From www.bloodjournal.org by guest on June 14, 2017. For personal use only. Analysis of the Survival of Mature Human Eosinophils: Interleukin-5 Prevents Apoptosis in Mature Human Eosinophils By Yuji Yamaguchi, Toshio Suda, Shigeo Ohta, Kaoru Tominaga, Yasusada Miura, and Tadashi Kasahara We and other groups have previously shown that interleukin-5 (IL-5) maintained the viability of mature eosinophils in an in vitro liquid culture system. Mature eosinophils did not proliferate but their survival was maintained in the presence of IL-5. Using this culture system, we investigated the mechanism of IL-Smediated survival. In the absence of human IL-5 (hlL-5) mature eosinophils succumbed after 4 days, while in the presence of hlL-5 they survived up to 10 days. When DNA extracts of cultured eosinophils were analyzed on an agar gel electrophoresis, marked DNA fragmentation was observed in the absence of hlL-5, while no significant DNA fragmentation was observed in the culture with hlL-5 for 48 hours. The DNA fragmentation appeared as early as 6 to 12 hours after hlL-5 deprivation. Concomitantly, IL-5 stimulated total RNA and protein synthesis, but did not induce DNA synthesis in mature eosinophils. Because cycloheximide or actinomycin D impeded the protectionof apoptosir by hlL-5, some new RNA and protein synthesis appeared to be required in this phenomena. These findings indicate that IL-5 maintains survival of mature eosinophils with induction of new RNA and protein synthesis, thus leading to the inhibition of apoptosis. o 1991 by The American Society of Hematology. T found that IL-5 maintained survival of eosinophils by inhibiting apoptosis. The mechanism of eosinophil survival by IL-5 is to be discussed. HE SURVIVAL,, differentiation, and proliferation of hematopoietic precursor cells and the functional maturation of blood cells are all under the influence of various cytokines including colony-stimulatingfactors (CSFs). Many hematopoietic cell lines have been established, and their maintenance requires the exogenous addition of cytokines such as interleukin-2 (IL-2), IL-3, IL-6, and CSFs. Most in vitro cell lines do not survive on the removal of cytokines. Cell death caused by the withdrawal of factors resembles active cell death or apoptosis, which is characterized by the condensation of nuclear chromatin, followed by DNA fragmentati~n.”~ This programmed cell death is observed first in thymocyte death exposed to glucocorticoids’.’ and target cell destruction by cytotoxic T lymphocytes.’ In addition, apoptosis has been observed in IL-Zdependent T-cell clones on the removal of IL-2: in factor-dependent continuous cell lines, Paterson Laboratories (FDCP-Mix) cell clones on the removal of IL-3, granulocyte-CSF (GCSF), or granulocyte-macrophage CSF (GM-CSF),’ as well as in erythroid progenitor cells on the removal of erythropoietin ( E ~ o ) These .~ observations suggested that CSFs promote cell survival by suppressing this process. We have previously shown that recombinant murine IL-5 (mIL-5) maintained the viability of mature murine eosinophils in an in vitro liquid culture system.’ Mature eosinophils did not proliferate but survived only in the presence of IL-5. In the present study we have examined the mechanism of action of IL-5 on the survival of mature eosinophils. We From the Department of Medical Biology and Parasitology, Division of Hematology, Department of Medicine, Department of Biochemistry, Jichi Medical School, Tochigi-ken,Japan. Submitted September 24, 1990; accepted July 8, 1991. Supported by Grants-in-Aidfrom the Ministry of Education, Science and Culture of Japan, from Sandoz Pharmaceuticals, Ltd, and from the Ryoichi Naito Foundation for Medical Research. Address reprint requests to Tadashi Kasahara, PhD, Dept. of Medical Biology and Parasitology, Jichi Medical School, Minamikawachi-machi, Tochigi-ken,329-04, Japan. The publication costs of this article were defrayed in part by page charge payment. