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Lv M, Chang Y, Huang X. Everyone has a donor: contribution of the Chinese experience to global practice of haploidentical hematopoietic stem cell transplantation. Front Med 2018; 13:45-56. [DOI: 10.1007/s11684-017-0595-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 09/30/2017] [Indexed: 12/22/2022]
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52
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Hematopoietic cell transplantation comorbidity index and risk of developing invasive fungal infections after allografting. Bone Marrow Transplant 2018; 53:1304-1310. [PMID: 29654289 DOI: 10.1038/s41409-018-0161-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 12/30/2017] [Accepted: 03/01/2018] [Indexed: 11/12/2022]
Abstract
We evaluated the potential correlation of the hematopoietic cell transplantation comorbidity index (HCT-CI) with the risk of developing post-transplant invasive fungal infections (IFIs). Between January 2009 and March 2015, 312 consecutive patients who received a first allograft entered the study. Low/intermediate HCT-CI risk score (0-2) was observed in 172/312 (55%), whereas high HCT-CI score (≥3) was seen in 140/312 (45%). Overall, 51/312 (16%) patients experienced IFI, defined as possible in 19 (6%), probable in 27 (9%), and proven in 5 (2%). Cumulative incidence of probable-proven IFI at 1 year was 8.5% with a significant higher incidence in patients with high HCT-CI (12%) vs. those with low-intermediate HCT-CI (5%; p = 0.006). There was a strong trend for a higher incidence of baseline severe pulmonary comorbidity in patients who developed probable-proven IFI (p = 0.051). One-year cumulative incidence of non-relapse mortality was higher in patients with IFI vs. those without, 49 and 16% (p < 0.001). By multivariate analysis, disease status at transplant and high HCT-CI, when combined with acute GVHD, were independently associated with the risk of post-transplant IFI. This study shows that a high HCT-CI predicts the risk of developing IFI and may indicate the need of mold-active antifungal prophylaxis in high-risk patients.
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53
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Risk factors associated with development and mortality by invasive fungal diseases in pediatric allogeneic stem cell transplantation. A pediatric subgroup analysis of data from a prospective study of the Gruppo Italiano Trapianto di Midollo Osseo (GITMO). Bone Marrow Transplant 2018; 53:1193-1197. [DOI: 10.1038/s41409-018-0160-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/07/2018] [Accepted: 02/15/2018] [Indexed: 01/07/2023]
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54
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Li Y, Liu M, Zhai B, Zhao X, Wang L, Li H, Wang S, Zhu H, Wang Q, Gao C, Huang W, Yu L. Primary antifungal prophylaxis: decrease of invasive fungal disease incidence and reduction of risk factors in haematological patients in a 5-year retrospective study. Intern Med J 2017; 48:713-720. [PMID: 29230923 DOI: 10.1111/imj.13711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 11/13/2017] [Accepted: 12/03/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Invasive fungal disease (IFD) is a major cause of morbidity and mortality in patients with haematological malignancies. AIM To evaluate the efficacy and rationality of primary antifungal prophylaxis (PAP) in a 5-year real-life setting and choose an appropriate PAP strategy. METHODS Clinical data of patients were retrospectively reviewed and IFD was diagnosed using the revised diagnostic criteria. The efficacy of PAP and the risk factors for IFD, especially the rationality of PAP, were evaluated. RESULTS Of the 1340 patients enrolled, 749 patients received PAP (55.9%), and IFD occurred in 157 patients: 51 (6.8%) in the PAP group and 106 (17.9%) in the non-PAP group (P = 0.000). The IFD-related mortality was 10.1 and 29.7% in the PAP group and non-PAP group (P = 0.000) respectively. PAP was an independent protective factor for IFD (odds ratio = 0.183, 95% confidence interval: 0.122-0.274, P = 0.000) and could reduce the effect of risk factors, such as allogeneic haemopoietic stem cell transplantation, prolonged neutropenia and corticosteroid. The IFD incidence was not significantly different among different PAP regimens and PAP start time subgroups, and it was lowest (4.2%) when PAP started after a short period of neutropenia (1-10 days). CONCLUSION PAP is necessary and efficient to prevent IFD in haematological patients, and the real-life PAP strategy is reasonable. Different drugs can be chosen, and it is better to start PAP as soon as neutropenia begins.
