Comparison of long-term outcomes after allogeneic hematopoietic stem cell transplantation from matched sibling and unrelated donors

Long-term survivors of hematopoietic stem cell transplants remain at risk of potentially fatal complications that detract from life quality. Long-term morbidity and mortality were compared between matched recipient cohorts surviving 2 or more years and defined by donor type, HLA matched sibling donor (MSD) or volunteer unrelated donor (URD). Patients were previously entered into the prospective multicenter International Unrelated Search and Transplant Study. Thirty-nine centers provided data on 108 URD and 355 MSD recipients surviving more than 2 years. Long-term survival, performance status, chronic GvHD (c-GvHD), secondary malignancy, endocrine dysfunction, cataracts, bone necrosis and dental pathology were compared between cohorts. Twelve year survival was 77+/-5% for the MSD and 67+/-11% for the URD cohort (P=0.1). Late death occurred in 105 of 463 recipients alive at 2 years, 73 after 355 (21%) MSD and 32 after 108 (30%) URD transplants, P=0.10. Of 105 deaths, the cause was relapse in 60 and unrelated to relapse in 45 cases. Cumulative incidence of extensive c-GvHD (P=0.002), cataracts (P=0.02) and bone necrosis (P=0.02) was higher after URD transplants. No long-term difference in endocrine dysfunction, secondary malignancy and major dental pathology was detected. This landmark study will assist physicians counseling patients pre-transplant and with their long-term care post transplant.

Impact of high-resolution matching in allogeneic unrelated donor stem cell transplantation in Switzerland

It is currently unknown what degree of human leukocyte antigen (HLA)-mismatching is acceptable in unrelated donor hematopoietic stem cell transplantation (UD-HSCT). Mismatches at some loci may be more permissive than others. We have analyzed the effect of high-resolution HLA-matching on outcome of all 214 consecutive recipients of UD-HSCT carried out in Switzerland. All typing was by the Swiss reference laboratory. Donor-recipient pairs were HLA-10/10 matched (n=130) or mismatched for either HLA-A/-B/-DRB1/multiple loci (n=33; (HLA-A/-B=10); (-DRB1=8); (multiple=15)); HLA-C (n=29) or HLA-DQ/-DRB3 (n=22; (DQ=16); (-DRB1=6)). The median follow-up was 32 months. Survival probabilities (+/-95% confidence interval) at 3 years were 57 (+/-10)% for recipients of HLA 10/10-matched transplants, 53 (+/-22)% for recipients of HLA-DQ/-DRB3-mismatched transplants, 44 (+/-20)% for recipients of HLA-C-mismatched transplants and 0% for recipients of transplants mismatched at HLA-A/-B/-DRB1/multiple loci (P<0.0001). In multivariate analyses, HLA compatibility was the variable most significantly associated with survival and treatment-related mortality. We found important differences in survival in recipients of UD-HSCT with best results for transplants from 10/10 matched donors. Single mismatches at HLA-DQ/-DRB3 were well tolerated, mismatches at HLA-C had intermediate results and mismatches at HLA-A/-B/-DRB1/multiple loci resulted in poor survival.

Bone marrow transplants from mismatched related and unrelated donors for severe aplastic anemia

For patients with acquired severe aplastic anemia without a matched sibling donor and not responding to immunosuppressive treatment, bone marrow transplantation from a suitable alternative donor is often attempted. We examined risks of graft failure, graft-versus-host disease and overall survival after 318 alternative donor transplants between 1988 and 1998. Sixty-six patients received allografts from 1-antigen and 20 from >1-antigen mismatched related donors; 181 from matched and 51 from mismatched unrelated donors. Most patients were young, had had multiple red blood cell transfusions and poor performance score at transplantation. We did not observe differences in risks of graft failure and overall mortality by donor type. The probabilities of graft failure at 100 days after 1-antigen mismatched related donor, >1-antigen mismatched related donor, matched unrelated donor and mismatched unrelated donor transplants were 21, 25, 15 and 18%, respectively. Corresponding probabilities of overall survival at 5 years were 49, 30, 39 and 36%, respectively. Although alternative donor transplantation results in long-term survival, mortality rates are high. Poor performance score and older age adversely affect outcomes after transplantation. Therefore, early referral for transplantation should be encouraged for patients who fail immunosuppressive therapy and have a suitable alternative donor.

