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Review in translational hematology

Diagnosis and management of paroxysmal nocturnal hemoglobinuria

Charles Parker, Mitsuhiro Omine, Stephen Richards, Jun-ichi Nishimura, Monica Bessler, Russell Ware, Peter Hillmen, Lucio Luzzatto,
Neal Young, Taroh Kinoshita, Wendell Rosse, and Gerard Socie, for the International PNH Interest Group

The primary clinical manifestations of paroxysmal nocturnal

hemoglobinuria (PNH) are hemolytic anemia, marrow failure, and
thrombophilia. However, PNH is not a simple binary diagnosis and
both flow cytometric characterization of glycosyl phosphatidylinositolanchored protein expression on peripheral blood cells and
marrow analysis are required for comprehensive disease classification. For optimum management, the contribution of both hemolysis
and marrow failure to the complex anemia of PNH should be
determined. Complement inhibition by eculizumab is a promising
new approach to treating the hemolytic anemia. Stem cell transplantation is potentially curative, but the decision on use is best made
on a case-by-case basis because of the heterogeneous natural
history of the disease. PNH clone size and ethnic/geographic
factors appear to influence thrombophilic propensity, but a consensus on prophylactic anticoagulation has not been reached. Involvement of unusual sites (hepatic, mesenteric, cerebral, dermal veins)
is characteristic of the thrombophilia of PNH. Indefinite anticoagulation is recommended following a thromboembolic event and
thrombolytic therapy should be considered for acute hepatic vein
thrombosis (Budd-Chiari syndrome). Pregnancy in a patient with
PNH is complicated and requires careful management including
prophylactic anticoagulation. To obtain a broad overview of the
natural history, approaches to management, and outcome, the
International PNH Registry was recently established.

Definition and diagnostic criteria

Definition

PNH is a consequence of nonmalignant clonal expansion of one or

several hematopoietic stem cells that have acquired a somatic
mutation of PIGA. Progeny of affected stem cells are deficient in
glycosyl phosphatidylinositolanchored proteins (GPI-APs). Deficiency of the GPI-anchored complement regulatory proteins CD55
and CD59 accounts for the intravascular hemolysis that is the
primary clinical manifestation of the disease. PNH frequently
arises in association with disorders of bone marrow failure,

From the Division of Hematology, University of Utah School of Medicine and the
George E. Whalen VA Medical Center, Salt Lake City, UT; the Department of
Medicine, Division of Hematology, Showa University Fujigaoka Hospital,
Kanagawa, Japan; the Research Committee for the Idiopathic Hematopoietic
Disorders, Ministry of Health, Labor, and Welfare, Government of Japan;
HMDS, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; Duke
University Medical Center, Department of Medicine, Division of Cellular
Therapy, and the Duke University School of Medicine, Durham, NC; the
Division of Hematology, Washington University School of Medicine, St Louis,
MO; the Division of Hematology, St Jude Childrens Research Hospital,
Memphis, TN; 1st Nazionale per la Ricerca sul Cancro, Genova, Italy; the
Hematology Branch, National Institutes of Health, Bethesda, MD; the Research
Institute for Microbial Diseases, Osaka University, Osaka, Japan; and Service
dHematologie Greffe de Moelle, Hospital Saint Louis, Paris, France.
Submitted April 27, 2005; accepted July 19, 2005. Prepublished online as
Blood First Edition Paper, July 28, 2005; DOI 10.1182/blood-2005-04-1717.

BLOOD, 1 DECEMBER 2005 VOLUME 106, NUMBER 12

particularly aplastic anemia. Thrombophilia is a major cause of

morbidity and mortality in PNH.
Classification

A scheme that incorporates variations in the presenting features,

clinical manifestations, and natural history among patients with
PNH was developed (Table 1). Continued investigation may
necessitate modification of the proposed 3 subcategories, but for
now, they serve as a working classification that provides a common
language for the field.
Classic PNH. Patients with classic PNH have clinical evidence of intravascular hemolysis (reticulocytosis, abnormally high
concentration of serum lactate dehydrogenase [LDH] and indirect
bilirubin, and abnormally low concentration of serum haptoglobin)
but have no evidence of another defined bone marrow abnormality.
A cellular marrow with erythroid hyperplasia and normal or
near-normal morphology, but without nonrandom karyotypic abnormalities, is consistent with classic PNH.
PNH in the setting of another specified bone marrow disorder.
The patients in this subcategory have clinical and laboratory
evidence of hemolysis but also have concomitantly, or have had a
history of, a defined underlying marrow abnormality. Bone marrow
analysis and cytogenetics are used to determine if PNH arose in
association with aplastic anemia, myelodysplastic syndrome (MDS),
or other myelopathy (eg, myelofibrosis). Standard criteria are used
for diagnosis of the bone marrow abnormality (eg, aplastic anemia,
MDS, or myelofibrosis). Finding nonrandom karyotypic abnormalities that are associated with a specific bone marrow abnormality
may contribute diagnostically (eg, abnormalities of chromosomes
5q, 7, and 20q are associated with MDS).
Subclinical PNH (PNH-sc). Patients with PNH-sc have no
clinical or laboratory evidence of hemolysis. Small populations of
GPI-APdeficient hematopoietic cells (peripheral blood erythrocytes, granulocytes, or both) are detected by very sensitive flow
cytometric analysis. PNH-sc is observed in association with bone
marrow failure syndromes, particularly aplastic anemia and refractory anemia-MDS.

Supported in part by the Health and Labor Sciences Research Grants for
Research on Measures for Intractable Diseases, Ministry of Health, Labor, and
Welfare, Japan (M.O. and T.K.); by the Japan Intractable Diseases Research
Foundation and the Japan Health Sciences Foundation (J.N.); by National
Institutes of Health grant RO1-CA89 091 and by the Bursary Award from the
Aplastic Anemia (AA) & Myelodysplastic Syndrome (MDS) International
Foundation (M.B.); and by an unrestricted educational grant from
Hemoglobinurie Paroxystique Nocturne (HPN) France Association (G.S.).
A complete list of the members of the International PNH Interest Group appears
in Appendix.
The online version of this article contains a data supplement.
Reprints: Charles J. Parker, Hematology/Oncology Section (111H), George E.
Whalen VA Medical Center, Salt Lake City, UT 84148; e-mail: charles.parker
@hsc.utah.edu.
2005 by The American Society of Hematology

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BLOOD, 1 DECEMBER 2005 VOLUME 106, NUMBER 12

PARKER et al

Table 1. Classification of PNH

A. Classic PNH
B. PNH in the setting of another specified bone marrow disorder (eg, PNH/aplastic
anemia or PNH/refractory anemia-MDS)
C. PNH-subclinical (PNH-sc) in the setting of another specified bone marrow
disorder (eg, PNH-sc/aplastic anemia)

Table 3. Recommended supporting studies

A. Medical history with emphasis on symptoms of hemoglobinuria,
thromboembolic disease, dysphagia, odynophagia, abdominal pain, and male
impotence
B. Determination by flow cytometry of the proportion of PNH I, PNH II, and PNH III
erythrocytes*
C. Determination by flow cytometry of the proportion of GPI-AP-deficient
granulocytes

Minimal essential diagnostic criteria

D. Serum iron studies (iron concentration, total iron binding capacity, and ferritin
concentration)

Flow cytometry is recommended to identify the GPI-AP deficient

peripheral blood cells that are diagnostic of PNH (see Diagnosis
of PNH). Assessment of hemolytic parameters and bone marrow
analysis are required to determine the subcategory into which each
patient falls (Classification, Table 1, Table 2).
Recommended ancillary studies

Appropriate management requires determination of a number of

factors that influence clinical manifestations and prognosis (Table 3).

