A screen for Fli-1 transcriptional modulators identifies PKC agonists that induce erythroid to megakaryocytic differentiation and suppress leukemogenesis.

The ETS-related transcription factor Fli-1 affects many developmental programs including erythroid and megakaryocytic differentiation, and is frequently de-regulated in cancer. Fli-1 was initially isolated following retrovirus insertional mutagenesis screens for leukemic initiator genes, and accordingly, inhibition of this transcription factor can suppress leukemia through induction of erythroid differentiation. To search for modulators of Fli-1, we hereby performed repurposing drug screens with compounds isolated from Chinese medicinal plants. We identified agents that can transcriptionally activate or inhibit a Fli-1 reporter. Remarkably, agents that increased Fli-1 transcriptional activity conferred a strong anti-cancer activity upon Fli-1-expressing leukemic cells in culture. As opposed to drugs that suppress Fli1 activity and lead to erythroid differentiation, growth suppression by these new Fli-1 transactivating compounds involved erythroid to megakaryocytic conversion (EMC). The identified compounds are structurally related to diterpene family of small molecules, which are known agonists of protein kinase C (PKC). In accordance, these PKC agonists (PKCAs) induced PKC phosphorylation leading to activation of the mitogen-activated protein kinase (MAPK) pathway, increased cell attachment and EMC, whereas pharmacological inhibition of PKC or MAPK diminished the effect of our PKCAs. Moreover, in a mouse model of leukemia initiated by Fli-1 activation, the PKCA compounds exhibited strong anti-cancer activity, which was accompanied by increased presence of CD41/CD61 positive megakaryocytic cells in leukemic spleens. Thus, PKC agonists offer a novel approach to combat Fli-1-induced leukemia, and possibly other cancers,by inducing EMC in part through over-activation of the PKC-MAPK-Fli-1 pathway.

Nonimmune hydrops fetalis caused by G6PD deficiency hemolytic crisis and congenital dyserythropoietic anemia.

We present a case of a female neonate who had a nonimmune hydrops fetalis and severe hemolytic anemia due to a rare combination of glucose-6-phosphate dehydrogenase (G6PD) deficiency and congenital dyserythropoietic anemia. We conclude that in severe cases with persistent anemia one should search after delivery for a second reason other than G6PD deficiency alone.

Iron overload impairs proliferation of erythroid progenitors cells (BFU-E) from patients with myelodysplastic syndromes.

In patients with myelodysplastic syndromes (MDS) iron overload caused by long-term red blood cell transfusions is an important factor for comorbidity especially in low-risk MDS. In this report we present the results of a comparative study based on colony formation assays of hematopoietic cells in MDS patients with and without iron overload. We demonstrate that iron overload suppresses the proliferation of erythroid progenitors cells (BFU-E), while the myeloid compartment (CFU-GM) was not found to be affected. Even patients with slightly elevated ferritin values show an impaired proliferation capacity in comparison to patients with normal ferritin levels. Furthermore, we show that this negative impact is reversible by sufficient iron chelation therapy.

Ineffective erythropoiesis with reduced red blood cell survival in serotonin-deficient mice.

Serotonin (5-HT) has long been recognized as a neurotransmitter in the central nervous system, where it modulates a variety of behavioral functions. Availability of 5-HT depends on the expression of the enzyme tryptophan hydroxylase (TPH), and the recent discovery of a dual system for 5-HT synthesis in the brain (TPH2) and periphery (TPH1) has renewed interest in studying the potential functions played by 5-HT in nonnervous tissues. Moreover, characterization of the TPH1 knockout mouse model (TPH1(-/-)) led to the identification of unsuspected roles for peripheral 5-HT, revealing the importance of this monoamine in regulating key physiological functions outside the brain. Here, we present in vivo data showing that mice deficient in peripheral 5-HT display morphological and cellular features of ineffective erythropoiesis. The central event occurs in the bone marrow where the absence of 5-HT hampers progression of erythroid precursors expressing 5-HT(2A) and 5-HT(2B) receptors toward terminal differentiation. In addition, red blood cells from 5-HT-deficient mice are more sensitive to macrophage phagocytosis and have a shortened in vivo half-life. The combination of these two defects causes TPH1(-/-) animals to develop a phenotype of macrocytic anemia. Direct evidence for a 5-HT effect on erythroid precursors is provided by supplementation of the culture medium with 5-HT that increases the proliferative capacity of both 5-HT-deficient and normal cells. Our thorough analysis of TPH1(-/-) mice provides a unique model of morphological and functional aberrations of erythropoiesis and identifies 5-HT as a key factor for red blood cell production and survival.

