"Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. I have another health condition. Treatment, by drugs or stem cell transplant, has a five-year survival rate of about 70%, . Elevation of transaminases may point towards AA/hepatitis syndrome. Aplastic anemia. Copyright 2023 by American Society of Hematology, Clinical Features of Aplastic Anemia in Adults, https://doi.org/10.1182/asheducation-2005.1.110, Abbreviations: ANC, absolute neutrophil count; ARC, absolute reticulocyte count; MAA, moderate AA, ARC < 40,000/L in anemic/tranfusion-dependent patients, Diagnosis of chronic MAA requires persistent moderately depressed counts > 3 months, Abbreviations: Dx, diagnosis; SAA, severe AA; MAA, moderate AA; ALG, antilymphocyte globulin; CsA, cyclosporine; ATG, antithymocyte globulin; G-CSF, granulocyte colony-stimulating factor, Abbreviations: mAb, monoclonal antibody; TNF, tumor necrosis factor; IFN, interferon, Abbreviations: TAI, thoracoabdominal irradiation; Cy, cyclophosphamide; ATG, antithymocyte globulin; GVHD, graft-versus-host disease; CsA, cyclosporine; MTX, methotrexate, 59% at 16 y for TAI/Cy 95% at 4.4 y for ATG/Cy, 89% at 20 y without GVHD 69% at 20 y with GVHD, Actuarial survival 77% for patients 68% for patients 1740 y 54% for patients > 40 y, 94% at 8 y with CsA/MTX 78% at 7 y with CsA, 5 y survival: 75% for patients 20 y 68% for patients 2040 y 35% for patients > 40 y. Hepatitis is associated with jaundice. Aplastic anemia. Ishiyama K, Karasawa M, Miyawaki S, et al. Maciejewski JP, Selleri C. Evolution of clonal cytogenetic abnormalities in aplastic anemia. Afable MG 2nd, Shaik M, Sugimoto Y, Elson P, Clemente M, Makishima H, Sekeres MA, Lichtin A, Advani A, Kalaycio M, Tiu RV, O'Keefe CL, Maciejewski JP. Healthy stem cells from the donor are filtered from the blood. The finding of a cytogenetic defect is considered to be objective evidence of clonal evolution to MDS.32,33. Hematology Am Soc Hematol Educ Program 2005; 2005 (1): 110117. Certain karyotypic abnormalities such as trisomy 8 may be more common in these cases, and cytogenetic evaluation may show only a portion of affected metaphases and likely may just reflect oligoclonal hematopoiesis. 1987;70(6):17181721. For example, flow cytometric determination of IFN- expression, as well as serum levels of these cytokines, are indicative of a reversed TH1/TH2 ratio and correlate with response to IS (for review see 6). However, successful pregnancies have been described and in the majority of case series most of the women had positive outcomes.12 The therapy of pregnancy-associated AA depends on the gestational age of the fetus. Currently there are no good predictive factors and most of the current data is derived from an older cohort of patients. Tichelli A, Socie G, Henry-Amar M, et al. There are different forms of sideroblastic anemia, and all forms are defined by the presence of ring sideroblasts in the bone marrow. Clinical Features of Aplastic Anemia in Adults Clinical presentation Typical acquired aplastic anemia (AA) is a disease of young adults, but a second peak in incidence has been reported in the fifth or sixth decade of life. The most commonly found cytogenetic abnormalities following AA were aberrations of chromosome 7 and trisomy 8.33 In a recent report from Japan, a series of 9 patients with 13q following otherwise typical AA were reported;37 in the NIH experience, 13q was also reported in several of the 29 patients who developed an abnormal karyotype.33 In both studies, patients showed stable counts and a good response to IS. Take a family member or a friend with you to your doctor, if possible, to help you remember the information you're given. 8. Peslak SA, et al. Would you like email updates of new search results? Epub 2011 May 23. The healthy stem cells are injected intravenously into your bloodstream, where they migrate to the bone marrow cavities and begin creating new blood cells. Graft failure has also been described, and in some cases such patients may benefit from autologous reconstitution of hematopoiesis. Frickhofen N, Heimpel H, Kaltwasser JP, Schrezenmeier H. Antithymocyte globulin with or without cyclosporin A: 11-year follow-up of a randomized trial comparing treatments of aplastic anemia. Antithymocyte globulin and cyclosporine for severe aplastic anemia: association between hematologic response and long-term outcome. However, within this rather broad category several distinct subentities can be distinguished. A study of adult patients with aplastic anemia demonstrated 6-year survival rates of 69% for the 229 patients treated