Management of PNH
Who should be screened for PNH?

Essentially all patients with classic PNH report gross hemoglobinuria at some point during the course of their illness, but this
symptom may be absent in patients with PNH/aplastic anemia or
PNH/refractory anemia-MDS because the clone size is often
relatively small. In a series of 80 unclassified patients, only 26%
reported hemoglobinuria at presentation (Table 4).1 As the hemolysis is a complement-mediated, intravascular process, all patients
with clinically significant hemolysis have an abnormally high
serum LDH. Therefore, in the absence of elevated LDH, screening
for clinical forms of PNH (eg, classic PNH or PNH/aplastic
anemia) is unwarranted. However, this diagnostic criterion is not
applicable for PNH-sc, because, by definition, clinical evidence of
hemolysis is absent in these patients. Screening for PNH in patients
with aplastic anemia, even in the absence of clinical evidence of
hemolysis, is recommended at diagnosis and at least yearly during
follow-up (Table 5). Identifying PNH-sc appears clinically relevant, as recent studies2 suggest that patients with a small
population of PNH cells, in combination with either aplastic
anemia or refractory anemia-MDS, have a high probability of
responding to immunosuppressive therapy (IST). Routine screening of patients with subcategories of MDS other than refractory
Table 2. Minimal essential criteria required for diagnosis
and categorization

E. Serum concentration of creatinine and blood urea nitrogen

F. Serum concentration of erythropoietin
G. Urine hemosiderin
H. HLA type
*Hemolysis depends on both the proportion and type of abnormal erythrocytes
(see Management of the anemia of PNH).
Determining the contribution of PIGA mutant hematopoiesis may influence
therapeutic decisions such as prophylactic anticoagulation.
The association between HLA type and subclinical PNH may have prognostic
and therapeutic implications (see Subclinical PNH).

anemia or with other clonal myelopathies (eg, myelofibrosis) who

have no clinical or biochemical evidence of hemolysis is not
recommended.
A thromboembolic event as the presenting manifestation of
PNH is uncommon (5%; Table 4). Routine screening for PNH of
all patients with thrombosis is not recommended, but patients who
present with thrombosis at unusual sites (Table 5) should be
screened, especially if coexistent cytopenias, intravascular hemolysis, or both are noted.
Gastrointestinal complaints (episodic abdominal pain and dysphagia/odynophagia, see Dysphagia, male impotence, abdominal
pain) may be the initial manifestation of the disease in approximately 10% of patients (Table 4). Due to chronic intravascular
hemolysis, urinary iron loss is high in patients with PNH, and iron
deficiency is common.
Diagnosis of PNH

Flow cytometry. Flow cytometric analysis3-5 using antibodies

directed against GPI-AP is the most sensitive and informative assay
available for diagnosis of PNH (Figures 1-3; Table 6). For initial
studies, quantitation of at least 2 GPI-APs is recommended to
exclude the possibility that the clinical process is a consequence of
an inherited, isolated deficiency of a single GPI-AP.6,7
For patients with established, stable disease, yearly analysis of
peripheral blood GPI-AP expression is recommended, however, a
change in clinical parameters (worsening or more frequent hemolysis or a thromboembolic event) warrants immediate re-evaluation
(Table 6). Clinical improvement should also prompt an interim

A. Evidence of a population of peripheral blood cells (erythrocytes, granulocytes,

or preferably both) deficient in GPI-APs. Flow cytometric analysis of peripheral
blood erythrocytes, granulocytes, or both using primary antibodies against
GPI-APs or the FLAER* assay reveals a population of hematopoietic cells that is
partially or completely deficient in all GPI-APs.
B. Complete blood count, reticulocyte count, serum concentration of lactate
dehydrogenase (LDH), bilirubin (fractionated), and haptoglobin
C. Bone marrow aspirate, biopsy, and cytogenetics
*FLAER (fluorescently labeled aerolysin). Aerolysin is a bacterial protein that
binds selectively to GPI-APs. When used for flow cytometric analysis, leukocytes that
express GPI-APs bind the fluorescently labeled reagent. PNH leukocytes do not bind
FLAER because they do not express GPI-APs. Therefore, PNH leukocytes are
identified in the flow cytometric histogram as a population of cells with absent or dim
fluorescence. FLAER cannot be used for analysis of erythrocytes because, for
unknown reasons, the reagent does not bind well to human red cells under the
conditions required for the assay.

Table 4. Presenting features in 80 patients with PNH

Signs and symptoms
Symptoms of anemia

No. of patients (%)

28 (35)

Hemoglobinuria

21 (26)

Hemorrhagic signs and symptoms

14 (18)

Aplastic anemia

10 (13)

Gastrointestinal symptoms

8 (10)

Hemolytic anemia and jaundice

7 (9)

Iron-deficiency anemia

5 (6)

Thrombosis or embolism

5 (6)

Infections

4 (5)

Neurologic signs and symptoms

3 (4)

Modified from Dacie and Lewis.1

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BLOOD, 1 DECEMBER 2005 VOLUME 106, NUMBER 12

DIAGNOSIS AND MANAGEMENT OF PNH

3701

Table 5. Who should be screened for PNH?

Patients with hemoglobinuria
Patients with Coombs-negative intravascular hemolysis (based on abnormally
high serum LDH), especially patients with concurrent iron deficiency
Patients with venous thrombosis involving unusual sites*
Budd-Chiari syndrome
Other intra-abdominal sites (eg, mesenteric or portal veins)
Cerebral veins
Dermal veins
Patients with aplastic anemia (screen at diagnosis and once yearly even in the
absence of evidence of intravascular hemolysis)
Patients with refractory anemia-MDS
Patients with episodic dysphagia or abdominal pain with evidence
of intravascular hemolysis
*Patients with PNH and thrombosis usually have a relatively large PNH clone.
Therefore, most PNH patients with thrombosis will have clinically apparent evidence
of intravascular hemolysis. Patients with primarily or exclusively PNH type II cells,
however, may represent an exception. In this case, patients could have a large PNH
clone with only subtle clinical evidence of spontaneous hemolysis. Arterial thrombosis has been observed in patients with PNH but is uncommon compared with venous
thrombosis.
Patients with aplastic anemia should be screened even in the absence of
evidence of intravascular hemolysis to identify those with subclinical PNH (PNH-sc/
aplastic anemia). Screening of patients with refractory anemia-MDS is also recommended even in the absence of clinical evidence of hemolysis. Routine screening of
patients with other forms of MDS or with myeloproliferative disease that have no
evidence of intravascular hemolysis is not recommended outside of a research
setting.