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. section 1734 solely to indicate this fact. 0 1991 by The American Society of Hematology. 0006-4971/91/7810-0003$3.00/0 2542 MATERIALS AND METHODS Preparation and purification of eosinophils. Venous blood was collected in a heparinized syringe from three patients with hypereosinophilic syndrome (HES) after obtaining their informed consent. Polymorphonuclear (PMN) leukocytes were separated by Mono-Poly Resolving Medium (M-PRM; Japan Flow Laboratories Ltd, Tokyo, Japan). PMN leukocytes separated by M-PRM were layered onto discontinuous metrizamide gradients (Nycomed, Oslo, Norway) as previously described by Vadas et a1.8 Enriched eosinophil preparations used in the following experiments always consisted of more than 90% eosinophils with the remainder being neutrophils. Lymphokines. We used purified recombinant factors as follows: recombinant human IL-2 (rhIL-2; specific activity, 1 x lo7 U/mg protein; provided by Shionogi Pharmaceutical Co, Osaka, Japan), rhIL-3 (specific activity, 21,900 U/mL; provided by the Genetic Institute, Cambridge, MA),9 rhIL-5 (purity is more than 80% by sodium dodecyl sulfate-polyacrylamide gel electrophoresis [SDSPAGE]; specific activity, 1to 2 x 10’ U/mg protein assayed by IgM secretion on murine B-cell lymphoma (BCL,) cells; provided by Suntory Central Research Institute, Osaka, Japan),” rhG-CSF (specific activity, 2.5 x lo7 U/mg protein; provided by Chugai Pharmaceutical Co, Tokyo, Japan),” and rhGM-CSF (specific activity, 1 x lo9U/mg protein; provided by Sumitomo Pharmaceutical Co, Osaka, Japan).I2 The optimal concentration of each factor was determined by titration using human normal bone marrow (BM) cells. Cell culture. Mature human eosinophils were cultured in 24well tissue culture plates (Coster, Cambridge, MA). Each well contained 1 mL RPMI 1640 supplemented with 20% fetal calf serum (FCS), lo6 eosinophils, and various CSFs. At various times, viable cells were counted by the eosin dye exclusion test. Analysis of DNA fragmentation. DNA fragmentation in mature human eosinophils and cytotoxic T-cell line (CTLL-2) cells was determined according to the method described previously by Nieto and Lopez-Rivas! Briefly, 1 to 5 x lo6cells were incubated at 37°C for 4 hours in 500 kL of lysing buffer (200 mmol/L Tris, pH 8.5,lOO mmol/L EDTA, 50 kg/mL proteinase K, 1% SDS). The DNA was phenol-extracted and then dialyzed for 12 hours against 10mmol/L Tris (pH 7.5), 1 mmol/L EDTA. After dialysis the DNA solution was incubated for 5 hours at 37°C with 50 kg/mL of RNase A, and further incubated with 150 kg/mL of proteinase K for 5 hours at 37°C. The DNA was extracted with phenol and chloroform and precipitated with ethanol. Each sample was electrophoresed on Blood, Vol78, No 10 (November 15L 1991:pp 2542-2547 From www.bloodjournal.org by guest on June 14, 2017. For personal use only. 2543 IL-5 BLOCKS EOSINOPHIL APOPTOSIS RESULTS Days h c u b e Fig 1. In vitro survival of mature human eosinophils in the presence of 40 ng/mL hG-CSF (A), 2 ng/mL hlL-3 (=), 1 ng/mL hGM-CSF (A),and 50 ng/mL hlL-5 ( 0 ) Control . means the absence of CSFs. At various times, the viable cell number was counted by eosin exclusion. Each value is the mean of data from duplicate cultures. agarose gels (1%) with TBE buffer (89 mmol/L Tris, 89 mmol/L borate, 2 mmol/L EDTA) containing 0.5 pg/mL ethidium bromide. DNA, RNA, and protein synthesis hv matitre human eosinophib Assay culture was performed as described elsewhere." In brief, enriched mature human eosinophils (1 x IO"/mL) in RPMI 1640 and 10% FCS were preincubated for 1, 2, and 3 days with various lymphokines and/or 2 pg/mL actinomycin D (Sigma Chemical Co, St Louis. MO) or 10 pg/mLcycloheximide (Sigma). Tubes containing 2.5 x IO-' cells and factors were preincubated and the incorporation of 740 kBq/mL 'H-thymidine (specific activity, 185 GBq/mmol; Amersham Japan, Tokyo, Japan). 2.8 x 10' kBq/mL 'H-uridine (specific activity. 