Analysis Of Immune Status And Its Clinical Significance In ITP And Adult HPS Patients

Changes and significance of peripheral blood immune cell subsets in ITP patients before and after treatment Background Immune thrombocytopenia(ITP)is an acquired immune-mediated disorder characterized by increased platelet destruction and reduced platelet production,eventually lead to decreased platelet count and hemorrhage symptoms.The pathogenesis of primary ITP still remains unclear,and is heterogeneous and complex.Recently,abnormal cellular immune responses have been reported in ITP patients,which may link to a breakdown of the normal balance between immunity and self-tolerance in ITP.Currently used first-line therapies(such as glucocorticoids)and second-line therapies(such as vincristine,azathioprine,rituximab,eltrombopag and romiplostim)all have the function of regulating immunity.Therefore,we need to further explore the changes of immune status in patients with ITP and its correlation with therapeutic efficacy,and ultimately provide a theoretical basis for rational drug used in clinical practice.Objectives To explore the immunological abnormalities in patients with primary ITP,and analyze its relationship with treatment.Methods Proportion of different immune cell subsets were detected in the peripheral blood of 124 ITP patients at different time points and 45 normal controls by flow cytometry.The treatments included glucocorticoids,intravenous IgG as first-line treatment and second-line drugs.Results Elevated CD4/CD8 ratio and decreased proportion of NK and CD4+CD25+CD127low regulatory T cells(Tregs)were found in pre-treated ITP patients than healthy controls.The newly diagnosed group had a significantly higher CD4/CD8 ratio than the relapsed group,but no differences in the proportion of B cells,NK cells and Tregs.No relationships were found between the curative effect and the pre-treated cell subsets within both the effective and ineffective groups.Furthermore,compared with the ineffective group,the effective group had higher Tregs and lower CD4/CD8 ratio post-treatment,but no significant differences in NK and B cells.Conclusion ITP patients presented with a high CD4/CD8 ratio and low levels of Tregs and NK cells,suggesting that immune deregulation was involved in the pathogenesis of ITP.The pre-treated immune status of ITP patients may not be related to the curative effect.Tregs significantly increased in the effective group post-treatment,highlighting that the mechanism of restoring Tregs may be involved in the treatment of ITP.However,whether or not the targeted regulation of Tregs is an effective treatment for ITP still requires further studies.Low dose IL-2 in the treatment of ITP Background In previous studies,we found that ITP patients have abnormal immune functions,especially for Treg cells.As a kind of immune incompetence and immunosuppressive cells,it is a research hotspot in recent years.Many studies have found that the level of Treg cells in patients with autoimmune diseases is significantly reduced,also,several diseases could be treated through improving the level of Tregs,such as graft-vs-host disease(GVHD),type 1 diabetes and so on.Our previous study also found that Tregs in the peripheral blood of ITP patients was significantly reduced pre-treatment,and the level of Tregs was closely related to the curative effect after treatment.The level of Treg cells in the peripheral blood of the patients who were effective treated was significantly higher than that in the ineffective treated group,even higher than that in the control group.It also suggests that ITP may be treated by improving the level of Treg cells.Recent studies have found that high dose IL-2 can stimulate the proliferation and activation of T cells in vivo,but low dose IL-2 mainly stimulates Tregs.At present,low dose IL-2 has also been used to treat some autoimmune diseases and has achieved good results.ITP is also a autoimmune disease,and the incidence of Treg cells significantly decreased in the onset of peripheral blood,spleen and even bone marrow.So,can low dose of IL-2 be used in ITP through improving the level of the Treg cells?Objectives To explore the value of low dose IL-2 in the treatment of ITP.Methods Here we report the efficacy of low-dose interleukin-2 in another four adults with ITP who failed the first-line treatment.All patients received a dose of 1.0 million IU IL-2 / day for 5 consecutive days per week as a cycle for 2 or 4 weeks.In addition to interleukin-2,Vincristine(2 mg IV weekly�3 weeks)was added to one patient as a combination therapy.No specific treatment was added in another three patients.Results Three cases exhibited significantly increased platelet counts with improved levels of regulatory T cells,while no changes were observed for the remaining patient.None of the patients had any adverse events.Conclusion Administration of daily subcutaneous low-dose interleukin-2 was safe,and it may be a new therapeutic option for treatment of ITP,especially refractory ITP.Clinical characteristics and immune status of adult HPS and its relationship to early prognosis Background Hemophagocytic syndrome(HPS),which was first described in 1939 by paediatricians Scott and Robb-Smith,is a life-threatening disease.HPS is