Background: In this single-arm phase II study (NCT03557099), we evaluated the efficacy and safety of hetrombopag, a small molecule thrombopoietin (TPO) receptor agonist, in patients with severe aplastic anemia (SAA) who were refractory to standard first-line immunosuppressive therapy (IST). Methods: SAA patients who were refractory to standard first-line IST were given hetrombopag orally at an initial dose of 7.5 mg once daily to a maximum of 15 mg once daily, for a total of 52 weeks. The primary endpoint was proportion of patients achieving hematologic responses in ⩾1 lineage at week 18. Results: A total of 55 eligible patients were enrolled and received hetrombopag treatment. This study met its primary endpoint, with 23 [41.8%, 95% confidence interval (CI) = 28.7–55.9] patients achieving hematologic response in ⩾1 lineage at week 18 after initiation of hetrombopag treatment. Twenty-four (43.6%, 95% CI = 30.3–57.7) and 27 (49.1%, 95% CI = 35.4–62.9) of the 55 patients responded in ⩾1 lineage at weeks 24 and 52, respectively. Median time to initial hematologic response was 7.9 weeks (range = 2.0–32.1). The responses were durable, with a 12-month relapse-free survival rate of 82.2% (95% CI = 62.2–92.2). Adverse events occurred in 54 (98.2%) patients, and 28 (50.9%) patients had treatment-related adverse events. Seventeen (30.9%) patients had adverse events of grade ⩾3. Serious adverse events occurred in 15 (27.3%) patients and three deaths (5.5%) were reported. Conclusion: Hetrombopag showed encouraging efficacy with durable hematologic responses in patients with SAA who were refractory to IST. Hetrombopag was well tolerant and safe for long-term use. ClinicalTrials.gov identifier: NCT03557099

Hetrombopag is the only CFDA-approved thrombopoietin (TPO) receptor agonist for severe aplastic anemia (SAA) in China. Its chemical structure has an iron chelation domain. To explore the iron chelation effect of hetrombopag, we performed a post hoc analysis of the phase II clinical trial (NCT03557099). Thirty-five immunosuppressive therapy (IST)–refractory SAA patients were enrolled in the study, and the longitudinal changes of serum ferritin (SF) were assessed. At 18 weeks post-hetrombopag initiation, 51.4

Posttransplant cyclophosphamide (PTCy) as graft-versus-host disease (GVHD) prophylaxis is an effective strategie for patients receiving matched sibling donor hematopoietic stem cell transplantation (MSD-HSCT) and haploidentical HSCT (haplo-HSCT). We evaluated the effectiveness and safety of reduced-dose cyclophosphamide, 20 mg/kg for 13 patients in MSD-HSCT cohort and 25 mg/kg for 22 patients in haplo-HSCT cohort, on days + 3, + 4 combined with cotransplantation of peripheral blood stem cells (PBSCs) and human umbilical cord-derived mesenchymal stem cells (UC-MSCs) for severe aplastic anemia (SAA). In MSD-PTCy cohort, the times to neutrophil and platelet engraftment were significantly shorter than those in the MSD-control cohort (P < 0.05). The cumulative incidence of acute GVHD (aGVHD) at day + 100 (15.4%) was lower than that in the MSD-control cohort (P = 0.050). No patient developed chronic GVHD (cGVHD). The 1-year overall survival (OS) and event-free survival (EFS) rates were 100% and 92.3%. In haplo-PTCy cohort, the times to neutrophil and platelet engraftment were significantly shorter than those in the haplo-control cohort (P < 0.05). The cumulative incidences of aGVHD at day + 100 and 1-year cGVHD were 31.8% and 18.2%, and the 1-year OS and EFS rates were 81.8% and 66.9%. Reduced-dose PTCy and cotransplantation of PBSCs and UC-MSCs is an acceptable alternative to patients with SAA.

