Condensed versus standard schedule of high-dose cytarabine consolidation therapy with pegfilgrastim growth factor support in acute myeloid leukemia.

The aim of this cohort study was to compare a condensed schedule of consolidation therapy with high-dose cytarabine on days 1, 2 and 3 (HDAC-123) with the HDAC schedule given on days 1, 3 and 5 (HDAC-135) as well as to evaluate the prophylactic use of pegfilgrastim after chemotherapy in younger patients with acute myeloid leukemia in first complete remission. One hundred and seventy-six patients were treated with HDAC-135 and 392 patients with HDAC-123 with prophylactic pegfilgrastim at days 10 and 8, respectively, in the AMLSG 07-04 and the German AML Intergroup protocol. Time from start to chemotherapy until hematologic recovery with white blood cells >1.0 G/l and neutrophils >0.5 G/l was in median 4 days shorter in patients receiving HDAC-123 compared with HDAC-135 (P<0.0001, each), and further reduced by 2 days (P<0.0001) by pegfilgrastim. Rates of infections were reduced by HDAC-123 (P<0.0001) and pegfilgrastim (P=0.002). Days in hospital and platelet transfusions were significantly reduced by HDAC-123 compared with HDAC-135. Survival was neither affected by HDAC-123 versus HDAC-135 nor by pegfilgrastim. In conclusion, consolidation therapy with HDAC-123 leads to faster hematologic recovery and less infections, platelet transfusions as well as days in hospital without affecting survival.

Immunoglobulin and T-cell receptor gene rearrangements in Hodgkin's disease.

We have examined tumor tissue DNA obtained from 32 cases of Hodgkin's disease of the following subtypes: lymphocyte predominance, six; nodular sclerosing, eight; mixed cellularity, 14; lymphocyte depleted, 4; using immunoglobulin and T-cell receptor beta and gamma gene probes. Immunoglobulin heavy chain rearrangements were detected in five patients; in three of them only a minor clonal cell population was visible. T-cell receptor gene rearrangement was not observed in any patient examined. Three patients exhibiting minor clonal immunoglobulin rearrangements showed polyclonal T-cells in the same sample. There was no correlation between the presence and intensity of the rearranged bands and the number of Reed-Sternberg cells. Our data do not confirm recent reports of a frequent occurrence of immunoglobulin or T-cell receptor gene rearrangements in Hodgkin's disease and suggest no possible relation between Reed-Sternberg cells and B- or T-lymphocytes, respectively.

Strategy for the treatment of hairy cell leukemia.

Both splenectomy and alpha-interferon are efficient treatments for hairy cell leukemia. Since interferon therapy seems to induce remissions of the disease, avoids the risks of surgery, and sustains the spleen, it should be discussed if this therapy may replace splenectomy as primary treatment for this disease. In order to make this decision the biologic relevance of complete remissions in hairy cell leukemia, the reliability of methods to confirm remission, the benefits and risks of both splenectomy and interferon therapy, and some aspects of the pathogenesis of the disease have to be considered. Based on our experimental and clinical results and data from other groups, we conclude that splenectomy should still be recommended as primary therapy in hairy cell leukemia provided that treatment is indicated and the patient is eligible for surgery.

In vivo recruitment of GM-CSF-response myelopoietic progenitor cells by interleukin-3 in aplastic anemia.

Previous studies have indicated that colony-stimulating factors may stimulate myelopoiesis and thus increase the number of circulating white blood cells in patients with hematopoietic failure including aplastic anemia. However, long-term administration of the factor was required to maintain its response. In the present article we report on a patient with severe aplastic anemia undergoing treatment with recombinant human (rh) granulocyte-macrophage colony-stimulating factor (GM-CSF). After an initial response, the patient became refractory to GM-CSF. However, treatment with interleukin (IL)-3 restored responsiveness to GM-CSF, suggesting that IL-3 may have replenished the bone marrow with myelopoietic progenitor cells sensitive to the action of GM-CSF. This observation suggests the value of application of sequentially acting hematopoietic growth factors in aplastic anemia patients.

Rearrangement of T cell receptor beta, gamma, and delta gene loci in human pre-T cell acute lymphoblastic leukemia.