Ex vivo expansion of highly purified NK cells for immunotherapy after haploidentical stem cell transplantation in children

BACKGROUND

Allogeneic natural killer (NK) cells are known to show medium to high cytotoxic activity against HLA-nonidentical leukemia or tumor cells. For a possible benefit of post transplant treatment with NK cells after haploidentical stem cell transplantation (haplo-SCT) we developed a clinical scale procedure for NK cell processing observing Good Manufacturing Practice (GMP).

METHODS

Allogeneic donor NK cells were selected from 15 unstimulated leukaphereses using two rounds of immunomagnetic T cell depletion, followed by an NK cell enrichment step. CD56 (+)CD3 (-) NK cells were stimulated and expanded in vitro according to GMP. Quality control of NK cell purity, residual T cells and cytotoxic activity was done by multi-coloured flow cytometric analyses.

RESULTS

Purification led to an absolute number of 234-1 237 x 10 (6) CD56 (+)CD3 (-) NK cells from leukapheresis harvests with a median purity of 95 % and a 4 to 6(1/2) log depletion of T cells. After two weeks stimulation with IL-2 a five-fold expansion of NK cells with a T cell contamination below 0.1 % was reached. Median cell viability was 95 % after purification and 99 % after expansion. The IL-2 stimulated NK cells showed a highly increased lytic activity against the MHC-I deficient K562 cells compared to freshly isolated NK cells and a medium cytotoxicity against patients' leukemic cells.

CONCLUSIONS

Clinical scale enrichment and activation of allogeneic donor NK cells is feasible. High dose NK cell application may be a new treatment option for pediatric patients with leukemia or solid tumors in case of minimal residual disease or unbalanced chimerism post haplo-SCT as we could show for the first three patients .

Transplant-associated microangiopathy (TAM) in recipients of allogeneic hematopoietic stem cell transplants

We studied occurrence, risk factors and outcome of patients with transplant-associated microangiopathy (TAM) after allogeneic stem cell transplantation (HSCT). A total of 221 consecutive patients were transplanted between 1995 and 2002. TAM is defined as evidence of hemolysis and schistocytes in the first 100 days. Outcomes analyzed included TAM and overall survival. Of 221 patients, 68 had TAM. The cumulative incidence was 31 (25-38)% at 100 days. Patients with TAM had higher LDH, higher bilirubin, higher creatinine and more often neurologic symptoms. TAM was not associated with stem cell source, cyclosporine levels and was not more frequent in recent years. In multivariate analysis, risk factors for TAM included donor type, age, gender, ABO-incompatibility and acute graft-versus-host disease (aGvHD). In patients with TAM, 1-year survival was lower than in patients without TAM (27 +/- 18% for TAM with high schistocyte counts; 53 +/- 15% for TAM with low schistocyte counts; vs 78 +/- 7% in patients without TAM; P<0.0001). TAM was independently associated with mortality adjusting for donor type, age and aGvHD occurrence and severity. TAM is frequent after HSCT and is associated with mortality even after adjustment for aGvHD grade. Risk factors of TAM are similar to aGvHD. TAM may represent endothelial damage driven by donor-host interactions.

Levels of Anti-A/B Antibodies After ABO-Incompatible Hematopoietic Stem Cell Transplantation

In contrast to solid organ transplantation, ABO incompatibility is generally not associated with survival differences in hematopoietic stem cell transplantation. Therefore, patients receiving ABO-incompatible stem cell transplantation can be analyzed to study the mechanism of tolerance induction after antigen-mismatched transplantation. The goal of this study was to analyze the levels of anti-A/B antibodies after ABO-incompatible transplantation. Host-derived antidonor antibodies disappeared rapidly after transplantation and did not reappear in the further posttransplant course. Donor-derived antihost antibodies did not significantly increase and compatible anti-A/B antibodies remained positive after hematopoietic stem cell transplantation. Thus, there is no evidence for stimulation of donor B lymphocytes to produce antirecipient antibodies suggesting a potential B cell tolerance.

Use of natural killer cells in hematopoetic stem cell transplantation

Adoptive immunotherapy using natural killer (NK) cells may prove useful, especially in situations where infusion of T cells is impractical such as in recipients of haploidentical stem cell transplantation (HSCT) from haploidentical donors. NK cells may induce potent antileukemic and possibly antirejection activity and may even mitigate graft versus host disease (GvHD). Whether such effects are clinically important and whether they are mediated mainly or exclusively by KIR-HLA class I interactions remains to be determined. Recent advances in graft engineering provide for methods to isolate large numbers of purified NK cells. Several groups have shown that clinical grade NK cells up to a dose of 10(7)/kg may be collected and purified for the purpose of infusion to patients. Early results, in a limited number of patients, show that these cell doses may be administered without adverse events and without inducing GvHD. Whether such infusions will be useful in preventing graft rejection, or exerting graft versus leukemia effects and hastening immune recovery requires further study.