1.37 GBq/mmol; Amersham Japan), and 10' kBq/mL 'H-leucine (specific activity, 2.74 TBq/mmol; Amersham Japan) into trichloroacetic acid (IO%)-insoluble materials for the last 5 hours was measured by a Packard liquid scintillation counter (Packard Instrument Co, Meriden, CT). In vitro sriniwl of human matiire eosinophils in the presence of hematopoietic cytokines. It is well known that normal mature eosinophils separated from peripheral blood do not survive more than 4 days in vitro without the addition of cytokines. When the culture medium was supplemented with hIL-5 (50 ng/mL) or hGM-CSF (1 ng/mL), eosinophils survived up to 10 days. Similarly, hIL-3 (2 ng/mL) supported 50% survival up to 6 days (Fig 1). hG-CSF (40 ng/mL) did not maintain viability. By removing hIL-5 from the culture medium, the number of cosinoFhils began to decrease rapidly and few viable cells were detected 4 days after the withdrawal. IL-5 inhibits the DNA fragmentation and cell death of matitre eosinophils. It is of a great interest to know whether the death of mature eosinophils accompanies DNA fragmentation, and if so, whether hIL-5 inhibits this process. We performed DNA fragmentation analysis of mature eosinophils on agarose gel electrophoresis. As shown in Fig 2, marked DNA fragmentation occurred in eosinophils incubated for 48 hours without IL-5, whereas DNA fragmentation was prevented in the presence of 50 ng/mL hIL-5. As a control, DNA from an IL-2-dependent cell line, CTLL-2, was similarly analyzed (Fig 2; CTLL-2). After the withdrawal of hIL-2, DNA from CTLL-2 cells exhibited the fragmentation rapidly, ie, as early as 4 hours after the withdrawal of hIL-2. Figure 3 shows the kinetic changes of DNA fragmentation in mature eosinophils in the absence of hIL-5. The DNA fragmentation in mature eosinophils appeared from 6 to 12 hours after hIL-5 deprivation, which preceded by 24 to 48 hours the morphologically observed death of eosinophils as shown in Fig 1. Protection against DNA fiapentation in matitre eosinophils by IL-5 reqitires de novo RNA and protein .ynthesi.s. eo Fig 2. Apoptosis in mature human eosinophils produced by hlL-5 deprivation (eo) and by hlL-2 deprivation of an IL-Z-dependent cell line (CTLL-2). Mature eosinophils were incubated in the presence or absence of hlL-5 for 48 hours. CTLL-2 cells were incubated in the absence of hlL-2 for various periods (0,4,6,8, and 10 hours). 947 bp 564 bp CTLL-2 From www.bloodjournal.org by guest on June 14, 2017. For personal use only. YAMAGUCHI ET AL 2544 L L a tn fi I 622 404 242 110 - 2100 bp -5000 -2000 1400 947 564 i4 -- bpbpbpbp I bp bP bp bp bp Fig 3. Analysis in agarose gels of DNA extracted from mature human eosinophils incubated in the absence of hlL-5 after various periods (0, 3, 6, 12, 24, and 48 hours). - We then examined whether some metabolic inhibitors affect the IL-5-induced survival of eosinophils to discover the role of IL-5. Figure 4 shows that viability of mature eosinophils was not supported by hIL-5 in the presence of 2 pg/mL actinomycin D (Act D), an inhibitor of transcription, or 10 pg/mL cycloheximide (CHX), an inhibitor of protein synthesis. This observation indicated that the hIL-5induced survival of mature eosinophils seemed to require de novo RNA and protein syntheses. Simultaneously, we determined whether IL-5 induces new RNA and protein syntheses in mature eosinophils. DNA synthesis was not observed in mature eosinophils incubated with hIL-5 or with other lymphokines, at least during 3-day incubation period (Fig 5A). However, the enhanced RNA synthesis occurred in eosinophils incubated with hIL-5 or hGM-CSF (Fig 5B). Total RNA synthesis in mature eosinophils reached a maximal level 1 day after incubation with either hIL-5 or hGM-CSF, and declined thereafter. Likewisc, a nearly threefold increase in protein synthesis was observed in mature eosinophils incubated with hIL-5, hGM-CSF, or hIL-3 (Fig 5C), reaching a maximal level at 2 days. The hIL-5-induced RNA or protein synthesis in mature eosinophils described above was completely inhibited in the prcsence of 