Configuration of the T cell receptor (TCR) beta, gamma, and delta chain genes, as well as immunoglobulin (Ig) heavy and light chain genes, was studied in 29 cases of E rosette-negative (pre-T cell) acute lymphoblastic leukemias that lack early B cell (CD19), myeloid (CD33), as well as most T cell associated membrane antigens such as CD1, C4, and CD8, but express CD7, cytoplasmic CD3 (cCD3), and TdT strongly, as well as CD5 and/or CD2 heterogeneously. Hematopoietic progenitor cell markers, namely HLA-DR, J5 (CD10), and My10 (CD34), further characterized this immature T ALL of putative prothymocytic phenotype. Eleven ALLs showed a germline configuration of TCR as well as Ig genes. In three cases, only TCR delta sequences were rearranged, and four additional cases were characterized by recombination of both, TCR gamma as well as TCR delta sequences. Eleven patients showed concurrent rearrangements of TCR beta, gamma, and delta chain genes. An Ig heavy chain rearrangement was observed in one case. These data support the hypothesis that, analogous to pre-B development, a cascade of TCR rearrangements occurs in pre-T cells. Moreover, findings reported here suggest that CD7, as well as CD2 and CD5, antigens appear on precursor cells prior to entry into the thymus and support a model for the developmental hierarchy of TCR genes during early T cell ontogeny.

T cell receptor alpha expression in B-type chronic lymphocytic leukemia.

Normal B lymphocytes are characterized by rearrangement and expression of immunoglobulin genes, but not of T cell receptor genes. These properties might assist in lineage assignment, but there are examples of fresh leukemic cells and of cell lines where exceptions to this rule have been noted. We have studied cell samples of patients with B-CLL for expression of TCR alpha and beta chain genes. Using in situ hybridization with fluorescein-labeled probes, TCR alpha mRNA was found to be expressed in 14 of 18 samples and TCR beta mRNA in 7 of 16 samples. Specificity of hybridization was demonstrated by near complete blockade of TCR alpha hybridization with unlabeled TCR alpha, but not with unlabeled TCR beta probe. Furthermore, in Northern blot analysis a truncated 1,4 kb message for TCR alpha was readily detectable. No significant cell surface staining with the anti-TCR alpha/beta monoclonal antibody WT31 was observed. A contribution of T cells within the leukemic sample could be excluded since only samples with leukemic cell counts of greater than 50,000 cells/mm3 and only samples with 5% or less CD2+ T lymphocytes were studied. Our data show that a large proportion of B-CLL samples may express a truncated version of the TCR alpha message, indicating that this gene can be activated in leukemic B cells frozen at a late stage of differentiation.

Recovery of immune functions in dogs after total body irradiation and transplantation of autologous blood or bone marrow cells.

The restoration of immune functions was followed in dogs for 101 days after fractionated total body irradiation and autologous transfusion of peripheral blood leukocytes (PBL) or bone marrow (BM) cells. Median numbers of 0.9 X 10(5) granulocyte-macrophage progenitor cells per kilogram of body weight were transferred in either group of recipients. The following parameters recovered more rapidly in PBL recipients as opposed to BM recipients: total blood lymphocyte, T- and B-cell counts, serum levels of immunoglobulins IgM and IgA, in vitro blastogenic responses after stimulation with concanavalin A and pokeweed mitogen, and in vitro plasma cell formation after polyclonal B-cell activation with pokeweed mitogen with or without lipopolysaccharide. No major differences were noted for the restoration of serum IgG levels. Circulating lymphocyte and T-cell numbers remained subnormal for more than three months in both groups, whereas B-cell numbers and serum levels of IgA continued to be depressed in BM recipients only. Thus, autologous PBL restored immune functions more rapidly than did BM. Transplantation of PBL, alone or in addition to autologous BM, might also shorten the period of immunodeficiency after cytoreduction in a variety of malignancies in man.

Progenitor cell (CFUc) reconstitution after autologous stem cell transfusion in lethally irradiated dogs: decreased CFUc populations in blood and bone marrow correlate with the fraction mobilizable by dextran sulphate.

