional detection methods, 25 cases (75.76%) carried potential pathogenic microorganisms. A total of 72 pathogenic microorganisms were identified from all cases, of which 65 (90.28%) were detected only by mNGS. ②All 33 cases were evaluated for diagnostic consistency, of which 2 cases (6.06%) were Composite, 18 cases (54.55%) were mNGS only, 2 cases (6.06%) were Conventional method only, 1 case (3.03%) was both common compliances (mNGS/Conventional testing) , and 10 cases (30.3%) were completely non-conforming (None) . ③All 33 cases were evaluated for clinical treatment benefit. Among them, 8 cases (24.24%) received Initiation of targeted treatment, 1 case (3.03%) received Treatment de-escalation, 13 cases (39.39%) received Confirmation, and the remaining 11 cases (33.33%) received No clinical benefit. ④ The sensitivity of 80.77%, specificity of 70.00%, positive predictive value of 63.64%, negative predictive value of 84.85%, positive likelihood ratio of 2.692, and negative likelihood ratio of 0.275 distinguished mNGS from conventional detection methods (21/12 vs 5/28, P<0.001) . Conclusion: mNGS can not only contribute to accurately diagnosing bloodstream infection in patients with aplastic anemia, but can also help to guide accurate anti-infection treatment, and the clinical accuracy is high.

Mutations in the mitochondrial aminoacyl tRNA synthetases (ARSs) are associated with various clinical phenotypes, including myopathy, lactic acidosis, and sideroblastic anemia (MLASA), which is a rare autosomal recessive disorder. Due to oxidative phosphorylation disorder and abnormal iron metabolism in the skeletal muscle and erythroid bone marrow lines, patients show progressive muscle weakness, exercise intolerance, lactic acidosis, siderocyte anemia, and growth retardation, etc. Herein, we report a case of MLASA caused by a novel homozygous missense mutation (c.597G>T p.R199S) in the pseudouridine synthase 1 ( PUS1) gene, causing the loss of protein function. The patient's parents had a consanguineous marriage, with a grandmother in common. All mutations were heterozygous without disease. While the patient was homozygous for the mutation and developed symptoms of anemia, no specific treatment exists for this genetic disease. Deferrization therapy can reduce iron overload, which leads to reduced heme synthesis in such patients but cannot treat the disease. Consanguineous marriage often causes autosomal recessive genetic diseases and prohibiting it can reduce the incidence of these diseases. The present patient's condition was caused by a mutation in nuclear PUS1, which manifested as SA, hyperlactatemia, iron overload, and muscle damage. PUS1 mutations can be missense, nonsense, or frameshift. We identified a novel missense mutation type in PUS1 in this patient, located on chromosome 12, c.597G>T (p.R199S), which is a homozygous mutation. This was confirmed by the PUS1 analysis revealing homozygosity for the novel mutation. Both the parents and grandmothers were heterozygous for the mutation, but none of them had a clinical manifestation. Combining the patient's family history, medical history, laboratory examination, and genetic characteristics of the disease, the mutation was identified as a pathogenic variant, and the clinical manifestations and genetic findings of the patient expanded the genotype-phenotype spectrum of MLASA. The possibility of MLASA should be suspected in cases of progressive muscle weakness, growth retardation, exercise intolerance in childhood, SA, and lactic acidosis before or after puberty. With the recognition of MLASA and the advent of NGS, identifying patients with PUS1 mutations characterizing incomplete MLASA syndrome became easier, thus further expanding the phenotypic and genotypic heterogeneities of these mitochondrial disorders. Targeting NGS may also significantly improve the prenatal and preimplantation genetic diagnosis of MLASA, providing better genetic counseling for parents. Genetic diseases lack effective treatment measures, and the curative effect is unsatisfactory. Therefore, prevention is more important. Prevention strategies include avoiding consanguineous marriage, genetic counseling, genetic testing for carriers, and a prenatal diagnosis.

