Analysis of pathogenesis and pathophysiology of congenital bone marrow failure for the establishment of the treatment strategy

钻石黑扇贫血(DBA)是一种先天性纯红细胞再生障碍性疾病，偶尔会出现生理异常。约20%的患者携带核糖体蛋白S19基因杂合突变(RPS19)。然而，由于单倍体功能不全导致的红细胞减少和异常的发病机制仍然不清楚，其他的致病基因也被提出。部分患者依赖输血和/或强的松龙(PSL)，然后需要造血干细胞移植(HSCT)。在日本，既没有关于DBA流行病学的信息，也没有报告有RPS19突变的患者。对先天性(遗传性)骨髓衰竭综合征的临床和实验分析，不仅将为患者的治疗提供有用的信息，而且将有助于阐明造血和形态发生的分子机制。我们研究了日本DBA患者的流行病学和治疗反应，揭示了基于…的异基因造血干细胞移植的结果和问题更多关于日本儿科血液病学会再生障碍性贫血委员会注册的随访数据(教授，筑本I，木岛H，大原A，小岛S，等)。此外，我们分析了无RPS19突变的有代表性的患者的基因表达，并认为非突变的RP基因表达减少可能参与了生理性贫血的潜在机制1)流行病学和治疗反应1)1988年至1998年在日本登记的54名儿童(男：女=26：28)进行了队列调查。年发病率为4.02例/百万新生儿，确诊时年龄中位数为60天，59%在3个月大时出现。3名患者有家族性发病。所有患者均接受PSL治疗，17例联合应用环孢素A(CsA)。47名患者接受了输血，13名患者接受了造血干细胞移植。诊断后5年以上，HSCT前无药物或无输血状态的累积概率分别为36%和69%。13名患者在没有接受HSCT的情况下从PSL治疗中脱机，CsA与脱机无关。分别有34名和13名患者在确诊后249天和933天停止输血和药物治疗，他们达到了非依赖状态。尽管我们的研究包括了5个可供选择的供者，但HSCT的成功率(85%)在所有以前的报告中都是最高的。2)利用几乎覆盖所有人类基因组的寡核苷酸末端进行微阵列分析比较了DBA和AA患者中具有代表性的患者的CD4^+细胞基因表达模式。DBA与再生障碍性贫血(AA)的基因表达水平差异无统计学意义。K-均值聚类分析显示，28个RP基因被显著归类为一小组(994个基因)(p=2.39E-17)5，其中所有基因在DBA中的表达水平均低于AA患者。RPS19在DBA患者中属于低表达基因集。这些结果表明，Rp基因的低表达是DBA与AA的一个显著特征。较少

Diamond-Black fan anemia(DBA) is a congenital pure red cell aplasia occasionally presenting physical anomalies. Approximately 20% of patients carry the heterozygous mutation of ribosomal protein S19 gene(RPS19). However, the etiopathogenesis of erythroblastopenia and anomalies due to the haploinsufficiency remains elusive, and other causative genes are suggested. A part of patients depend on transfusion and/or prednisolone(PSL), and then require hematopoietic stem cell transplantation(HSCT). In Japan, there has been neither information on the epidemiology of DBA, nor reported patients having the mutation of RPS19. Clinical and experimental analyses of congenital (inherited) bone marrow failure syndrome will provide useful informaion not only for the management of patients, but also for clarifying the molecular mechanism of hematopoiesis and morphogenesis. We studied the epidemiology and treatment responses of DBA patients in Japan, and revealed the outcomes and problems of HSCT, based … More on the follow-up data in the registration of the Aplastic Anemia Committee of the Japanese Society of Pediatric Hematology (Professors, Tsukimoto I, Mugishima H, Ohara A, Kojima S, et al.). Furthermore, we analyzed the gene expressions of representative patients carrying no RPS19 mutations, and suggested that reduced expression ofnon-mutated RP genes might be involved in the underlying mechanism of constitutional anemia1)Epidemiology and treatment responsesA cohort of 54 children (M:F=26:28) registered in Japan from 1988 to 1998 was surveyed. The annual incidence was 4.02 cases per million births, median age at diagnosis was 60 days, and 59% presented by 3 months of age. Three patients had a familial occurrence. All received PSL, and cyclosporine-A(CsA) was combined in 17 patients. Forty-seven received transfusions, and 13 underwent HSCT. The cumulative probability of a medication-or transfusion-free state prior to HSCT was 36% or 69%, respectively, more than 5 years after diagnosis. Thirteen patients were weaned from PSL-therapy without HSCT, and CsA was not associated with weaning from the therapy. Transfusion and medication were stopped at 249 and 933 days after diagnosis in 34 and 13 patients, respectively, who achieved a state ofindependency. HSCT led to the highest success (85%) of all previous reports, even though 5 alternative donors were included in our study.2)Microarray analysis by using Oligo DNA tip covering nearly all human genomesGene expression patterns of CD4^+ cells were compared in representative patients between DBA and AA. Differences in the gene expression levels between DBA and aplastic anemia(AA) did not reach the statistical significance. K-mean clustering analysis revealed the significant categorization of 28 RP genes into a small set of group (994 genes)(p=2.39E-17)5 in which all genes were expressed at lower levels in DBA than in AA patients. RPS19 was categorized into the set of low expressing genes in DBA patients. These results indicated that the lower expression of RP genes was a distinctive feature of DBA from AA. Less