The present study in dogs concerns the functional potentials of the myeloid progenitor cell system during hemopoietic recovery after lethal total-body irradiation and autotransfusion of cryopreserved stem cells derived from peripheral blood and bone marrow. CFUc were assayed in peripheral blood and bone marrow before and at various intervals after grafting. In addition, the net increase of CFUc mobilizable from extravascular sites into the blood was determined after i.v. injection of 15 mg/kg body weight of dextran sulphate (DS). The data indicate a sustained deficiency of CFUc in otherwise hematologically normal recipients. The DS-response was subnormal even 225 days after transplantation, suggesting residual damage of the hemopoietic system is present for a prolonged period of time. A significant correlation was found between the actual blood CFUc concentration and the numbers of CFUc mobilizable by DS. Insight into progenitor cell kinetics and corresponding changes in the size of a mobilizable pool in extravascular sites may be helpful in estimating the marrow reserve of transplanted individuals suffering myelosuppressive effects of chemotherapy.

Interleukin-5 is the predominant eosinophilopoietin produced by cloned T lymphocytes in hypereosinophilic syndrome.

Cloned T lymphocytes (TLC) of the CD4+CD8- phenotype established from peripheral blood of a patient with idiopathic hypereosinophilic syndrome (HES) were found to release a lineage-specific eosinophilic colony-stimulating factor (Eo-CSF). The present study was undertaken to identify the lymphokine accounting for this Eo-CSF activity. Comparison of TLC-derived Eo-CSF with recombinant human interleukin-5 (rhIL-5), recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) and recombinant human interleukin-3 (rhIL-3) by in vitro clonogenic assays revealed similar bioactivity of HES-derived Eo-CSF and IL-5. Neutralization studies using specific antibodies against IL-5, GM-CSF and IL-3 confirmed that IL-5 mainly accounts for the Eo-CSF activity in all 9 HES-derived TLC tested. Eosinophilic colony (CFU-Eo) formation supported by conditioned media of the TLC was significantly inhibited in all clones by addition of anti-IL-5 monoclonal antibody (MAB) to the conditioned media. Inhibition by anti-IL-5 MAB was specific and dose-dependent. In 2 of the 9 clones, anti-GM-CSF antibodies could partially neutralize the Eo-CSF activity in the conditioned media. In 4 clones, addition of a combination of anti-IL-5 MAB and anti-GM-CSF antiserum to the conditioned media reduced CFU-Eo formation significantly more than addition of anti-IL-5 MAB alone. In none of the TLC could a significant role for IL-3 in eosinophilic colony formation be shown. These results were confirmed at the mRNA level. Cytokine transcripts were detected by reverse transcription (RT) and subsequent polymerase chain reaction (PCR). Under the same experimental conditions, all HES-derived TLC, but only one third of tested TLC from healthy donors, expressed IL-5 mRNA 5 days after stimulation. In control TLC with inducible IL-5 mRNA expression, IL-5 transcripts were found for only 3 days after stimulation. In contrast, HES-derived TLC contained IL-5 mRNA at least until day 18 after restimulation. All HES clones expressed GM-CSF mRNA upon stimulation. Two HES-derived TLC were found to lack IL-3 mRNA even after stimulation. Whereas IL-5 was expressed abundantly in all HES-clones, the intensity of PCR products for GM-CSF and IL-3 showed striking differences. Our in vitro results suggest that IL-5 produced by activated CD4+ T lymphocytes plays a crucial role in the induction of eosinophilia in HES. In addition, GM-CSF but not IL-3 seems to contribute partially to the increased eosinophil production in HES.

A pathogenetic link between aplastic anemia and paroxysmal nocturnal hemoglobinuria is suggested by a high frequency of aplastic anemia patients with a deficiency of phosphatidylinositol glycan anchored proteins.

The clinical interrelationship between paroxysmal nocturnal hemoglobinuria (PNH) and aplastic anemia (AA) promoted a search for a pathogenetic link. Since the molecular defect in PNH is a failure to express phosphatidylinositol glycan-anchored proteins (PIG-AP), we investigated whether this defect could also be demonstrated on peripheral blood cells of patients with typical AA. Quantification of the expression of PIG-AP was performed by flow cytometry using the monoclonal antibodies (MAbs) CD16 and CD66b for granulocytes, CD14 and CD48 for monocytes, CD48 and CD52 for lymphocytes, and CD55 and CD59 for erythrocytes. We analyzed cells from 52 patients with acquired AA. A PIG-AP-defective population was identified in 27 of 52 patients (52%) in at least one cell lineage. Granulocytes were involved in 25 of 27, monocytes in 18 of 25, lymphocytes in seven of 27, and erythrocytes in seven of 27 AA patients who were affected by a PIG-AP deficiency. The response rate to standard immunosuppressive therapy was significantly higher in the group of patients without a PIG-AP-deficient population than in patients with a PIG-AP-deficient population in at least one cell lineage (85.7 vs. 30.4%; p < 0.0003). Our results demonstrate that on the basis of PIG-AP expression, the proportion of AA patients who show features of typical AA along with a PNH phenotype is substantially higher than previously recognized. The pattern of PIG-AP expression might identify subgroups of AA patients who differ in the underlying mechanism as well as in the course of their disease.