In essential thrombocythemia, multiple JAK2-V617F clones are present in most mutant-positive patients: a new disease paradigm.

In essential thrombocythemia (ET), the JAK2-V617F mutation is usually restricted to a subpopulation of neutrophils and platelets, and production of JAK2 wild-type (WT) platelets is not suppressed. Nonmutated precursor cells may, therefore, be susceptible to the acquisition of further JAK2 mutations. We used a common single nucleotide polymorphism (SNP) in the JAK2 coding sequence to genotype V617F alleles obtained either by allele-specific restriction enzyme digestion (RED) or by cloning. Both SNP alleles were detected in JAK2 mutant-positive alleles from neutrophils of 10 of 11 ET patients studied using RED compared with 0 of 5 with polycythemia vera. These results were confirmed in cloned products from 5 ET patients and indicate the occurrence of at least 2 separate JAK2 mutation events in the majority of ET patients investigated. In a further ET patient, JAK2 mutant-positive erythroid colonies with either X-allele inactivated were detected, demonstrating they could not have arisen from a common clonal precursor. These results indicate that at least 2 independent JAK2-V617F events occur commonly in ET patients, and they may arise on a polyclonal background. The presence of a JAK2 mutation in ET patients should not, therefore, be equated with a malignant disease.

Effects of rapamycin on accumulation of alpha-, beta- and gamma-globin mRNAs in erythroid precursor cells from beta-thalassaemia patients.

We studied the effects of rapamycin on cultures of erythroid progenitors derived from the peripheral blood of 10 beta-thalassaemia patients differing widely with respect to their potential to produce foetal haemoglobin (HbF). For this, we employed the two-phase liquid culture procedure for growing erythroid progenitors, high performance liquid chromatography for analysis of HbF production and reverse transcription polymerase chain reaction for quantification of the accumulation of globin mRNAs. The results demonstrated that rapamycin induced an increase of HbF in cultures from all the beta-thalassaemia patients studied and an increase of their overall Hb content/cell. The inducing effect of rapamycin was restricted to gamma-globin mRNA accumulation, being only minor for beta-globin and none for alpha-globin mRNAs. The ability of rapamycin to preferentially increase gamma-globin mRNA content and production of HbF in erythroid precursor cells from beta-thalassaemia patients is of great importance as this agent (also known as sirolimus or rapamune) is already in clinical use as an anti-rejection agent following kidney transplantation. These data suggest that rapamycin warrants further evaluation as a potential therapeutic drug in beta-thalassaemia and sickle cell anaemia.

EFA (9-beta-D-erythrofuranosyladenine) is an effective salvage agent for methylthioadenosine phosphorylase-selective therapy of T-cell acute lymphoblastic leukemia with L-alanosine.

The deficiency of methylthioadenosine phosphorylase (MTAP) in T-cell acute lymphoblastic leukemia (T-ALL) and other cancers, while constitutively expressed in normal cells, allows for selective therapy using L-alanosine, an inhibitor of de novo AMP synthesis. We demonstrate that MTAP- T-ALL cells obtained at relapse are as sensitive to L-alanosine toxicity as diagnosis samples. The therapeutic index of L-alanosine can be increased by the use of a MTAP substrate, which protects MTAP+ normal cells. Since MTAP substrates MTA and 5'deoxyadenosine are prone to toxicities associated with adenosine, we synthesized and evaluated a potentially nontoxic MTAP substrate, 9-beta-D-erythrofuranosyladenine (EFA). The cytotoxicity of EFA to hematopoietic progenitors erythroid burst-forming units (BFU-Es) and granulocyte-macrophage colony-forming units (CFU-GMs) was at least 26- to 41-fold less than that of MTA. In addition, EFA selectively rescued MTAP+ MOLT-4 cells from L-alanosine toxicity at 25 microM with negligible toxicity even at 100 microM. As for MTA, significant, albeit incomplete, rescue was achieved at 12.5 microM, but higher concentrations were toxic. EFA at 20 microM or less rescued primary MTAP+ T-ALL cells and normal lymphocytes from L-alanosine toxicity. Collectively, these data indicate that EFA is an effective agent for salvaging MTAP+ cells from L-alanosine toxicity and is superior to MTA due to lower cytotoxicity.

Drugs elevating extracellular adenosine promote regeneration of haematopoietic progenitor cells in severely myelosuppressed mice: their comparison and joint effects with the granulocyte colony-stimulating factor.

