Aplastic anemia. Paroxysmal nocturnal hemoglobinuria Symptoms of nocturnal hemoglobinuria

Paroxysmal nocturnal hemoglobinuria is a rare acquired life-threatening blood disease. The pathology causes the destruction of red blood cells - erythrocytes. Doctors call this process hemolysis, and the term “hemolytic anemia” fully characterizes the disease. Another name for such anemia is Marchiafava-Micheli disease, after the names of the scientists who described the pathology in detail.

Causes and essence of the disease

Paroxysmal nocturnal hemoglobinuria is uncommon - usually 1-2 cases are recorded per 1 million people in the population. This is a disease of relatively young adults, the average age of diagnosis is 35-40 years. Manifestation of Marchiafava-Miceli disease in childhood and adolescence is very rare.

The main cause of the disease is a mutation in a single stem cell gene called PIG-A. This gene is located on the X chromosome of bone marrow cells. The exact causes and mutagenic factors of this pathology are still unknown. The occurrence of paroxysmal nocturnal hemoglobinuria is closely related to aplastic anemia. It has been statistically proven that 30% of cases of identified Marchiafava-Miceli disease are a consequence of aplastic anemia.

The process of forming blood cells is called hematopoiesis. Red blood cells, white blood cells and platelets are formed in the bone marrow, a special spongy substance located in the center of some bone structures in the body. The precursors of all cellular elements of the blood are stem cells, during the gradual division of which new blood elements are formed. Having gone through all the processes of maturation and formation, the formed elements enter the bloodstream and begin to perform their functions.

For the development of Marchiafava-Micheli disease, the presence of a mutation in the above-mentioned PIG-A gene in one stem cell is sufficient. The abnormal progenitor cell continually divides and “clones” itself. So the entire population becomes pathologically altered. Inferior red blood cells mature, form and release into the bloodstream.

The essence of the changes lies in the absence on the red blood cell membrane of special proteins responsible for protecting the cell from its own immune system - the complement system. The complement system is a set of blood plasma proteins that protect the body from various infectious agents. Normally, all cells of the body are protected from their immune proteins. With paroxysmal nocturnal hemoglobinuria, such protection is absent. This leads to the destruction or hemolysis of red blood cells and the release of free hemoglobin into the blood.

Clinical manifestations and symptoms

Due to the variety of clinical manifestations, the diagnosis of paroxysmal nocturnal hemoglobinuria can sometimes be reliably made only after several months of diagnostic search. The fact is that the classic symptom - dark brown urine (hemoglobinuria) occurs only in 50% of patients. The classic presence of hemoglobin in the morning portions of urine, during the day it usually becomes lighter.

The release of hemoglobin in the urine is associated with massive resolution of red blood cells. Doctors call this condition a hemolytic crisis. It can be triggered by an infectious disease, excessive alcohol intake, physical activity or stressful situations.

The term paroxysmal nocturnal hemoglobinuria arose from the belief that hemolysis and activation of the complement system are triggered by respiratory acidosis during sleep. This theory was later disproved. Hemolytic crises occur at any time of the day, but the accumulation and concentration of urine in the bladder during the night leads to specific color changes.

The main clinical aspects of paroxysmal nocturnal hemoglobinuria:

1. Hemolytic anemia is a decrease in the number of red blood cells and hemoglobin due to hemolysis. Hemolytic crises are accompanied by weakness, dizziness, and flashing “spots” before the eyes. The general condition in the initial stages does not correlate with hemoglobin levels.
2. Thrombosis is the main cause of death in patients with Marchiafava-Micheli disease. Arterial thrombosis is much less common. The hepatic, mesenteric and cerebral veins are affected. Specific clinical symptoms depend on the vein involved in the process. Budd-Chiari syndrome occurs with thrombosis of the hepatic veins; blockade of cerebral vessels has neurological symptoms. A scientific review on paroxysmal nocturnal hemoglobinuria published in 2015 suggests that hepatic vascular blockage is more common in women. Dermal vein thrombosis is manifested by red, painful nodes that rise above the surface of the skin. Such lesions cover large areas, for example, the entire skin of the back.
3. Insufficient hematopoiesis - a decrease in the number of red blood cells, leukocytes and platelets in the peripheral blood. This pancytopenia makes a person susceptible to infections due to the low number of white blood cells. Thrombocytopenia leads to increased bleeding.

The hemoglobin released after the destruction of red blood cells undergoes splitting. As a result, the degradation product, haptoglobin, enters the bloodstream, and hemoglobin molecules become free. Such free molecules bind irreversibly to nitric oxide (NO) molecules, thereby reducing their quantity. NO is responsible for smooth muscle tone. Its deficiency causes the following symptoms:

• stomach ache;
• headache;
• spasms of the esophagus and swallowing disorders;
• erectile dysfunction.

Excretion of hemoglobin in the urine leads to impaired kidney function. Kidney failure gradually develops, requiring replacement therapy.

Diagnostic and therapeutic measures

At the initial stages, making a diagnosis of Marchiafava-Miceli disease is quite difficult due to the diverse clinical symptoms and scattered complaints of patients. The appearance of characteristic changes in the color of urine, as a rule, directs the diagnostic search in the right direction.

Treatment of paroxysmal nocturnal hemoglobinuria

The main diagnostic tests used for paroxysmal nocturnal hemoglobinuria:

1. Complete blood count - to determine the number of red blood cells, white blood cells and platelets.
2. The Coombs test is an analysis that allows you to determine the presence of antibodies on the surface of red blood cells, as well as antibodies circulating in the blood.
3. Flow cytometry allows for immunophenotyping, that is, to determine the presence of a particular protein on the surface of red blood cell membranes.
4. Measurement of serum hemoglobin and haptoglobin levels.
5. General urine analysis.

An integrated diagnostic approach makes it possible to identify Strübing-Marchiafava disease in a timely manner and begin its treatment before the manifestation of thrombotic complications. Treatment of paroxysmal nocturnal hemoglobinuria is possible with the following groups of drugs:

1. Steroid hormones (Prednisolone, Dexamethasone) inhibit the functioning of the immune system, thereby stopping the destruction of red blood cells by proteins of the complement system.
2. Cytostatics (Eculizumab) have a similar effect. They suppress the immune response and eliminate the signs of paroxysmal nocturnal hemoglobinuria.
3. Sometimes patients need transfusions of washed red blood cells, specially selected by hematologists, to correct hemoglobin levels.
4. Maintenance therapy in the form of iron and folic acid supplements.

The described treatment of paroxysmal nocturnal hemoglobinuria cannot relieve the patient of the disease, but only muffles the symptoms. A real therapeutic option is bone marrow transplantation. This procedure completely replaces the pool of abnormal stem cells, curing the disease.

The disease described in the article is potentially life-threatening without appropriate treatment. Complications in the form of thrombosis and renal failure can have serious consequences for life and health. Timely treatment can stop the progression of the disease and prolong the patient’s full life.

In this group of patients there is no familial tendency to anemia, no concomitant congenital anomalies and no disorders in the neonatal period. Aplastic anemia can occur at any age in children and adults; sometimes it can be associated with specific intoxication or infection, but often such a connection is not observed and then the anemia is considered “idiopathic.”

Some medications, such as 6-mercaptopurine, methotrexate, cyclophosphamine, and busulfan, have a predictable, dose-dependent ability to suppress bone marrow. If this depression continues, it will lead to bone marrow aplasia, which usually resolves quickly after discontinuation of the drug. These medications damage normal bone marrow cells through the same mechanism that they inhibit the growth of leukemia cells. The biochemical principles of their action are quite well studied. Radiation damage to the bone marrow also falls into this category.