Hematopoietic colony formation after allogeneic bone marrow transplantation: enhancement by cyclosporin A and anti-gamma-(immune) interferon antiserum in vitro.

Bone marrow hematopoietic progenitors (CFU-GM, CFU-E, and BFU-E) were found to be markedly decreased in 21 bone marrow transplant recipients studied from one to 51 months after transplantation. In these patients, bone marrow colony formation could be significantly enhanced by in vitro incubation of the bone marrow target with cyclosporin A (CyA; 0.5 microgram/ml) or with a monoclonal anti-gamma-(immune) interferon (IFN-gamma) antibody. Both effects were highly correlated. The data indicate that (a) endogenous elaboration of IFN-gamma may contribute to decreased colony formation in allogeneic bone marrow transplant recipients, and (b) CyA may induce a gradual release of the progenitor cell pool from IFN-gamma-mediated suppression.

In vitro induction of B cell differentiation in canine mononuclear blood cells: bacterial lipopolysaccharide modulates the action of pokeweed mitogen.

Pokeweed mitogen (PWM) was shown to induce the generation of plasmacytoid cells (PC) from canine peripheral blood mononuclear cells in vitro. PC were detected by immunofluorescence staining of cytoplasmic immunoglobulin. Optimal culture conditions for PC formation were established and the range of the PC response in normal dogs assessed. Addition to PWM of bacterial lipopolysaccharide enhanced PC formation in most instances. This occurred in the absence of increased cell proliferation and without altering the time course of the response. Mitogen-induced PC generation may provide a useful tool for delineating the capacity of canine blood cells to mount a humoral immune response.

Fetal liver transplantation in the dog. II. Repopulation of the granulocyte-macrophage progenitor cell compartment by fetal liver cells from DLA-identical siblings.

The restoration of the granulocyte-macrophage progenitor cell (CFU-GM) compartments in blood and bone marrow, and the recovery of blood monocytes were followed for up to one year in ten beagles that had been exposed to fractionated (3 X 6 Gy) total-body irradiation before being transfused with cryopreserved fetal liver cells (FLC) from sibling donors that were genotypically matched for dog leukocyte antigens. Grafts contained 0.2-1.6 X 10(8) mononuclear cells and 0.9-19.8 X 10(4) CFU-GM/kg body weight. Numbers of circulating monocytes rose parallel to granulocyte numbers after day 6 and became normal by day 18 posttransplant. In bone marrow aspirates, low numbers of CFU-GM were detected on day 3 and their incidence per 10(5) mononuclear cells was normal after day 14. Circulating CFU-GM were present in significant numbers by day 7 and their elevated concentration per milliliter of blood after day 14 continued for one year. Dextran sulfate injection mobilized normal numbers of CFU-GM into the blood early after transplantation, and spontaneously circulating CFU-GM in a later phase did not differ from blood progenitors of normal animals with respect to radiation sensitivity and sedimentation velocity. Thus, FLC transplantation effected a rapid restoration of granulopoiesis and monocytopoiesis, which was reflected at both the level of mature blood cells and the compartments of CFU-GM in blood and bone marrow, underlining the high repopulating capacity of fetal liver stem cells.

Fetal liver transplantation in the dog. I. Restoration of hemopoiesis with cryopreserved fetal liver cells from DLA-identical siblings.