We tested capabilities of drugs elevating extracellular adenosine and of granulocyte colony-stimulating factor (G-CSF) given alone or in combination to modulate regeneration from severe myelosuppression resulting from combined exposure of mice to ionizing radiation and carboplatin. Elevation of extracellular adenosine was induced by joint administration of dipyridamole (DP), a drug inhibiting the cellular uptake of adenosine, and adenosine monophosphate (AMP), serving as an adenosine prodrug. DP+AMP, G-CSF or all these drugs in combination were administered in a 4-d treatment regimen starting on day 3 after induction of myelosuppression. Comparable enhancements of haematopoietic regeneration due to elevation of extracellular adenosine or to action of G-CSF were demonstrated as shown by elevated numbers of haematopoietic progenitor cells for granulocytes/macrophages (GM-CFC) and erythrocytes (BFU-E) in the bone marrow and spleen in early time intervals after termination of the drug treatment, i.e. on days 7 and 10 after induction of myelosuppression. Coadministration of all the drugs further potentiated the restoration of progenitor cell pools in the haematopoietic organs. The effects of the drug treatments on progenitor cells were reflected in the peripheral blood in later time intervals of days 15 and 20 after induction of myelosuppression, especially as significantly elevated numbers of granulocytes and less pronounced elevation of lymphocytes and erythrocytes. The results substantiate the potential of drugs elevating extracellular adenosine for clinical utilization in myelosuppressive states, e.g. those accompanying oncological radio- and chemotherapy.

[Effect of immunomagnetic selection in purging autologous peripheral blood progenitor cell of breast cancer patients].

OBJECTIVE: To evaluate the effect of immunomagnetic technique in purging of peripheral blood progenitor cell (PBPC) of breast cancer patients. METHODS: A sample of APBSC from non-breast cancer patients mixed with 1% MCF-7 cell lines and 10 samples of APBSC from breast cancer patients were subjected to positive purging, negative purging, and positive/positive purging. The CD34 + cell purity, CD34 + cell recovery rate and the enrichment of colony form units were compared. The number of tumor cells before and after immunochemistry (ICC) and flow detected purging procedure cytometry (FCM). The influence of refrigeration on the effect of purging was analyzed. RESULTS: The TC depletion in 10 samples of PBPC of breast cancer patients after positive purging was 2.1 (1.1 approximately 2.7) log steps, the CD34 + cell purity was 55.1 (25.9 approximately 99.5)%, and the CD34 + cell recovery was 39.4 (34.0 approximately 80.0)%. After the 6 samples of ICC positive PBPC from breast cancer patients were subjected to negative selection and subsequent positive purging, the mean CD34 cell purity was 64.3 (34.0 approximately 86.4)%, the mean CD34 + cell recovery was 35.0 (24.0 approximately 52.5)%, the purging efficiency was 3.0 (1.8 approximately 3.9) log, and the enrichment of colony-forming units-granulocyte macrophage (CFU-GM) and burst-forming unit-erythrocyte (BFU-E) were 2.2 and 3.1 respectively. TCs were detectable in all 6 cases prior to the purging procedure by ICC and FCM. After the -/+ purging procedure, only one case was tumor cell positive by ICC and residual tumor cells could be detected by FCM, however the number of TCs was evidently decreased. Along with the extension of refrigeration time, the CD34 cell purity, CD34 cell recovery, and tumor cell clearance rate decreased. CONCLUSION: Immunomagnetic double negative/positive selections an effective, rapid and simple purging method.

betaMinor-globin messenger RNA accumulation in reticulocytes governs improved erythropoiesis in beta thalassemic mice after erythropoietin complementary DNA electrotransfer in muscles.