Other medications, such as quinine, chloramphenicol, phenylbutazone and anticonvulsants used in normal therapeutic doses, can cause profound bone marrow aplasia in a very small number of people, and this aplasia cannot be predicted in advance. It is often irreversible and approximately half of patients die. Intoxication with insecticides such as DDT and some organic solvents also falls into this category. It is often unclear whether anemia can be linked to a particular medication. A necessary condition for such a connection is taking medications within the last 6 months. The most well-known and studied of these is chloramphenicol. This drug is at the top of the list of known etiological agents in the group of patients with acquired aplastic anemia described by Scott et al., and in the same groups of sick children by Shahidi. Gurman observed 16 cases in Sydney over 8 years in which the disease was believed to be associated with the use of chloramphenicol. Absolute incidence of fatal acquired aplastic anemia in populations with no known exposure to any hazardous medication and known exposure to a variety of medications, including chloramphenicol.

Treatment with chloramphenicol increases the likelihood of developing aplastic anemia by 13 times, but it is also clear that this increase is small. For other medications the risk is even lower. However, the UK Medicines Safety Committee recommends that for all diseases other than typhoid fever and haemophilus influenza meningitis, chloramphenicol should be used systemically only after careful clinical and usually laboratory testing has indicated that another antibiotic will not be sufficient. It should never be used systemically for a simple infection.

The mechanism of development of aplastic anemia under the influence of chloramphenicol is unclear. The occurrence of aplastic anemia is not related to the dose or duration of treatment, nor can it be explained by insufficient excretion in susceptible individuals. In vitro, inhibition of nucleic acid synthesis in normal bone marrow cells can be demonstrated, but only at drug concentrations that exceed those used in vivo. It has been suggested that small amounts of chloramphenicol may be consumed in milk from cows treated for mastitis and that these small amounts may sensitize the bone marrow to subsequent therapeutic doses. It was also assumed that there is an as yet undiscovered synergism with other medications, which are probably harmless if used alone. In discussing the etiology of pancytopenic lethal aplasia caused by chloramphenicol, it should be noted that a significant proportion of patients receiving this medication experience a completely different, reversible and dose-dependent bone marrow suppression. In 10 of 22 patients receiving chloramphenicol, multiple large vacuoles were found in early bone marrow erythroblasts, which was often accompanied by a drop in the number of red blood cells and reticulocytes. These changes disappear a week after stopping the medication. Their development appears to be facilitated by increased doses, delayed plasma clearance, and accelerated erythropoiesis. The same vacuoles can be seen with a deficiency of phenylalanine or riboflavin.

With regard to the etiology of other drug-induced aplasias, there has always been a temptation to assume the action of immune mechanisms, perhaps such as a drug - hapten. However, these mechanisms have never been demonstrated. Only in one clinical situation, namely graft-versus-host disease in immunologically incompetent infants who received transfusions, was the immunological origin of aplastic anemia established. The development of a severe anaphylactoid reaction after accidental re-exposure to DDT in a sensitive patient also suggests an immune mechanism. Newwig proposed three explanations for drug-induced aplasia: a) a direct and toxic effect on bone marrow cells, for example, after chronic occupational exposure to benzene; b) true allergy, the manifestations of which occur quickly after contact with a small dose; c) prolonged contact with large doses, i.e. “high dose allergy”. This is the most common form. The author explains this primarily by damage to cell membranes. A genetic predisposition may also be suspected, as indicated by a case of blood dyscrasia after exposure to chloramphenicol in identical twins. Review articles on drug-induced aplastic anemia of Newwig were recently published in the Lancet.

Similar problems arise in connection with a viral infection preceding the development of aplastic anemia. This phenomenon has been well studied in infectious hepatitis. Aplastic anemia developed in 5 patients aged 4 to 19 years 1-7 weeks after the onset of hepatitis. A number of similar cases have been described, including 3 cases by Schwartz et al. These authors noted that in infectious hepatitis there is often a temporary decrease in the number of granulocytes, platelets and hemoglobin and that progressive changes leading to bone marrow aplasia in a very small number of patients may represent a continuation of the entire process, probably depending on genetic predisposition. Here you can see an analogy with chloramphenicol intoxication. Pancytopenia with transient bone marrow hypoplasia has also been described in association with a number of infections caused by RNA viruses, including rubella viruses and influenza microviruses, parainfluenza viruses, mumps and measles viruses. Two experimental viral infections in mice, i.e., MVH-3 and the Trinidad strain of Venezuelan equine encephalitis, cause pancytopenia and bone marrow hypoplasia, and virus can be cultured from the bone marrow. As with other causes of aplastic anemia, an autoimmune process is assumed.

In approximately half of cases of acquired aplastic anemia, no history of serious previous infection or exposure to toxic agents can be detected. Wolf published a large material, including 334 cases of acquired pancytopenia, and in 191 cases, i.e. 57.2%, the anemia was recognized as idiopathic.

In Gurman's material, the relative number of patients with idiopathic anemia was smaller, i.e., 28 out of 104, who suffered from acquired aplasia. In 5 out of 17 cases according to Shahidi and in 5 out of 9 cases according to Desposito, the anemia was idiopathic. It is not yet clear whether the illnesses in these cases are caused by infection with an unidentified virus. At least some of the idiopathic cases seem to fall into a special group that might be called preleukemia or leukemia in the aplastic phase.

Mehlhorn et al describe 6 children who were diagnosed with strong, indisputable evidence of aplastic anemia between the ages of 1 year 11 months and 6 years, but all of these children subsequently developed acute lymphoblastic leukemia at 9 weeks to 20 months. . These 6 patients had one common feature - a faster than usual therapeutic response to initial corticosteroid therapy compared to aplastic anemia. Gurman noted the same thing, and we also observed this effect in one case in which acute lymphoblastic leukemia developed after 3 months. This rapid response of pancytopenia to treatment with corticosteroids alone is markedly different from the usual lack of response in other cases of aplastic anemia. It should be noted that a similar leukemic transformation of aplastic anemia caused by benzene and chloramphenicol has been described.

Symptoms of acquired aplastic anemia

Acquired aplastic anemia is characterized by approximately the same symptoms and objective signs as the constitutional form, but there is no pigmentation, short stature and congenital anomalies of the skeleton or internal organs. The age range in which the disease occurs is wider, with the possible exception of aplasia caused by chloramphenicol, in which the “peak” of maximum incidence lies between the 3rd and 7th year. 43% of patients with the acquired form of the disease in Wolf's large summary: and 67% in Gurman's large summary material had a history of contact, sometimes repeated, usually within the previous 6 months, with medications or chemicals known to be , predispose to aplastic anemia.

Newman et al described 14 children with idiopathic pancytopenia and noted that, in addition to the three main signs - anemia, fever and purpura, there were important negative signs, i.e. the absence of hepatosplenomegaly, lymphadenopathy, oral ulcers and jaundice. However, purpura of the oral mucosa and bleeding from the gums can be observed. Sometimes there may be inflammatory lymphadenopathy associated with local sepsis.

If a child develops red urine, the development of paroxysmal nocturnal hemoglobinuria should be assumed.

Laboratory diagnostics

The picture of peripheral blood is approximately the same as in the constitutional form, but the neutropenia is deeper, sometimes approaching agranulocytosis. In addition, there is a more pronounced aplasia of the bone marrow, which consists almost entirely of fatty areas devoid of hemic cells. In the 5-90% of erythroid progenitors still present in the bone marrow, megaloblastic changes and other signs of “dyserythropoiesis” are observed. In patients with dose-related inverse bone marrow suppression caused by chloramphenicol, vacuolation of erythroid and myeloid precursors is observed in the bone marrow, similar to what can be seen with phenylalanine deficiency. The level of fetal hemoglobin may be elevated to the same extent as in constitutional forms, but less permanently. Levels above 400 μg% (or 5%) were thought to indicate a better prognosis for acquired disease, but analysis of more recent cases treated at the same institute did not confirm these findings, possibly due to the use of a different method.

Aminaciduria, observed in approximately half of patients with the constitutional form, is absent and there is no lag in bone age.

More than half of the adult patients suffering from this disease have lymphopenia and hypogammaglobulinemia with subnormal IgG levels.