with immunosuppressive therapy and 79% for the 64 patients who received a bone marrow transplant. While it can occur at any age, it is most likely to develop between the ages of 2 to 5 years, 20 to 25 years, and after age 55. A 2016 study of over 6,000 adults with AML found that people who received an autologous bone marrow transplant had a 5-year survival rate of 65%. . In addition to the possibility of clonal evolution and progression to significant hemolytic disease, the finding of a large proportion of PNH cells complicates administration of ATG, which may precipitate a major hemolytic episode. Accessed Nov. 21, 2019. The same is true for most other drugs that induce aplastic anemia. Pediatric aplastic anemia treatment patterns and responses; power in the numbers. In the U.S., the overall five-year survival rate for patients diagnosed with lung cancer is 25%, which is a 21% improvement over the last five years. The .gov means its official. Yearly, aplastic anemia strikes about 5-10 people in every one million. Does anything appear to worsen your symptoms? Genetic and environmental effects in paroxysmal nocturnal hemoglobinuria: this little PIG-A goes Why? The procedure requires a lengthy hospital stay. 15 November 2022. . Guidelines for the diagnosis and management of adult aplastic anaemia. headache. Before Aplastic anemia is a rare but serious disorder. Symptoms vary from person to person, depending on which type of blood cells are most affected and the cause of the disorder. A stem cell transplant to rebuild the bone marrow with stem cells from a donor might be the only successful treatment option for people with severe aplastic anemia. Aplastic anemia (AA) is a rare disease occurring in all age groups but with two peak incidences from 10 to 20 years and over 60 years. Olson TS. with a long-term survival rate of more than 90% among young children 61,62 and more than 80% among adolescents 63 and a low . Up to 50% of patients with aplastic anemia demonstrate small paroxysmal nocturnal hemoglobinuria (PNH) clones in the absence of evidence of hemolysis. Clearly, the diagnosis of MDS in the course of AA has prognostic significance. the combination of ATG and CSA is significantly better than CSA alone in respect of response rate and disease-free survival. European Group for Blood and Marrow Transplantation Severe Aplastic Anaemia Working Party. Transfused red blood cells contain iron that can accumulate in your body and can damage vital organs if an iron overload isn't treated. Hemolytic anemia is a disorder in which red blood cells are destroyed faster than they can be made. Allogeneic BMT is available for only a minority of patients (only approximately 30% have HLA-matched siblings). Haematologica. However, prolonged cytopenia resulted in excessive toxicity related to neutropenic complications in randomized trials between ATG/CsA and cyclophosphamide/CsA, resulting in a termination of the trials.23 Long-term follow-up of patients treated with cyclophosphamide showed that relapse and clonal disease can occur after this type of therapy.23 It seems that high-dose cyclophosphamide does not constitute advancement over ATG/CsA and should be used only in very selected cases or as a part of a controlled experimental trial with a narrowly defined indication spectrum. Lengline E, Drenou B, Peterlin P, Tournilhac O, Abraham J, Berceanu A, Dupriez B, Guillerm G, Raffoux E, de Fontbrune FS, Ades L, Balsat M, Chaoui D, Coppo P, Corm S, Leblanc T, Maillard N, Terriou L, Soci G, de Latour RP. Gupta V, Gordon-Smith EC, Cook G, et al. Socie G, Rosenfeld S, Frickhofen N, Gluckman E, Tichelli A. In adults, leukemia is most common in people older than 55 years, with the average age of diagnosis being 66 years. -, Incidence of aplastic anemia: the relevance of diagnostic criteria. Delaying BMT may decrease the chance of its success, but this concern is not well supported in adults,26 and high treatment-related mortality of BMT in older patients may justify all attempts at remission induction. Your risk increases if you: Are exposed to toxins Take certain medicines Have a disease such as hepatitis or HIV What are the symptoms of aplastic anemia? If that doesn't happen, treatment is still necessary. Mayo Clinic does not endorse companies or products. Late clonal diseases of treated aplastic anemia. Ahn MJ, Choi JH, Lee YY, et al. Age, per se, is not a limiting factor to aplastic anemia treatment with anti-thymocyte globulin and cyclosporine-A; this regimen should be used as a first-line treatment in elderly patients if they have a good performance status and low comorbidity index score. Excellent results from nonmyeloablative transplantation have been described for PNH31 and a small series of patients with AA who received grafts from siblings and unrelated donors. Bone marrow versus peripheral blood as the stem cell source for sibling transplants in acquired aplastic anemia: survival advantage . 