Mechanisms governing the induction of effective erythropoiesis in response to erythropoietin (Epo) oversecretion have been investigated in beta thalassemic C57Bl/6(Hbbth) mice. Naked DNA encoding an expression vector for mouse Epo was introduced into skeletal muscles by electrotransfer. A transient increase of serum Epo concentrations with a proportional augmentation of hematocrit values was observed. Various parameters relevant to beta thalassemia were surveyed in blood samples taken before treatment, at the peak of Epo secretion, and when the phenotype reverted to anemia. We measured globin messenger RNA (mRNA) levels in reticulocytes by real-time quantitative polymerase chain reaction, globin chain synthesis levels, and several indicators of erythrocyte membrane quality, including bound alpha chains, bound immunoglobulins, main protein components, and iron compartmentalization. Data indicated that high serum Epo levels primarily affect betaminor-globin mRNA accumulation in reticulocytes. Other changes subsequent to intense Epo stimulation, like increased betaminor/alpha-globin chain synthesis ratio, reduced levels of alpha chains and immunoglobulins bound to membranes, improved spectrin/band 3 ratio, increased red blood cell survival, and improved erythropoiesis appeared as consequences of increased betaminor-globin mRNA levels. This conclusion is consistent with models postulating that intense Epo stimulation induces the expansion and differentiation of erythroid progenitors committed to fetal erythropoiesis. Although phenotypic correction was partial in mice, and comparable achievements will probably be more difficult to obtain in humans, naked DNA electrotransfer may provide a safe and low-cost method for reassessing the potentials of Epo as an inducer of fetal erythropoiesis reactivation in patients with beta thalassemia.

[Effects of quanjia yangshen capsule on rate of polychromatic erythrocytic micronucleus formation and peripheral blood picture in mice treated by cyclophosphamide].

OBJECTIVE: To observe the effect of Quanjia Yangshen capsule (QJYS) on cyclophosphamide (Cy) induced teratogenesis and bone marrow in mice and to explore the mechanism of its clinical therapeutic effect. METHODS: Mice were separately administered with QJYS solely, Cy solely and QJYS + Cy and the effect on polychromatic erythrocytic (PE) micronucleus formation rate in the bone marrow of mice, and peripheral blood picture were observed and compared with the control group. RESULTS: High dosage of QJYS has no apparent effect on PE micronucleus formation rate and peripheral blood picture in the normal mice; Cy can obviously raise PE micronucleus formation rate (P < 0.01), and lowered WBC, RBC and Hb obviously (P < 0.01) in mice. After taking QJYS, the Cy induced micronucleus formation rate increasing and blood picture parameters lowering were controlled. The improvement in the high and middle dose QJYS group was significantly higher in comparing to that in the sole Cy group (P < 0.01); while the low dose QJYS group in comparing with Cy group also showed significant improvement (P < 0.01), except Hb value. CONCLUSION: QJYS could significantly antagonize teratogenic effect and inhibition to bone marrow of Cy, i.e., play an antagonistic role against the toxic and side-effects of Cy.

Desferrioxamine improves burst-forming unit-erythroid (BFU-E) proliferation in haemodialysis patients.

BACKGROUND: In chronic renal failure, desferrioxamine (DFO) may improve erythropoiesis independent from its aluminium (Al) chelating effect. The mechanism of this action is still unknown. METHODS: To verify whether DFO influences proliferation of erythropoietic precursors, we studied 10 patients on chronic haemodialysis, free from malignancies or other haematological diseases, iron deficiency, bone marrow fibrosis, and Al toxicity. Al accumulation was excluded by the DFO test. Peripheral blood samples were drawn for basal burst-forming unit erythroid (BFU E) assay. Mononuclear cells were isolated by density gradient centrifugation with Ficoll Hypaque, and incubated for 15 days with three different experimental conditions: (a) low-dose recombinant human erythropoietin (rHuEpo) (3 U/ml); (b) high dose rHuEpo, (30 U/ml); (c) both DFO (167 microg/ml) and rHuEpo (3 U/ml). We determined TIBC, transferrin, ferritin, reticulocytes, hypochromic erythrocytes, soluble transferrin receptor (sTR), haemoglobin (Hb), and haematocrit (Hct) at baseline and then every 14 days. Patients received 5 mg/kg DFO infused during the last hour of each dialysis session for 6 weeks; six patients remained in the study for an additional 6 more weeks. BFU E assays were set up after 6 and 12 weeks of DFO therapy. RESULTS: At baseline DFO had small effect on BFU E proliferation (33.9+/-25 vs 30.4+/-25.9) and high-dose rHuEpo had a significant effect (45.15+/-27 vs 30.4+/-25.9, P<0.01). After 6 weeks of DFO therapy a significant increase in BFU E proliferation was observed in all culture conditions (78.25+/-32 vs 30.45+/-25.9 standard culture, P<0.01; 110.9+/-30 vs 45.15+/-27 high dose rHuEpo, P<0.01; 98.75+/-32 vs 45.15+/-27 DFO culture, P<0.01). Moreover, the increase in BFU E proliferation was significant greater with DFO culture than standard culture (P<0.01). The same trend was found at the third BFU E assay, performed in only six patients, when all culture conditions showed a further increase of erythroid precursor proliferation. However, the DFO culture was not significantly greater than the standard culture, while the high-dose rHuEpo was significantly greater than the DFO culture. Patients in group I (n=10), had a significant increase in reticulocytes (1.5+/-0.6 vs 1.72+/-0.3, P<0.01) and of hypochromic erythrocytes (HE) (5.6+/-5.1 vs 14.4+/-12.7, P<0.01), while sTR, Epo, Hb, and Hct were only minimally increased. Ferritin decreased significantly (448+/-224 vs 196+/-215, P<0.01) and TIBC and transferrin were unchanged. CONCLUSIONS: Thus DFO increases erythroid activity by BFU E proliferation and increases reticulocytes in haemodialysis patients. Such an effect may be related to increased iron utilization. DFO may be a useful tool for anaemic patients with good iron stores and without Al overload.