Associated hemolysis, including paroxysmal nocturnal hemoglobinuria. Some patients with aplastic anemia have a shortened lifespan of red blood cells. This suggests that the defect of erythrocytes is sometimes not only quantitative, but also qualitative. In this case, increased sequestration in the spleen can be observed. Reticulocytosis, which should be present, is usually excluded due to bone marrow aplasia. In some cases, the content of haptoglobin is reduced. One of the causes of hemolysis in this disease is an unusual syndrome of combination of paroxysmal nocturnal hemoglobinuria (PNH) and aplastic anemia. This syndrome should be assumed when a patient with aplastic anemia has increased bilirubin or spontaneous reticulocytosis. The diagnosis is confirmed by an acid serum hemolysis (ASH) test for PNH, as well as tests for hemosiderinuria. In some cases, PNH can only be detected by examining the most sensitive population of red blood cells, i.e., reticulocytes and young red blood cells, obtained by carefully removing the layer below the leukocyte-platelet clot with a pipette after centrifuging 20-35 ml of blood at 500 G.

Typically, in this syndrome, PNH is detected against the background of aplastic anemia, often after erythropoiesis has been restored to a certain extent. In several cases, the reverse sequence was observed, i.e., severe or fatal bone marrow failure developed against the background of PNH. Lewis and Days systematically tested all their patients with aplastic anemia and found that 7 of 46 (15%) had laboratory criteria for PNH. 2 of them subsequently developed a typical picture of PNH. Approaching this issue from a different point of view, the authors found that at least 15 of 60 patients with PNH initially had signs of aplasia. Typically, PNH is a disease of adult men. However, the form that occurs with aplasia appears to occur at a younger age and may affect children. Gardner observed 11 such patients, including 6 to 25 years old, 2 patients were 7 and 9 years old. These two were boys. Their aplastic anemia lasted 2 years and 5 years before the diagnosis of PNH.

An interesting feature of this combined syndrome is that aplastic anemia can be of the Fanconi type, can be acquired after contact with chloramphenicol, tranquilizers, insecticides, herbicides and other substances, or can be idiopathic. Lewis and Days believe that the primary relationship is between bone marrow aplasia and PNH, and not between the etiological factors causing bone marrow damage and PNH. Both of these authors, as well as Gardner and Bloom, suggest that during the period of aplasia, a somatic mutation of bone marrow stem cells occurs, which leads to the appearance of a secondary clone of pathological erythrocytes inherent in PNH, which begin to be produced during subsequent bone marrow regeneration. It should be added that although the characteristic defect in PNH is concentrated in erythrocytes, granulocytes are also altered. The skin window method shows a decrease in their phagocytic activity and alkaline phosphatase activity. In contrast, in uncomplicated aplastic anemia, alkaline phosphatase activity in granulocytes is usually increased.

Treatment

Treatment is in principle the same as for constitutional aplastic anemia, but it is necessary to ensure that all contact with the medication or toxic agent, if known, is stopped. Repeated exposure can cause a fatal relapse in patients who survived the first attack of aplasia, and can even provoke fatal anaphylactic shock.

Supportive measures also include blood transfusions while the anemia is severe enough to cause symptoms, usually at a hemoglobin level of 4-6 g%. Red blood cell mass is used not only for the treatment of obvious bleeding, and one should strive to increase the level to 8-9 g%. A higher level of hemoglobin leads to a more severe inhibition of erythropoiesis. Thrombocytopenic bleeding is treated with rapid infusions of platelet-rich plasma or platelet concentrates (4 units/m2). Intramuscular injections should be avoided. Strict asepsis must be observed during all procedures and infections must be treated vigorously with bactericidal antibiotics. Since neutropenia is usually especially severe in acquired forms of aplastic anemia, during the neutropenic phase you can use a special neutropenic regimen: rinsing the mouth with a 0.1% solution of hibitan 4 times a day after meals (made from pure antiseptic without detergents and dyes); lubricating the nostrils with naseptin ointment 3 times a day; daily bath. Lubricate the gums with 1% hibitan tooth gel 2 times a day (instead of brushing your teeth). When patients are in the hospital, some kind of isolation with a reversible barrier is necessary to reduce the risk of infection by hospital microflora. Prophylactic systemic antibiotic therapy should be completely avoided as it increases the susceptibility to fungal and antibiotic-resistant infections. An incipient infection may manifest itself as an increased tendency to bleed. With infection, not only does the platelet count decrease, but the hemorrhagic tendency for a given platelet count also increases.

Androgens. Specific therapy with androgens + corticosteroids is carried out in the same way as for constitutional forms, i.e. oxymethalone orally - 4-5 mg/kg per day + prednisolone 5 mg 2 times a day in children weighing up to 20 kg, 5 mg 3 once a day for body weights from 20 to 40 kg and 4 times a day for body weights over 40 kg. The difference is that with acquired forms of anemia, the effect is achieved in a smaller percentage of patients, the response to treatment is slower, but remission in patients amenable to treatment continues after the androgen and corticosteroids are discontinued. In Fanconi anemia, bone marrow failure recurs rapidly after discontinuation of this therapy. It was even pointed out that this circumstance can be used in difficult cases when differentiating the acquired form from the constitutional one.

The first results of treatment with androgens and steroids were very impressive. Of 17 children with acquired aplastic anemia (toxic in 12 cases, idiopathic in 5 cases), 10 had persistent reticulocytosis, which peaked at 5-15% after 1-7 months of combined treatment with androgens and corticosteroids. Of these children, 9 survived, and their hemoglobin levels subsequently increased. Transient reticulocytosis without other reactions was observed in 3 children. The discrepancy between the timing of the onset of reticulocytosis and the increase in hemoglobin in these patients was explained by hemolysis. In addition, red blood cells, which are formed in the early stage of bone marrow regeneration, are hypochromic with a normal level of iron in the serum and an increased content of free protoporphyrin in red blood cells, which indicates a cellular block in hemoglobin synthesis. The maximum increase in hemoglobin was observed 2-15 months after the start of androgen treatment. When studying bone marrow dynamics in the early stage of treatment, groups of reticular cells were found that mature and turn into erythroid foci in those patients who subsequently develop a response to treatment. In all patients with increased hemoglobin, there was also an increase in the number of segmented cells to more than 1500 per 1 µl, but the platelet response was less pronounced and they reached only 25,000-90,000 per 1 µl. Typically, the number of segmented neutrophils increased more slowly than the hemoglobin level, and the number of platelets increased even more slowly. The total duration of androgen treatment in these patients ranged from 2 to 15 months; after cessation of treatment, they remained in remission indefinitely. 2 patients who responded positively to treatment had idiopathic aplasia, and 8 had toxic aplasia. Among the patients who did not respond, 3 had idiopathic and 4 had toxic forms of aplasia. The authors suggested that long-term treatment with high doses of corticosteroids may impair bone marrow function due to an increase in the amount of adipose tissue in the bone marrow.

Desposito et al obtained similar results using androgens + steroids. In 5 out of 9 children with acquired aplastic anemia, there was a pronounced hematological improvement, which turned out to be stable. 2 children had an idiopathic form and 3 had a toxic form. (Of the patients who did not respond to treatment, 3 had idiopathic and 1 toxic anemia.) Similar timing ratios were observed. The platelet count increased significantly only 9-17 months after the start of treatment, and even then it reached only 50,000 in one patient and 100,000 per 1 μl in 2 patients, while hemoglobin and segmented cells were normal. Treatment was stopped after 7-11 months; in 4 out of 5 patients, hemoglobin levels temporarily dropped for 1-3 months. The patients were followed up for 1 to 3 years. During this time they had no relapses.

According to these two reports, a positive response was observed in slightly more than half of the children, and the treatment was effective in both idiopathic and toxic forms of aplastic anemia. Among patients with toxic forms, the frequency of reactions was perhaps slightly higher.

Until the last of these articles appeared, it was the impression that patients rarely survived without androgen treatment. The improved survival observed in the two most recent reports has been attributed to advances in symptomatic therapy, including antibiotics and platelet transfusions. In particular, the paper by Hayne et al sheds new light on the natural history of the disease and appears to fill the gap between androgen-treated and androgen-free patients (in 30 of 33 patients the etiology of anemia was toxic rather than idiopathic, which may explains the more favorable prognosis). Gurman, in a review of 104 children with acquired aplastic anemia from Boston and Sydney, indicated that overall survival was 34% with combined androgen and corticosteroid treatment and 19% with corticosteroid or supportive care alone.