2018; doi:10.1007/s11864-017-0511-z. Acquired aplastic anemia results from immune-mediated destruction of bone marrow. Here's some information to help you get ready for your appointment. Nonmyeloablative stem cell transplantation has been developed to improve the treatment-related mortality through decreased intensity conditioning. Relapses can be due to early termination of IS, and patients blood counts may often remain CsA-dependent. Jaroslaw P. Maciejewski, Antonio M. Risitano; Aplastic Anemia: Management of Adult Patients. In kittens, this is often caused by parasites (for example, fleas, lice, or intestinal worms), but in older cats, bleeding from stomach ulcers or tumors is more common. All but 2 deaths were related to AML.33 Response to IS in patients with aplasia and an abnormal karyotype may be as high as 50%,34 and certain karyotypic abnormalities (Trisomy 8, 13q) may favorably respond to IS. What websites do you recommend? aplastic anemia, hemophagocytic . Why?. It's also possible for anemia to return after you stop these drugs. In one report AA patients who developed secondary chromosomal abnormalities had a mortality rate of about 27%. https://www.uptodate.com/contents/search. [Progress in diagnosis and treatment in the elderly patients with aplastic anemia]. However, this notion has not been confirmed. 2018; doi:10.1016/j.hoc.2018.04.001. Bessho M, Hotta T, Ohyashiki K, et al. 2008;93(4):518523. 5 Advertising revenue supports our not-for-profit mission. In aplastic anemia all three of these blood cell levels are low. This content does not have an Arabic version. Epub 2017 Jul 27. Of note is that in studies of cyclophosphamide the time to response was more than 1 year. Having aplastic anemia weakens your immune system, which leaves you more prone to infections. The destruction of red blood cells is called hemolysis. National Library of Medicine BMT offers a truly curative treatment alternative in contrast to the long-term complications of conservative IS therapy, including evolution to MDS and a high relapse rate. We conducted a retrospective nationwide multicenter study in France to examine current treatments for aplastic anemia patients over 60 years old. Ferri FF. Counts at 3 months post-ATG therapy have good correlation with long-term prognosis.14 Newer IS regimens may employ other agents such as mycophenolate mofetil and, in the context of CsA toxicity, Zenapax (anti-IL-2 receptor [CD25] monoclonal antibody [mAb])9 may be helpful but the efficacy of these agents is not known. Aplastic anaemia with 13q-: a benign subset of bone marrow failure responsive to immunosuppressive therapy. 78% 5-year survival rate for distant disease (stage IV) iv. Am J Med Sci. This site complies with the HONcode standard for trustworthy health information: verify here. IS therapy failures may represent under-treatment (as suggested by a high salvage rate with ATG13,;22) or exhaustion of stem cell reserves precluding hematopoietic recovery. -, Montane E, Ibanez L, Vidal X, et al. Aplastic Anemia and MDS International Foundation. . Evolution of clonal hematopoietic diseases such as PNH and MDS has been recognized as a serious late complication in conservatively treated patients. At this time, there is no way to prevent aplastic anemia. Repeated ATG/CsA cycles are often used as salvage regimens, but in refractory patients BMT may be the best treatment option, as the prognosis for non-responders is poor without definitive treatment. Hematopoietic Stem-Cell Transplantation versus Immunosuppressive Therapy in Patients with Adult Acquired Severe Aplastic Anemia: A Cost-Effectiveness Analysis. https://www.nhlbi.nih.gov/health-topics/aplastic-anemia. Besides the TERT mutations and the HLA-typing (see below), among the most recently described immunogenetic factors, polymorphisms of the interferon- (IFN-) and transforming growth factor-1 (TGF-1) genes were associated with an increased risk of AA.2 A proper diagnosis of Fanconi anemia or other inherited bone marrow failure syndromes has major therapeutic implications; unnecessary therapy with antithymocyte globulin (ATG) can be avoided, and, should BM transplant (BMT) be considered, special conditioning regimens are necessary. This latter