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Affiliation(s)
- Yan Li
- Department of Hematology and BMT Center, Chinese PLA General Hospital, Beijing, China
| | - Mingjuan Liu
- Department of Hematology and BMT Center, Chinese PLA General Hospital, Beijing, China.,Department of Hematology, The 309th Hospital of Chinese PLA, Beijing, China
| | - Bing Zhai
- Department of Hematology and BMT Center, Chinese PLA General Hospital, Beijing, China.,Department of Geriatric Hematology, Chinese PLA General Hospital, Beijing, China
| | - Xiaoli Zhao
- Department of Hematology and BMT Center, Chinese PLA General Hospital, Beijing, China.,Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Lijun Wang
- Department of Hematology and BMT Center, Chinese PLA General Hospital, Beijing, China.,Department of Hematology, The 264th Hospital of Chinese PLA, Taiyuan, China
| | - Honghua Li
- Department of Hematology and BMT Center, Chinese PLA General Hospital, Beijing, China
| | - Shuhong Wang
- Department of Hematology and BMT Center, Chinese PLA General Hospital, Beijing, China
| | - Haiyan Zhu
- Department of Hematology and BMT Center, Chinese PLA General Hospital, Beijing, China
| | - Quanshun Wang
- Department of Hematology and BMT Center, Chinese PLA General Hospital, Beijing, China
| | - Chunji Gao
- Department of Hematology and BMT Center, Chinese PLA General Hospital, Beijing, China
| | - Wenrong Huang
- Department of Hematology and BMT Center, Chinese PLA General Hospital, Beijing, China
| | - Li Yu
- Department of Hematology and BMT Center, Chinese PLA General Hospital, Beijing, China
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Pergam SA. Fungal Pneumonia in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation. Clin Chest Med 2017; 38:279-294. [PMID: 28477639 DOI: 10.1016/j.ccm.2016.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Invasive fungal infections, which occur primarily as a consequence of prolonged neutropenia and immunosuppression, are a life-threatening complication seen among patients with hematologic malignancies. The routine use of triazole antifungal prophylaxis, enhanced diagnostics, and newer antifungal agents have led to improvements in the care of fungal pneumonias, but invasive fungal infections remain a major cause of morbidity and mortality. This article covers risk factors for major fungal infections, diagnostic approaches, and treatment options for specific fungal pathogens, including Aspergillus and Mucorales species, and discusses current approved strategies for prevention of common and uncommon fungal pneumonias.
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Affiliation(s)
- Steven A Pergam
- Vaccine & Infectious Disease Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, E4-100, Seattle, WA 98109, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, E4-100, Seattle, WA 98109, USA; Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; Infection Prevention, Seattle Cancer Care Alliance, 825 Eastlake Avenue East, Seattle, WA 98109, USA.
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Zhang S, He Y, Jiang E, Wei J, Yang D, Zhang R, Zhai W, Zhang G, Wang Z, Zhang L, Liu L, Han M, Feng S. Efficacy and safety of posaconazole in hematopoietic stem cell transplantation patients with invasive fungal disease. Future Microbiol 2017; 12:1371-1379. [PMID: 28880124 DOI: 10.2217/fmb-2017-0131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Invasive fungal disease (IFD) is a significant cause of morbidity and mortality in hematopoietic stem cell transplantation (HSCT) patients. This study reports real-world efficacy and safety of posaconazole (POS) in HSCT recipients with IFD. PATIENTS & METHODS We performed a retrospective study to investigate the efficacy and safety of POS oral suspension in 45 HSCT patients with IFD from December 2013 to December 2016. RESULTS The success rate at 12 weeks after POS treatment was 57.8%. Multivariate logistic regression analysis showed that persistent neutropenia, severe graft-versus-host disease, high-dose steroid and cytomegalovirus infection were independently associated with inferior responses to POS. POS caused some adverse effects of mild or moderate severity that were of short duration. CONCLUSION This study provides encouraging data regarding the efficacy and safety of POS in HSCT recipients. Neutropenia, graft-versus-host disease, steroid use and cytomegalovirus infection are possibly associated with inferior responses to POS therapy.
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Affiliation(s)
- Sudong Zhang
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
| | - Yi He
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
| | - Erlie Jiang
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
| | - Jialin Wei
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
| | - Donglin Yang
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
| | - Rongli Zhang
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
| | - Weihua Zhai
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
| | - Guixin Zhang
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
| | - Zhao Wang
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
| | - Lining Zhang
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
| | - Li Liu
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
| | - Mingzhe Han
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
| | - Sizhou Feng
- Hematopoietic Stem Cell Transplantation Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Heping District, 300020, Tianjin, PR China
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57
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2016 guideline strategies for the use of antifungal agents in patients with hematological malignancies or hematopoietic stem cell transplantation recipients in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2017; 51:287-301. [PMID: 28781151 DOI: 10.1016/j.jmii.2017.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 07/12/2017] [Indexed: 12/11/2022]
Abstract
The Infectious Diseases Society of Taiwan (IDST), the Hematology Society of Taiwan, the Taiwan Society of Blood and Marrow Transplantation, Medical Foundation in Memory of Dr. Deh-Lin Cheng, Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Education, and CY Lee's Research Foundation for Pediatric Infectious Diseases and Vaccines cooperatively published this guideline for the use of antifungal agents in hematological patients with invasive fungal diseases (IFDs) in Taiwan. The guideline is the first one endorsed by IDST focusing on selection of antifungal strategies, including prophylaxis, empirical (or symptom-driven) and pre-emptive (or diagnostic-driven) strategy. We suggest a risk-adapted dynamic strategy and provide an algorithm to facilitate decision making in population level as well as for individual patient. Risk assessment and management accordingly is explicitly emphasized. In addition, we highlight the importance of diagnosis in each antifungal strategy among five elements of the antimicrobial stewardship (diagnosis, drug, dose, de-escalation and duration). The rationale, purpose, and key recommendations for the choice of antifungal strategy are summarized, with concise review of international guidelines or recommendation, key original articles and local epidemiology reports. We point out the interaction and influence between elements of recommendations and limitation of and gap between evidences and daily practice. The guideline balances the quality of evidence and feasibility of recommendation in clinical practice. Finally, this version introduces the concept of health economics and provides data translated from local disease burdens. All these contents hopefully facilitate transparency and accountability in medical decision-making, improvements in clinical care and health outcomes, and appropriateness of medical resource allocation.
