{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T10:10:04Z","timestamp":1777630204095,"version":"3.51.4"},"reference-count":42,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2021,10,27]],"date-time":"2021-10-27T00:00:00Z","timestamp":1635292800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cells"],"abstract":"<jats:p>Idiopathic acquired aplastic anemia can be successfully treated with Anti Thymocyte Globulin (ATG)-based immune suppressive therapy and is therefore considered a T cell-mediated auto immune disease. Based on this finding, several other forms of idiopathic acquired bone marrow failure are treated with ATG as well. For this review, we extensively searched the present literature for evidence that ATG can lead to enduring remissions in different forms of acquired multi- or single-lineage bone marrow failure. We conclude that ATG-based therapy can lead to an enduring hematopoietic response and increased overall survival (OS) in patients with acquired aplastic aplasia. In patients with hypocellular myelodysplastic syndrome, ATG can lead to a hematological improvement without changing the OS. ATG seems less effective in acquired single-lineage failure diseases like Pure Red Cell Aplasia, Amegakaryocytic Thrombocytopenia and Pure White Cell Aplasia, suggesting a different pathogenesis in these bone marrow failure states compared to aplastic anemia. T cell depletion is hypothesized to play an important role in the beneficial effect of ATG but, as ATG is a mixture of polyclonal antibodies binding to different antigens, other anti-inflammatory or immunomodulatory effects could play a role as well.<\/jats:p>","DOI":"10.3390\/cells10112905","type":"journal-article","created":{"date-parts":[[2021,10,27]],"date-time":"2021-10-27T22:00:23Z","timestamp":1635372023000},"page":"2905","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":12,"title":["Anti Thymocyte Globulin-Based Treatment for Acquired Bone Marrow Failure in Adults"],"prefix":"10.3390","volume":"10","author":[{"given":"Jennifer M.-L.","family":"Tjon","sequence":"first","affiliation":[{"name":"Department of Hematology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Saskia M. C.","family":"Langemeijer","sequence":"additional","affiliation":[{"name":"Department of Hematology, Radboudumc, 6500 HB Nijmegen, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Constantijn J. M.","family":"Halkes","sequence":"additional","affiliation":[{"name":"Department of Hematology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,10,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1643","DOI":"10.1056\/NEJMra1413485","article-title":"Aplastic Anemia","volume":"379","author":"Young","year":"2018","journal-title":"N. Engl. J. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1387","DOI":"10.1038\/sj.leu.2404683","article-title":"Mechanisms of action of antithymocyte globulin: T-cell depletion and beyond","volume":"21","author":"Mohty","year":"2007","journal-title":"Leukemia"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1097\/MOH.0b013e32834da9a4","article-title":"Immunosuppressive therapies in the management of acquired immune-mediated marrow failures","volume":"19","author":"Risitano","year":"2012","journal-title":"Curr. Opin. Hematol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"609","DOI":"10.1016\/j.hoc.2018.03.003","article-title":"Recent advances and long-term results of medical treatment of acquired aplastic anemia: Are patients cured?","volume":"32","author":"Scheinberg","year":"2018","journal-title":"Hematol. Oncol. Clin. N. Am."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1056\/NEJM198301203080301","article-title":"Antithymocyte globulin treatment in patients with aplastic anemia: A prospective randomized trial","volume":"308","author":"Champlin","year":"1983","journal-title":"N. Engl. J. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1236","DOI":"10.1182\/blood-2002-04-1134","article-title":"Antithymocyte globulin with or without cyclosporin A: 11-year follow-up of a randomized trial comparing treatments of aplastic anemia","volume":"101","author":"Frickhofen","year":"2003","journal-title":"Blood"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1130","DOI":"10.1001\/jama.289.9.1130","article-title":"Antithymocyte globulin and cyclosporine for severe aplastic anemia: Association between hematologic response and long-term outcome","volume":"289","author":"Rosenfeld","year":"2003","journal-title":"JAMA"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"348","DOI":"10.3324\/haematol.13829","article-title":"Treatment of severe aplastic anemia with a combination of horse antithymocyte globulin and cyclosporine, with or without sirolimus: A prospective randomized study","volume":"94","author":"Scheinberg","year":"2009","journal-title":"Haematologica"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1056\/NEJMoa1103975","article-title":"Horse versus rabbit antithymocyte globulin in acquired aplastic anemia","volume":"365","author":"Scheinberg","year":"2011","journal-title":"N. Engl. J. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1540","DOI":"10.1056\/NEJMoa1613878","article-title":"Eltrombopag Added to Standard Immunosuppression for Aplastic Anemia","volume":"376","author":"Townsley","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1269","DOI":"10.3324\/haematol.2011.042622","article-title":"Efficacy of rabbit anti-thymocyte globulin in severe aplastic anemia","volume":"96","author":"Afable","year":"2011","journal-title":"Haematologica"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"5391","DOI":"10.1182\/blood-2012-02-407684","article-title":"Prospective study of rabbit antithymocyte globulin and cyclosporine for aplastic anemia from the EBMT Severe Aplastic Anaemia Working Party","volume":"119","author":"Marsh","year":"2012","journal-title":"Blood"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"312","DOI":"10.1111\/j.1365-2141.2012.09064.x","article-title":"Final results of the phase II study of rabbit anti-thymocyte globulin, ciclosporin, methylprednisone, and granulocyte colony-stimulating factor in patients with aplastic anaemia and myelodysplastic syndrome","volume":"157","author":"Kadia","year":"2012","journal-title":"Br. J. Haematol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2504","DOI":"10.1182\/blood-2016-05-717140","article-title":"Pure red cell aplasia","volume":"128","author":"Means","year":"2016","journal-title":"Blood"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"342","DOI":"10.1111\/cas.12341","article-title":"STAT3 gene mutations and their association with pure red cell aplasia in large granular lymphocyte leukemia","volume":"105","author":"Ishida","year":"2014","journal-title":"Cancer Sci."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1485","DOI":"10.1007\/s00277-020-04105-3","article-title":"Immunosuppression therapy is effective for both acquired tumor-associated and primary pure red cell aplasia: A match pair case-control study","volume":"99","author":"Chen","year":"2020","journal-title":"Ann. Hematol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1016\/j.lungcan.2021.05.010","article-title":"Management of thymoma associated autoimmune pure red cell aplasia: Case report and systematic review of the literature","volume":"157","author":"Lesire","year":"2021","journal-title":"Lung Cancer"},{"key":"ref_18","first-page":"221","article-title":"Diagnosis and management of acquired pure red cell aplasia","volume":"103","author":"Sawada","year":"2009","journal-title":"Hematol. Oncol. Clin. N. Am."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"363","DOI":"10.1002\/ajh.2830230408","article-title":"Pure red cell aplasia: Response to therapy with anti-thymocyte globulin","volume":"23","author":"Abkowitz","year":"1986","journal-title":"Am. J. Hematol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1182\/blood.V63.2.277.277","article-title":"Studies on pure red cell aplasia. XI. Results of immunosuppressive treatment of 37 patients","volume":"63","author":"Clark","year":"1984","journal-title":"Blood"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1002\/ajh.2830200212","article-title":"Treatment of red cell aplasia with antithymocyte globulin: Repeated inductions of complete remissions in two patients","volume":"20","author":"Harris","year":"1985","journal-title":"Am. J. Hematol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1413","DOI":"10.3109\/10428190109097772","article-title":"Clonality of acquired primary pure red cell aplasia: Effectiveness of antithymocyte globulin","volume":"42","author":"Aktan","year":"2001","journal-title":"Leuk. Lymphoma"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1111\/j.1600-0609.1988.tb00194.x","article-title":"Pure red cell aplasia. Stable complete remission following antilymphocyte globulin administration","volume":"40","author":"Jacobs","year":"1988","journal-title":"Eur. J. Haematol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"723","DOI":"10.1001\/jama.1988.03720050059024","article-title":"Complete resolution of pure red cell aplasia in a patient with chronic lymphocytic leukemia following antithymocyte globulin therapy","volume":"259","author":"Radosevich","year":"1988","journal-title":"JAMA"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"221","DOI":"10.3324\/haematol.2017.175810","article-title":"Rational management approach to pure red cell aplasia","volume":"103","author":"Balasubramanian","year":"2018","journal-title":"Haematologica"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1016\/j.ejim.2005.04.014","article-title":"Acquired amegakaryocytic thrombocytopenic purpura: Review of a not very well-defined disorder","volume":"16","author":"Tristano","year":"2005","journal-title":"Eur. J. Intern. Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1007\/s12185-008-0125-0","article-title":"Successful treatment of acquired amegakaryocytic thrombocytopenic purpura refractory to corticosteroids and intravenous immunoglobulin with antithymocyte globulin and cyclosporin","volume":"88","author":"Niparuck","year":"2008","journal-title":"Int. J. Hematol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1002\/(SICI)1096-8652(199910)62:2<115::AID-AJH10>3.0.CO;2-2","article-title":"Acquired pure megakaryocytic aplasia report of two cases with long-term responses to antithymocyte globulin and cyclosporine","volume":"62","author":"Leach","year":"1999","journal-title":"Am. J. Hematol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1111\/j.1365-2141.1986.tb07511.x","article-title":"Remission of amegakaryocytic thrombocytopenia induced by antilymphocyte globulin (ALG)","volume":"63","year":"1986","journal-title":"Br. J. Haematol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1002\/1096-8652(200102)66:2<154::AID-AJH1037>3.0.CO;2-H","article-title":"Successful treatment of acquired pure red cell aplasia and acquired amegakaryocytic thrombocytopenia with anti-thymocyte globulin","volume":"66","author":"Ueda","year":"2001","journal-title":"Am. J. Hematol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"146","DOI":"10.1002\/ajh.10475","article-title":"Acquired megakaryocytic thrombocytopenia purpura and eosinophilic fasciitis: A long relapsing and remitting course","volume":"75","author":"Chaudhary","year":"2004","journal-title":"Am. J. Hematol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"720","DOI":"10.7326\/0003-4819-102-5-720_1","article-title":"Amegakaryocytic thrombocytopenic purpura treated with antithymocyte globulin","volume":"102","author":"Khelif","year":"1985","journal-title":"Ann. Intern. Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1995","DOI":"10.1007\/s00277-018-3342-5","article-title":"A portion of expanded granular lymphocytes cause pure white cell aplasia?","volume":"97","author":"Isobe","year":"2018","journal-title":"Ann. Hematol."},{"key":"ref_34","first-page":"4161679","article-title":"Pure White Cell Aplasia and Necrotizing Myositis","volume":"2016","author":"Kim","year":"2016","journal-title":"Case Rep. Hematol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1136\/flgastro-2013-100427","article-title":"Pure white cell aplasia: Report of first case associated with autoimmune hepatitis","volume":"5","author":"Keast","year":"2014","journal-title":"Frontline Gastroenterol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"271","DOI":"10.1111\/j.1600-0609.2007.00901.x","article-title":"Prolonged remission of pure white cell aplasia (PWCA), in a patient with CLL, induced by rituximab and maintained by continuous oral cyclosporin","volume":"79","author":"Chakupurakal","year":"2007","journal-title":"Eur. J. Hematol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1031","DOI":"10.1182\/blood-2018-10-844639","article-title":"The mesenchymal niche in MDS","volume":"133","author":"Pronk","year":"2019","journal-title":"Blood"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1016\/j.beha.2013.09.003","article-title":"Myelodysplastic Syndromes (MDS) and autoimmune disorders (AD): Cause or consequence?","volume":"26","author":"Braun","year":"2013","journal-title":"Best Pract. Res. Clin. Haematol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"156","DOI":"10.7326\/0003-4819-137-3-200208060-00007","article-title":"Antithymocyte globulin for treatment of the bone marrow failure associated with myelodysplastic syndromes","volume":"137","author":"Molldrem","year":"2002","journal-title":"Ann. Intern. Med."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1200\/JCO.2010.31.2686","article-title":"Immunosuppressive therapy for patients with myelodysplastic syndrome: A prospective randomized multicenter phase III trial comparing antithymocyte globulin plus cyclosporine with best supportive care--SAKK 33\/99","volume":"29","author":"Passweg","year":"2010","journal-title":"J. Clin. Oncol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1765","DOI":"10.1182\/bloodadvances.2018019414","article-title":"The use of immunosuppressive therapy in MDS: Clinical outcomes and their predictors in a large international patient cohort","volume":"2","author":"Stahl","year":"2018","journal-title":"Blood Adv."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"954","DOI":"10.1111\/bjh.17403","article-title":"Acquired severe aplastic anaemia: How medical therapy evolved in the 20th and 21st centuries","volume":"194","author":"Scheinberg","year":"2021","journal-title":"Br. J. Haematol."}],"container-title":["Cells"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2073-4409\/10\/11\/2905\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:24:37Z","timestamp":1760167477000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2073-4409\/10\/11\/2905"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,10,27]]},"references-count":42,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2021,11]]}},"alternative-id":["cells10112905"],"URL":"https:\/\/doi.org\/10.3390\/cells10112905","relation":{},"ISSN":["2073-4409"],"issn-type":[{"value":"2073-4409","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,10,27]]}}}