[Effect of Sancai injection on red blood cell line in mice].

OBJECTIVE: To study the effective mechanism of Sancai Fensui Dan in mice. METHODS: Sancai injection (SCI) was given to normal or anemia mice and their hemoglobin (Hb), red blood cell (RBC), reticulocyte (Ret) of peripheral blood, mitosis index (MI) of red cells, bone marrow nucleated cell (BMC) were measured. And the cultured hemopoietic progenitor cells of burst forming unit-erythroid (BFU-E) and colony forming unit-erythroid (CFU-E) were used to observe the hemopoiesis effect of SCI. RESULTS: SCI could promote the increase of Hb, RBC, Ret, MI and BMC in anemia mice. At the presence of spleen cells or macrophages in peritoneal cavity, it could enhance the proliferation of BFU-E and CFU-E. CONCLUSION: SCI could promote hemopoiesis by activating the hemo-opsonin.

[Clinical study on effect of bushen shengxue paste in treating renal anemia patients].

OBJECTIVE: To evaluate the therapeutical mechanism of Bushen Shengxue Paste (BSSXP) on anemia. METHODS: Chronic renal failure induced anemia patients were treated with BSSXP, clinical manifestation, anemia and renal function as indicators were observed in patients. The erythropoietin (EPO) and inhibition of colony-forming unit-erythrocyte (CFU-E) in patients' serum were determined by CFU-E in vitro. RESULTS: The patients' symptoms, renal function and anemia were improved after administration with BSSXP 1-2 course. EPO in serum was slightly increased. The inhibition of CFU-E in patient's serum was significantly decreased. CONCLUSIONS: BSSXP could improve the anemia degree, its mechanism might be through clearing the inhibitor of CFU-E in serum.

[Activating blood circulation and removing stasis in treating polycythemia vera: clinical observation and therapeutical mechanism].

OBJECTIVE: To assess the efficacy of "method of activating blood circulation and removing stasis (ABCRS)" in treating polycythemia vera. METHODS: 28 cases of polycythemia vera were treated with ABCRS and observed with bone marrow colonies. RESULTS: 15 casses were responsibe, of them 4 cases reached clinical remission, 11 cases were improved. Both bone marrow colonies of colony forming unit-erythroid dependent of erythropoietin (EPO + CFU-E) and colonies of CFU-E independent of EPO. (EPO-CFU-E) from these cases decreased significantly, especially the latter. ABCRS mainly suppressed the proliferation and differentiation of EPO-CFU-E. In addition, bone marrow colonies of colony formng unit-fibroblastoids (CFU-F) from these cases also changed obviously. CONCLUSION: ABCRS is effective in treating polycythemia vera.

[Changes in hematological indices, iron levels and marrow erythroids through autologous blood donation before cardiac surgery--predonation with versus without recombinant human erythropoietin].

Preoperative autologous blood donation is widely used in cardiac surgery. However, some patients are unable to store adequate amounts of blood before surgery, and some develop anemia after the operation. We attempted to clarify the limitations of blood donation alone and its influence on erythropoiesis in comparison with those associated with adding recombinant human erythropoietin (rEPO). Subjects were twenty-five patients who were scheduled to undergo elective cardiac surgery. A unit of autologous blood (200 ml) was to be donated every 3 or 4 days for 2 weeks. 200mg of ferrous sulfate was given orally every day in 10 patients (the simple donation group), while 200 U/kg of rEPO was given intravenously 3 times a week in combination with oral ferrous sulfate supplementation in 15 patients (the rEPO-treatment group). After donation, reticulocyte counts increased significantly in both groups. In the simple donation group, hematocrit levels decreased significantly (p < 0.02), while serum iron levels did not change significantly. In the rEPO-treatment group, hematocrit levels remained unchanged and serum ferritin levels decreased significantly (p < 0.02) after the donation; in addition, serum iron levels in the rEPO-treatment group decreased significantly (p < 0.05) than those in the simple donation group during donation. The erythroid/nucleated cell ratio remained almost normal in the simple donation group. This ratio was significantly higher in the rEPO-treatment group than in the simple donation group (36.4 +/- 8.3% versus 26.2 +/- 6.8%, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

The two-step liquid culture: a novel procedure for studying maturation of human normal and pathological erythroid precursors.