Abstract Objective: To investigate the potential genotype-degree of hemolysis association in hereditary spherocytosis (HS). Methods: 23 HS patients in our cohort all conducted next-generation sequencing (NGS) to detect erythrocyte membrane protein gene mutations and Levitt's carbon monoxide (CO) breath test to detect erythrocyte (RBC) lifespan. The data of RBC lifespan were statistically analyzed according to different mutation genes, types and sites. Results: There were 8 ANK1,9 SPTB,5 SLC4A1 and 1 SPTA1 mutations in our cohort, and the median RBC lifespan of 23 HS patients was 14(8-48) days. The median RBC lifespan of patients with ANK1, SPTB and SLC4A1 mutations was 13(8-23), 13(8-48) and 14(12-39) days, with no statistically significant difference( P =0.618). The median RBC lifespan of patients with missense, splice and nonsense/insertion/deletion mutations was 16.5 (8-48), 14 (11-40) and 13(8,-20) days, respectively, with no statistical difference( P =0.514). The median RBC lifespan of patients with mutations located in the spectrin-binding domain and the non-spectrin-binding domain was 14(8-18) and 12.5(8-48) days, with no statistical difference( P =0.959). 25% of patients with mild hemolysis carried ANK1 or SPTA1 mutations and 75% carried SPTB or SLC4A1 mutations, while 46.7% of patients with severe hemolysis had ANK1 or SPTA1 mutations and 53.3% had SPTB or SLC4A1 mutations. The composition of mutated genes did not differ statistically between the two groups( P =0.400). Conclusion: This is the first study focusing on the genotype-degree of hemolysis association in HS. Our findings indicate that there is no clear correlation between genotype and degree of hemolysis in HS.

Characteristics of mucormycosis in adult acute leukemia: a case report and literature review Fan Huihui, Yang Wenrui, Zhao Xin, Xiong Youzhen, Zhou Kang, Yang Xiawan, Li Jianping, Ye Lei, Yang Yang, Li Yuan, Zhang Li, Jing Liping, Zhang Fengkui State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China Corresponding author: Jing Liping, Email: jingliping@ihcams.ac.cn

Idiopathic aplastic anemia is a primary bone marrow failure disease that manifests with pancytopenia. Standard IST combined with eltrombopag (EPAG) is recommended as a first-line regimen for severe aplastic anemia patients who are ineligible for HSCT. HPAG is also a small molecule non-peptide TPO-RA developed in China, and the preclinical experiments have demonstrated that hetrombopag (HPAG) can promote the proliferation and differentiation of hematopoietic stem cells and the strength of stimulation was superior to eltrombopag. HPAG also can achieve hematological response for over 40% of IST-refractory SAA patients, and it was approved for use in IST-refractory SAA patients in China in 2021. Our previous report showed that as a first-line treatment, it could improve the HR and CR rate of SAA patients by 68.7% and 34.4% within 6 months, but there has yet to be a report on its efficacy compared to EPAG. Therefore, this study aims to evaluate the difference in early treatment efficacy of SAA patients with HPAG/EPAG combined with IST as first-line therapy. A total of 109 patients were included in this study, with a median age of 38 years, 53 male and 56 female. Among them, 67 patients received treatment with HPAG combined with ATG+CSA, and 42 patients received treatment with EPAG combined with ATG+CSA. The median follow-up time for the HPAG group was 13.7 (8.1-19.6) months, with a median usage duration of 12 (9.4-14.5) months. For the EPAG group, the median follow-up time was 22.5 (9.9-30.5) months, with a median usage duration of 13.5 (7.8-18.7) months. At 3 months, 34 (50.7%) cases in the HPAG group achieved HR, including 9 (13.4%) CR. In the EPAG group, 21 (50%) cases achieved HR, including 5 (11.9%) CR. The HR rates in the HPAG group after 3 months of IST were similar to those in the EPAG group, with no statistically significant difference ( P=0.973). At 6 months, there were no differences in HR and CR between the HPAG and EPAG groups, 65.6% vs 73.8% and 31.3% vs 28.6%, respectively ( P=0.494 and 0.452). The median time to first response in the HPAG group was similar to the EPAG group [3.7 (95% CI: 3.1-6) months vs 3.5 (95% CI: 3.2-6) months, P=0.79]. We further compared the efficacy of TPO-RA combined with IST in patients with different severity of disease. The results showed that the HR and CR of patients with VSAA at 3 and 6 months in the HPAG group were no different compared to that in the EPAG group (HR at 3 and 6 months, 22.2% vs 35.7% and 33.3% vs 57.1%, P=0.671 and 0.404, respectively; CR at 3 and 6 months, 11.1% vs 14.3% and 16.7% vs 28.6%, P=1.000 and 1.000, respectively). In the patients with SAA, the HR, and CR at 3 and 6 months in the HPAG group were comparable to that in the EPAG group (HR, 61.2% vs 57.1% and 77.6% vs 82.1%, P=0.883 and 0.557, respectively; CR, 14.3% vs 10.7% vs 36.7% vs 28.6%, P=1.000 and 0.486, respectively). In the multivariable analysis, for all 109 patients, the acquisition of HR at 6 months was unrelated to TPO-RA types, and positively correlated with higher HGB and PLT levels and PNH positivity, while negatively correlated with disease severity and ALC levels. Baseline PLT levels were the only predictive factor for EPAG group patients to achieve HR 6 months after IST. The acquisition of HR in HPAG group patients after IST was negatively correlated with disease severity and ALC levels, and positively correlated with baseline PNH positivity. Overall, both HPAG and EPAG have good safety profiles, and no patients discontinued treatment due to adverse drug reactions. Abnormal liver function is a concern for both drugs and changes in the main liver function indicators (AST, ALT, DBIL, IBIL) at 3 and 6 months after IST. Among them, significant increases in indirect bilirubin levels were observed in patients using EPAG at 3 and 6 months ( P<0.001), while no significant increases in indirect bilirubin levels were observed in the HPAG group. Overall, HPAG added to standard IST can provide SAA patients with similar efficacy to EPAG, while achieving deeper and faster hematological responses. Moreover, the hepatic safety of HAPG may be superior to EPAG. However, this study is a retrospective study with a small number of cases, and large-scale prospective clinical studies are still needed to verify the results.