analysis as the mutant clone sometimes becomes significantly

smaller or undetectable.8 A reduction in the percentage of GPI-AP
deficient granulocytes might influence the decision about prophylactic anticoagulation, as thrombophilic proclivity appears related
to PNH clone size9-11 (see Thrombosis).
Flow cytometric analysis is more than binary (ie, positive or
negative). In addition to identifying a population of GPI-AP
deficient cells, the analysis can both determine the percentage of
cells that are abnormal and identify discrete populations with
different degrees of deficiency (particularly on erythrocytes; Figure 1).
Erythrocytes with complete deficiency of GPI-APs are called PNH
III, those with subtotal deficiency (usually 10% of normal
expression) are called PNH II, and those with normal expression
are called PNH I (Figure 1). Knowing both the percentage and type
Table 6. Recommendations for flow cytometric analysis
in diagnosis and management of PNH
For patients with clinical evidence of hemolysis (classic PNH
and PNH/aplastic anemia)
At diagnosis, flow cytometric analysis of both erythrocytes* and granulocytes
is recommended.
After establishment of the diagnosis, flow cytometric analysis is recommended
every 6 months for 2 years and yearly thereafter if the parameters are stable.
If there is evidence of clinical progression (or amelioration), more immediate
analysis should be performed.
For patients with aplastic anemia or refractory anemia-MDS without
clinical evidence of hemolysis
At diagnosis, analysis of erythrocytes and granulocytes using high-sensitivity
flow cytometry.
Every year, even in the absence of clinical evidence of hemolysis (including
patients treated with immunosuppressive therapy).
*Best performed prior to transfusion or, if clinically feasible, during a period of
transfusion abstinence. The results of the analysis for erythrocytes should include the
percentage type I, type II, and type III cells.
Analysis of granulocytes is needed for the following 2 reasons: (1) analysis
provides the best estimate of the size of the PNH clone(s); (2) analysis is unaffected
by red cell transfusion.
Regardless of marrow cellularity.

Figure 1. Flow cytometric analysis of red cells in PNH using a combination of

anti-CD59 FITC, anti-CD55 PE, and anti-CD235a CyChrome. (Ai-ii) Flow cytometry
plots show the gating strategy for identifying a pure population of red cells. An initial
region (R1) is set on CD235aFSCHigh events. A second region (R2) is then drawn
around the logFSC/SSC characteristics of these cells. Only events that meet both
these criteria are analyzed. (Aiii) CD59 and CD55 bivariate expression on these
erythroid events. A small population of complete deficiency cells (type III) are
detected (region R3 8.0%). (Aiv) Histogram analysis of CD59 expression also
shows a major population of partially deficient cells (type II) comprising 53.9% of the
total. Type I (normal expression) cells comprise 38.1% of the total. (Bi-iii) Detection of
a very small red cell clone in a patient with PNH-sc/aplastic anemia. The red cell PNH
clone comprises 0.4% of the total red cells (Bi). Confidence that this population is not
an artifact is shown by simultaneous CD59 (Bii) and CD55 (Biii) deficiency and strong
expression of CD235a. Illustration enhanced by A. Y. Chen.

of deficient red cells is helpful in managing the anemia of PNH (see

Management of the anemia of PNH). Recent red cell transfusion
is unlikely to obscure the diagnosis of PNH, but the flow cytometric
histogram will be affected, as transfusion will increase the proportion of cells with normal expression of CD55 and CD59. Therefore,
to obtain accurate information about the percentage of GPI-AP
deficient erythrocytes, analysis should be performed prior to
transfusion or during a period of transfusion abstinence (at least
1 month, but longer if clinically safe).
Analysis of expression of GPI-AP on granulocytes provides
additional clinically relevant information. In contrast to GPI-AP
deficient red cells,12 the life span of PNH granulocytes is normal.13
Therefore, the proportion of abnormal granulocytes more accurately reflects the PNH clone size and is unaffected by red cell
transfusion (Figure 2).
Subclinical PNH. Standard single-color flow cytometry is
sufficiently sensitive to detect accurately 3% GPI-APdeficient
cells.5 By using 2-color analysis and careful gating, sensitivity can
be increased by 3 orders of magnitude (Figure 3).2,14 Patients with
small PNH clones ( 10% GPI-APdeficient granulocytes) have
little or no clinical evidence of hemolysis. Most of these patients
have aplastic anemia or refractory anemia-MDS.2,14,15 As discussed
in Who should be screened for PNH? finding small populations
of GPI-APdeficient cells in the setting of aplastic anemia or
refractory anemia-MDS appears to have important prognostic and
therapeutic implications.2,14,15 For this reason, high-sensitivity flow
cytometric analysis is recommended for these patients both at

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PARKER et al

BLOOD, 1 DECEMBER 2005 VOLUME 106, NUMBER 12

number of samples using modern technology, disease-specific

abnormalities may be identified; and (2) nonrandom karyotypic
abnormalities associated with other underlying disease processes
may help in categorizing individual patients (Table 2).
PIGA mutations. Deficiency of GPI-AP in patients with PNH
is due to an acquired somatic mutation in PIGA.30 Therefore,
documentation of the PIGA mutation(s) would confirm the diagnosis of PNH.31 Because of technical challenges, identification of
PIGA mutations has been limited to the research setting; however,
new technology may eventually make routine clinical determination of PIGA mutations feasible.32-34
Management of the anemia of PNH

Figure 2. Flow cytometric analysis of granulocytes in PNH using a combination

of anti-CD15 FITC, anti-CD24 PE, and anti-CD16 PE:Cy5. Flow cytometry plots
(A-B) show the gating strategy for identifying a pure population of granulocytes based
on light scatter characteristics and a transmembrane lineage marker (CD15). An
initial region (R1) is set on CD15aSSCHigh events (A). A second region (R2) is then
drawn around the FSC/SSC characteristics of these cells to further refine the gating
procedure (B). Only events that meet both these criteria are analyzed. (C-E) Using
this combination, normal eosinophils (blue) can be clearly separated from PNH cells
(red) and normal granulocytes (green). Plots are from 3 representative patients with
PNH. (C) A small PNH granulocyte clone of 0.18% of total granulocytes in a patient
with aplastic anemia (PNH-sc/aplastic anemia). (D) A larger PNH granulocyte clone
of 8.7% in a patient with aplastic anemia (PNH/aplastic anemia). (E) Plot is from a
patient with classic PNH and shows a large PNH granulocyte pool (98.8%). In this
instance, the majority of hematopoiesis is derived from PNH stem cells. There is
some residual normal granulocyte production (the 1% of cells that are CD16CD24)
and this population serves as an internal positive control for antibody staining.
Illustration enhanced by A. Y. Chen.