Newer reports, including results from the same Boston Children's Hospital, are less satisfactory. Mortality was 70–80% despite androgens, corticosteroids, and supportive care. The survival curve is two-phase. Many early stage patients die from infections and bleeding within the first 6 months. Currently, the effectiveness of androgens in patients with severe acquired aplasia is questioned.

Prognostic signs. According to Gurman's work, the prognosis appears to be worse in aplastic anemia after infections, especially infectious hepatitis, or after a single short course of chloramphenicol. The prognosis is better in idiopathic cases, as well as in patients with anemia, which can be explained by taking anticonvulsants or repeated courses of chloramphenicol. It has been suggested that the bone marrow of a child who develops aplastic anemia after one short course is often more depressed than that of a child whose pancytopenia is induced only by repeated courses of medication. It is known that in children with severe hypocellularity of the bone marrow, a particularly severe prognosis is indicated by the number of lymphocytes in the bone marrow of more than 85%, the number of neutrophils less than 200 in 1 μl or platelets less than 20,000 in 1 μl. Based on these data, Hamitt et al suggested that severe aplasia after hepatitis should be considered an indication for early bone marrow transplantation due to the fact that only about 10% of patients of this type survive with maintenance therapy + androgens and steroids.

Bone marrow transplantation . Because of the failure of androgen treatments for severe acquired aplastic anemia, researchers have turned to the possibility of bone marrow transplantation. After intravenous infusions of bone marrow from identical twins, rapid recovery of bone marrow function occurred in 5 out of 10 cases. If identical twin donors are not available, a major obstacle is possible graft rejection or, if it survives, graft-versus-host disease. However, among normal siblings, there is a one in 4 chance that a histocompatible donor will be found, selected using HL-A typing and mixed lymphocyte culture to identify the remaining histocompatibility loci. These precautions reduce the problem of graft incompatibility, but do not completely solve it. To reduce or eliminate the possibility of rejection, additional immunosuppressive therapy is required, such as high-dose cyclophosphamide before bone marrow transplant and a course of methotrexate after transplant. Before attempting this therapeutic measure, it is necessary to carry out massive supportive therapy, including nursing the patient in a sterile environment, leukocyte and platelet transfusions during the critical first days, as well as the presence of a medical team with extensive experience. Thomas et al describe the technique of bone marrow collection, processing, and infusion. 24 patients (including 8 under 14 years old) with severe aplastic anemia (14 cases of idiopathic anemia, 4 cases of anemia after hepatitis, 4 - drug-induced, 1 - PNH, 1 - Fanconi anemia), who did not respond to conventional treatment, received transplants from siblings identical in HL-A. In 21 patients, rapid bone marrow regeneration was observed, which in most cases, as determined using genetic markers, was due to donor cells. In 4 patients the transplant was rejected and they died. Four patients died from secondary disease, 11 people are living with functioning transplants. The observation period ranged from 141 days to 823 days. Ten patients returned to a normal active lifestyle. These results, obtained by a group of researchers from Seattle, prompted others to use this method. In Fig. Figure 25 shows the result of the first transplant in the UK, performed by the bone marrow transplant team at the Royal Marsden Hospital. It is possible that this is how further treatment of individual patients with poor prognostic signs will proceed when they first seek help.

Various types of treatment. In patients who are refractory to other treatment and have cellular bone marrow, splenectomy is indicated. However, the expected effect of this operation was not confirmed in a large group of cases, and since splenectomy is quite dangerous in these patients with thrombocytopenia, it is generally not recommended. A possible exception is patients with an element of hemolysis and with detected sequestration of red blood cells in the spleen. It has been established that splenectomy increases the life expectancy of platelets in patients with aplasia who have ceased to benefit from platelet transfusion.

For aplastic anemia, it has been proposed to administer intravenous phytohemagglutinin, but the data collected to date do not support assumptions about the feasibility of this method. Treatment with iron is contraindicated, as is treatment with cobalt, which causes nausea, vomiting and enlargement of the thyroid gland. Folic acid and vitamin B12 are ineffective even in patients with megaloblastic changes.

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1

1 KGBUZ "Krasnoyarsk Interdistrict Clinical Hospital No. 7"

2 Federal State Budgetary Educational Institution of Higher Education “Krasnoyarsk State Medical University named after Professor V.F. Voino-Yasenetsky" of the Ministry of Health of the Russian Federation

The article presents a case of successful treatment of a patient with a super-severe form of aplastic anemia in combination with paroxysmal nocturnal hemoglobinuria and chronic hemolysis. The interest of the clinical case is that the patient was simultaneously treated for severe intravascular hemolysis caused by paroxysmal nocturnal hemoglobinuria and a super-severe form of aplastic anemia. Considering the severity of intravascular hemolysis before and after the allogeneic bone marrow transplantation procedure, the patient was given a short induction course of therapy with Soliris (Eculizumab) 600 mg/day into a vein D-8, D-1, D+10. The patient received an allogeneic bone marrow transplantation from her sibling. Currently, the functioning of the graft is satisfactory, without the need for growth factors and replacement blood transfusions. No manifestations of graft-versus-host disease were observed, and immunosuppressive therapy with cyclosporine A was continued.

aplastic anemia

paroxysmal nocturnal hemoglobinuria

bone marrow transplantation (bmt)

blood diseases

2. Kulagin A.D. Aplastic anemia: immunopathogenesis, clinical picture, diagnosis, treatment / A.D. Kulagin, I.A. Lisukov, V.A. Kozlov. – Novosibirsk: Nauka, 2008. – 236 p.

3. Development of aplastic anemia: why and what to do? [Electronic resource]. – Access mode: http://asosudy.ru/anemiya/razvitie-aplasticheskoj-anemii (date of access: 06/28/2017).

4. Kulagin A.D., Lisukov I.A., Ptushkin V.V. and others. National clinical guidelines for the diagnosis and treatment of paroxysmal nocturnal hemoglobinuria / A.D. Kulagin, I.A. Lisukov, V.V. Ptushkin // Oncohematology. – 2014. – No. 2. – P. 3-11.

5. Paroxysmal nocturnal hemoglobinuria: Information and review brochure for hematologists / ed. Kulagina A.D. – Scientific Society of Medical Innovations. –Moscow: Literature, 2015. – 29 p.

6. Kelly R. The pathophysiology of paroxysmal nocturnal hemoglobinuria and treatment with eculizumab / R. Kelly, S. Richards, P. Hillman, A. Hill // Ther. Clin. Risk Manag. – 2009. – V.2009:5. – P. 911-921.

7. Parker C.J. Bone marrow syndrome failures: paroxysmal nocturnal hemoglobinuria / C.J. Parker // Hematol. Oncol. Clin. North Am. – 2009; 23: 333-46.

8. Hillmen P. Long-term safety and efficacy of sustained eculizumab treatment in patients with paroxysmal nocturnal hemoglobinuria / P. Hillmen, P. Muus, A. Roth et al. // Br. J. Haemotol. – 2013. –162(1). – P. 62-73.

This disease was first described in 1888 by Paul Ehrlich. The name aplastic anemia was proposed in 1904 by Chauford. The annual incidence of the disease is from 6 to 13 cases per 1,000,000 population. Aplastic anemia (AA) is a blood disease in which pancytopenia is formed as a result of inhibition of bone marrow hematopoiesis. Immune aggression directed at hematopoietic progenitor cells due to the activity of T-lymphocytes and killer cells is the main mechanism of hematopoietic impairment in aplastic anemia. There is overproduction of cytokines that suppress hematopoietic cells and stimulate the activation of T-lymphocytes. In bone marrow microslides with aplastic anemia, complete depletion of the bone marrow is noted, small foci of hematopoiesis are present. The bone marrow microenvironment plays a major role in the development of hematopoietic cells and in the functioning of the bone marrow, which in turn depends on the brain microcirculation network. The density of bone marrow vessels (microcirculation density) in patients with aplastic anemia is low. This plays a role in the pathophysiology of brain failure. It is possible that the use of proangiogenic agents in the treatment of aplastic anemia will play a role in restoring bone marrow function.