Acquired severe aplastic anemia (SAA) is a life-threatening bone marrow failure disease and its pathogenesis involves T cell-mediated autoimmunity. Antithymocyte globulin (ATG) and cyclosporine based immunosuppressive therapy (IST) is effective for patients not eligible for hematopoietic stem cell transplant, and the response rate is 60-70%. Complete hematological response (CR) predicts better survival of patients received IST treatment, but only a few patients achieve CR within 6 months (5% at 3 months and 12-17% at 6 months). Thrombopoietin receptor agonist (TPO-RA) eltrombopag improves the overall response (OR) rate and CR rate of SAA patients when combined with IST, but its hepatotoxicity is still worrying. Avatrombopag is another small-molecule TPO-RA without hepatic toxicity. We previously found that SAA patients received avatrombopag and IST as first-line treatment showed both higher CR rate and OR rate at 3 and 6 months. To validate our findings, a prospective, single-arm study of avatrombopag and IST for newly diagnosed SAA was carried out (NCT05720234). There were 25 patients enrolled in the study by June 31, 2023, including 21 SAA patients and 4 very severe aplastic anemia patients. Patients were diagnosed as AA within 6 months and received ATG, cyclosporine and avatrombopag as first-line treatment. Avatrombopag was administered at the first day of ATG initiation at dose of 60mg per day for patients weight ≥ 50kg and 40mg per day for patients weight < 50kg. ATG was given for 5 consecutive days. Cyclosporine was given orally at dose of 3.5-5mg/kg.d. There were 15 males and 10 males, at a median age of 37 years old. Eighteen patients achieved the end-point of 3 months and 10 patients achieved end-point of 6 months. There were 15 patients achieved hematologic response at 3 months (83.3%), including 5 complete responders (27.8%) and 10 partial responders. The overall response rate at 6 months was 80%, and CR rate was 60%. One patient evolved to hemolytic paroxysmal nocturnal hemoglobinuria at 3 months, with normal count of platelet and white blood cell. In conclusion, the addition of avatrombopag to IST as first-line treatment showed earlier hematologic response and higher complete response rate for patients with SAA.