The anemia of PNH is complex. Coombs-negative hemolytic

anemia is the clinical hallmark of PNH, but because the disease
usually arises in the setting of an underlying abnormality of the
bone marrow, hemolysis may account for only part of a patients
anemia. Further, the erythrocytes of PNH are a mosaic of normal
and abnormal cells, and the portion of GPI-APdeficient red blood
cells (RBCs) varies among patients (Figures 1-4).35,36 For example,
in hypothetical patient 1, only 15% of the circulating RBCs may be
GPI-AP deficient, whereas in hypothetical patient 2, 75% GPI-AP
deficient erythrocytes may be observed.35 In the former, hemolysis
would contribute modestly to an observed anemia, whereas in the
latter, a significant hemolytic component would be expected
(Figure 4).35 Another complicating factor is that deficiency of
GPI-AP may be partial rather than complete (Figures 1 and 4), and
partial expression of CD55 and CD59 is sufficient to protect PNH
II cells from spontaneous complement-mediated lysis in vivo.35,37

diagnosis and yearly during and after treatment, even in the

absence of clinical or biochemical evidence of hemolysis (Table 6).
Not all flow cytometry laboratories have the capacity to perform
high-sensitivity analysis. To diagnose and follow patients with
PNH-sc, physicians are encouraged to identify laboratories that can
consistently and reproducibly detect less than 1.0% GPI-AP
deficient erythrocytes and granulocytes.
Other approaches to diagnosis. The FLAER (fluorescently
labeled aerolysin) assay takes advantage of binding of a bacterial
protein, aerolysin, to GPI-AP.16-19 This assay is useful for analyzing
leukocytes for expression of GPI-AP but cannot be used for
analysis of erythrocytes (Table 6).
Although they have much biologic and historic importance,20
the acidified serum lysis test (Ham test) and the sucrose lysis test
(sugar water test) have largely been abandoned as diagnostic assays
because they are both less sensitive and less quantitative than flow
cytometry. Testing for expression of other GPI-AP using functional
or immunohistochemical assays (eg, erythrocyte acetylcholine
esterase or neutrophil alkaline phosphatase) can be used as part of
the screening process or as ancillary studies to support the
diagnosis, but they should not be used in place of flow cytometry.
Bone marrow analysis. While deficiency of GPI-AP can be
demonstrated on CD34 bone marrow cells using 2-color flow
cytometry,21 this type of analysis is unnecessary for standard
diagnosis of PNH.
Morphologic analysis of the bone marrow aspirate and biopsy
and cytogenetics are needed for proper classification, as PNH is
often observed in association with marrow failure syndromes22-24
and sometimes with clonal myelopathies2,15,25-27 (Tables 1 and 2).
Although nonrandom karyotypic abnormalities associated with
PNH have not been identified,28,29 cytogenetic analysis is recommended for the following 2 reasons: (1) by analyzing a large

Figure 3. High-sensitivity flow cytometric analysis of erythrocytes. By careful

gating and by using dual-color flow cytometry, GPI-deficient cells that comprise less
than 1% of the total erythrocyte population can be reliably and reproducibly
demonstrated (B-C).2 Using this technique, GPI-APdeficient cells are not identified
in the peripheral blood of the controls (volunteer donors; A). A combination of
FITC-labeled anti-CD55 and anti-CD59 was used along with phycoerythrin (PE)
labeled antiglycophorin A for the dual staining. These data were kindly provided by
Dr Shinji Nakao and Dr Chiharu Sugimori, Kanazawa University, Japan, and are used
with their permission. Illustration enhanced by A. Y. Chen.

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BLOOD, 1 DECEMBER 2005 VOLUME 106, NUMBER 12

Figure 4. Phenotypic mosaicism in PNH. Hypothetical histograms of erythrocytes

from patients with PNH stained with anti-CD59 are illustrated. The proportion and
type of abnormal erythrocytes varies greatly among patients with PNH and these
characteristics are important determinants of clinical manifestations. In general,
patients with a high percentage of type III erythrocytes have clinically apparent
hemolysis (A). If the erythrocytes are partially deficient in GPI-AP, hemolysis may be
modest even if the percentage of the affected cells is high (B). A patient may have a
diagnosis of PNH, but if the proportion of type III cells is low, only biochemical
evidence of hemolysis may be observed (C). Illustration enhanced by A. Y. Chen.

Therefore, even if a patient has a high proportion of PNH II cells,

only modest evidence of spontaneous hemolysis is usually observed (Figures 1 and 4). But brisk hemolysis may occur in patients
with predominantly PNH II erythrocytes in a situation where
complement activation is enhanced (eg, by infection, trauma,
surgery, pregnancy, unusual stress).
What is the contribution of hemolysis to the anemia? Prior to
initiating therapy, an effort should be made to determine how much
of the anemia is a consequence of hemolysis and how much is due
to impaired erythropoiesis (Table 7). Review of the complete blood
count is informative because evidence of thrombocytopenia, leukopenia, or both suggests stem cell dysfunction. The capacity of the
marrow to respond to the anemia can be inferred from the
reticulocyte count. An element of marrow failure is likely a
contributing factor in a patient with PNH who has anemia with an
inappropriately low reticulocyte count.
Biochemical parameters of hemolysis should be assessed (Table
7). Normal or minimal elevation of LDH argues against hemolysis
as a major contributing factor to the anemia. The presence of urine
hemosiderin suggests chronic intravascular hemolysis but provides
no quantitative information, while gross hemoglobinuria indicates
clinically significant intravascular hemolysis.
The concentration of erythropoietin should be determined as
renal dysfunction may complicate PNH.38 Iron deficiency due to
hemosiderinuria/hemoglobinuria is common.39,40
Is treatment of hemolysis necessary? If the assessment in
What is the contribution of hemolysis to the anemia? suggests
that hemolysis contributes significantly to the anemia, treatment is
indicated for the following reasons: (1) patients with chronic
hemolysis complain of lethargy, malaise, myalgia and loss of sense
of well being that diminishes significantly quality of life; (2) there