Use of lung resection and voriconazole for successful treatment of invasive pulmonary Aspergillus ustus infection

Invasive pulmonary aspergillosis (IPA) is a common infection in neutropenic patients and is associated with high mortality. Aspergillus ustus is a species that has only rarely been implicated in human disease. All reported cases of IPA due to A. ustus have been fatal. Here, we describe a case of invasive pulmonary A. ustus infection successfully treated with lung resection and voriconazole. A 43-year-old man with acute myeloid leukemia underwent two courses of chemotherapy and experienced prolonged neutropenia. Treatment with amphotericin B was given for persistent fever. While he was receiving amphotericin B, a progressive opacity developed in the upper right lobe. Lung tissue obtained through pulmonary wedge resection for histology showed a mold with septate hyphae, consistent with IPA due to Aspergillus. A. ustus was grown in culture. The patient was then treated with voriconazole and remained in remission of the mold infection in spite of additional chemotherapy and a leukemic relapse. In summary, this report describes the successful treatment of invasive pulmonary A. ustus infection by lung resection and antifungal treatment with voriconazole in a neutropenic patient.

Purified donor NK-lymphocyte infusion to consolidate engraftment after haploidentical stem cell transplantation

This pilot study tested feasibility of natural killer cell purification and infusion (NK-DLI) in patients after haploidentical hematopoietic stem cell transplantation (HSCT). The aim was to obtain >or=1.0 x 10(7)/kg CD56+/CD3- NK cells and <1.0 x 10(5)/kg CD3+ T cells. Mononuclear cells were collected by 10 l leukapheresis. A two-step ex vivo procedure was used to purify NK cells, using an immunomagnetic T-cell depletion, followed by NK-cell enrichment. Five patients with high-risk myeloid malignancies were included, presenting 3-12 months after a haploidentical HSCT with mixed chimerism (3), impending graft failure (1) or early relapse (1). The purified product contained a median of 1.61 x 10(7)/kg (range 0.21-2.2) NK cells and 0.29 x 10(5)/kg (0.11-1.1) T cells. A purity of NK cells of 97% (78-99), a recovery of 35.5% (13-75), and a T-cell depletion of 3.55 log (2.9-4.5) was achieved. Infusions were well tolerated and none of the patients developed graft-versus-host disease. We observed an increase in donor chimerism in 2/5, stable mixed chimerism, decreasing chimerism and relapse of AML in one patient each. Selection of NK-DLI is technically feasible. NK cells are well tolerated when used as adoptive immunotherapy in recipients of haploidentical HSCT.

Autologous/syngeneic stem cell transplantation to treat refractory GvHD

Severe graft-versus-host disease (GvHD) refractory to corticosteroids responds poorly to experimental treatment and is often fatal. Attempts have been made to 'rescue' such patients by transfusing autologous cells in order to ablate the lymphoid component of the graft or to introduce regulatory cells capable of suppressing the GvHD. Here, we report details of eight patients with severe grade III-IV acute GvHD (n=7) or extensive chronic GvHD (n=1) who after failing a median of four lines of treatment were then treated with either autologous or syngeneic nucleated cell transfusions. Patients received standard conditioning (n=3), low intensity (n=2) or no conditioning (n=3) before the rescue procedure. In four of the five patients who received some form of conditioning, mixed chimerism or complete recipient hematopoiesis was restored. The GvHD resolved in four patients, of whom one died subsequently of multiorgan failure and two died of leukemia; one is still alive. A fifth patient had transient improvement in GvHD, which recurred when the corticosteroids were reduced. Three patients obtained no benefit from the procedure. We conclude that 'rescue' by transfusion of autologous or syngeneic nucleated cells may be valuable to treat severe refractory GvHD; the best approach to conditioning remains to be defined.