Introduction: Severe aplastic anemia (SAA) is a hematologic disorder characterized by bone marrow hypoplasia and peripheral pancytopenia. Immunosuppressive therapy (IST) with antithymocyte globulin (ATG) and cyclosporine (CsA) is the standard first-line treatment for patients with SAA who are ineligible for hematopoietic stem cell transplantation (HSCT). For those refractory to or relapsed after IST, eltrombopag (an oral thrombopoietin receptor agonist) were recommended as the second-line therapy by US FDA and European Medicines Agency (EMA). However, in several countries including China, eltrombopag has not been approved for use in patients with SAA, so there is an urgent unmet medical need for additional efficient treatment options. Hetrombopag, another oral thrombopoietin receptor agonist, has similar mechanism in stimulating thrombopoietin receptor signaling pathway as eltrombopag and better pharmacological performance than eltrombopag in pre-clinical study (Xie et al, JCMM 2018). In a phase 1 trial, hetrombopag was safe and well-tolerated in healthy subjects with potent thrombopoietic activity and acceptable pharmacokinetic profiles (Zheng et al, BCPT 2017). Here, in this phase 2 trial (NCT03557099), we aimed to assess the activity and safety of hetrombopag in patients with SAA who have had an insufficient response to IST. Methods: This open-label, single-arm, phase 2 study enrolled patients with SAA who have had an insufficient response to IST and were ineligible for transplantation. Patients were given hetrombopag orally at an initial dose of 7.5 mg once daily after overnight fasting. If increase of platelet count was less than 20×109/L from baseline, the dose of hetrombopag was gradually up-titrated by 2.5 mg every 2 weeks to a maximum of 15 mg once daily, for a total of 52 weeks. The primary endpoint was proportion of patients achieving hematologic responses in at least one lineage at week 18. Results: Between June 20, 2018 and May 24, 2019, 55 eligible patients were enrolled and received hetrombopag treatment. The median age was 40 years (range 19-65) and 34 (61.8%) patients were male. As of data cutoff on June 12, 2020, 52 (94.5%) patients received the maximum dose of 15 mg once daily, and the final dose of the other three patients was 7.5 mg, 10 mg, and 12.5 mg, respectively. A total of 24 (43.6%, 95% CI 30.3-57.7) of the 55 patients met primary endpoint, achieving at least one lineage hematologic response at week 18 after the initiation of hetrombopag treatment (Figure 1). Of them, 11 (20.0%) patients had unilineage responses, 7 (12.7%) had bilineage responses, and 6 (10.9%) had trilineage responses. Twenty-four (43.6%, 95% CI 30.3-57.7) patients responded in at least one lineage at week 24 and 27 (49.1%, 95% CI 35.4-62.9) patients responded in at least one lineage at week 52 (Figure 1). Of the 32 patients with responses at week 18, 24, or 52, median time to initial hematologic response was 7.9 weeks (range 2.0-32.1). The responses were durable in majority of patients who remained on hetrombopag treatment, with only six patients relapsed, achieving a probability of recurrence-free survival at 12-month of 79.5% (95% CI 59.9-90.3). Adverse events of any attribution were reported in 54 (98.2%) of the 55 patients, with the most common ones being upper respiratory tract infection (22, 40.0%), increased aspartate aminotransferase (12, 21.8%), and pyrexia (12, 21.8%). Twenty-eight (50.9%) patients had treatment-related adverse events. Adverse events of grade 3 or higher occurred in 17 (30.9%) patients, with only one (1.8%) related to hetrombopag. Three (5.5%) patients underwent dose reduction or treatment interruption and three (5.5%) patients were discontinued from treatment because of adverse events, but none of which was considered as drug-related. Fifteen (27.3%) patients had serious adverse events. Three (5.5%) deaths were reported, and all of them were judged to be not treatment-related. Clonal cytogenetic evolution occurred in two (3.6%) patients during hetrombopag administration, with one patient had a loss of chromosome 7 and one had an increase of chromosome 8. Conclusions: Hetrombopag showed encouraging activity with multilineage hematologic responses in patients with SAA who have had an insufficient response to prior IST. Hetrombopag was well-tolerated and safe. This study provided evidences that hetrombopag might represent a novel treatment option for patients with SAA. Disclosures He: LongBio Pharma: Consultancy, Research Funding; F. Hoffmann-La Roche: Consultancy, Other: Medical writing support, furnished by Scott Battle, PhD, of Health Interactions, was funded by F. Hoffmann-La Roche Ltd, Basel, Switzerland. Shen:Jiangsu Hengrui Medicine Co., Ltd: Current Employment. Tai:Jiangsu Hengrui Medicine Co., Ltd: Current Employment. Zhang:Jiangsu Hengrui Medicine Co., Ltd: Current Employment. Zhu:Jiangsu Hengrui Medicine Co., Ltd: Current Employment. Zou:Jiangsu Hengrui Medicine Co., Ltd: Current Employment.