DIAGNOSIS AND MANAGEMENT OF PNH

3703

is evidence that chronic hemolysis has an untoward effect on renal

function38; (3) the dysphagia and male impotence of PNH appear
related to hemolysis41; (4) a correlation between thrombosis and
hemolysis may exist.
Treatment of the hemolysis of PNH. If a modality with a
favorable therapeutic index were available, there would be little
debate about whether treatment of hemolysis is appropriate.
Although such an agent appears to be forthcoming in the form of
eculizumab,42 current options are limited, and the outcome of
treatment is often unsatisfactory because of inconsistent response
rates and unfavorable toxicity profiles.
Corticosteroids. Corticosteroids as treatment, for both chronic
hemolysis and acute hemolytic exacerbations,39,43-45 is a subject of
debate, and some members of the International PNH Interest Group
do not advocate the use of steroids in PNH in any circumstances.
Part of the debate is fueled by the empiric nature of the therapy, as
there are no experimental data that provide a plausible explanation
for why steroids should ameliorate the hemolysis of PNH. Nonetheless, some patients appear to respond rapidly and dramatically to
glucocorticoids (given in the dosage range of 0.25-1.0 mg/kg per
day of prednisone). The rapid response (often within 24 hours of
initiating therapy) suggests that complement inhibition accounts
for antihemolytic activity of glucocorticoid therapy. Such an effect
could be direct (the result of inhibition of the activity of some
component of the alternative pathway of complement) or indirect
(the result of dampening a process, such as inflammation, that
stimulates activation of complement).
The main value of corticosteroids may be in attenuating acute
hemolytic exacerbations. Under these circumstances, brief pulses
of prednisone may reduce the severity and duration of the crisis
while avoiding the untoward consequences associated with longterm use. The value of steroids in treating chronic hemolysis is
limited by toxicity, and the harm that can accrue from long-term
use cannot be overemphasized. An every-other-day schedule may
attenuate some of the adverse effects of chronic steroid use,39 but
patients may note worsening of symptoms on the off day. Careful
follow-up is essential and both bacterial prophylaxis and prophylaxis against steroid-induced osteopenia are recommended. Awareness of the potentially debilitating effects of steroid myopathy and
sensitivity to the disfiguring consequences of iatrogenic Cushing
syndrome are essential for proper management.
Androgens. Androgen therapy, either alone or in combination
with steroids, has been used successfully to treat the anemia of
PNH.39,40 As with glucocorticoids, the mechanism by which
androgenic steroids ameliorate the anemia of PNH is not fully
understood, although the rapid onset of action is consistent with
complement inhibition.40
Table 7. Information useful for managing anemia in patients
with PNH
A. Complete blood count
B. Reticulocyte count
C. Serum concentration of lactate dehydrogenase (LDH), bilirubin (total and direct
fractions), and haptoglobin
D. Flow cytometric analysis of erythrocytes and granulocytes for expression of
GPI-AP
E. Serum iron studies (iron concentration, total iron binding capacity, transferrin
saturation index, and ferritin concentration)
F. Serum concentration of blood urea nitrogen and creatinine
G. Serum erythropoietin concentration
H. Urine hemosiderin*
*Indicative of chronic hemolysis but provides no quantitative information.

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Potential complications of androgen therapy include liver

toxicity (cholestatic jaundice, peliosis hepatis), prostatic hypertrophy, and virilizing effects. The toxicity profile is more favorable for
attenuated synthetic androgens such as Danazol, making long-term
use of this drug a reasonable management option. A starting dose of
400 mg twice a day is recommended, but a lower dose (200-400
mg/d) may be adequate to control chronic hemolysis. Monitoring
of liver function studies during therapy is mandatory. Whether
androgen therapy increases the risk of developing Budd-Chiari
syndrome in patients with PNH is unknown.
Iron replacement. Patients with PNH frequently become iron
deficient as a result of both hemoglobinuria and hemosiderinuria.39,40 Clinically important iron loss from hemosiderinuria can
occur even in the absence of gross hemoglobinuria. Replacement is
often associated with exacerbation of hemolysis, regardless of the
route of administration.39,40 Compared with parenteral replacement, oral administration of iron may be accompanied by less
severe hemolytic exacerbations, but urinary iron loss may be so
great that repletion cannot be achieved through this mechanism.39
Parenteral repletion is generally safe. Concern for inducing a
hemolytic exacerbation should not deter iron repletion, as iron
deficiency not only limits erythropoiesis but also exacerbates the
hemolysis of PNH.40 If a hemolytic exacerbation occurs in the
setting of iron repletion, the episode can be controlled by treatment
with corticosteroids or androgens or by suppression of erythropoiesis by transfusion.
Transfusion. In addition to increasing the hemoglobin concentration, transfusion may ameliorate hemolysis by suppressing
erythropoiesis. Concerns about inducing a hemolytic exacerbation
as a consequence of infusion of small amounts of donor plasma that
may contaminate red cell preparations appear unwarranted.46
However, hemofiltration is recommended to prevent transfusion
reaction arising from the interaction between donor leukocytes and
recipient antibodies. Iatrogenic hemochromatosis from chronic
transfusion may be delayed in patients with PNH due to iron loss
from hemoglobinuria/hemosiderinuria.39 In fact, iron overload in
patients with classic PNH is rare. But iron overload remains a
concern in patients who require chronic transfusion when the
anemia is primarily a consequence of marrow failure rather than
hemolysis.
Splenectomy. The role of splenectomy in the management of
patients with PNH is unclear. Reports of amelioration of hemolysis
and improvement in cytopenias following splenectomy are anecdotal. Concerns about lack of proven efficacy and the potential for
postoperative complications, particularly thrombosis, have led
some members of the International PNH Interest Group to argue
that splenectomy has no role in the management of PNH.
Folate. Supplemental folate (5 mg/d) is recommended to
compensate for increased utilization associated with heightened
erythropoiesis that is a consequence of hemolysis.
Complement inhibitors. As the hemolysis of PNH is a
consequence of complement-mediated cytolysis, inhibition of
complement is a logical approach to therapy.47 Recently, the results
of a phase 2 study using a humanized monoclonal antibody against
complement C5 (eculizumab) to treat patients with PNH were
reported.42 This reagent was effective in controlling the symptoms
and signs of the hemolysis, and a marked improvement in
quality-of-life parameters was documented in most patients. Significant adverse events were not observed. A phase 3 transfusion
avoidance trial in which the efficacy of eculizumab is compared
with placebo began enrolling patients in the late fall of 2004.

Management of nonhemolytic anemia. Treatment of anemia

that is primarily due to bone marrow failure should be aimed at the
underlying disease (eg, aplastic anemia, MDS). If absolute or
relative erythropoietin deficiency is felt to contribute to the anemia,
replacement with the recombinant protein is warranted, but patients
should be closely monitored as erythropoietin supplementation
could exacerbate hemolysis by increasing production of GPI-AP
deficient erythrocytes.
Androgens may also be beneficial in patients with PNH who
have a hypoproliferative component to their anemia.39
Stem cell transplantation

The issues that confound recommendations for transplantation for

PNH center both on the heterogeneous presentation and natural
history and on its close association with marrow failure syndromes.
To date, the 220 patients with PNH from the registry of the French
Society of Hematology represents the largest natural history study
group.48 Although the French cohort had a median survival of 12
years, the study identified risk factors associated with a worse
outcome. While some of the risk factors are of little help for
transplant decision-making (eg, age older than 55 years; relative
risk of death [RR] 4.0), others may provide guidance. There
were 4 factors associated with worse survival: (1) occurrence of
thrombosis (regardless of location; RR 10.2); (2) progression to
pancytopenia (RR 5.5); (3) transformation to MDS or acute
leukemia (RR 19.1); and (4) thrombocytopenia at diagnosis
(RR 2.2).
Data from 67 patients from single centers experience and from 2
registries studies were reviewed.49-72 The details of the literature
review can be found in Document S1 (see the Supplemental
Document link at the top of the online article, at the Blood website).
The conclusions that were derived from the reviewed literature on
transplantation for PNH are shown in Table 8. We are also left with
several unresolved questions related to PNH and transplantation.
Given the unpredictable course of the disease, including the
possibility of spontaneous remission, what is the optimal time for
stem cell transplantation (SCT)? Should a conventional or a
nonmyeloablative conditioning regimen be proposed given that the
latter may be associated with less early transplant-related mortality
(although graft-versus-host disease [GVHD] is still a problem)?
What is the place of transplantation using stem cells from an
unrelated donor in the era of HLA molecular matching that appears
to produce outcomes similar to those observed for transplantation
using stem cells from HLA-identical sibling donors? How will new
treatment options (eg, eculizumab) influence recommendations
for SCT?
By establishing a worldwide PNH registry (see PNH registry
and future directions) that will allow comparison of the outcome
of patients who have not undergone transplantation to those who
undergo SCT, these questions can begin to be answered.
Thrombosis