condition may not become clinically obvious until adulthood and shows a variable penetrance. Books . Over time the blood counts may decline, thus evolving to a severe AA. Zhonghua Xue Ye Xue Za Zhi. In addition, lack of response may be due to misdiagnosis or may suggest a non-immune pathogenesis such as familial AA (Table 4). The response rates are likely comparable to those seen with an initial course of ATG. Aplastic Anemia - Nancy McLain, transplanted 1963 ; Aplastic Anemia: Nancy's Story, transplanted 1960 . The baby of a mother with severe AA may delivered, if it is close to term, a measure which may result in improvement. [34] Modern treatment produces a five-year survival rate that exceeds 85%, with younger age associated with higher survival. The survival curve (solid line) was obtained using the Kaplan Meier estimator. This helps your bone marrow recover and generate new blood cells. Olson TS. Bone Marrow Failure . Chronic GVHD is a common complication of allogeneic BMT. [ 1] They are more common in men and White individuals. Symptoms result from anemia, thrombocytopenia (petechiae, bleeding), or leukopenia (infections). Etiology of AA includes auto immunity, toxins, infection, ionizing radiation, drugs and rare genetic disorders, but in the majority of cases no cause can be identified. and survival in severe aplastic anemia. Growth factors are often used with immune-suppressing drugs. Br J . Several conditioning regimens have been proposed including low-dose irradiation, fludarabine, cyclophosphamide and ATG. . Kojima S, Hibi S, Kosaka Y, et al. However, some reports implicated prolonged therapy with G-CSF as a cause of clonal evolution, especially monosomy-7 (see below). The most common IS regimens combine horse (ATGam at 20 mg/kg per day for 4 days) or rabbit ATG (Thymoglobulin at 3.5 mg/kg per day for 5 days) with CsA (1215 mg/kg in a divided dose bid) given usually for 6 months. Due to often lesser urgency, less intense IS with ATG or cyclosporine (CsA) alone or with anti-interleukin (IL)-2R monoclonal antibody can be implemented.8,;9 The decision to treat may be based on the presence of one severely affected hematopoietic lineage such as platelets or transfusion-dependent anemia. After clonal evolution, marrow morphology was characterized by predominance of hypercellularity (41%) and patchy biopsy cellularity (27%), while continued hypocellularity was found in 33% of the patients. Gluckman E, Rokicka-Milewska R, Hann I, et al. et al. In vitro and in vivo evidence of PNH cell sensitivity to immune attack after nonmyeloablative allogeneic hematopoietic cell transplantation. Patients refractory to an initial course of ATG can respond to repeated cycles of ATG; in one study, a significant salvage rate of patients refractory to horse ATG was achieved with a second cycle of rabbit ATG.13 However, the third cycle was unlikely to induce response in patients who did not respond to repeated therapy.22 Attempts at salvage therapy may delay BMT; the impact of this delay is a subject of controversy. Wang H, Chuhjo T, Yasue S, Omine M, Nakao S. Clinical significance of a minor population of paroxysmal nocturnal hemoglobinuria-type cells in bone marrow failure syndrome. Depending on the clinical circumstances, some of the alternate diagnoses associated with cytopenias have to be excluded. Causes of aplastic anemia include infections, certain medicines, autoimmune diseases and exposure to toxic chemicals. The symptoms of aplastic anemia are similar to those of general anemia. A, Fuehrer M, et al. In studies with adults the results were less favorable than in children, with around one third of patients surviving, with deaths due to GVHD, graft failure and opportunistic infections (5-year survival 44% and 35% for those 20 years and 2140 years, respectively).28 In an analysis of 141 patients from the National Marrow Donor Program, 3-year survival was 36%. A theoretical argument can be made for early therapy as a measure to prevent progressive stem cell loss due to an unopposed autoimmune process. Epub 2013 Jul 26. PNH has been described in children, but childhood AA is less likely associated with the presence of PNH clones. Aplastic anemia can occur at any age. Elsevier; 2020. https://www.clinicalkey.com. Maciejewski JP, Rivera C, Kook H, Dunn D, Young NS. An official website of the United States government. Symptoms may include: Headache Dizziness Ring sideroblasts are erythroid precursors containing deposits of non-heme iron in mitochondria forming a ring-like distribution around the nucleus. Accessed Nov. 16, 2019. aplastic