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Indian Pediatr 2012;49: 839-840
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Good Outcome with ATG in Aplastic Anemia:
Welcome News, Though Thought-provoking!
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Sapna Oberoi and Deepak Bansal
Hematology-Oncology Unit, Department of
Pediatrics, Advanced Pediatric Center, Post Graduate Institute
of Medical Education and Research, Chandigarh, India.
Email:
[email protected]
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We read with interest the article by Nair, et al. [1] on
immunosuppressive therapy (IST) in children with aplastic. It is
encouraging that authors have shared their experience and reported good
results. A uniform dose and preparation of anti-thymocyte globulin was
administered to all patients. There are a few points that we would like
to highlight.
The response rate reported in earlier studies from
India is nearly half as compared to reported by Nair et al. The
difference is difficult to explain from better supportive care alone, as
the patients dying from infections during first 3-months of therapy were
excluded from analysis in earlier Indian studies [2-5]. Additional
causes for the better response could be lower number of children with
very severe aplastic anemia (VSAA) and a lower symptom-to-IST interval.
• The number of children with VSAA is much lower
as compared to earlier studies from India (12% vs. 27-45%)
[2-4]. The data from western countries is conflicting on response of
VSAA to IST. Chandra, et al.[2], and Sharma, et al.[3],
have reported lower response rates in VSAA as compared to SAA (33%
vs. 54.5% and 25% vs. 68.7%), respectively. Similarly,
children with higher neutrophil count were found to have superior
response by Gupta, et al. [4].
• The median symptom-to-IST interval in
the study was 2.5 months. This interval is nearly the same or less
than diagnosis-to-IST interval in earlier Indian studies,
except the one from Varanasi [2,4-5]. A quicker referral and early
administration of IST in armed forces hospitals, as compared to
‘civilian institutions’ is possibly another reason for the superior
outcome. Recent studies have documented that a shorter
diagnosis-to-IST interval predicts better response by preventing
irreversible damage to hematopoietic progenitor cells from
auto-reactivated T cells.
The relapse rate observed (3%) is significantly less
as compared to several Indian/Western pediatric series (10-33%).
Although relapses can occur several years following IST, the median time
to relapse in majority of the reports is 18-30 months. A prolonged
duration and slow tapering of cyclosporine has been reported to be
associated with a lower relapse rate. Although, the authors have
mentioned the cyclosporine schedule in the treatment protocol, the
median duration of administration of cyclosporine and cyclosporine
dependence has not been cited. This information may help to explain the
lower relapse rate.
It would be interesting to learn if such good results
are replicated from other centers in India in the future.
References
1. Nair V, Sondhi V, Sharma A, Das S, Sharma S.
Survival after immunosuppressive therapy in children with aplastic
anemia. Indian Pediatr. 2012;49:371-6.
2. Chandra J, Naithani R, Ravi R, Singh V, Narayan S,
Sharma S, et al. Antithymocyte globulin and cyclosporin in
children with acquired aplastic anemia. Indian J Pediatr.
2008;75:229-33.
3. Sharma R, Chandra J, Sharma S, Pemde H, Singh V.
Antithymocyte globulin and cyclosporine in children with aplastic anemia:
a developing country experience. J Pediatr Hematol Oncol. 2012;34:93-5.
4. Gupta V, Kumar A, Tilak V, Saini I, Bhatia B.
Immunosuppressive therapy in aplastic anemia. Indian J Pediatr. 2012 Jan
25. [Epub ahead of print]
5. George B, Mathews V, Viswabandya A, Lakshmi KM,
Srivastava A, Chandy M. Allogeneic hematopoietic stem cell
transplantation is superior to immunosuppressive therapy in Indian
children with aplastic anemia—a single-center analysis of 100 patients.
Pediatr Hematol Oncol. 2010;27:122-31.6.
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