Overview of thromboembolic disease in PNH. Thrombophilia is

the leading cause of mortality in PNH.8,48 But, in contrast to our
thorough understanding of the basis of the hemolysis, much less is
known about the mechanism that underlies the thrombophilia of
PNH (Table 9).73
Recent clinical studies support the hypothesis that the probability of a thromboembolic event is directly related to the size of
the PNH clone.9-11 In the study by Hall and colleagues,10 the
10-year risk of thrombosis in patients with more than 50%

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BLOOD, 1 DECEMBER 2005 VOLUME 106, NUMBER 12

Table 8. Bone marrow/stem cell transplantation

for patients with PNH
Indications for consideration of transplantation
Bone marrow failure
Decision on transplantation is based on underlying marrow abnormality (eg,
aplastic anemia)*
Major complication of PNH
Recurrent, life-threatening thromboembolic disease
Refractory, transfusion-dependent hemolytic anemia
PNH-specific transplant-related issues
The conditioning regimen of cyclophosphamide/ATG is recommended
for patients with PNH/aplastic anemia. For patients with classic PNH, a more
myeloablative regimen is indicated.
Additional investigation is required to define the role of nonmyeloablative
regimens.
For syngeneic twin transplants, a myeloablative conditioning regimen is
recommended to prevent recurrence of PNH.
There are no PNH-specific adverse events associated with transplantation;
severe, acute graft-versus-host disease (GVHD) occurs in more than a third
of the patients and the incidence of chronic GVHD is roughly 35%.
Overall survival for unselected PNH patients who undergo transplantation
using an HLA-matched sibling donor is in the range of 50% to 60%.
*If the dominant clinical abnormalities are a consequence of bone marrow failure
(eg, hypoproliferative anemia, neutropenia with recurrent infections, thrombocytopenia with major bleeding complications) the decision to recommend transplantation
should be based on guidelines for management of the specific marrow failure
syndrome.
Factors including age, comorbid conditions, availability of an HLA-matched
sibling donor, and time from initial diagnosis should be considered before recommending transplantation for major complications of PNH.
The availability of new treatment options (eg, eculizumab) may influence the
decision to recommend transplantation.
Radiation- or busulfan-based.

GPI-APdeficient granulocytes was 44% compared with 5.8% for

patients with less than 50%. Using a logistic regression model,
Moyo et al9 calculated that the odds ratio for thrombosis was 1.64
for each 10% increase in the percentage of GPI-APdeficient
granulocytes. According to that study, a patient with more than
70% GPI-APdeficient granulocytes had an 11.8-fold greater risk
of thrombosis than a patient with a PNH clone of 20%.
Prophylaxis. Prophylaxis against thromboembolic events in
patients with PNH is an issue of debate among members of the
International PNH Interest Group. Current estimates of the risk are
based on retrospective analysis.9-11,73 The relatively high risk of a
thromboembolic complication led Hall and colleagues to advocate
prophylaxis with warfarin for patients with PNH with more than
50% GPI-APdeficient granulocytes who have no contraindications to anticoagulation.10 Those investigators reported no thromboembolic events in 39 patients who received warfarin prophylaxis
compared with a 36.5% 10-year risk of thrombosis for 56 patients
who did not. In that study, there were 2 serious hemorrhages in
approximately 100 patient years of warfarin therapy.
Even when differences in clone size are taken into account,11 the
prevalence of thromboembolism (2%) among patients from
Japan, China, and Mexico11,74-76 appears lower than in patients
from the United States and Europe, making anticoagulant prophylaxis for patients with PNH from these ethnic/geographic backgrounds difficult to justify.
Due to the lack of randomized, prospective studies, evidencebased guidelines for antithrombotic prophylaxis cannot be formulated satisfactorily. Available data (and its limitations) should be
discussed with patients, and factors such as age, activity level,
compliance, and comorbid conditions (in addition to the size of the
PNH clone) should enter into decisionmaking about anticoagulant
prophylaxis. The role of reagents that inhibit platelet function in

DIAGNOSIS AND MANAGEMENT OF PNH

3705

prophylaxis against the thrombophilia of PNH is undefined. Newer

pharmacologic agents (eg, oral thrombin inhibitors) with a more
favorable therapeutic index than warfarin may liberalize recommendations for prophylactic anticoagulation in patients with PNH.
Management of thromboembolic disease. Although arterial
thrombosis may be observed, thromboembolic events in patients
with PNH usually involve the venous system. Acute thrombotic
events require anticoagulation with heparin. Thrombolytic
therapy77,78 or radiologic intervention79 should be strongly considered in patients with acute onset of Budd-Chiari syndrome.
Thrombocytopenia often complicates PNH, and this issue must be
addressed when formulating an anticoagulation management plan.
Thrombocytopenia is a relative but not an absolute contraindication
to anticoagulation, and transfusions should be given to maintain the
platelet count in a safe range rather than withholding therapy.80
Patients with PNH who experience a thromboembolic event
should be anticoagulated indefinitely (Table 9). There are no
satisfactory guidelines for management of patients who fail standardintensity warfarin therapy. High-intensity warfarin therapy (International Normalized Ratio [INR], 3.0-4.0) or subcutaneous lowmolecular-weight heparin are options in this setting. In the absence
of proven efficacy, the risk of hemorrhage makes the addition of
antiplatelet agents to therapeutic anticoagulation difficult to support. Recurrent, life-threatening thrombosis merits consideration
for bone marrow transplantation (see Stem cell transplantation).
The role of complement inhibitors such as eculizumab in the
management of the thrombophilia of PNH is currently undefined.
Pregnancy

Women with PNH can have serious morbidity and increased

mortality during pregnancy.81 A retrospective review showed that,
in 25% of the cases, the diagnosis of PNH was first made during
pregnancy.80 In that study, a high mortality rate was reported (5
deaths in 24 women), with an all-cause mortality of 20.8%
(confidence interval [CI] 7.3-39.0). Three deaths were attributed to
venous thromboembolism and 2 to infections.
In women with PNH, anemia from hemolysis, underlying bone
marrow failure, or both frequently worsens during pregnancy.80
Table 9. Thrombosis and PNH
The pathogenesis of the thrombophilia of PNH is speculative.
Sites of thrombosis that are disproportionately represented in PNH
Hepatic vein (Budd-Chiari syndrome)
Mesenteric veins
Portal vein
Cerebral veins
Dermal veins
Propensity toward thrombosis appears roughly proportional to the size of the
PNH clone.*
The risk of thromboembolic disease appears higher in white and AfricanAmerican patients than in patients of Asian/Pacific Island or Hispanic ancestry
even when adjusted for clone size.
White and African-American patients with greater than 50% GPI-AP-deficient
granulocytes who have no contraindications are candidates for prophylactic
anticoagulation with warfarin.
Patients with PNH who have experienced a thromboembolic event should
remain anticoagulated indefinitely.
*The size of the PNH clone is determined by flow cytometric analysis of
expression of GPI-APs on peripheral blood granulocytes.
Standard-intensity warfarin therapy (INR 2.0-3.0) is recommended for chronic
therapy.
Long-term anticoagulation should be reassessed in any patient who undergoes
a spontaneous remission or in whom the PNH clone size falls to below 50%.