Haematopoetic stem cell transplantation for refractory autoimmune cytopenia

This study describes the outcome of patients receiving haematopoietic stem cell transplantation (HSCT) to treat severe refractory autoimmune cytopenia. The registry of the European Group of Blood and Marrow Transplantation holds data on 36 patients receiving 38 transplants, the first transplant was autologous for 27 and allogeneic for nine patients. Patients had autoimmune haemolytic anaemia (autologous: 5; allogeneic: 2), Evans's syndrome (autologous: 2; allogeneic: 5); immune thrombocytopenia (autologous: 12), pure red cell aplasia (autologous: 4; allogeneic: 1), pure white cell aplasia (autologous: 1; allogeneic 1), or thrombotic thrombocytopenic purpura (autologous: 3). Patients had longstanding disease having failed multiple prior treatments. Among 26 evaluable patients mobilized for autologous HSCT, three died of treatment-related causes, one died of disease progression, seven were non-responders, six patients had transient responses and nine had continuous partial or complete remission. Of the seven evaluable patients receiving allogeneic HSCT, one died of treatment-related complications, one with transient response died of progressive disease and five had a continuous response. Autologous and allogeneic HSCT may induce a response in a subset of patients with autoimmune cytopenia of long duration albeit at the price of considerable toxicity.

High-dose chemotherapy using BEAM for tumor debulking without stem cell support followed by early allogeneic reduced intensity conditioning transplantation to induce a graft-versus-lymphoma effect in patients with high risk or refractory lymphoma

In patients with refractory lymphoma, we tested the hypothesis that high-dose chemotherapy (BEAM) without stem cell support followed by a reduced intensity (RIC) allogeneic transplant with fludarabine and 2 Gy TBI 28 days later results in tumor debulking and establishment of a graft vs lymphoma effect, with acceptable toxicity. In a pilot protocol we treated 10 patients, 22-62 (median 47) years of age with high-risk or refractory Hodgkin's or non-Hodgkin's lymphoma. Donors were HLA identical siblings (eight) or unrelated volunteers. None died during the neutropenic phase after BEAM which lasted up to the RIC HSCT. The duration of neutropenia was 31-43 (median 36) days. All patients engrafted and nine achieved CR. All developed acute GvHD (median grade III) and all patients at risk developed chronic GvHD. Three patients died of GvHD. One relapsed and six patients are in continuous CR 10-32 (median 15) months after HSCT. This approach appears feasible and results in a high response rate. Neutropenia duration is of concern. It remains to be tested whether separation of debulking chemotherapy and induction of allogeneic effects confers an advantage.

High stem cell dose will not compensate for T cell depletion in allogeneic non-myeloablative stem cell transplantation

The best strategies for non-myeloablative stem cell transplants (NST) are not known. We hypothesized that a high stem cell dose and post-transplant donor lymphocyte infusions (DLI) in a T cell-depleted NST setting may result in stable engraftment without severe GvHD. We used conditioning with 200 mg/kg cyclophosphamide, and ATG, a high peripheral stem cell dose of >10 x 10(6) CD34(+) cells/kg, T cell-depleted to <1 x 10(5) CD3(+) cells/kg followed by incremental DLI. Ten patients, 53 (42-61) years of age with hematological malignancy (CML in 3, MDS in 2, myeloma in 3 and CLL in 2) were included. All patients achieved initial engraftment, at a median 13.5 (10-20) days. Three patients achieved complete chimerism, four achieved a complete hematologic remission. In seven patients the graft ultimately failed. Acute GvHD grade II was seen in three patients after DLI. At a median follow-up of 28 months (range 15-35), eight patients are alive, none died of treatment-related complications. NST with T cell depletion to prevent GVHD results in a high graft failure rate. High stem cell dose (> or =10 x 10(6) CD34(+)cells/kg) and post-transplant DLI will not compensate for the lack of T cells to ensure stable engraftment.

Hematopoietic stem cell transplantation for multiple sclerosis. A retrospective multicenter study

RATIONALE

Phase I/II studies of autologous hematopoietic stem cell transplantation (HSCT) for multiple sclerosis ( MS) were initiated, based on results of experimental transplantation in animal models of multiple sclerosis and clinical observations in patients treated concomitantly for malignant disease.

PATIENTS

Eighty-five patients with progressive MS were treated with autologous HSCT in 20 centers and reported to the autoimmune disease working party of the European Group for Blood and Marrow Transplantation (EBMT). 52 (61 %) were female, median age was 39 [20-58] years. The median interval from diagnosis to transplant was 7 [1-26] years. Patients suffered from severe disease with a median EDSS score of 6.5 [4.5-8.5]. Active disease prior to transplant was documented in 79 of 82 evaluable cases.