10 pg/mL CHX or 2 pg/mL Act D. Eflect of metabolic inhibitors on the IL-Sinduced protection of DNA fragmentation. Under the conditions described above, we tested how the metabolic inhibitors affected the DNA fragmentation of eosinophils. Figure 6 shows that DNA fragmentation was prevented by the incubation with hIL-5, whereas marked DNA fragmentation occurred in eosinophils incubated with IL-5 in the presence of CHX or in the presence of Act D. Neitl-.erCHX nor Act D alone prevented the spontaneously occurring DNA fragmentation. DISCUSSION I 2 3 4 5 days Fig 4. In vitro survival of mature human eosinophils in the presence of 50 ng/mL hlL-5 alone, 50 ng/mL hlL-5 plus 2 pg/mL Act D or 10 pg/mL CHX. Control means the absence of CSFs. At various times, the viable cell number was counted by eosin exclusion. Each value is the mean of data from duplicate cultures. The viability of both human and murine mature eosinophils is maintained in the presence of IL-5, as has been previously rep~rted.'.'~Usually, deprivation of growth factors results in cell death of factor-dependent cell lines, such as CTLL-2 and FDCP-mix, with morphologic changes called apopto~is.~.' Apoptosis is characterized by condensation of nuclear chromatin and DNA fragmentation into nucleosome-length fragments.I5 This type of cell dcath is also found in the glucocorticoid-induced death of immature thymocytes, cytotoxic T-cell-mediated cytolysis, and/or From www.bloodjournal.org by guest on June 14, 2017. For personal use only. 2545 11-5 BLOCKS EOSINOPHIL APOPTOSIS A I: hlL-8 ?: hlL-SrCHX 3: hlL-5+AOl.D 4: hGU-CSC 5: hlL-5 % hG-CBC 7: OO"l.01 , 2 3 4 , 1 1 7 dl 1 2 3 4 1 8 7 a2 1 2 3 4 1 e 7 d3 - C '2 n '2 E n Fig 5. DNA, RNA, and protein syntheses in mature human eosinophils stimulated with various factors. (A), (E), and (C) show the incorporation of 'Hthymidine, 3H-uridine,and 3H-leucine,respectively. 1, 50 ng/mL hlL-5; 2, 50 ng/mL hlL-5 plus 10 pg/mL CHX; 3, 50 ng/mL hlL-5 plus 2 pg/mL Act D; 4, 1 ng/mL hGM-CSF; 5, 2 ng/mL hlL-3; 6, 40 ng/mL hG-CSF; 7, medium alone (control). ! , I ai irradiation of lymphocytes."' In the present liquid culture system, human mature eosinophils did not proliferate and were only maintained in the presence of hIL-5 or hGMCSF. Therefore, this culture system has been thought to c c c c 21 Kbp 5 Kbp 2 Kbp 1.4 Kbp 947 bp 564 bp Fig 6. Analysis in agarose gels of DNA extracted from mature human eosinophils incubated in the presence of 50 nglmL hlL-5, 10 pg/mL CHX, 2 pg/mL Act D, hlL-5 plus CHX, and hlL-5 plus Act D for 24 hours. a? a3 ' 3 . 1 8 7 a3 provide one of the most suitable systems for the elucidation of survival and cell death in mature blood cells. Eosinophilopoietic factors such as IL-5, GM-CSF, and IL-3 are capable of supporting eosinophil s~rvival?'~.'~ The order of potency of the factors on eosinophil survival was hIL-5, hGM-CSF, and hIL-3. This order of potency may correlate with the number of receptors for each factor on mature human eosinophils.The outstanding feature of IL-5 is that it prevents the DNA fragmentation of mature eosinophils that inevitably proceeds in the absence of IL-5. Thus, the prolonged survival of mature eosinophils by '1IL-5 may be due to the inhibition of DNA cleavage. This survival was not maintained in the presence of Act D or CHX. Presumably, some proteins inhibiting endonuclease activity might be produced in mature eosinophils in response to stimulation by hIL-5. It has been reported that the half-life of human blood eosinophils is 13 to 18 hour^.''.