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3706

BLOOD, 1 DECEMBER 2005 VOLUME 106, NUMBER 12

PARKER et al

Because of concerns about fetal/maternal risks from exposure to

potentially toxic therapy, transfusion is the mainstay of management (Table 10). There is no experience with complement inhibitors such as eculizumab42 in this setting. Moderate to severe
thrombocytopenia may complicate the pregnancy, and clinically
significant bleeding in this setting necessitates platelet transfusion.
The incidence of clinically apparent venous thromboembolism
during pregnancy in women with PNH is about 10%,80 and these
events are associated with a high risk of mortality.81 Similar to
nonpregnant patients with PNH, cerebral and hepatic veins are
commonly involved sites of thrombosis. Patients who develop
thrombosis should be therapeutically anticoagulated, and thrombolytic therapy should be considered for those with Budd-Chiari
syndrome. Concurrent thrombocytopenia may necessitate platelet
transfusion in patients who require anticoagulation.
The role of prophylactic anticoagulation for pregnant women
with PNH has not been studied systematically; however, because of
the significant morbidity and mortality associated with thromboembolism in this setting, prophylaxis is recommended. Coumadin is
contraindicated because of teratogenic potential in the first trimester and hemorrhagic risks later in gestation. Anticoagulation with
heparin should begin immediately once the combination of pregnancy and PNH is documented. Low-molecular-weight heparin has
a hypothetical advantage over unfractionated heparin because of a
lower incidence of drug-induced thrombocytopenia. Careful monitoring of the platelet count is required because thrombocytopenia
may worsen during the period of anticoagulation (Table 10).
Anticoagulation can be discontinued briefly around the time of
delivery. However, it should be restarted as soon as is feasible and
continued for at least 6 weeks postpartum, as thrombosis during the
puerperium is a major concern.81
Most deliveries can be accomplished vaginally, although premature delivery may be necessary. Ray et al80 identified 3 infant deaths
(2 still births and 1 neonatal) among 34 births for a perinatal
mortality rate of 8.8% (CI 1.9-23.7). All surviving infants had
normal growth and development after delivery.
In summary, there are both maternal and fetal risks when PNH
complicates pregnancy. Untoward events can be expected in at least half
of the mothers and in some of the infants. Counseling female patients
with PNH about pregnancy should take into account age, overall health,
extent of hemolysis, degree of bone marrow failure (especially thrombocytopenia), previous thrombosis, and comorbid conditions. Despite the
many concerns, successful outcomes appear to be the rule rather than the
exception.11,80 But management is complicated and should involve the
combined efforts of an experienced hematologist and an obstetrician
specializing in high-risk pregnancy.81
Table 10. PNH and pregnancy
Complications of PNH
Anemia (hemolytic, hypoproliferative, or both)
Thrombocytopenia
Venous thromboembolic events
Management recommendations
Prior to pregnancy, counsel patient on potential risks and possible need for
intervention
Management team should include an experienced hematologist and an
obstetrician who specializes in high-risk pregnancies
Prophylactic anticoagulation with heparin* should begin immediately and
continue for 6 weeks after giving birth
Blood products as required for treatment of anemia and thrombocytopenia
*Low-molecular-weight heparin may be advantageous because it is associated
with a lower incidence of heparin-induced thrombocytopenia compared with unfractionated heparin. Regardless of the form of heparin used, frequent (at least every
other week) monitoring of the platelet count is needed.
Warfarin can be used for anticoagulation in the postpartum period.

Table 11. Future directions for clinical and laboratory studies

in PNH
Clinical studies
Guidelines for management of the thrombophilia of PNH based on prospective
randomized studies
Treatment
Does treatment of hemolysis with complement inhibitors modify the
thrombophilia of PNH?
Prophylaxis
Guidelines for bone marrow and stem cell transplantation in the era of
therapeutic complement inhibitors such as eculizumab
Pregnancy and PNH
Maternal and fetal risks
Management
Ethnic and geographic differences
Are different management guidelines necessary?
Natural history of subclinical PNH (PNH-sc)
Basic studies
What is the mechanism of the thrombophilia of PNH?
What is the basis of the disproportionate involvement of hepatic, mesenteric,
cerebral, and dermal veins?
What is the basis of clonal selection?
What is the relationship between PNH and aplastic anemia and PNH
refractory anemia-MDS?
How is PNH-sc different from PNH/aplastic anemia and classic PNH?
What is the basis of clonal dominance?

Pediatric PNH

PNH can occur in the young (about 10% of patients are younger
than 21)8,11,48 but is often misdiagnosed and mismanaged.82,83 A
retrospective analysis of 26 cases82 underscored the many similarities between childhood and adult PNH. Signs and symptoms of
hemolysis, bone marrow failure, and thrombosis dominate the
clinical picture, although hemoglobinuria may be less common in
young patients. A generally good response to immunosuppressive
therapy (6 of 9 patients) was observed. However, based on the lack
of spontaneous remissions and poor long-term survival (80% at 5
years, 60% at 10 years, and only 28% at 20 years), sibling-matched
stem cell transplantation is the recommended treatment of childhood PNH. A recent Dutch study confirmed the common presentation of bone marrow failure in 11 children with PNH,83 and
reported that 5 patients eventually underwent bone marrow transplantation (BMT; 3 matched unrelated donors and 2 matched
family donors), of whom 4 are alive. Mortality appears high in
young patients with PNH treated with transplantation using unrelated donors although surviving cases have been reported.72,83
Dysphagia, male impotence, abdominal pain

Many patients with PNH are troubled by dysphagia and odynophagia, especially during hemolytic exacerbations.41,84 These symptoms appear to be a consequence of esophageal spasm. The cause
of the spasm is speculative, but may be due to acquired deficiency
of nitric oxide (NO), a bioactive gas that mediates smooth muscle
relaxation.85 Males with PNH may experience episodes of impotence, particularly during hemolytic exacerbations.41 The cause of
the impotence may also be a consequence of decreased bioavailability of NO. Sildenafil citrate has shown efficacy in the treatment of
hypercontractile motility disorders of the esophagus, including
idiopathic achalasia, where the mechanism of disease appears to be
impaired NO production similar to that reported for erectile
dysfunction.86-88 Therefore, sildenafil citrate and pharmacologically related compounds are candidate therapies for both the
dysphagia/odynophagia and male impotence of PNH. Agents such