RESULTS

The stem cell source was bone marrow in 6 and peripheral blood in 79, and stem cells were mobilized into peripheral blood using either cyclophosphamide combined with growth factors or growth factors alone. Three patients experienced transient neurological complications during the mobilization phase. The high dose regimen included combination chemotherapy, with or without anti-lymphocyte antibodies or, with or without, total body irradiation. The stem cell transplants were purged of lymphocytes in 52 patients. Median follow-up was 16 [3-59] months. There were 7 deaths, 5 due to toxicity and infectious complications, 2 with neurological deterioration. The risk of death of any cause at 3 years was 10 (+/-7)% (95 % confidence interval). Neurological deterioration during transplant was observed in 22 patients; this was transient in most but was associated with MS progression in 6 patients. Neurological improvement by > or = 1 point in the EDSS score was seen in 18 (21 %) patients. Confirmed progression-free survival was 74 (+/-12)% at 3 years being 66 (+/-23)% in patients with primary progressive MS but higher in patients with secondary progressive or relapsing-remitting MS, 78 (+/-13)%; p = 0.59. The probability of confirmed disease progression was 20 (+/-11)%. MRI data were available in 78 patients before transplant showing disease activity (gadolinium enhancing, new or enlarging lesions) in 33 %. Posttransplant MRI showed activity at any time in 5/61 (8 %) evaluable cases.

CONCLUSION

Autologous HSCT suggest positive early results in the management of progressive MS and is feasible. These multicentre data suggest an association with significant mortality risks especially in some patient groups and are being utilised in the planning of future trials to reduce transplant related mortality.

Consequences of ABO incompatibility in allogeneic hematopoietic stem cell transplantation

Aside from causing hemolytic reactions the ABO blood group system does not have an impact on outcome after allogeneic bone marrow or peripheral blood stem cell transplantation (SCT). However, only a few studies have addressed the effect of ABO incompatibility on the incidence of GVHD, time to engraftment, relapse and survival. Therefore, we performed a retrospective two-center analysis of 562 consecutive patients receiving allogeneic SCT, including 361 ABO-identical, 98 minor, 86 major and 17 bidirectional ABO-incompatible SCT. In multivariate analysis adjusted for potential confounders survival was significantly associated with ABO incompatibility (P = 0.006). Compared to ABO-identical SCT, bidirectional ABO incompatibility increased the risk significantly (RR, 2.8; 95% CI, 1.5-5.1; P = 0.0009), whereas survival of patients with minor (RR, 1.2; 95% CI, 0.9-1.7; P = 0.27), or major ABO-incompatible SCT (RR, 1.3; 95% CI, 0.9-1.8; P= 0.18) was not significantly different. RBC engraftment was delayed in major ABO-incompatible SCT (RR, 0.66; 95% CI, 0.51-0.85; P = 0.001). The incidence of acute GVHD (grade I-IV) was higher in minor ABO-incompatible SCT as compared to ABO identity (RR, 2.8; 95% CI, 1.3-5.9, P = 0.009). This difference was limited to mild GVHD; in moderate-to-severe GVHD (grade II-IV) no significant difference was found among the groups (P = 0.53). The relapse rate was not influenced by ABO incompatibility (P = 0.78). In conclusion, these results suggest that ABO incompatibility represents a risk factor not only for post-transplant hemolysis, but also for survival and the rate of mild GVHD after allogeneic SCT.

Invasive pulmonary fungal infection in hematologic patients: is resection effective?

INTRODUCTION

Invasive pulmonary aspergillosis carries a high mortality in neutropenic patients. Descriptive reports have shown early surgery to be feasible with acceptably low morbidity. The possible benefit of surgery has not been investigated in comparative studies.

MATERIALS AND METHODS

In a retrospective cohort study encompassing a 15-year period, 54 (8%) of 697 consecutive patients with severe hematological disease required treatment for localized invasive pulmonary aspergillosis. Patients treated by antifungal drugs (medical group, n = 24) were compared to patients treated with additional early lung resection (surgical group, n = 30). Outcomes analysed were fungal progression and survival.

RESULTS

Fungal progression at six months was 17% (95% CI 3-31) in the surgical group and 52% (95% CI 34-73) in the medical group (P = 0.005). Survival at six months was 70% (95% CI 53-87) in surgically and 42% (95% CI 24-62) in medically treated patients (P = 0.009). Adjusting for differences in WHO performance score (worse in the medical group) and duration of neutropenia (longer in the surgical group) in a multivariate analysis, a difference in relative risk of death (0.26; 95% CI 0.08-0.88; P = 0.03) remained in favor of surgery.

CONCLUSION

In this retrospective study surgical intervention to treat invasive pulmonary fungal disease appeared to have a beneficial effect on the impact of disease control and survival. Differences in baseline characteristics of the two patient groups calls for cautious interpretation. A prospective randomized trial seems warranted.