Treatment of aplastic anemia:

1. Therapy aimed at restoring bone marrow.
2. Replacement therapy with blood components, treatment and prevention of infectious complications.
3. Additional treatments for aplastic anemia

• steroids;
• splenectomy;
• Colony stimulating factors.

Paroxysmal nocturnal hemoglobinuria (PNH) - Harley disease, Marchiafava-Micheli disease, Strübing-Marchiafava disease - is an acquired, progressive systemic disease in which intravascular hemolysis is observed. The incidence of PNH reaches approximately 1 case per 1,000,000 inhabitants per year. The cause is a somatic mutation in the stem cell, total cytopenia develops with the involvement of platelets and leukocytes in the process. Thrombosis is formed, the activity of many organs is disrupted, including physiological and immune failure of the bone marrow. It should be remembered that differential diagnosis of paroxysmal nocturnal hemoglobinuria should be carried out in patients with cytopenia. Since acquired hematopoietic cell deficiency can be differentiated between diseases such as aplastic anemia, poroxysmal nocturnal hemoglobinuria, myelodysplastic syndrome, as well as age-related bone marrow degeneration in completely healthy people, and syndromes with a non-tumor process, the pathogenetic mutation should, whenever possible, be clarified by sequencing with hematopoietic deficiency syndrome.

There are three forms of Paroxysmal nocturnal hemoglobinuria:

• Classic form with signs of hemolysis.
• PNH in patients with aplastic anemia.

Subclinical form of the disease in patients without clinical and laboratory signs of hemolysis, but in the presence of a small clone of cells with signs of Paroxysmal nocturnal hemoglobinuria.

Treatment of Paroxysmal nocturnal hemoglobinuria, presented earlier: transfusions of blood components, therapy for hemolysis, iron deficiency, stimulators of the development of young forms of red blood cells, anti-inflammatory drugs. Mainly, the therapy was symptomatic and polyactive.

Allogeneic bone marrow transplantation (BMT) is currently the only radical treatment for paroxysmal nocturnal hemoglobinuria. BMT is associated with high mortality and complications. In addition, in the post-transplant period, restoration of the PNH clone and relapse of Paroxysmal nocturnal hemoglobinuria sometimes occur.

Due to the high risk of complications, allo-BMT is performed for hematopoietic aplasia (AA/PNH and AA/subclinical PNH), as well as for malignant clonal transformation of Paroxysmal nocturnal hemoglobinuria into Myelodysplastic syndrome, acute leukemia.

To date, the only effective pathogenic therapy for paroxysmal nocturnal hemoglobinuria is eculizumab (Soliris®, Alexion Pharmaceuticals, Cheshire, CT). Eculizumab is a humanized monoclonal antibody that binds to complement, which prevents the cleavage of the complement C group, thereby inhibiting the formation of the membrane attack complex. The effectiveness of the prescription has been proven only in patients who have undergone transfusion of blood or its components. The drug is used with caution in patients who are carriers or have an active form of infection with meningococcal neisseria and who have congenital complement deficiency. It is also necessary to use the drug with caution in patients with renal and hepatic insufficiency. Although there are reports of the successful use of eculizumab in patients with chronic renal failure. Prescribing Soliris in patients with Paroxysmal nocturnal hemoglobinuria reduces the risk of thrombosis, hemolytic complications, relieves the incidence of pulmonary hypertension, weakness, and apnea attacks. The drug has no effect on the aplastic symptom in paroxysmal nocturnal hemoglobinuria. The drug was recommended for use in patients, including those over 65 years of age, with caution in adolescents 12-17 years of age.

Treatment consists of an induction phase (600 mg IV for 4 weeks) and a maintenance phase (900 mg IV for the 5th week and every 14 days thereafter). Soliris is safe for long-term use and can significantly reduce the incidence of complications and mortality in patients with paroxysmal nocturnal hemoglobinuria. Currently, eculizumab is used in patients with Paroxysmal nocturnal hemoglobinuria in the presence of thrombotic complications, chronic hemolysis with dysfunction of organs and systems, transfusion dependence due to chronic hemolysis, pregnancy in patients with Paroxysmal nocturnal hemoglobinuria.

Aplastic anemia, according to epidemiological studies, occurs in Europe, North America, the Far and Middle East. Aplastic anemia is quite common in Korea. In European countries, the prevalence of aplastic anemia is 2 cases per 1 million population per year, with this indicator fluctuating depending on the specific country from 0.6 to 3 or more per 1 million population per year. Aplastic anemia is often combined with paroxysmal nocturnal hemoglobinuria (PNH). The clone of Paroxysmal nocturnal hemoglobinuria in patients with aplastic anemia is found in 50%. Aplastic anemia in combination with paroxysmal nocturnal hemoglobinuria is observed in 2-4 cases per 1 million population per year.

We present a clinical case of diagnosis and successful treatment of a patient with super-severe aplastic anemia in combination with paroxysmal nocturnal hemoglobinuria.

Patient M.Ya.V., born in 1993

Diagnosis: Acquired idiopathic aplastic anemia, super-severe form. A course of combined immunosuppressive therapy (thymoglobulin-22.01-26.01.16) + cyclosporine A). Allogeneic related bone marrow transplantation (06/14/16).

Paroxysmal nocturnal hemoglobinuria (12.2015). Chronic intravascular hemolysis.

Complications: Transient drug-induced nephrotoxicity (CsA). Secondary hemosiderosis.

The disease debuted in August 2015 - the appearance of heavy, prolonged menstruation for up to 7 days, subcutaneous hemorrhages from minor injuries, and did not seek medical help. Since November 2015, the appearance of blood in the stool.

On December 8, 2015, the patient was urgently hospitalized in the hematology department of KMCH No. 7 in Krasnoyarsk. The clinical picture shows a pronounced anemic syndrome (severe general weakness, fatigue, dizziness, shortness of breath when walking and physical activity); hemorrhagic syndrome (menametrorrhagia, subcutaneous hemorrhages, blood in the stool).

In the hemogram, erythrocytes 1.32*10 12 /l, reticulocytes 72.5% 0, spherocytosis, erythrocyte aggregation, hemoglobin 49 g/l, platelets 16*10 9 /l, leukocytes 2.66*10 9 /l, stab 1 %, segmented 4%, lymphocytes 87%, monocytes 7%, ESR 52 mm/h. Myelogram: punctate of significantly reduced cellularity. Megakaryocytes were not found in the punctate. There are no blasts. Coombs test (direct, indirect) - negative. In the biochemical blood test: Lactate dehydrogenase - 1194.0 U/l (N up to 450 U/l), total bilirubin 22.2 mmol/l (direct - 5.6 mmol/l, indirect 16.6 mmol/l). Trephine biopsy: changes reflect hypoplasia of bone marrow hematopoiesis. The PNH clone was detected: among granulocytes (FLAER-CD24) - 52.72%, among monocytes (FLAER-CD14) - 58%, on erythrocytes 11%.

Thus, based on histological, cytological, enzyme-linked immunosorbent typing studies, a diagnosis was made: Acquired idiopathic aplastic anemia, super-severe form/paroxysmal nocturnal hemoglobinuria, first identified.

Replacement therapy was carried out - hemocomponent therapy (transfusion of erythrocyte suspension No. 4, platelet concentrate No. 40), symptomatic therapy.

In December 2015, the patient was consulted in absentia by a professor at the Research Institute of Pediatric Oncology, Hematology and Transplantology (DOGiT) named after. R.M. Gorbacheva (St. Petersburg), MD. HELL. Kulagin: HLA typing of the patient and sibling is recommended. But at that time, the sibling (sister) was in the 7th month of pregnancy. According to the typing results, the patient and her sister are completely compatible.