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BLOOD, 1 DECEMBER 2005 VOLUME 106, NUMBER 12

as oral or dermal nitroglycerine that supply NO pharmacologically

have also shown efficacy.
Some patients with PNH are debilitated by recurrent episodes of
colicky abdominal pain. The etiology of the abdominal pain is largely
speculative, but thrombosis of mesenteric vessels appears to play a role
in some cases.39 Vascular spasm may also contribute to this process.
Vigorous hydration and pain control are the mainstays of management,
but mesenteric vein thrombosis can result in intestinal infarction
necessitating surgical intervention. Still to be determined are the roles of
anticoagulation, complement inhibition, and NO supplementation in the
management of abdominal pain of PNH.
Geographic and ethnic differences

The natural history of PNH appears different for Americans and

Europeans compared with Asian/Pacific Islanders and Hispanics.8,11,48,74-76,82,89,90 In general, the manifestations of bone marrow
failure are more common in Asians/Pacific Islanders and Hispanics.
In contrast, thrombosis and infection appear more common in
American and European patients. The basis of these phenotypic
differences is unknown, but the relationship of ethnicity and
geography to the natural history of PNH should be considered
when formulating a management plan.
PNH registry and future directions

The International PNH Interest Group supported the development

of a worldwide patient registry in order to generate more detailed
epidemiologic data and to gain greater insight into both the natural
history of the disease and the outcomes of therapy. The registry also
has the potential to provide the framework upon which controlled,
randomized clinical studies can be organized. Enrollment began in
the fall of 2004. Physicians who follow patients with PNH are
encouraged to enter patients into the registry. Information about
registry participation can be found on the World Wide Web
(http://www.pnhregistry.com).
The International PNH Interest Group encourages clinical and basic
research. Some potential topics for investigation are shown in Table 11.

Acknowledgments
The expert advice and support of members of the International
PNH Interest Group are gratefully acknowledged. We also thank Dr
David E. Jenkins Jr, Hummelstown, PA, for informative discussions.

Appendix
The International PNH Interest Group is composed of approximately 60
physicians and investigators who have a special interest in the disease. This
paper represents the efforts of the group to develop guidelines for the
diagnosis and management of PNH. The members of the International PNH
Interest Group are as follows:

DIAGNOSIS AND MANAGEMENT OF PNH

3707

Fiorella Alfinito, Division of Hematology, Federico II University, Naples, Italy;

Leslie Andritsos, Washington University School of Medicine, St Louis; David J.
Araten, Memorial Sloan Kettering Cancer Center; Han Bing, Peking Union
Medical College; Morey Blinder, Departments of Internal Medicine and Pathology, Washington University School of Medicine, St Louis; Michael Bombara,
Alexion Pharmaceuticals Inc; Christopher Bredeson, International Bone Marrow
Transplant Registry; Robert A. Brodsky, The Sidney Kimmel Comprehensive
Cancer Center at Johns Hopkins, Division of Hematologic Malignancies; Tatsuya
Chuhjo, Protected Environment Unit, Kanazawa University Hospital; Matthew
Cullen, Haematological Malignancy Diagnostic Service, Leeds General Infirmary; Carlos M. de Castro, Duke University Medical Center; Lisa DeBoer,
Alexion Pharmaceuticals Inc; Steven M. Devine, Washington University School
of Medicine, St Louis; Modupe Elebute, Hematology and Transfusion Medicine,
St Georges Health Care NHS Trust; Xingmin Feng, Cellular Transplantation
Biology, Kanazawa University Graduate School of Medical Science; Paul
Finnegan, Alexion Pharmaceuticals Inc; Norbert Gattermann, Heinrich-Heine
University Department of Hematology/Oncology and Clinical Immunology;
Ulrich Germing, Heinrich-Heine University Department of Hematology/
Oncology and Clinical Immunology; Susan Harris, Alexion Pharmaceuticals Inc;
Robert Hayashi, Department of Pediatrics, Division of Hematology-Oncology,
Washington University School of Medicine, St Louis; Anita Hill, Academic Unit
of Haematology, Leeds General Infirmary; Thad Howard, St Jude Childrens
Research Hospital; Eric Hsi, Section of Hematopathology, Director of Flow
Cytometry, Cleveland Clinic Foundation; Norimitsu Inoue, Osaka Medical
Center for Cancer and Cardiovascular Diseases; Yuzuru Kanakura, Osaka
University Graduate School of Medicine; Akihisa Kanamaru, Kinki University
School of Medicine; Tatsuya Kawaguchi, Departments of Hematology &
Infectious Diseases, Kumamoto University School of Medicine; Peter Keller,
Division of Hematology, Inselspital Bern, University of Berne; Masahiro Kizaki,
Division of Hematology, Keio University School of Medicine; Seiji Kojima,
Department of Pediatrics, Nagoya University Graduate School of Medicine;
Elisabeth Korthof, Leiden University Medical Center; Loree Larratt, University
of Alberta Hospitals; Jaroslaw P. Maciejewski, Taussig Cancer Center, The
Cleveland Clinic Foundation; Philip J. Mason, Department of Internal Medicine
and Department of Genetics, Washington University School of Medicine, St
Louis; Gabrielle Meyers, University of Utah School of Medicine; Christopher
Mojcik, Alexion Pharmaceuticals Inc; Shoichi Nagakura, Kumamoto National
Hospital; Hideki Nakakuma, Wakayama Medical University; Shinji Nakao,
Cellular Transplantation Biology, Kanazawa University Graduate School of
Medical Science; Rosario Notaro, National Institute for Cancer Research (IST);
Keiya Ozawa, Professor and Chairman, Division of Hematology, Department of
Medicine, Division of Cell Transplantation and Transfusion, Division of Genetic
Therapeutics, Center for Molecular Medicine, Jichi Medical School; Andrew
Rawstron, Haematological Malignancy Diagnostic Service, Leeds General
Infirmary; Stephen Richards, Haematological Malignancy Diagnostic Service,
Leeds General Infirmary; Antonio M. Risitano, Division of Hematology,
Federico II University, Naples; Wendell F. Rosse, Duke University; Russell P.
Rother, Alexion Pharmaceuticals Inc; Bruno Rotoli, Federico II University,
Naples; Hubert Schrezenmeier, Institute for Clinical Transfusion Medicine and
Immunogenetics; Joerg Schubert, Internal Medicine I, Saarland University
Medical School; Tsutomu Shichishima, First Department of Internal Medicine,
Fukushima Medical University; Elaine M. Sloand, National Heart, Lung, and
Blood Institute, National Institutes of Health; Chiharu Sugimori, Cellular
Transplantation Biology, Kanazawa University Graduate School of Medical
Science; Akiyoshi Takami, Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science; David B. Wilson, Department of
Pediatrics, Division of Hematology-Oncology, Washington University School of
Medicine, St Louis; Paul Woodard, Hematology/Oncology, Division of Stem
Cell Transplantation, St Jude Childrens Research Hospital.

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2005 106: 3699-3709

doi:10.1182/blood-2005-04-1717 originally published online
July 28, 2005

Diagnosis and management of paroxysmal nocturnal hemoglobinuria

Charles Parker, Mitsuhiro Omine, Stephen Richards, Jun-ichi Nishimura, Monica Bessler, Russell
Ware, Peter Hillmen, Lucio Luzzatto, Neal Young, Taroh Kinoshita, Wendell Rosse and Gerard Soci

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