Intensive care unit admission in patients with haematological disease: incidence, outcome and prognostic factors

OBJECTIVES

To examine incidence and outcome of intensive care unit (ICU) admission in patients with haematological malignancy and analyse prognostic factors associated with outcome.

DESIGN

Retrospective cohort study in an intensive care unit of a tertiary referral center.

PATIENTS

78 patients with severe haematological malignancy were admitted 97 times between 1990-97 to the medical ICU for septic shock (18), respiratory failure (30), postoperative monitoring (19), cardiovascular (10) and central nervous complications (8) or for other reasons (12). Median age was 43 (4-73) years, average duration of ICU stay was 4 (1-43) days. Forty-two patients required mechanical ventilation, 46 vasopressors and 8 haemodialysis.

RESULTS

Rates of ICU admission differed by treatment of the underlying disease. There were 18, 10 and 27 ICU admissions per 100 treatments in patients undergoing chemotherapy for acute leukaemia, autologous and allogeneic stem cell transplantation (p <0.005) respectively. Thirty-two of 78 patients died within 60 days of ICU admission. Organ failure, i.e. cardiovascular failure requiring vasopressors, respiratory failure requiring mechanical ventilation and renal failure, requiring haemodialysis, was most significantly associated with outcome. Mortality by day 60 after admission was 16%, 36%, 64%, and 83% (p <0.0002) for patients without organ failure, and for patients with 1, 2 or 3 failing organs. In a multivariate logistical regression model, only the organ failure score (p <0.0005) and evidence of liver damage, defined as ASAT or ALAT >100 IU/ L (p <0.007), but not age, sex, primary disease and treatment of the underlying disease predicted outcome.

CONCLUSION

Multi-organ failure and evidence of liver damage but no other patient, disease, or treatment related factor predict outcome in patients with haematological disease admitted to the ICU.

Intensive care unit admission in patients with haematological disease: incidence, outcome and prognostic factors

OBJECTIVES

To examine incidence and outcome of intensive care unit (ICU) admission in patients with haematological malignancy and analyse prognostic factors associated with outcome.

DESIGN

Retrospective cohort study in an intensive care unit of a tertiary referral center.

PATIENTS

78 patients with severe haematological malignancy were admitted 97 times between 1990-97 to the medical ICU for septic shock (18), respiratory failure (30), postoperative monitoring (19), cardiovascular (10) and central nervous complications (8) or for other reasons (12). Median age was 43 (4-73) years, average duration of ICU stay was 4 (1-43) days. Forty-two patients required mechanical ventilation, 46 vasopressors and 8 haemodialysis.

RESULTS

Rates of ICU admission differed by treatment of the underlying disease. There were 18, 10 and 27 ICU admissions per 100 treatments in patients undergoing chemotherapy for acute leukaemia, autologous and allogeneic stem cell transplantation (p <0.005) respectively. Thirty-two of 78 patients died within 60 days of ICU admission. Organ failure, i.e. cardiovascular failure requiring vasopressors, respiratory failure requiring mechanical ventilation and renal failure, requiring haemodialysis, was most significantly associated with outcome. Mortality by day 60 after admission was 16%, 36%, 64%, and 83% (p <0.0002) for patients without organ failure, and for patients with 1, 2 or 3 failing organs. In a multivariate logistical regression model, only the organ failure score (p <0.0005) and evidence of liver damage, defined as ASAT or ALAT >100 IU/ L (p <0.007), but not age, sex, primary disease and treatment of the underlying disease predicted outcome.

CONCLUSION

Multi-organ failure and evidence of liver damage but no other patient, disease, or treatment related factor predict outcome in patients with haematological disease admitted to the ICU.

Phase I/II trial of autologous stem cell transplantation in systemic sclerosis: procedure related mortality and impact on skin disease

BACKGROUND

Systemic sclerosis (SSc, scleroderma) in either its diffuse or limited skin forms has a high mortality when vital organs are affected. No treatment has been shown to influence the outcome or significantly affect the skin score, though many forms of immunosuppression have been tried. Recent developments in haemopoietic stem cell transplantation (HSCT) have allowed the application of profound immunosuppression followed by HSCT, or rescue, to autoimmune diseases such as SSc.