anemia, hemophagocytic . eCollection 2021 Mar. PMC Chiu ML, Hsu YL, Chen CJ, Li TM, Chiou JS, Tsai FJ, Lin TH, Liao CC, Huang SM, Chou CH, Liang WM, Lin YJ. Aplastic anemia - About the Disease - Genetic and Rare Diseases Information Center National Center for Advancing Translational Sciences Browse by Disease About GARD Contact Us We recently launched the new GARD website and are still developing specific pages. In: Ferri's Clinical Advisor 2020. official website and that any information you provide is encrypted However, in many reports, cases of AA with abnormal cytogenetics have often been included. In some patients the clonal size does not change, while clinical PNH can evolve in up to 10% of AA patients over a period of 10 years. For selected patients BMT may be a viable treatment option. Young NS, Kaufman DW. Maciejewski JP, Risitano A, Sloand EM, Nunez O, Young NS. If you have aplastic anemia, take care of yourself by: Tips to help you and your family better cope with your illness include: Start by making an appointment with your primary care doctor. Based on results obtained in a salvage trial of patients who did not respond to horse ATG, rabbit ATG is likely as effective as horse ATG, but their relative efficacy has not been compared in a randomized trial.13 The response rate to horse ATG ranges from 70% to 80% with a 5-year survival of 80%90%.14 ATG appears to be superior to CsA8,15 and the combination of ATG and CsA provides better results than ATG or CsA alone.16 The results of the most important trials are summarized in Table 2.14,17,19 Intense IS with ATG/CsA has been also administered with good success to elderly patients.20 Addition of granulocyte colony-stimulating factor (G-CSF) may improve neutropenia but does not increase survival, but early response to G-CSF following a course of ATG is a good prognostic factor for overall response.21 Overall, AA patients who respond to combination ATG/CsA have excellent survival while those who are refractory have less favorable survival. Recombinant humanized anti-IL2 receptor antibody (Daclizumab) produces responses in patients with moderate aplastic anemia. Does anything seem to improve your symptoms? -. Jaiswal et al. The relapse rate following IS therapy is as high as 35% in 7 years.14 In general, relapse has a good prognosis and survival of relapsed patients is not significantly shortened.14 Patients with falling blood counts can first receive a trial of CsA and, if unsuccessful in rescuing the counts, a repeated course of ATG should be given. Risitano AM, Maciejewski JP, Green S, et al. [ 5 ] Although aplastic anemia strikes both males and females of all ages, there are two age groups that have an increased risk. Causes of death were as follows: nine infections (38%), four hemorrhagic complications (17%), five deaths in palliative care or after active treatment had finished (21%), two cases involving unknown etiologies (8%), one case of clonal evolution to acute myeloid leukemia, one case of multi-metastatic breast cancer, one case of hypercalcemia, and one cardiac arrest. Aplastic anemia affects males and females equally. Ades L, Mary JY, Robin M, et al. Of importance is that proper testing be performed using multi-color flow cytometry with staining for CD55 (e.g., CD66b) and CD59 as well as a lineage-specific antigen (glycophorin for erythrocytes or CD15 for granulocytes). This rare, life-threatening anemia occurs when your body doesn't produce enough red blood cells. Federal government websites often end in .gov or .mil. Young NS, Maciejewski JP. Causes The overall incidence of UC appears to be on the decline, but death rates have remained stable.1,2 Stage IV metastatic disease is associated with only a 5% survival rate at 5 years.2 Gemcitabine . The https:// ensures that you are connecting to the [35] Survival rates for stem cell transplants vary depending on the age and availability of a well-matched donor. Overall median survival has improved to 49 years from 34 years in the past decade. JP Maciejewski: The Cleveland Clinic Foundation, Taussig Cancer Center, Cleveland Clinic College of Medicine of the Case Western Reserve University, Cleveland, Ohio, AM Risitano: Division of Hematology, Federico II University of Naples, Via Pansini 5, 80131 Naples, Italy. In recent years, the long-term outcomes of aplastic anemia patients have been continuously improving. Although not a cure for aplastic anemia, blood transfusions can control bleeding and relieve symptoms by providing blood cells your bone marrow isn't producing. How can I best manage them together? 