Objectives: To elucidate the clinical characteristics of AA patients with cytogenetic abnormalities.Methods: We retrospectively screened 30 patients (30/1206, 2.5%) with cytogenetic abnormalities from 1206 patients with severe and very severe AA who received immunosuppressive therapy (IST) during the years 2012-2019.Results: The most common abnormalities were trisomy 8 (+8, 10/30, 33.3%) and loss of Y (-Y, 8/30, 26.7%). The abnormal clones disappeared 6 months after IST in 14 patients and sustained in 12 patients. Patients with sustained abnormal clones had a lower hematologic response at 6 months after IST than the disappeared (33.3% vs. 64.3%, p = .116). The hematologic response after IST, 5-year overall survival, 5-year event-free survival, myelodysplastic syndrome or acute myeloid leukemia transformation in AA patients with cytogenetic abnormalities were not statistically different from those in normal cytogenetic patients. Conclusion: For AA patients with chromosome abnormalities but ineligible for hematopoietic stem cell transplant, IST is effective and appropriate as first-line treatment.

Backgroun d: As a high-risk group of clinical infection, patients with severe aplastic anemia (SAA) have high mortality due to agranulocytosis or immune function impairment. The current conventional detection methods such as blood culturetissue chulture etc. often cannot identify pathogenic bacteria. We evaluate the diagnostic performance of metagenomic next-generation sequencing (mNGS), and explore the application value of mNGS in infected patients in SAA, in order to provide help for precision therapy. Methods: From Ocb 2020 to Dec 2022 in our center, we enrolled 70 SAA patients with infection and investigated the usefulness of mNGS of plamsa or tissue DNA for identification of infectious pathogens. The consistency of the results of mNGS and the results of routine etiological detection (blood culture(BC), swab/tissue culture) with clinical infection diagnosis and the influence of the results of mNGS on clinical infection treatment were compared. Results: 70 SAA patients of mNGS were detected, including plasma-mNGS 66 cases and tissue-mNGS 4 cases. Among all patients, 48 cases(68.6%) were positive. In comparison to blood culture, the positive and negative agreement of mNGS were 100% (13/13) and 38.6% (22/57), respectively. In 48 mNGS positive cases, 36 patients (75%) underwent antimicrobials adjustment, resulting in positive impact on 30 patients. Fungi were detected in 29 cases, the detection rate was 41.4% (29/70) by mNGS, otherwise 2.8% (2/70) by BC. Of the 70 patients with SAA, 55 infections eventually impproved (78.6%). Conclusion: The positive rate of mNGS detection and the consistent rate with clinical diagnosis are higher than that of conventional etiological detection, which provides a faster and more sensitive detection method for infected patients in SAA. 【 Key words 】 Metagenomic Sequencing ; Plasma Microbial Cell-free DNA; Aplastic anemia; Infection; pathogen diagnosis

Objective The objective is to evaluate the early hematologic response (HR) rate and safety of immunosuppressive therapy (IST) combined with avatrombopag as the first-line treatment for severe/very sever aplastic anaemia(V/SAA) in elderly patients. Methods Prospective，multi-center, single-arm, clinical research. IST treatment regimen: pig anti-human lymphocyte globulin (ALG-p, Wuhan Institute of Biological Products Co., Ltd. China) 20 mg/kg/d for five days and cyclosporin A (CsA) 3 mg/kg/d with adjusted concentration of 150-250 ng/mL, and oral avatrombopag 40 mg/d from the first day of IST initiation up to six months. The patients' treatment responses were evaluated and the major adverse events were collected. Results Ten patients have been enrolled in the study at our centre from June 2022 to October 2022.Among 10 patients, six had SAA and four had VSAA; male: female = 1:1, median age of 68 (60-82) years, and median time from diagnosis to treatment of 44 (20-480) days. The patients' treatment responses were evaluated after initiation of IST, at 3 months: 7 HR [1 complete response (CR), 3 good partial response (GPR), 3 partial response (PR), and 3 no response (NR)]; and at 6 months: 8 HR (1 CR, 5 GPR, 2 PR) and 2 deaths due to infection. The median time of red-cell transfusion independence was 60 (3-168) days in HR patients and that of platelets was 60 (16-153) days. No relapse and clonal evolution occurred within six months. Major adverse events within three months were infection in five cases, electrolyte disturbance in five cases, and cardiac insufficiency in three cases. Liver function abnormalities occurred in two cases, both of which showed elevated alanine aminotransferase up to 174 μ/L and 208.7 μ/L on day 8 and 20 of IST treatment, respectively. Two of the five infected patients had sepsis caused by Enterobacter cloacae. Except for infection, the remaining adverse events were of grade I-II. All the adverse events were effectively controlled. Table 1 summarises the characteristics and clinical status of patients before and after the treatment. Conclusion This preliminary study of IST combined with avatrombopag for the treatment of elderly patients with V/SAA showed the potential of the combination to improve haematologic response rate and quality in elderly patients with AA, and it is well tolerated as well. Keywords: immunosuppressive therapy, severe aplastic anaemia, avatrombopag, elderly