METHODS

Results for 41 patients included in continuing multicentre open phase I/II studies using HSCT in the treatment of poor prognosis SSc are reported. Thirty seven patients had a predominantly diffuse skin form of the disease and four the limited form, with some clinical overlap. Median age was 41 years with a 5:1 female to male ratio. The skin score was >50% of maximum in 20/33 (61%) patients, with some lung disease attributable to SSc in 28/37 (76%), the forced vital capacity being <70% of the predicted value in 18/36 (50%). Pulmonary hypertension was described in 7/37 (19%) patients and renal disease in 5/37 (14%). The Scl-70 antibody was positive in 18/32 (56%) and the anticentromere antibody in 10% of evaluable patients. Peripheral blood stem cell mobilisation was performed with cyclophosphamide or granulocyte colony stimulating factor, alone or in combination. Thirty eight patients had ex vivo CD34 stem cell selection, with additional T cell depletion in seven. Seven conditioning regimens were used, but six of these used haemoimmunoablative doses of cyclophosphamide +/- anti-thymocyte globulin +/- total body irradiation. The median duration of follow up was 12 months (3-55).

RESULTS

An improvement in skin score of >25% after transplantation occurred in 20/29 (69%) evaluable patients, and deterioration in 2/29 (7%). Lung function did not change significantly after transplantation. One of five renal cases deteriorated but with no new occurrences of renal disease after HSCT, and the pulmonary hypertension did not progress in the evaluable cases. Disease progression was seen in 7/37 (19%) patients after HSCT with a median period of 67 (range 49-255) days. Eleven (27%) patients had died at census and seven (17%) deaths were considered to be related to the procedure (direct organ toxicity in four, haemorrhage in two, and infection/neutropenic fever in one). The cumulative probability of survival at one year was 73% (95% CI 58 to 88) by Kaplan-Meier analysis.

CONCLUSION

Despite a higher procedure related mortality rate from HSCT in SSc compared with patients with breast cancer and non-Hodgkin's lymphoma, the marked impact on skin score, a surrogate marker of mortality, the trend towards stabilisation of lung involvement, and lack of other treatment alternatives justify further carefully designed studies. If future trials incorporate inclusion and exclusion criteria based on this preliminary experience, the predicted procedure related mortality should be around 10%.

Anemia: an indicator for malnutrition in the elderly

The prevalence of anemia increases with age and is frequently multifactorial. We postulated that malnutrition contributes to anemia in the elderly and is underdiagnosed. Our objective was to analyze the prevalence of anemia and its association with nutritional status in a hospitalized geriatric population. Included in this retrospective cohort study were 186 consecutive patients admitted in 1997 to a geriatric unit of a university hospital. We compared hematological and chemical blood tests routinely performed upon admission in patients with anemia (hemoglobin <120 g/l) and without anemia (hemoglobin > or = 120 g/l). Using these admission parameters, we defined a multiparameter score of malnutrition by low lymphocyte counts, decreased values of albumin, cholesterol, transferrin, cholinesterase, and zinc, iron deficiency by low transferrin saturation and normal C-reactive protein, and inflammation by increased C-reactive protein and high transferrin saturation. Of the 186 patients, 82 (44%) met the criteria for anemia on admission. In univariate analysis, patients with anemia differed significantly from patients with normal hemoglobin exhibiting lower serum values of albumin, iron, transferrin, cholesterol, cholinesterase, zinc, transferrin saturation, and lymphocyte count and higher C-reactive protein levels. Using a multiparameter score, anemia correlated significantly with parameters of malnutrition (P=0.0001) but not with iron deficiency (P=0.5) or with inflammation (P=0.08). In a multivariate logistic regression model, anemia was significantly associated with serum albumin (RR: 1.138; 95% CI: 1.056-1.227; P=0.0007), cholinesterase (RR: 1.387; 95% CI 1.122-1.714; P=0.0025), and transferrin saturation (RR: 1.05; 95% CI: 1.012-1.09; P=0.009). We conclude that malnutrition may play an important etiologic role in anemia in the elderly.

