摘要目的:观察3例骨髓型急性放射病（ARS）患者造血系统的远后效应，探究急性外照射后造血系统的远后变化规律及其影响因素。方法:对1999年河南"4.26" 60Co辐射事故中2例中度骨髓型ARS患者（"天"和"旺"，均为男性，年龄分别为37岁和8岁）和1例重度骨髓型ARS患者（"梅"，女性，38岁）进行临床随访，随访时间截至2019年，共随访11次。依据《外照射急性放射病的远期效应医学随访规范》，于患者受照后半年开始定期采集3例患者的外周血和骨髓进行外周血象、骨髓穿刺涂片、骨髓祖细胞培养及造血刺激因子等检查。（1）外周血象检查：使用全自动血细胞分析仪分析外周血白细胞、血小板（PLT）、红细胞计数和血红蛋白（Hb）水平，以及中性粒细胞（NEUT）百分比和淋巴细胞（LYM）百分比。（2）骨髓穿刺检查：行骨髓穿刺涂片及造血祖细胞培养，检测红细胞集落生成单位（CFU-E）、爆式红细胞集落生成单位(BFU-E)、粒细胞-单核细胞集落生成单位（CFU-GM）。（3）造血刺激因子检查：检测促红细胞生成素（EPO）和粒细胞-巨噬细胞集落刺激因子（GM-CSF）。 结果:20年随访期间，3例患者的白细胞计数基本在正常范围内。受到照射后半年，LYM百分比均偏低，NEUT百分比均偏高。"梅"在随访期间多次出现NEUT百分比升高，"旺"多次出现LYM百分比和NEUT百分比异常。"梅"在受到照射后半年及第1年的随访中PLT计数轻度下降，分别为80×10 9个/L和91×10 9个/L；"旺"受到照射后半年，PLT计数轻度下降，为91×10 9个/L；"天"的PLT计数正常。"梅"的Hb水平多次轻度降低，受到照射后第5年中度下降，为85 g/L；"天"受到照射后第9年Hb水平异常升高；随访期间"天"和"旺"的Hb水平数次轻度升高或降低。3例患者随访期间的6次骨髓穿刺涂片检查的结果均为骨髓增生活跃或增生明显活跃。3例患者受到照射后半年的CFU-E、BFU-E和CFU-GM均异常升高；第2年，上述3项指标均降为0；其后缓慢回升，至第7年，CFU-E均高于正常值，CFU-GM基本恢复，BFU-E仍显著减低。在前3年的随访中，"天"的半年和1年EPO轻度异常，"梅"和"旺"EPO均在正常范围。受到照射后半年，3例患者的GM-CSF均<1.00 pg/mL ；"梅"第1年的GM-CSF异常升高，为14.3 pg/mL，第2年恢复正常；"天"和"旺"第1~2年的GM-CSF均正常。 结论:急性照射对造血系统的损伤具有剂量依赖性和长期性；造血刺激因子对骨髓造血功能的恢复具有长期影响；反映骨髓造血功能恢复情况的各指标间可缺乏一致性改变，随访中需要综合评估。

abstractsObjective:To observe the late effects of hematopoietic system damage in patients with a bone marrow form of acute radiation sickness (ARS) and to explore the rules and influencing factors of distant posterior changes in the hematopoietic system after acute irradiation.Methods:Clinical follow-up was conducted on two patients with moderate bone marrow form of ARS ("Tian" and "Wang", both male, aged 37 and 8 years, respectively) and one patient with severe bone marrow form of ARS ("Mei", female, 38 years old) during the "4.26" 60Co radiation accident in Henan Province in 1999. The follow-up period was until 2019 with a total of 11 times. According to the Standard in Medical Follow-up of the Long-Term Effects of Acute Radiation Sickness by External Irradiation, the peripheral blood and bone marrow of 3 patients were collected regularly for peripheral hemogram, bone marrow smear, bone marrow progenitor cell culture, and hematopoietic stimulating factor examination from half a year after irradiation until 2019. (1) Peripheral hemogram examination: automatic blood cell analyzer was used to analyze white blood cell (WBC), platelet (PLT), and red blood cell counts; hemoglobin (Hb) level; and neutrophil (NEUT) and lymphocyte (LYM) percentages in peripheral blood. (2) Bone marrow aspiration examination: bone marrow smear and hematopoietic progenitor cell culture were performed to detect colony-forming unit-erythroid (CFU-E), burst-forming unit-erythrocytic(BFU-E), colony forming unit-granulocyte-monocyte (CFU-GM). (3)Hematopoietic stimulating factor examination: erythropoietin (EPO) and granulocyte-macrophage colony-stimulating factor (GM-CSF) were detected. Results:During the 20-year follow-up, the WBC counts of all three patients were within the normal range. The percentages of LYM were low, and those of NEUT were high half a year after irradiation. During the follow-up period, "Mei" repeatedly had increased NEUT percentage, and "Wang" repeatedly showed abnormal LYM and NEUT percentages. The PLT counts of"Mei" decreased slightly to 80×10 9/L and 91×10 9/L respectively in half a year and the first year after irradiation. A half year after irradiation, the PLT count of "Wang" decreased slightly to 91×10 9/L, whereas that of "Tian" was normal. The Hb level of "Mei" decreased slightly several times and moderately decreased to 85 g/L in the fifth year after irradiation. The Hb level of "Tian" increased abnormally in the ninth year after irradiation, and the Hb levels of "Tian" and "Wang" increased or decreased slightly several times during the follow-up period. The results of the six bone marrow biopsy smears of all three patients showed active or remarkably active myelodysplastic during the follow-up period. The CFU-E, BFU-E, and CFU-GM levels of the three patients increased abnormally half a year after irradiation, decreased to 0 in the second year, and then recovered slowly in the seventh year. The CFU-Es of the three patients were higher than the normal range, the CFU-GMs almost recovered, and the BFU-Es still decreased considerably. In the first three years of follow-up, the EPOs of "Tian" were slightly abnormal in half a year and the first year, whereas those of "Mei" and "Wang" were within the normal range. Half a year after irradiation, the GM-CSF levels of the three patients were all less than 1.00 pg/mL. The GM-CSF level of "Mei" increased abnormally to 14.3 pg/mL in the first year and returned to normal in the second year. "Tian" and "Wang" had normal GM-CSF levels in the first and second years. Conclusions:Hematopoietic system damage by acute irradiation is dose dependent and long term. Hematopoietic stimulating factor has a long-term effect on the recovery of bone marrow hematopoietic function. No consistent change was observed among the indexes that reflect the recovery of bone marrow hematopoietic function, which needs comprehensive evaluation during medical follow-up.