In January and March 2016, repeated correspondence consultations at the Research Institute of Dog and Telecommunications and Technology named after. R.M. Gorbacheva, St. Petersburg: allogeneic related bone marrow transplantation is indicated after delivery and cessation of breastfeeding from a related donor. Taking into account the severity of intravascular hemolysis, a short induction course of therapy with eculizumab is indicated to reduce the risks of allogeneic bone marrow transplantation.

Before allogeneic bone marrow transplantation, the patient repeatedly underwent inpatient treatment in the hematology department of KMCH No. 7 in Krasnoyarsk, where hemocomponent therapy was carried out (transfusions of red blood cell suspension, platelet concentrate).

During the next hospitalization in January 2016, a course of ATG (thymoglobulin 800 mg/course) + GCS was administered. The patient tolerated the therapy satisfactorily, there were no signs of serum sickness. Since March 2016, she started taking cyclosporine A at a dose of 400 mg/day, the tolerability is satisfactory.

Hospitalization in the bone marrow transplantation department of PSPbSMU named after. Academician I.P. Pavlov Scientific Research Institute of Dog and Telecommunications named after. R.M. Gorbacheva - 06.06.16 Donor: sister born in 1988, fully compatible according to the HLA system with major and minor incompatibility according to ABO-AII>BIII).

Conditioning regimen: fludarabine 240 mg intravenous, busulfan 520 mg per os, thymoglobulin 326 mg intravenous. Graft versus host prophylaxis (GVHD): cyclosporine 1560 mg intravenous, methotrexate 60 mg intravenous. Prevention of chronic intravascular hemolysis - eculizumab 600 mg/day intravenous D-8, D-1, D+10. 06/14/16 Allogeneic bone marrow transplantation was performed. The patient underwent the administration of the conditioning regimen and underwent transplant transfusion without complications. During the early post-transplantation period, complications were observed: toxic hepatitis stage 2, against the background of the administration of methotrexate, therapy with hepatoprotectors was carried out with positive dynamics; febrile neutropenia, response to tienam.

Recovery of peripheral blood: leukocytes >1x10 9 /l/D+24; neutrophils >0.5x10 9 /l/D+19, platelets >50x10 9 /l/D+20. Bone marrow puncture: D+28 - normocellular bone marrow, all sprouts are present, karyotype 46.XX, donor chimerism 90-97%; D+43/D+62 - all germs are represented in the myelogram, complete donor chimerism (97%). Study of the PNH clone: ​​D+24 - a minor clone is preserved among granulocytes (FLAER-CD24) - 0.01%, among monocytes (FLAER-CD14) - 0.01%; There are no laboratory or clinical manifestations of intravascular hemolysis. D+43 - the PNH clone is not detected among monocytes and granulocytes, among erythrocytes it is minor (CD59 - 0.55%). D+65 - not detected among monocytes and granulocytes, minor among erythrocytes (CD59 - 0.30%).

C D+23 was transferred to oral cyclosporine A 200 - 250 mg/day. There were no signs of acute graft-versus-host disease. The patient continued to take antimicrobial, antibacterial, and antifungal drugs on an outpatient basis, in order to prevent infectious complications, at the prescribed dose. The patient was observed weekly by hematologists in Krasnoyarsk, blood tests and biochemical parameters were monitored, and the dose of cyclosporine A was adjusted.

In September 2016, the patient was undergoing a routine examination and treatment in the BMT department for adults of the Institute of Gynecology and Traumatology named after. R.M. Gorbacheva, St. Petersburg. Bone marrow puncture (D+97): normocellular bone marrow, all sprouts are present, complete donor chimerism (90-97%). Hemogram: erythrocytes 3.31 * 10 9 / l, hemoglobin 105 g / l, reticulocytes 1.24% 0, platelets 165 * 10 9 / l, leukocytes 2.5 * 10 9 / l, neutrophils 71.8%. Study of the PNH clone (D+98): PNH clone is not detected.

The functioning of the graft is satisfactory, without the need for growth factors or replacement blood transfusions. There were no manifestations of graft-versus-host disease, immunosuppressive therapy with cyclosporine A (125 mg/day) was continued, the dose was reduced due to organic toxicity (hypercreatininemia).

Repeated scheduled examination from November 2016 in the bone marrow transplantation department for adults of the IDGiT named after. R.M. Gorbacheva, St. Petersburg. Bone marrow puncture (D+153): bone marrow is of moderate cellularity, all sprouts are present. Hemogram: red blood cells 3.58 * 10 9 / l, hemoglobin 116 g / l, reticulocytes 2.31% 0, platelets 162 * 10 9 / l, leukocytes 3.3 * 10 9 / l, neutrophils 65.9%. Study of the PNH clone (D+157): PNH clone is not detected. The functioning of the graft is satisfactory, without the need for growth factors and replacement blood transfusions. Donor blood type. There are no manifestations of graft-versus-host disease, immunosuppressive therapy with cyclosporine A continues. The patient continues to be observed by hematologists in the bone marrow transplantation department for adults of the IDHiT named after. R.M. Gorbacheva of St. Petersburg and hematologists of the city of Krasnoyarsk.

Discussion. Aplastic anemia and paroxysmal nocturnal hemoglobinuria are two progressive systemic diseases that are associated with high mortality. A large percentage of patients diagnosed with this pathology die within 5 years. Our patient, at the age of 22, was diagnosed with a super-severe form of AA with a large PNH clone and chronic intravascular hemolysis, which, according to the literature, is associated with a high percentage of lethal thrombotic complications. The patient did not experience any effect from the use of hemocomponent or combined immunosuppressive therapy (thymoglobulin + cyclosporine A). There remained a pronounced anemic, hemorrhagic syndrome, deep pancytopenia in the hemogram, and signs of intravascular hemolysis. The only possible treatment method for this young patient in this situation was allogeneic BMT in combination with the use of pathogenetic therapy for PNH with a high-tech drug - eculizumab. In the TCM department of PSPbSMU named after. Academician I.P. Pavlov Scientific Research Institute of Dog and Telecommunications named after. R.M. Gorbacheva, the patient was treated: administration of eculizumab 600 mg per day intravenously No. 3, followed by allogeneic BMT from a related donor, which ultimately led to the patient’s recovery. The patient's anemic, hemorrhagic syndrome was relieved, blood counts returned to normal, signs of hemolysis disappeared, and the PNH clone was not detected.

Thus, timely, highly qualified diagnostics and a modern approach to the treatment of this disease ensured a satisfactory outcome for the patient, with an improvement in the clinical condition and a favorable prognosis for health.

Bibliographic link

Kuznetsova E.Yu., Syrtseva E.B., Olkhovik T.I., Mikhalev M.A., Sokolova-Popova T.A., Savyak L.M. CLINICAL CASE OF SUCCESSFUL TREATMENT OF A PATIENT WITH APLASTIC ANEMIA AND PAROXYSMAL NOCTUAL HEMOGLOBINURIA USING SOLIRIS IN THE PRE- AND POST-TRANSPLANTATION PERIOD // Modern problems of science and education. – 2017. – No. 5.;
URL: http://site/ru/article/view?id=26773 (date of access: 02/22/2020).

We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"

NOCTURE HEMOGLOBINURIA

Paroxysmal nocturnal hemoglobinuria(PNH) (Marchiafava-Micheli disease) is a rare acquired disease characterized by chronic hemolytic anemia, intermittent or constant hemoglobinuria and hemosiderinuria, thrombosis and cytopenia of peripheral blood and bone marrow aplasia.

PNH is a clonal bone marrow disease resulting from a mutation in a blood stem cell.
The consequence of the mutation is the appearance of a clone of abnormal hematopoietic cells with a defect in the cytoplasmic membrane, making them hypersensitive to complement in an acidic environment.

Epidemiology.
In 1 year, 2 new cases of PNH are detected per 1 million people.
People aged 20-40 years old are somewhat more likely to get sick, regardless of gender.
The etiology of PNH is not well understood.
The proven clonality of the disease allows us to talk about the role of etiological factors that can cause mutation of the blood stem cell.