C-reactive protein and fever in neutropenic patients

The predictive value of daily C-reactive protein (CRP) monitoring to distinguish causes of fever in neutropenic patients was studied retrospectively. A total of 143 fever episodes during 113 consecutive hospitalizations were studied in 71 patients who had been referred for chemotherapy or haemopoietic stem cell transplantation (HSCT). There were, on average, 1.3 fever episodes per hospital stay, attributed to: infection (55, 27 invasive bacterial, 5 fungal, 3 viral and 20 probable infections); acute graft vs host disease (GvHD) (20); drugs (22); transfusions (7); and not attributable (39). 130 (91%) fever episodes were accompanied by a rise in CRP, 6 (4%) episodes were fatal. Maximal CRP levels (CRPmax) and maximal temperature (Tmax) were higher in invasive bacterial infections than in aGvHD and higher in aGvHD than in drug- or transfusion-related fever (p < 0.0001). Temperature and CRP rose in parallel. A total of 16 patients developed grade II-IV aGvHD by day 11 (9-21) (median, range) after allogeneic HSCT. Acute GvHD was preceded by fever for 3 d (1-7), and by CRP increase for 5 d (0-15) (p < 0.0001). CRP monitoring may be useful to distinguish between causes of fever. Very high CRP levels tend to be associated with invasive bacterial infections. CRP is not an early warning sign. An increase in CRP and fever may precede other clinical manifestations of aGvHD.

Increased stem cell dose, as obtained using currently available technology, may not be sufficient for engraftment of haploidentical stem cell transplants

The best strategies for haploidentical stem cell transplants are not known. We used a standard myeloablative pretransplant conditioning regimen (30 mg/kg VP-16, 120 mg/kg cyclophosphamide, and 12 Gy of TBI in six fractions), an increased peripheral stem cell dose of > 10 x 10(6) CD34+ cells/kg, T cell depletion (with CD34+ cell selection and CD4/CD8 depletion steps) to < 1 x 10(5) CD3+ cells/kg and cyclosporine post transplant. Ten patients (7M/3F, median age 11 (3-33) years) with high-risk leukemia (AML in 4, MDS in 2, CML in 1 and T-ALL in 3) received a hemopoietic stem cell transplant (HSCT) from a haploidentical father or sibling. The median number of CD34+ cells was 12.9 (9.5-45.7) x 10(6) cells/kg; median number of CD3+ cells was 0.41 (0.09-1.89) x 10(5) CD3+ cells/kg. All patients initially achieved 0.5 x 10(9)/l neutrophils at a median 12 (10-21) days. Graft failure in two consecutive patients out of four on the original protocol led to a modification adding ATG pretransplant and OKT3 post transplant. Graft failure was observed in one out of six subsequent patients. Acute GVHD > or = grade II was observed in three patients. Three of 10 patients are alive in CR at > 24 and >3 (2) months after transplant. Seven patients died: four of transplant related complications and three of relapse. Increased stem cell dose (> or = 10 x 10(6) CD34+ cells/kg) as obtained using currently available technology may not be sufficient to ensure stable engraftment in patients with high-risk leukemia using standard myeloablative conditioning regimens.

T-cell depletion of bone marrow transplants for leukemia from donors other than HLA-identical siblings: advantage of T-cell antibodies with narrow specificities

T-cell depletion of donor marrow decreases graft-versus-host disease resulting from transplants from unrelated and human leukocyte antigen (HLA)-mismatched related donors. However, there are diverse strategies for T-cell-depleted transplantation, and it is uncertain whether any improve leukemia-free survival (LFS). To compare strategies for T-cell-depleted alternative donor transplants and to compare T-cell depleted with non-T-cell-depleted transplants, we studied 870 patients with leukemia who received T-cell-depleted transplants from unrelated or HLA-mismatched related donors from 1982 to 1994. Outcomes were compared with those of 998 non-T-cell-depleted transplants. We compared LFS using different strategies for T-cell-depleted transplantation considering T-cell depletion technique, intensity of pretransplant conditioning, and posttransplant immune suppression using proportional hazards regression to adjust for other prognostic variables. Five categories of T-cell depletion techniques were considered: narrow-specificity antibodies, broad-specificity antibodies, Campath antibodies, elutriation, and lectins. Strategies resulting in similar LFS were pooled to compare T-cell-depleted with non-T-cell-depleted transplants. Recipients of transplants T-cell depleted by narrow-specificity antibodies had lower treatment failure risk (higher LFS) than recipients of transplants T-cell depleted by other techniques. Compared with non-T-cell-depleted transplants (5-year probability +/- 95% confidence interval [CI] of LFS, 31% +/- 4%), 5-year LFS was 29% +/- 5% (P = NS) after transplants T-cell depleted by narrow-specificity antibodies and 16% +/- 4% (P <.0001) after transplants T-cell depleted by other techniques. After alternative donor transplantation, T-cell depletion of donor marrow by narrow-specificity antibodies resulted in LFS rates that were higher than those for transplants T-cell depleted using other techniques but similar to those for non-T-cell-depleted transplants. (Blood. 2000;95:3996-4003)