Fetal liver cells (FLC) were obtained from beagle fetuses 52 days postconception, and were cryopreserved prior to transplantation into ten sibling recipients that had previously been exposed to total-body irradiation delivered in 3 fractions of 6 Gy each at 4 days, 2 days, and 2 hr before grafting. Donors and hosts were genotypically identical for dog leukocyte antigens (DLA)-A, B, and D. A rapid and lasting engraftment was achieved in all animals following the transfer of 0.2 X 10(8) to 1.6 X 10(8) mononuclear FLC/kg body weight, which were equivalent to 0.9 X 10(4) to 19.8 X 10(4) granulocyte/macrophage progenitor cells (CFU-GM)/kg. Between days 14 and 20 posttransplant pretreatment levels were detected for blood granulocytes, between days 23 and 28 for circulating platelets, and between days 35 and 40 for the erythrocyte count and hemoglobin concentration. Increasing the number of CFU-GM transfused resulted in an accelerated granulocyte and platelet recovery. Bone marrow cells were of donor origin throughout the observation interval, but declining proportions of host lymphocytes circulated in the peripheral blood during the initial recovery phase. In two dogs, skin alterations that might indicate slight graft-versus-host disease (GVHD) were noted following days 20 and 70, respectively. Six recipients had to be sacrificed due to inanition, probably secondary to radiation-induced pancreatic insufficiency two to three months after grafting. The results of this study indicate that cryopreserved FLC are highly effective in restoring hemopoiesis in DLA-compatible sibling dogs. Transplantation of canine FLC may prove valuable in analyzing mechanisms pathogenetically related to graft rejection or to the development of GVHD following the transfer of T-cell-depleted hemopoietic grafts at a preclinical stage.

Evidence for the involvement of host-derived OKT8-positive T cells in the rejection of T-depleted, HLA-identical bone marrow grafts.

The recent introduction of a variety of techniques for removing T cells from bone marrow grafts has reduced the incidence of graft-versus-host disease (GVHD)-associated morbidity and mortality. Whether this advance will be translated into improved patient survival is unclear at present, mainly because these procedures increase the risk of graft failure. Since 1983 we have transplanted 25 consecutive leukemia patients with HLA-identical sibling grafts purged of T cells by a single incubation with the monoclonal antibody Campath-1 and donor complement. This approach was successful in reducing T cell contamination of the graft and preventing acute and chronic GVHD. In this group of patients two suffered irreversible graft failure and one developed reversible graft failure. In a similarly sized group of patients previously transplanted with unpurged marrow according to the Seattle protocol, no episodes of graft failure occurred. Since other causes of graft failure, such as drug toxicity or viral infections, could be largely excluded, this suggested that the graft failures were specifically related to the purging process. In haploidentical bone marrow transplantation (BMT) O'Reilly has identified residual host-versus-graft activity (HVG) as a cause of graft failure. The causes and mechanisms of graft failure in T-depleted HLA-identical sibling transplants have not been extensively investigated to date. In the three graft failures observed by us, the loss of the graft was preceded by the appearance of a population of activated lymphocytes. We have determined the phenotype and origin of this population and investigated its interactions with donor hemopoietic tissue in vitro.

Conversion of acute undifferentiated leukemia phenotypes: analysis of clonal development.

The cellular origin of acute undifferentiated leukemia (AUL) is still a matter of controversy. We report on two cases in which the diagnosis of AUL was established according to restricted criteria. Blast cells of both patients showed phenotypic conversion during the course of disease. In one case, within 24 days from starting treatment, the leukemic phenotype changed from AUL to acute myelomonocytic leukemia (FAB L1, TdT+ to FAB M4, TdT-). The initial phenotype of this acute leukemia was characterized by the co-expression of both B-lymphoid and myeloid markers on the same cell. Moreover, analysis of esterase isoenzyme pattern showed the whole spectrum of isoenzymes typically seen in myelomonocytic leukemias already at diagnosis, yet blast cells additionally contained all three isoenzymes of beta-hexosaminidase typically seen in AUL. However, examination of immunoglobulin (Ig) heavy chain gene rearrangement initially and after conversion revealed an identical monoclonal configuration of Ig heavy chain sequences in both samples. The second AUL patient relapsed after allogeneic bone marrow transplantation with common ALL-antigen (CALLA) positive acute leukemia. Subsequent Southern blot analysis showed a novel rearranged Ig fragment compared to the analysis before transplantation indicating that the leukemic clones prior to and after transplantation were not identical. No chromosomal abnormalities were observed in both cases. These data support the view that AUL cells originate from a pluripotent stem cell that is capable to differentiate in the myelomonocytic lineage (patient 1), and confirm the value of Ig gene analysis as marker for cellular clonality.

Graft rejection and second bone marrow transplants for acquired aplastic anaemia: a report from the Aplastic Anaemia Working Party of the European Bone Marrow Transplant Group.

