背景：获得性骨髓衰竭性疾病（acquired bone marrow failure syndromes, aBMFS）是由于造血干/组细胞（hematopoietic stem/progenitor cells，HSPCs）数量及质量缺陷而引起的一组异质性造血系统疾病，其主要表现为骨髓衰竭及外周血细胞减少。再生障碍性贫血（aplastic anemia，AA），阵发性睡眠性血红蛋白尿征（paroxysmal nocturnal hemoglobinuria，PNH）、骨髓增生异常综合征（myelodysplastic syndrome，MDS），此三种疾病是临床中最为常见的aBMFS，骨髓衰竭为该组疾病的共同特征，但每一种疾病在临床表现及治疗决策方面均有其独特性。除此之外，此三种疾病均可以进一步发生克隆性演变，并有不同程度转变为其他恶性疾病的风险。因而，该类疾病的鉴别诊断为临床工作的重点和难点问题。Wilms 肿瘤基因1（Wilms tumor gene 1, WT1）位于染色体11p13区域并在Wilms瘤的发生过程中发挥重要作用，亦有研究表明，WT1在非成熟细胞，尤其是CD34⁺ HSPCs的生长分化中起决定性作用。目前，越来越多的研究表明，WT1可以作为监测血液系统恶性克隆性疾病的微小残留病（minimal residual disease, MRD）的标志物，但其在aBMFS中的作用尚未明确。

目的：本研究目的在于检测WT1基因在AA, PNH及MDS患者中的表达水平，以期揭示WT1在aBMFS中的意义，为aBMFS的鉴别诊断、疗效、疾病预后的评估提供新策略。

方法：（1）回顾分析了387例aBMFS患者，其中包括初诊AA（76例）、PNH（20例）以及MDS（84例）患者，确诊AA并接受免疫抑制剂治疗（immunosuppressive therapy, IST）至少2年的患者共189例，其余为AA治疗后发生疾病演变并转化为MDS或急性髓系白血病（acute myeloid leukemia, AML）的患者共18例。（2）以ABL管家基因作为内参对照，利用实时荧光定量聚合酶链式反应（quantitative real-time polymerase chain reaction, qRT-PCR）技术检测患者骨髓单个核细胞WT1 基因的表达；（3）应用Mann–Whitney U 检验和秩和检验进行组间WT1表达水平的比较，应用受试者工作特征（receiver operating characteristic, ROC）曲线评估WT1在疾病鉴别诊断及发生演变等诊断性试验中的应用价值和效能。

结果：（1）初治患者中，AA骨髓中WT1表达水平均显著低于PNH（p=0.023）及MDS患者（p<0.001）；（2）MDS患者中，骨髓中WT1表达水平随着疾病危险评分的增高而升高；（3）低增生MDS患者与非重型AA（non-severe AA, NSAA）患者的骨髓WT1表达水平差异显著（p<0.001）；（4）AA患者经治疗后取得部分反应（partial response, PR）及完全反应（complete response, CR）者，其骨髓WT1表达水平均显著高于初治状态（p=0.017; p =0.003），而治疗后无反应（no response, NR）者与初诊状态无明显差异。（5）AA患者经治疗后发生疾病演变者，WT1水平亦显著升高。

结论：AA，PNH，MDS患者的骨髓单个核细胞WT1表达水平差异显著；WT1在危险度评分不同组别的MDS患者中表达水平差异明显；WT1在AA患者中的表达随着疾病状态不同而动态波动。因而，WT1可以作为aBMFS的鉴别诊断及疗效、预后的评估的可靠指标。

background: acquired bone marrow failure syndromes (abmfs) are a group of heterogeneous disorders that are caused by quantitative and qualitative defects of hematopoietic stem/progenitor cells (hspcs), and bone marrow failure and underlying cytopenia are the main manifestation. hematological disorders, such as aplastic anemia (aa), paroxysmal nocturnal hemoglobinuria (pnh) and myelodysplastic syndrome (mds) are common paradigms of abmfs in clinical work. bone marrow failure is the shared feature of these diseases, but each has its specialty in clinical feature and treatment. besides, each of these diseases can undergo clonal evolution and bear the varying degree risk of transforming into another malignant diseases. therefore, it is of importance and challenge to diagnose these diseases. wt1, which is located at chromosome 11p13, plays a vital role in the tumorigenesis of wilms’tumor. additionally, it has been reported that wt1 plays a substantial role in controlling the growth and differentiation of various immature cell types, including cd34⁺ hspcs. recent years, accumulating reports have demonstrated that wt1 can commonly serve as an target indicator for minimal residual disease (mrd) in malignant hematology diseases, however, wt1 expression level has not yet been thoroughly validated on abmfs.

ive: the study was designed to monitor the dynamic expression level of wt1 in patients with aa, pnh and mds, explore the effect of wt1 in patients with abmfs, and take this one step further, to afford novel strategies for differential diagnoses and prognostic evaluation for abmfs.

methods: (1) a cohort of 387 patients in total were included in our study, there were 180 naïve cases with cytopenia which were finally diagnosed with aa (76 cases), pnh (20 cases), and mds (84 cases). additionally, there were 189 confirmed cases of aa who had volunteered to receive immunosuppressive therapy (ist) for at least 2 years; the remaining 18 cases were mds/aml patients who had evolved from aa. (2)  housekeeping gene c-abl worked as reference gene for normalization. quantitative measurement of wt1 tran level in bone marrow mononuclear cells was performed using quantitative real-time polymerase chain reaction (qrt-pcr). (3) for intergroup comparison of wt1 mrna expression, a mann–whitney u test and a wilcoxon rank-sum test were performed. to evaluate the diagnostic accuracy of bone marrow wt1 mrna, receiver operating characteristic (roc) analysis was used.

results: (1) the wt1 level in naïve cases with aplastic anemia (aa) was significantly lower than that in patients with paroxysmal nocturnal hemoglobinuria (pnh, p=0.023) and myelodysplastic syndrome (mds, p<0.001). (2) the wt1 level in patients with mds significantly increased as the disease progressed to an advanced stage. (3) patients with hypoplastic mds had a differentiated expression level of wt1 compared with that of non-severe aa (nsaa) (p<0.001). (4) post-treatment patients of aa with partial response (pr) or complete response (cr) status had relatively higher wt1 levels than those with naive aa (p=0.017, p=0.003, respectively). (5) patients with aa who undergone disease evolution had relatively higher level of wt1 after receiving ist.

conclusion: the expression level of wt1 mrna in bm varied widely in naïve patients with abmfs. wt1 expression had an overt ascendant trend as disease progressed to each advanced stage. in patients with aa, wt1 expression level fluctuate with disease status. thus, we can come to conclude that wt1 can serve as a novel parameter for differential diagnoses, curative effect and prognostic evaluation for abmfs.