We have recently described a novel two-phase liquid culture procedure for growing human erythroid cells in vitro. The two phases are 1) an erythropoietin (EPO)-independent phase, in which the cells are first cultured in the presence of a combination of growth factors excluding EPO; during this phase, early erythroid committed progenitors, burst forming units (BFU-e), proliferate and differentiate into colony forming unit (CFU-e)-like progenitors; 2) a second phase, in which the latter cells are cultured in an EPO-supplemented medium, in which the CFU-e-like progenitors continue to proliferate and mature into orthochromatic normoblasts and then enucleated erythrocytes. This procedure yields large (up to 5 x 10(8)) and pure (95-98%) populations of erythroid cells, which allow detailed study of normal and pathologic erythroid maturation, including 1) the effects of growth factors on proliferation and differentiation at various erythroid developmental stages, 2) intracellular iron metabolism in normal and thalassemic erythroid cells and the role of ferritin as an iron donor for heme synthesis, 3) the expression of surface antigens: transferrin receptor, glycophorin, A, B, H, D and I/i antigens, 4) synthesis of erythroid-specific membrane proteins, 5) the kinetics of globin mRNA accumulation during erythroid maturation, 6) the expression of exogenous human beta globin gene in beta-thalassemic cells as a model for gene therapy, and 7) the enhancement of gamma globin chain synthesis by chemical agents.

Subcutaneous erythropoietin for treatment of refractory anemia in hematologic disorders. Results of a phase I/II clinical trial.

We have used recombinant human erythropoietin (rHuEPO) in a phase I/II clinical trial to evaluate its ability to reverse refractory anemia in hematologic disorders. rHuEPO was administered subcutaneously 5 days per week at escalating doses (50 to 150 U/kg per day). The aim of treatment was a hemoglobin (Hb) level greater than or equal to 10 g/dL without blood transfusion. Of 25 patients treated, 17 were evaluable, most of them with a regular need for transfusion. Eight of these had lymphoproliferative disorders (three cases of malignant lymphoma and five of monoclonal gammopathy) and were exposed to cytotoxic therapy. The other nine patients had hematopoietic stem cell disorders (four cases of myelodysplastic syndrome, three of idiopathic myelofibrosis, and two of chronic myelogenous leukemia). All patients with lymphoproliferative disorder had serum EPO levels inappropriately low for the degree of anemia, while patients with stem cell disorder showed variable values. Erythroid marrow activity was inadequate in all cases. Seven of eight patients with lymphoproliferative disorder responded to treatment maintaining Hb above 10 g/dL without transfusion. The median dose of rHuEPO required for correction of anemia was 75 U/kg. In four cases response was maintained with 50 U/kg, three times per week. There was no complete response among patients with hematopoietic stem cell disorder, although transfusion requirement was eliminated or reduced in four cases. Four patients developed functional iron deficiency during rHuEPO treatment and required iron supplementation to obtain response. Aggravation of splenomegaly was observed in two cases of myeloproliferative disorder. We conclude that: (1) subcutaneous administration of rHuEPO can be effective and safe in patients with lymphoproliferative disorder exposed to chemotherapy and showing inappropriate EPO response to anemia; (2) this is less likely in hematopoietic stem cell disorders, although favorable responses may be observed in occasional patients; and (3) functional iron deficiency as a cause of nonresponse to rHuEPO is frequent also in nonrenal anemia.

Pure red cell aplasia following pernicious anemia.

A rare case of pure red cell aplasia (PRCA) in association with pernicious anemia is reported. A 40-year-old man presented with typical clinical and laboratory features of pernicious anemia and received intramuscular injections of vitamin B12, with satisfactory response. Anemia recurred 6 months later despite continued therapy, and the patient was noted to have PRCA, which was treated successfully with two courses of high-dose bolus methylprednisolone therapy. His peripheral mononuclear cells before the therapy suppressed colony formation of early erythroid precursors (BFU-E) from normal bone marrow; such a suppressive effect was not found after recovery from anemia.