Hepatitis-associated aplastic anemia (HAAA) is an uncommon but distinct variant of aplastic anemia (AA), in which an episode of seronegative acute hepatitis precedes the onset of pancytopenia. Previous studies indicated that about only 20% of HAAA patients can get their hematologic partially restored after 3 months treatment with standard immunosuppressive therapy (IST). Recent studies have shown that adding thrombopoietin receptor agonist (TPO-RA) eltrombopag to standard IST can lead to a more, faster, and better hematologic responses. Nevertheless, eltrombopag is often associated with hepatic adverse effects, i.e., elevated transaminases and bilirubin, which maybe limit its use in patients with HAAA who have just experienced severe liver damage. Avatrombopag is also a TPO-RA, which was approved for the treatment of thrombocytopenia in patients with chronic liver disease (CLD) and patients with chronic immune thrombocytopenia (ITP) by the U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA). The pre-clinical studies indicated that avatrombopag can promote the hematopoietic and megakaryocyte progenitor cells proliferation and differentiation by the dose-dependence. These in vitro effects are similar to those of other TPO-RAs, including Eltrombopag. Theoretically, on the basis of adequate IST, avatrombopag can also promote hematopoietic recovery in patients with aplastic anemia just as Eltrombopag works. If this is true, then avatrombopag should be particularly suitable for HAAA due to its favorable hepatic adverse effect profile. Nevertheless, avatrombopag added to standard IST as first-line treatment for aplastic anemia could increase the rapidity and strength of hematologic response is still unknown. Herein, we retrospectively reviewed 8 consecutive cases of patients with hepatitis-associated aplastic anemia who were treated with avatrombopag plus IST regimen. From September 2021 to December 2022, eight patients with hepatitis-associated aplastic anemia treated with avatrombopag in combination with standard IST were enrolled in this study. Among them, seven patients were diagnosed as VSAA and one SAA. The median age was 17 (9-20) years old and the median absolute neutrophil count was 0.09 (0.02-0.39) ×10 9/L. The median time from onset of hepatitis to hematopoietic failure was 2 (0.5-5.5) months, and at the time of beginning of IST all the eight patients had their liver biochemical testing returns to normal. The karyocytes were normal in all patients. One patient presented positive PNH clone at the diagnosis of HAAA, with PNH clone size of 4.7%. Avatrombopag was incorporated into day 1 of standard immunosuppressive therapy with p-ATG and cyclosporine for all the eight HAAA patients. The dose of avatrombopag was 40 mg/d at least 6 months. Dosage adjusting of avatrombopag was according to patient's platelet counts and adverse events. Encouragingly, four of the eight patients (50.0%) achieved hematologic response (HR) with two (20.0%) getting complete response (CR) at 3 months after IST and avatrombopag. Between 3 and 6 months after IST, the other two patient entered their hematologic responded. Then, six of eight (75.0%) patients got HR at 6 months, including 3 CR, 2 good partial hematologic response (GPR), and 1 partial response (PR). Unfortunately, one patient who was diagnosed as very severe HAAA, was without getting hematologic response and died at 118 days after treatment due to gastrointestinal infection. We evaluate the side effects of avatrombopag and graded according to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. No hepatic adverse events were observed in all the eight patients, that indicated avatrombopag may not increase the hepatic burden and is safe for HAAA. The median follow-up time was 371(118-665) days. Except for one patient who died within 6 months, six cases achieved hematologic response, with 4 CR and 2 GPR. There is no clonal evolution, i.e., MDS, AML, and PNH, was observed. In conclusion, avatrombopag may be used as a safe and effective TPO-RA, added to IST for the treatment of hepatitis-associated aplastic anemia, which maybe improve the efficacy and the strength of hematologic response in HAAA.