Pathogenesis.
Due to a mutation in a blood stem cell, an abnormal clone of cells develops in the bone marrow, giving rise to abnormal red blood cells, granulocytes and platelets.
At the genetic level, the cause of the development of PNH is a point mutation of the PIG-A gene (from the English phosphatidilinositol glycan complementation class A), associated with the active X chromosome.
This mutation leads to disruption of the synthesis of the glycosylphosphatidylinositol anchor (GPI anchor), which is responsible for attaching a number of membrane proteins to the cell membrane.
The descendants of a mutated stem cell acquire special sensitivity to complement due to a restructuring of the structure of their cytoplasmic membrane.
Being a clonal disease, PNH can transform into ALLL (most often acute erythroblastic leukemia) and MDS.

Clinical picture.
In most cases, the disease manifests itself with symptoms of anemia: weakness, fatigue, shortness of breath, palpitations, dizziness.
Hemolytic crises can be triggered by infection, heavy physical activity, surgery, menstruation, and medication.

In the classic form of the disease, a hemolytic crisis usually develops at night, when there is a slight shift in blood pH to the acidic side.
In this case, after waking up, black urine appears. Hemoglobinuria is usually considered as a characteristic sign, however, it is not obligatory.
A more permanent symptom is hemosiderinuria.
Hemolysis may be accompanied by pain in the lumbar, epigastric regions, bones and muscles, nausea and vomiting, and fever.

On examination: pallor, jaundice, bronze coloration of the skin and splenomegaly.
Hemolytic crises are replaced by a relatively calm state, in which the degree of hemolysis and the severity of clinical manifestations decrease.
Patients are prone to thrombosis leading to death (thrombosis of cerebral vessels, coronary vessels of the heart, large vessels of the abdominal cavity and liver).

Occlusion of the glomeruli of the kidneys is the cause of acute renal failure.
Excessive accumulation of iron in the kidneys (hemosiderosis) can cause chronic renal failure.

Diagnostics.
The primary idea of ​​PNH is formed by identifying clinical and laboratory signs of intravascular hemolysis: normochromic anemia; increase in the number of reticulocytes; the appearance of black urine (hemoglobinuria); detection of hemosiderin in urine; pain in the lumbar and epigastric region.

Suspicion of PNH increases when all of the above signs are combined with changes in the hemogram: normochromic anemia, leukopenia and thrombocytopenia are detected.
As the disease progresses, anemia becomes hypochromic due to significant losses of iron in the urine.
Detection of repeated thromboses also helps in making a diagnosis. The absence of signs of intravascular hemolysis (for example, in the intercrisis period) makes the diagnosis of PNH difficult.
In such a situation, it is possible to suspect the existence of a disease only with a careful analysis of anamnestic data.

To confirm or exclude PNH, it is necessary to perform a Hem test and (or) a sucrose test.
These tests make it possible to detect the increased sensitivity of erythrocytes to complement in an acidic environment, even in the absence of clinical manifestations of intravascular hemolysis.
A positive result obtained when performing any of these tests is a necessary and sufficient condition for ascertaining PNH.
Negative results of both tests exclude the diagnosis of PNH.
Relatively recently, to verify the diagnosis of PNH, the method of flow cytofluorimetry began to be used, based on determining the reduced expression of CD-55 and CD-59 on erythrocytes and leukocytes, CD-14 on monocytes, CD-16 on granulocytes and CD-58 on lymphocytes.
According to some data, this method is not inferior in reliability to the samples discussed above.

Pathomorphology of the bone marrow: moderate hyperplasia of the erythroid lineage of hematopoiesis.
The number of granulocyte precursors and megalocytes is reduced.
In some cases, fields of severe hypoplasia, represented by edematous stroma and fat cells, may be detected.

Differential diagnosis.
When identifying signs of intravascular hemolysis, diagnosis is not difficult, since the range of diseases with intravascular hemolysis is limited.
Difficulties in this group can only be encountered when distinguishing between PNH and AIHA with warm hemolysins.
Both diseases are very similar in clinical picture, but with PNH the number of leukocytes and (or) platelets is often reduced.
The doubts are finally resolved by immunological methods of detecting the AT class of hemolysins in the patient’s blood serum and (or) anti-erythrocyte ATs fixed on the surface of erythrocytes.
In all cases of detection of intravascular hemolysis, it seems advisable to include a sucrose test and (or) a Hem test among the priority tests.

When cytopenia is detected and there are no clinical and laboratory signs of intravascular hemolysis, there is a need for differential diagnosis with diseases accompanied by pancytopenia in the peripheral blood, namely aplastic anemia and myelodysplastic syndrome.
Performing a cytological examination of the bone marrow will slightly narrow the scope of the differential diagnostic search.

Treatment.
The pathogenetic treatment method for PNH is bone marrow transplantation from a histocompatible donor.
If it is impossible to select a donor for myelotransplantation, then symptomatic therapy is carried out aimed at stopping the complications that arise, and replacement therapy with washed erythrocytes or thawed washed erythrocytes is carried out.

The use of prednisolone or other corticosteroids and (or) immunosuppressants has no effect due to the lack of a point of application for the action of these drugs.

Forecast.
The life expectancy of patients is on average 4 years.
Cases of long-term spontaneous remissions have been described.

Prevention.
There is no effective prevention of PNH.
Heparin is prescribed for the prevention and treatment of thrombosis.
Rheopolyglucin is also used to improve rheology.

Catad_tema Blood diseases - articles

ICD 10: D61.1, D61.2, D61.3, D61.8, D61.9

Year of approval (revision frequency): 2014 (reviewed every 2 years)

ID: KR121

Professional associations:

• National Society of Hematology

Approved

Russian Society of Hematologists

Agreed

Scientific Council of the Ministry of Health of the Russian Federation__ __________201_

Quality criteria

Level of evidence

Diagnostic measures

Perform an advanced clinical blood test

Morphological and cytochemical studies of the bone marrow preparation were performed

A cytogenetic study of bone marrow cells was performed

A morphological (histological) study of a bone marrow preparation was performed

A chest X-ray and/or computed tomography scan of the chest and brain was performed

Event-based (semantic, content, process) quality criteria

A morphological and/or histological and/or standard cytogenetic study of a bone marrow specimen was performed

Combined immunosuppressive therapy was carried out (in the absence of contraindications)

HLA typing of siblings was performed

A consultation was performed at the transplant center within 3 months from the moment the refractory course was determined

Temporary quality assessment criteria

Immunosuppressive therapy was performed within 1 month after histological and/or cytogenetic confirmation of the diagnosis (in the absence of medical contraindications)

Clinical and hematological parameters were assessed during therapy at least 2 times a week until a complete hematological response was achieved

A morphological study of a bone marrow preparation was performed with an assessment of bone marrow hematopoiesis after completion of the therapy program

A standard cytogenetic study of a bone marrow preparation was performed (study of at least 20 metaphases) and/or a bone marrow study using fluorescent hybridization (in case the cytogenetic study was not informative to identify abnormalities characteristic of myelodysplastic syndrome)

The clone of paroxysmal nocturnal hemoglobinuria was determined using highly sensitive flow cytometry every 6-12 months, clinical and laboratory signs of hemolysis were assessed

A morphological and/or histological and/or standard cytogenetic study was performed before the next stage of treatment

A repeated course of antithymocyte globulin and HLA typing were carried out (to determine the availability of allogeneic bone marrow donors, in the absence of a response after 3-6 months)