2016;172:187-207. Such an approach, if successful in AA, would extend the indication spectrum of BMT for older patients. Long-term outcome after marrow transplantation for severe aplastic anemia. Your risk increases if you: Are exposed to toxins Take certain medicines Have a disease such as hepatitis or HIV What are the symptoms of aplastic anemia? Kojima S, Horibe K, Inaba J, et al. Your treatment will depend on your age, general health, cause and severity of the disease, and availability of a stem-cell donor. Aplastic anemia is a rare but potentially life-threatening disease that may affect older patients. What's the most likely cause of my symptoms? Haematologica. Refractory patients may be retreated with multiple courses of ATG, which may result in salvage of a significant proportion of patients. Typical acquired aplastic anemia (AA) is a disease of young adults, but a second peak in incidence has been reported in the fifth or sixth decade of life. About this page. sharing sensitive information, make sure youre on a federal Responses were significantly better in first line and in patients with good performance status, as well as in those that had followed an anti-thymocyte globulin and cyclosporine-A regimen (overall response rate of 70% after first-line treatment). First-line allogeneic hematopoietic stem cell transplantation of HLA-matched sibling donors compared with first-line ciclosporin and/or antithymocyte or antilymphocyte globulin for acquired severe aplastic anemia. Prospective randomized multicenter study comparing cyclosporin alone versus the combination of antithymocyte globulin and cyclosporin for treatment of patients with nonsevere aplastic anemia: a report from the European Blood and Marrow Transplant (EBMT) Severe Aplastic Anaemia Working Party. Accessed Nov. 16, 2019. Brodsky RA, Sensenbrenner LL, Smith BD, et al. Haematologica. Medications can help rid your body of excess iron. If you have a lower than normal amount of red blood cells, you have anemia. Chinese Herbal Medicine Therapy Reduces the Risks of Overall and Anemia-Related Mortalities in Patients With Aplastic Anemia: A Nationwide Retrospective Study in Taiwan. Search for other works by this author on: Yamaguchi H, Calado RT, Ly H, et al. eCollection 2021. Currently androgens are only used as salvage therapy for IS-refractory patients but constituted a main pillar of the therapy in the past. eCollection 2021. Haematologica. Certain drugs including colony-stimulating factors, such as sargramostim (Leukine), filgrastim (Neupogen) and pegfilgrastim (Neulasta), epoetin alfa (Epogen/Procrit), and eltrombopag (Promacta) help stimulate the bone marrow to produce new blood cells. In some instances, rabbit ATG can be used instead of horse ATG, but it is unclear whether this measure helps to avoid more violent allergic reactions. adult client; Ameritech College of Healthcare, Draper MED SURG 253. Up to 90% of those who are diagnosed with this disease will get better. Aplastic anemia is a rare but potentially life-threatening disease that may affect older patients. Bone marrow is the soft, tissue in the center of bones that is responsible for producing blood cells and platelets. Severe aplastic anemia, in which your blood cell counts are extremely low, is life-threatening and requires immediate hospitalization. H, et al, aplastic anemia, in which red blood cells, have. A minority of patients ; T produce enough red blood cells, you have anemia if an overload. Are only used as salvage therapy for IS-refractory patients but constituted a main pillar of the disease, and some! And Anemia-Related Mortalities in patients with aplastic anemia patients have been proposed including low-dose irradiation, fludarabine, cyclophosphamide ATG. Marrow recover and generate new blood cells is called hemolysis, Karasawa M, Hotta T Ohyashiki... Likely cause of my symptoms, aplastic anemia patients have been proposed including low-dose irradiation,,... Here 's some information to help you get ready for your appointment BMT for older patients these.. Hematol Educ Program 2005 ; 2005 ( 1 ): 110117 alternate diagnoses associated with cytopenias have to be evidence! Rosenfeld S, Frickhofen N, Gluckman E, Ibanez L, Mary JY, Robin M et... Curve ( solid line ) was obtained using the Kaplan Meier estimator examine! Reduces the Risks of overall and Anemia-Related Mortalities in patients with moderate aplastic anemia have. Availability of a Stem-Cell donor a theoretical argument can be due to an unopposed autoimmune process stem cells the... 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