For patients with pure red cell aplasia (PRCA), cyclosporine (CsA) is the first line therapy. Occasionally, some patients who suffer from renal insufficiency cannot tolerate CsA. To explore the efficacy and tolerance of sirolimus treatment for those patients, twelve PRCA patients with renal insufficiency from May 2014 to May 2018 in Peking Union Medical College Hospital were enrolled, treated with sirolimus, and followed up at the median time of 16 (10–50) months. Eleven patients (91.7%) responded to sirolimus, with 58.3% complete response (CR) and 41.7% partial response (PR). The median time to achieve the optimum effect was 4 (1–7) months. The serum creatinine level remained stable or even reduced during the treatment period for eleven patients. Seven patients (58.3%) reported adverse events during sirolimus therapy, including increased blood glucose, infection, skin rash, elevated triglyceride or total cholesterol, and elevated serum creatinine compared with baseline. No treatment-related death was noticed during the follow-up time. Three patients relapsed with an overall response rate of 75.0% at 1 year. These results suggested that sirolimus was effective and tolerable for patients with PRCA complicated with renal insufficiency.

BACKGROUND:For symptomatic non-severe aplastic anemia (NSAA) patients who cannot afford anti-thymocyte globulin (ATG) or allogeneic hematopoietic stem cell transplantation (HSCT), tacrolimus (FK) may be an option if these patients do not respond or become tolerant to cyclosporine A (CsA).METHODS:We enrolled 101 NSAA patients who were refractory or intolerant to CsA with no chance of HSCT or ATG treatment and treated these patients with tacrolimus for at least 6 months, with follow-up for at least one year.RESULTS:The overall response rate (ORR) was 38.6% (complete response: 9.9%; partial response: 28.7%), and the median time to optimal response was 6 (3～10) months. Thirty-two (31.7%) cases had elevated creatinine levels. Eight (7.9%) cases had elevations in AST/ALT. A total of 25.6% (10/39) of patients relapsed at the end of follow-up. Age (P=0.0005), FK concentration (4.0~12 ng/mL, P=0.0005) and intolerance to CsA (P=0.012) were the independent risk factors for ORR. Treg cell levels pre-FK treatment were much lower than those of healthy controls (3.7±0.6% vs 6.8±0.7%, P=0.0004) but increased significantly after FK treatment (3.7±0.6% vs 7.1±0.8%, P=0.0039).CONCLUSION:Our data suggest that tacrolimus is a salvage treatment for patients with NSAA that is refractory or intolerant to CsA.

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired hemolytic disease with thrombosis as a major complication. The mechanism of thrombosis and related risk factors in PNH patients are still not well characterized. We retrospectively enrolled 99 patients with newly diagnosed PNH at our institute from 2011 to 2016. According to binary logistic regression model analysis, we first identified four baseline clinical risk factors which may be associated with incidence of thrombosis in the PNH cohort, including PNH clone sizes (fluorescent aerolysin of neutrophil) ≤ 80 (OR 1.056, 95%CI 1.016–1.097, P = 0.005), hemoglobin ≤ 75 g/L (OR 4.202, 95%CI 0.984–17.954, P = 0.053), platelet > 100 × 109/L (OR 6.547, 95%CI 1.490–28.767, P = 0.013) and rs495828 = G (OR 5.243, 95%CI 1.314–20.916, P = 0.019). These independent risk factors were combined together to develop a risk model to evaluate thrombosis risk (AUC = 0.756, 95%CI 0.607–0.905, P < 0.001). Our risk model revealed a higher cumulative incidence of thrombosis and an earlier thrombosis events in PNH patients with high risk (risk score ≥ 23) compared with those with low risk (risk score < 23, P < 0.001 and P = 0.043, respectively). Although with some limitations, we set up a prediction model for thrombosis risk in patients with PNH for the first time, but it needed to be verified in a prospective study with larger patients and longer follow-up time in the future.