Six hundred and eighteen patients with acquired aplastic anaemia grafted from an HLA-identical sibling donor between 1976 and 1990 in eight European centres were reported to the Working Party for Severe Aplastic Anaemia (SAA) Registry and were evaluable for analysis of the incidence of graft failure/rejection and the outcome of second bone marrow transplants (BMT). The number of patients experiencing graft rejection declined significantly over the study period from 32% to 8% (p < 0.0001). This coincided with the introduction of cyclosporine to the conditioning regimen for BMT. The graft rejection rate in the post-hepatitis SAA group was significantly lower than in the group with idiopathic SAA (4% vs 20%) (p = 0.001). The use of irradiation in the conditioning regimen significantly reduced the number of patients experiencing graft rejection (7% vs 21%) (p = 0.004). Age, sex and severity of disease did not influence the rate of sustained engraftment. Of the 85 patients experiencing graft rejection, 41 received a second transplant: their survival is 33% vs 8% for patients not transplanted a second time (p = 0.003). The major factor predicting the outcome of second BMT for SAA was the interval from first BMT. Patients receiving a second BMT within 60 days from the first BMT had a significantly poorer outcome.

Bone marrow structure and its possible significance for hematopoietic cell renewal.

The authors review the progress made during the last quarter of a century in the fields of hematopoietic cellular proliferation and differentiation in relation to the bone marrow structure and the microenvironment provided by the marrow stroma in which unlimited self-renewal occurs. The marrow is conceived of as an organ in which the stroma originates from local mesenchymal elements which form a vascularized and innervated matrix, seeded later by blood-borne stem cells. Transplantation studies using total-body-irradiated dogs show that stem cells derived from the marrow, as well as those from the blood and from the fetal liver, are able to repopulate a marrow rendered aplastic by irradiation. By grafting equal numbers of GM-CFU from peripheral blood and bone marrow, a faster hemopoietic reconstitution is provided by blood-derived stem cells. The most efficient stem cells in the long range are those derived from fetal liver. Bone marrow and peripheral blood GM-CFU differ in some in vitro characteristics such as radiation sensitivity. These peripheral blood cells are more radiosensitive than those derived from the marrow. Autografting of bone marrow mononuclear cell fractions obtained by velocity sedimentation techniques demonstrates that the fraction of small mononuclear cells holds a repopulating potential similar to that of circulating blood stem cells. The cells collected in fraction 2 of a discontinuous albumin gradient contain most of the blood stem cells and repopulate the marrow without causing GVHD, while cells collected in fractions 3 and 4 contain a minimal amount of stem cells and cause severe GVHD.

Treatment of chronic neutropenia of childhood responsive to cyclosporin A in vitro and in vivo.

The clinical course of a 17-year-old patient who suffered from chronic neutropenia without cyclic variation since the age of 2 is presented. The bone marrow showed absent granulopoiesis and yielded very few colony-forming units (CFU-GM) in vitro with maturation up to segmented neutrophils. Incubation with cyclosporin A (CyA) increased CFU-GM markedly. Such an increase was not found after incubation of normal bone marrow with CyA in vitro. The patient also responded to CyA in vivo and maintained adequate granulocyte counts for 7 months when she became neutropenic again. She subsequently responded to high doses of prednisolone. The clinical course and bone marrow studies suggest that the defective granulopoiesis is due to an immunologically mediated mechanism sensitive to CyA and prednisolone. Other findings in this patient, such as impaired natural killer (NK) cell activity and random and chemotactic leukocyte motility, could further point to an imbalance in the regulation of hematopoiesis. Neutropenia, NK cell defect and impaired chemotaxis may be pathogenetically connected.

Pure red cell aplasia: review of treatment and proposal for a treatment strategy.

The management of pure red cell aplasia (PRCA) continues to challenge clinical investigators because the pathophysiology is heterogeneous and poorly understood. There are five treatment regimens that have established efficacy for patients with chronic PRCA. In patients with congenital hypoplastic anemia the best results have been reported using corticosteroids. Cyclosporine A is recommended as the treatment of choice in acquired PRCA. High-dose intravenous immunoglobulin therapy is highly effective in PRCA associated with parvovirus B19 infections and impaired IgG-antibody response. Treatment failures may be successfully managed with horse anti-human thymocyte globulin or cyclophosphamide plus corticosteroids. The potential of hematopoietic growth factors in the treatment of PRCA awaits further studies.