characterized as cytokine release syndrome which caused by excessive but non-malignant activation of macrophages and/or histiocytes in bone marrow and other reticuloendothelial systems.According to its different pathogenesis,HPS has been divided into two categories: primary and secondary form.The primary autosomal recessive form-familial hemophagocytic lymphohistiocytosis(FHL)was usually found under 3 years old.Secondary HPS is often related to infection,malignance and autoimmune diseases and occur at any age,especially adults.However,although the etiology,pathogenesis,clinical manifestations and treatment of adult HPS are different from children's HPS,the clinical experience of HPS is still mainly from children's HPS.Therefore,more research should be done on adult HPS.Objectives To improve the understanding,early diagnosis,and predication of early outcome of adult hemophagocytic syndrome.In order to specifically identify prognostic factors of early death in reactive HPS,we divided the patients into two groups: One survived longer than 30 days(survivors n=18),and the other less than 30 days(non-survivors,n=11).Than analyse the clinical data and results of the two groups.Methods we examined the medical records from 29 adults hospitalized with HPS and analyzed correlations among clinical features,laboratory examinations,immune status,prognostic factors and outcomes.Results Total 29 patients diagnosed with HPS were examined,including 18 males and 11 females.The median age was 42.0(25.5-61.0)years old.In terms of etiology,the most common are hematologic tumors(n=14,48.3%),followed by infectious diseases(n=7,24.1%)and autoimmune diseases(n=1,3.4%).In 7 patients(24.1%),the cause was unknown.In terms of clinical manifestations,29 patients were different,the most common is fever(n=28,96.6%),followed by splenomegaly(n=26,89.7%),superficial or abdominal lymphadenopathy(n=16,55.2%),hepatomegaly(n=10,34.5%)and rash(n=1,3.4%).In terms of laboratory tests,cytopenia(n=29,100%)and serum calcium(n=29,100%)are the most common,followed by elevated serum ferritin(n=28,96.6%),and liver function impairment(n=24,82.8%),elevated alanine aminotransferase(n=21,72.4%),elevated aspartate aminotransferase(n=24,82.8%),elevated lactate dehydrogenase(n=24,82.8%),hypertriglyceridemia(n=23,79.3%),hypofibrinogenemia(n = 20,69.0%),elevated C-reactive protein levels(n = 20,69.0%)and total bilirubin levels Elevated(n=16,55.2%),renal impairment(n=12,41.4%),urinary protein positive(n=17,58.6%).Of the 28 patients who underwent bone marrow cytology,27(96.4%)had blood smears in the bone marrow.Except for patients with B-cell lymphoma,all patients had normal immunoglobulins(Ig G,Ig A,and Ig M).C4 was normal in all patients,and mild C3 reduction(13.8%)occurred in 4 patients.Eleven patients underwent PET-CT examination.Among them,9 patients with malignant tumors had increased FDG intake,and 2 patients with increased FDG intake had unknown etiology.In terms of treatment,glucocorticoids and immunosuppressive drugs are the main strategies for controlling excessively ineffective immune responses to HPS.For patients with HPS who have a definite secondary factor,corresponding treatment for the primary disease is also given.In terms of early prognosis,there were 18 patients in the survival group and 11 in the death group,with a mortality rate of 37.9%.In addition,we compared the clinical data and laboratory test results at the time of diagnosis between the two groups of patients to analyze the factors affecting the early prognosis of HPS.The results suggest that there is no significant difference in general clinical data and clinical performance between the two groups of patients.In laboratory tests,the platelet count and serum calcium levels in the death group were significantly lower than those in the survivor group,with statistically significant differences(P=0.006 and 0.042,respectively).The levels of alanine aminotransferase,aspartate aminotransferase,and total bilirubin in the death group were also significantly higher than those in the death group(P values were 0.008,0,and 0.008,respectively).The proportion of CD4+ Treg cells in the death group was significantly lower than that in the survival group(P=0.019),and both groups were lower than normal levels,but there was no significant difference in the CD4/CD8 ratio between the two groups.In addition,in the treatment of a patient with HPS secondary to malignant histiocytoma,we successfully controlled the patient's symptoms by using low-dose IL-2,but the patient eventually died after 6 months because of drug withdrawal and primary disease progression.Conclusion Adult HPS is mainly caused by infection or tumor,but a considerable number of patients are still unknown.The clinical manifestations and laboratory tests of this disease are not specific.Clinically,patients suspected of HPS should be examined immediately,including blood routine,triglyceride,fibrinogen and serum ferritin.should The activity of s CD25 and NK cells should also be examined if possible.The platelet count,degree of liver function impairment,serum calcium and CD4+Treg cells are important early prognostic factor.Low dose IL-2 may be a new approach for the treatment of HPS,but the actual therapeutic effect still need more studies.