^^ However, the survival time of eosinophils in tissues is not known. The blood eosinophil half-life is prolonged during eosinophilia, which may be due to the prevention of apoptosis in mature eosinophils by increased IL-5 level. We determined whether DNA, RNA, and protein synthesis occurred in mature eosinophils incubated with hIL-5, hGM-CSF, or hIL-3. In these cells, significant RNA and protein synthesis were observed but no DNA synthesis was seen. The absence of DNA synthesis indicates that mature human eosinophils do not proliferate. On the other hand, RNA and protein syntheses did not take place in mature eosinophils incubated with hIL-5 plus actinomycin D or cycloheximide, which resulted in cell death. In addition, no RNA and protein synthesis was observed in eosinophils From www.bloodjournal.org by guest on June 14, 2017. For personal use only. 2546 YAMAGUCHI ET AL incubated with hG-CSF, which did not maintain survival. These findings strongly suggest that the prolonged survival of mature eosinophils by hIL-5 is associated with some newly synthesized proteins induced by hIL-5 stimulation. Although no particular endonuclease involved in DNA fragmentation has been defined, a set of nuclear proteins that increases during the apoptosis of T-cell line induced by dexamethasone has been identified as histone proteins.” On the other hand, Vaux et almand Nunez et a1” reported that transfection of proto-oncogene bcl-2 prolonged the survival of IL3-dependent cell lines deprived of a facThus, it is possible that such bcl-2 gene expression or altered histone proteins may also be directly or indirectly involved in IL-5-induced suppression of apoptosis in eosinophils. All cellular activities in the human body are driven by energy obtained through the breakdown of ATP. The major energy-supplying enzyme is ATP synthase in inner mitochondrial membranes. Therefore, we attempted to look at whether hIL-5-modulated gene transcription encoding some mitochondrial ATP synthases, ie, cytochrome c oxidase subunit 11, which is encoded by mitochondrial DNA,” and ATP synthase p subunit and the cytochrome c oxidase subunit VI,, which are encoded by nuclear Northern blot analysis showed, however, that the expression of these mitochondrial protein genes was increased variably among HES patients and that no specific correlation between hIL-5 stimulation and particular enzyme gene expression has been obtained so far (data not shown). On the other hand, it has been pointed out that mitochondrial gene transcripts increased in immortalized cell lines with transfection of polyoma large T protein, adenovirus E,A, and myc oncogenes.25Mitochondrial gene expression study remains one of the interesting issues to be explored in the eosinophil survival. Thus, we have shown that IL-5 maintains survival of mature eosinophils presumably by inhibiting apoptosis and that it was associated with newly synthesized proteins. No definitive information regarding the nature of the proteins or enzymes involved in apoptosis is yet available, but it must be characterized soon. ACKNOWLEDGMENT We thank Prof Kohei Nakano for his suggestions and Kyoko Kokuho for her help with the manuscript. REFERENCES 1. Wyllie AH: Glucocorticoid-induced thymocyte apoptosis is associated with endogenous endonuclease activation. Nature 284: 555,1980 2. Cohen JJ, Duke R C Glucocorticoid activation of a calciumdependent endonuclease in thymocyte nuclei leads to cell death. J Immunol132:38,1984 3. Ucker DS: Cytotoxic T lymphocytes and glucocorticoids activate an endogenous suicide process in target cells. Nature 32752,1987 4. Nieto MA, Lopez-Rivas A: IL-2 protects T lymphocytes from glucocorticoid-induced DNA fragmentation and cell death. J Immunol143:4166,1989 5. Williams GT, Smith CA, Spooncer E, Dexter TM, Taylor DR: Haemopoietic colony stimulating factors promote cell survival by suppressing apoptosis. Nature 343:76,1990 6 . Koury MJ, Bondurant MC: Erythropoietin retards DNA breakdown and prevents programmed death in erythroid progenitor cells. Science 248:378, 1990 7. Yamaguchi Y, Hayashi Y, Sugama Y, Miura Y, Kasahara T, Kitamura S, Torisu M, Mita S, Tominaga A, Takatsu K, Suda T Highly purified murine interleukin 5 (IL-5) stimulates eosinophil function and prolongs in vitro survival: IL-5 as an eosinophil chemotactic factor. J Exp Med 167:1737,1988 8. Vadas MA, David JR, Butterworth A, Pisani NT, Siongok T A A new method for the purification of human eosinophils and neutrophils, and a