Bibliography

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1. Kulagin A.D. Aplastic anemia / Kulagin A.D. / ed. K.V.A. Lisukov I.A. – – Novosibirsk: Nauka, 2008. Vol. The science.
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4. Bacigalupo A. Treatment strategies for patients with severe aplastic anemia. / A. Bacigalupo // Bone Marrow Transplant. – 2008. – T. 42 Suppl 1 – No. SUPPL.1 – S42–S44с.
5. Borowitz M.J. Guidelines for the diagnosis and monitoring of paroxysmal nocturnal hemoglobinuria and related disorders by flow cytometry. / M. J. Borowitz, F. E. Craig, J. A. Digiuseppe, A. J. Illingworth, W. Rosse, D. R. Sutherland, C. T. Wittwer, S. J. Richards // Cytometry B. Clin. Cytom. – 2010. – T. 78 – No. 4 – 211–30 p.
6. Kulagin A. Prognostic value of paroxysmal nocturnal haemoglobinuria clone presence in aplastic anemia patients treated with combined immunosuppression: Results of two-centre prospective study / A. Kulagin, I. Lisukov, M. Ivanova, I. Golubovskaya, I. Kruchkova, S. Bondarenko, V. Vavilov, N. Stancheva, E. Babenko, A. Sipol, N. Pronkina, V. Kozlov, B. Afanasyev // Br. J. Haematol. – 2014. – T. 164 – No. 4 – 546–554 p.
7. Marsh J.C.W. Guidelines for the diagnosis and management of aplastic anemia / J. C. W. Marsh, S. E. Ball, J. Cavenagh, P. Darbyshire, I. Dokal, E. C. Gordon-Smith, J. Keidan, A. Laurie, A. Martin, J. Mercieca, S. B. Killick, R. Stewart, J. A. L. Yin // Br. J. Haematol. – 2009. – T. 147 – No. 1 – 43–70 p.
8. Marsh J.C.W. Guidelines for the diagnosis and management of aplastic anemia. / J. C. W. Marsh, S. E. Ball, J. Cavenagh, P. Darbyshire, I. Dokal, E. C. Gordon-Smith, J. Keidan, A. Laurie, A. Martin, J. Mercieca, S. B. Killick, R. Stewart, J. A. L. Yin / / Br. J. Haematol. – 2009. – T. 147 – No. 1 – 43–70 p.
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Appendix A1. Composition of the working group

Voitsekhovsky V.V. doctor, Blagoveshchensk

Vopilina N.A. GBUZ Tambov Regional Clinical Hospital named after. V.D.Babenko", Tambov

Gaponova T.V. Candidate of Medical Sciences, Deputy General Director of the Federal State Budgetary Institution Hematological Scientific Center of the Ministry of Health of Russia, Moscow

Golubeva M.E.. "City Hematology Center" at the Municipal Budgetary Healthcare Institution "GKP No. 5", Perm

Kaporskaya T.S. Candidate of Medical Sciences, Head of the Department of Hematology, Irkutsk Order of the Badge of Honor Regional Clinical Hospital, Irkutsk,

Klyasova G.A. Doctor of Medical Sciences, Professor, Head of the Scientific and Clinical Laboratory of Microbiology, Federal State Budgetary Institution Hematological Research Center of the Ministry of Health of Russia, Moscow,

Konstantinova T.S. Head of the Department of Hematology, Regional Hematology Center, Sverdlovsk Regional Clinical Hospital No. 1, Yekaterinburg,

Kulagin A.D. Doctor of Medical Sciences, Deputy Chief Physician at the Clinic of the State Budgetary Educational Institution of Higher Professional Education "St. Petersburg State Medical University named after. acad. I.P. Pavlov" Ministry of Health of Russia, St. Petersburg Research Institute of Pediatric Hematology and Transplantology named after. R.M.Gorbacheva,

Lapin V.A. Candidate of Medical Sciences, Head of the Department of Hematology, Yaroslavl Regional Clinical Hospital, Yaroslavl

Mikhailova E.A. Doctor of Medical Sciences, Professor, Leading Researcher at the Department of Chemotherapy for Hematological Malignancies and Hematopoietic Depressions, Federal State Budgetary Institution Hematological Scientific Center of the Ministry of Health of Russia, Moscow,

Parovichnikova E.N. Doctor of Medical Sciences, Head of the Scientific and Clinical Department of Chemotherapy of Hemoblastosis, Hematopoietic Depression and Bone Marrow Transplantation, Federal State Budgetary Institution Hematological Research Center of the Ministry of Health of Russia, Moscow,

Ploskikh M.A. GBUZ PC "Perm Regional Clinical Hospital", Perm

Savchenko V.G. Academician, Doctor of Medical Sciences, Professor, General Director of the Federal State Budgetary Institution Hematological Research Center of the Ministry of Health of Russia, Moscow,

Samoilova O.S. Candidate of Medical Sciences, Head of the Department of Hematology, Nizhny Novgorod Region Nizhny Novgorod Regional Clinical Hospital. N.A. Semashko, Nizhny Novgorod,

Skripkina N.S. hematologist GAUZ JSC "Amur Regional Clinical Hospital", Blagoveshchensk,

Tikunova T.S. OGBUZ "Belgorod Regional Clinical Hospital of St. Joasaph", Belgorod

Troitskaya V.V. Candidate of Medical Sciences, Head of the Scientific and Clinical Department of Chemotherapy of Hematological Malignancies and Hematopoietic Depressions, Federal State Budgetary Institution Hematological Research Center of the Ministry of Health of Russia, Moscow,

Ustinova E.N. Candidate of Medical Sciences, Researcher at the Department of Chemotherapy for Hematological Malignancies and Depressions of Hematopoiesis, Federal State Budgetary Institution Hematological Research Center of the Ministry of Health of Russia, Moscow,

Chagorova T.V. GBUZ "Regional Oncology Dispensary", Penza

Hematology specialists;

Oncology specialists;

Specialist therapists;

Evidence collection methodology

Methods used for collecting/selecting evidence: searching electronic databases.

Description of the methods used for collecting/selecting evidence: the evidence base for the recommendations is publications included in the Cochrane Library, the EMBASE and MEDLINE databases. The search depth was 10 years.

Levels of Evidence	Description
	High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with very low risk of bias
	Well-conducted meta-analyses, systematic ones, or RCTs with low risk of bias
	Meta-analyses, systematic, or RCTs with a high risk of bias
	High-quality systematic reviews of case-control or cohort studies. High-quality reviews of case-control or cohort studies with very low risk of confounding effects or bias and moderate probability of causality
	Well-conducted case-control or cohort studies with moderate risk of confounding effects or bias and moderate probability of causality
	case-control or cohort studies with a high risk of confounding effects or bias and a moderate probability of causation
	Non-analytical studies (for example: case reports, case series
	Expert opinion

Methods used to assess the quality and strength of evidence:

Expert consensus;

Methods used to analyze evidence:

Systematic reviews with evidence tables.

Description of methods used to analyze evidence:

When selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure its validity. The outcome of the study influences the level of evidence assigned to the publication, which in turn influences the strength of the recommendations resulting from it.

Methodological examination is based on several key questions that focus on those features of the study design that have a significant impact on the validity of the results and conclusions.

The assessment process can undoubtedly be affected by the subjective factor. To minimize potential bias, each study was assessed independently, i.e. at least two independent members of the working group. Any differences in assessments were discussed by the whole group as a whole. If it was impossible to reach consensus, an independent expert was involved.

Evidence tables:

evidence tables were completed by members of the working group.

Methods used to formulate recommendations:

expert consensus.

Indicators of good practice (Good Prastic Points - GPPs):

Economic analysis:

No cost analysis was performed and pharmacoeconomics publications were not reviewed.

External expert assessment;

Internal expert assessment.

	Description
	At least one meta-analysis, systematic review, or RCT rated 1++, directly applicable to the target population and demonstrating robustness of the results, or body of evidence that includes study results rated 1+, directly applicable to the target population, and demonstrating overall robustness of the results
	a body of evidence consisting of study results rated 2++, directly applicable to the target population and demonstrating overall robustness of the results, or extrapolated evidence from studies rated 1++ or 1+
	a body of evidence consisting of study results rated 2+, directly applicable to the target population, and demonstrating overall robustness of the results; or extrapolated evidence from studies rated 2++
	Level 3 or 4 evidence; or extrapolated evidence from studies rated 2+

These draft recommendations were peer-reviewed by independent experts who were asked to comment primarily on the extent to which the interpretation of the evidence underlying the recommendations was clear.

Comments were received from primary care physicians and local therapists regarding the clarity of the recommendations and their assessment of the importance of the recommendations as a working tool in everyday practice.

A preliminary version was also sent to a non-medical reviewer for comments from a patient perspective.