AIM:To compare the survivals and treatment related complications between immunosuppression therapy (IST) and haploidentical hematopoietic stem cell transplantation (haplo-HSCT) on children and young adults with severe aplastic anemia (SAA) in East Asia during the last 10 years.METHODS:After looking through Pubmed, Embase, Web of Science and Wanfang Data, a total of 491 patients from 7 retrospective studies conducted in East-Asia were included for meta-analysis based on Stata program. Publication bias was measured by Begger and Egger tests. 1/3/5/10 years overall survivals (OS), failure free survivals (FFS), incidence rates of adverse events and their 95% confidence intervals (CI) were pooled and compared.RESULTS:There was no difference of 1/3/5/10 years OS between IST group and haplo-HSCT group, but the 1/3/5/10 years FFS were significantly better in haplo-HSCT group compared with IST group (p < 0.01). However, higher incidence of infections was observed in haplo-HSCT group compared with IST group (76% versus 45%, p < 0.001). The pooled estimates for acute graft versus host disease (aGVHD) and chronic graft versus host disease (cGVHD) were 54% (95% Cl, 43%～64%) and 43% (95% CI, 18%～68%), respectively for haplo-HSCT group. Among them 38% (95%CI, 22%～54%) was grade III aGVHD and 11% (95% Cl, 0%～22%) was grade III-IV aGVHD. Death causes included severe infection, bleeding in IST group and infection, GVHD in haplo-HSCT group.CONCLUSIONS:The long-term survivals were similar for young patients with SAA who received IST or haplo-HSCT as the frontline treatment. The haplo-HSCT group showed a better FFS, on the other hand, had higher incidence of infection and GVHD.

The aim of this study was to detect the alterations in histone methylation and acetylation in patients with chronic lymphocytic leukemia (CLL). Global histone H3/H4 acetylation and H3K4/H3K9 methylation were detected by the EpiQuik™ global histone H3/H4 acetylation and H3K4/H3K9 methylation assay kits. The mRNA expression of selected chromatin modifier genes was measured by real-time polymerase chain reaction (RT-PCR). Our results found that the global histone H3/H4 hypoacetylation in the CD19+ B cells of patients with CLL (P=0.028 and P=0.03, respectively) and the global histone H3K9 methylation in patients with CLL were significantly increased compared with controls (P=0.02), while there was no significant difference in the global histone H3K4 methylation between the two groups. The level of SIRT1 and EZH2 mRNA expression was upregulated in patients with CLL (P=0.03 and P=0.02, respectively), which increased significantly with progression from Binet stage A to stage C (P=0.015 and P=0.01, respectively) and Rai good to high risk stage (P=0.007 and P=0.008, respectively). The level of HDAC1 and HDAC7 mRNA expression was significantly increased (P=0.02 and P=0.008, respectively) and HDAC2 and P300 mRNA expression was reduced in patients with CLL (P=0.002 and P=0.001, respectively). In conclusion, it is observed that the aberrant histone modification plays an important role in the pathogenesis of CLL.

Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated low platelet count and suppression of megakaryocyte development. Abnormalities of cell-mediated immunity have drawn more and more attention in the pathologic process of ITP. Insulin-like growth factor-1(IGF-1) plays an important role in the regulation of immune response and inflammation, which takes place in innate and acquired immunity. A series of studies had demonstrated IGF-1/IGF-1R pathway was involved in several autoimmune disorders. Thus, we speculated that the IGF-1R rs2229765 polymorphism might be associated with genetic susceptibility to ITP in a Chinese Han population. We compared distributions of rs2229765 polymorphism in 197 patients with chronic ITP and 262 normal controls by polymerase chain reaction and direct sequencing. We also investigated IGF-1 plasma level in normal controls and ITP patients associated with gender, age, genotype, and severity by enzyme-linked immunosorbent assay (ELISA). Both A allele and AA genotype distributions revealed statistical difference in male between childhood ITP and gender-matched controls (p<0.05). However, neither the allele nor genotype frequencies reached significant differences among patients with chronic ITP patients, adult ITP group, female in childhood ITP group and normal controls (p>0.05). The IGF-1 plasma level in ITP patients was significantly decreased compared with the controls (p<0.05). In addition, we observed that the IGF-1 concentration of severe group was evidently lower than non-severe group (p<0.05). However, when ITP patients were respectively stratified by gender, age, and genotype, no significant differences were observed. These results suggest IGF-1R rs2229765 polymorphism may have no relationship with chronic ITP in a Chinese population, but it confirmed at least that IGF-1R rs2229765 polymorphism can be used as an independent predictor for the male in childhood ITP. Abnormal IGF-1 plasma level has contributed to the pathogenesis of chronic ITP patients. IGF-1 plasma level may be used to access the severity of disease, but it has no relationship with IGF-1R rs2229765 polymorphism. These results suggest IGF-1R rs2229765 polymorphism may have no relationship with chronic ITP in a Chinese population, but it confirmed at least that IGF-1R rs2229765 polymorphism can be used as an independent predictor for the male in childhood ITP. Abnormal IGF-1 plasma level has contributed to the pathogenesis of chronic ITP patients. IGF-1 plasma level may be used to access the severity of disease, but it has no relationship with IGF-1R rs2229765 polymorphism.