comparison of the ability of their cells to damage Schistosomula of Schbtosoma mansoni. J Immunol 122:1228, 1979 9. Yang Y-C, Ciarletta AB, Temple PA, Chung MP, Kovacic S, Witek-Giannoti JS, Leary AC, Kriz R, Donaheu RE, Wong GG: Human IL-3 (multi-CSF): Identification by expression cloning of a novel hematopoietic growth factor related to murine IL-3. Cell 47:3,1986 10. Azuma C, Tanabe T, Konishi M, Kinashi T, Noma T, Matsuda F, Yaoita Y, Takatsu K, Hammarastrom L, Smith CIE, Severinson E, Honjo T Cloning of cDNA for human T-cell replacing factor (interleukin-5) and comparison with the murine homologne. Nucleic Acids Res 14:9179,1986 11. Nagata S, Tsuchiya M, Asano S, Kaziro Y, Yamazaki T, Tamamoto 0,Hirata Y, Kubota N, Oheda M, Nomura H, Ono M: Molecular cloning and expression of cDNA for human granulocyte colony-stimulating factor. Nature 319:415,1986 12. 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Begley CG, Lopez AF, Nicola NA, Warren DJ, Vadas MA, Sanderson CJ, Metcalf D: Purified colony-stimulating factors enhance the survival of human neutrophils and eosinophils in vitro: A rapid and sensitive microassay for colony-stimulating factors. Blood 68:162,1986 17. Panvaresch MR, Walle AJ, Arndt D: The peripheral kinetics of human radiolabelled eosinophils. Virchows Arch [B] 2157, 1976 18. Steinbach KH, Shick P, Trepel F, Raffler H, Dohrmann J, Heilgeist G, Hetzel W, Li K, Past W, Lamge JA, Them1 H, Fliedner TM, Begemann H: Estimation of kinetic parameters of neutrophilic, eosinophilic, and basophilic granulocytes in human blood. Blut 39:27, 1979 19. Baxter GD, Smith PJ, Lavin MF: Molecular changes associated with induction of cell death in a human T-cell leukemia line: From www.bloodjournal.org by guest on June 14, 2017. For personal use only. IL-5 BLOCKS EOSINOPHIL APOPTOSIS Putative nucleases identified as histones. Biochem Biophys Res Commun 162:30,1989 20. V a w DL, Cory S, Adams JM: Bcl-2 gene promotes haematopoietic cell survival and cooperates with c-myc to immortalize pre-B cells. Nature 335:440,1988 21. Nunez G, London L, Hockenbery D, Alexander M, Mckearn JP, Korsmeyer SJ: Deregulated Bcl-2 gene expression selectively prolongs survival of growth factor-deprived hemopoietic cell lines. J Immunol144:3602,1990 22. Anderson S, Bankier AT, Barrel BG, DeBruijin MHL, Coulson AR, Drouin J, Eperon IC, Nierlich DP, Roe BA, Sanger F, Schreier PH, Smith AJH, Staden R, Young EG: Sequence and 2547 organization of the human mitochondrial genome. Nature 290457, 1981 23. Ohta S, Kagawa Y Human F,-ATPase: Molecular cloning of cDNA for the beta subunit. J Biochem 99:135,1986 24. Otsuka M, Mizuno Y, Yoshida M, Kagawa Y, Ohta S: Nucleotide sequence of cDNA encoding human cytochrome c oxidase subunit VIc. Nucleic Acids Res 16:10916,1988 25. Glaichenhaus N, Leopold P, Cuzin F Increased levels of mitochondrial gene expression in rat fibroblast cells immortalized or transformed by viral and cellular oncogenes. EMBO J 5:1261, 1986 From www.bloodjournal.org by guest on June 14, 2017. For personal use only. 1991 78: 2542-2547 Analysis of the survival of mature human eosinophils: interleukin-5 prevents apoptosis in mature human eosinophils Y Yamaguchi, T Suda, S Ohta, K Tominaga, Y Miura and T Kasahara Updated information and services can be found at: http://www.bloodjournal.org/content/78/10/2542.full.html Articles on similar topics can be found in the following Blood collections Information about reproducing this article in parts or in its entirety may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#repub_requests Information about ordering reprints may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#reprints Information about subscriptions and ASH membership may be found online at: http://www.bloodjournal.org/site/subscriptions/index.xhtml Blood (print ISSN 0006-4971, online ISSN 1528-0020), is published weekly by the American Society of Hematology, 2021 L St, NW, Suite 900, Washington DC 20036. 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