Clinical studies have demonstrated that omacetaxine mepesuccinate exerts beneficial effects on acute myelogenous leukemia. It has been suggested that omacetaxine mepesuccinate, used alone or with interferon‑α or cytarabine, induces remission in patients with chronic myelogenous leukemia. These effects are possibly mediated by its ability to induce apoptosis of leukemia cells and inhibit the activity of telomerase. To determine whether omacetaxine mepesuccinate is beneficial in diffuse large B‑cell lymphoma (DLBCL), two DLBCL cell lines [a germinal center B cell‑like subtype (GCB) and an activated B cell‑like subtype (ABC)] were treated with omacetaxine mepesuccinate at various concentrations for different durations. The present study indicated that omacetaxine mepesuccinate exerts proapoptotic effects in the two cell types in a dose‑ and time‑dependent manner. The ABC subtype demonstrated increased sensitivity compared with the GCB subtype. At 40 ng/ml, omacetaxine mepesuccinate exhibited a marked proapoptotic effect on DLBCL cells compared with the other tumor cells investigated. Furthermore, omacetaxine mepesuccinate induced cell cycle arrest at G0/G1 phase, and promoted cell terminal differentiation of pro‑B cells. The present study also demonstrated that omacetaxine mepesuccinate exerted its antitumor effect by reducing telomerase activity. In conclusion, the present study demonstrated that omacetaxine mepesuccinate may induce apoptosis and cell cycle arrest, promote cell differentiation, and reduce telomerase activity in DLBCL cells, thus aiding the development of omacetaxine mepesuccinate‑based DLBCL therapeutic strategies.

OBJECTIVE:To investigate the effect of ERK1/2 inhibitor AZD8330 on human Burkitt's lymphoma cell line Raji cells and its mechanism.METHODS:Raji cells were treated with different concentrations of AZD8330. CCK-8 was used to detect the cell viability. The apoptosis rate of Raji cells was detected by flow cytometry using Annexin V/PI-staining. Real-time PCR was used to assess the expression of Bcl-2, Bcl-xl, caspase-3 and VEGF genes. The protein expression level of Bcl-2, Bcl-xl, caspase-3 and p-ERK1/2 was tested with Western blot.RESULTS:The cell survival rate decreased to(62.09±0.86)%,(50.06±1.33)% and (39.13±2.34)% respectively after cells were treated with AZD8330 at 1.00 μmol/L in vitro for 24 h, 48 h and 72 h, and statistically significant differences were observed in groups with different time of treatment(P<0.05). Apoptosis of cells treated with AZD8330 at 0.10, 1.00, 10.00 μmol/L in vitro for 24 h, 48 h and 72 h was analyzed, and the statistically significant differences were observed in groups of different time and concentration treatment (P<0.05). AZD8330 induced Raji cell apoptosis and upregulated expression of Bcl-2, Bcl-xl, VEFG and decreased the expression of caspase-3 in a dose and time dependent manner, and statistically significant differences were observed in groups of different time and concentration treatment (P<0.05). At the same time, the Bcl-2, Bcl-xl and p-ERK1/2 proteins expression is suppressed obviously, but the expression of caspase-3 protein increased.CONCLUSION:AZD8330 induces cell apoptosis by down-regulating the activation of ERK1/2 signal transduction pathway in Burkitt's lymphoma cell line Raji cells in a dose and time dependent manner.