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58
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Sun YQ, Liu ZY, Huang XJ, Yan CH, Xu LP, Zhang XH, Liu KY, Wang Y. A Retrospective Study of Central Nervous System Invasive Fungal Disease after Allogeneic Stem Cell Transplantation: Risk Factors, Clinical Characteristics, and Outcomes. Biol Blood Marrow Transplant 2017; 23:1158-1164. [DOI: 10.1016/j.bbmt.2017.03.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/17/2017] [Indexed: 10/19/2022]
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59
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Young AY, Leiva Juarez MM, Evans SE. Fungal Pneumonia in Patients with Hematologic Malignancy and Hematopoietic Stem Cell Transplantation. Clin Chest Med 2017; 38:479-491. [PMID: 28797490 DOI: 10.1016/j.ccm.2017.04.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Fungal pneumonias cause unacceptable morbidity among patients with hematologic malignancies (HM) and recipients of hematopoietic stem cell transplantation (HSCT). The high incidence of fungal pneumonias in HM/HSCT populations arises from their frequently severe, complex, and persistent immune dysfunction caused by the underlying disease and its treatment. The cytopenias, treatment toxicities, and other immune derangements that make patients susceptible to fungal pneumonia frequently complicate its diagnosis and increase the intensity and duration of antifungal therapy. This article addresses the host factors that contribute to susceptibility, summarizes diagnostic recommendations, and reviews current guidelines for management of fungal pneumonia in patients with HM/HSCT.
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Affiliation(s)
- Alisha Y Young
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The University of Texas Health Sciences Center, 6431 Fannin Street, MSB 1.434, Houston, TX 77030, USA
| | - Miguel M Leiva Juarez
- Division of Internal Medicine, Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1100, Houston, TX 77030, USA
| | - Scott E Evans
- Division of Internal Medicine, Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1100, Houston, TX 77030, USA.
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60
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Zhang XH, Zhang JM, Han W, Chen H, Chen YH, Wang FR, Wang JZ, Zhang YY, Mo XD, Chen Y, Wang Y, Chang YJ, Xu LP, Liu KY, Huang XJ. Viral encephalitis after haplo-identical hematopoietic stem cell transplantation: Causative viral spectrum, characteristics, and risk factors. Eur J Haematol 2017; 98:450-458. [PMID: 28129450 DOI: 10.1111/ejh.12855] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2017] [Indexed: 12/25/2022]
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61
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Immunity to Infections after Haploidentical Hematopoietic Stem Cell Transplantation. Mediterr J Hematol Infect Dis 2016; 8:e2016057. [PMID: 27872737 PMCID: PMC5111540 DOI: 10.4084/mjhid.2016.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 09/21/2016] [Indexed: 02/06/2023] Open
Abstract
The advantage of using a Human Leukocyte Antigen (HLA)-mismatched related donor is that almost every patient who does not have an HLA-identical donor or who urgently needs hematopoietic stem cell transplantation (HSCT) has at least one family member with whom shares one haplotype (haploidentical) and who is promptly available as a donor. The major challenge of haplo-HSCT is intense bi-directional alloreactivity leading to high incidences of graft rejection and graft-versus-host disease (GVHD). Advances in graft processing and pharmacologic prophylaxis of GVHD have reduced these risks and have made haplo-HSCT a viable alternative for patients lacking a matched donor. Indeed, the haplo-HSCT has spread to centers worldwide even though some centers have preferred an approach based on T cell depletion of G-CSF-mobilized peripheral blood progenitor cells (PBPCs), others have focused on new strategies for GvHD prevention, such as G-CSF priming of bone marrow and robust post-transplant immune suppression or post-transplant cyclophosphamide (PTCY). Today, the graft can be a megadose of T-cell depleted PBPCs or a standard dose of unmanipulated bone marrow and/or PBPCs. Although haplo-HSCT modalities are based mainly on high intensity conditioning regimens, recently introduced reduced intensity regimens (RIC) showed promise in decreasing early transplant-related mortality (TRM), and extending the opportunity of HSCT to an elderly population with more comorbidities. Infections are still mostly responsible for toxicity and non-relapse mortality due to prolonged immunosuppression related, or not, to GVHD. Future challenges lie in determining the safest preparative conditioning regimen, minimizing GvHD and promoting rapid and more robust immune reconstitution.
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62
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Douglas AP, Slavin MA. Risk factors and prophylaxis against invasive fungal disease for haematology and stem cell transplant recipients: an evolving field. Expert Rev Anti Infect Ther 2016; 14:1165-1177. [PMID: 27710140 DOI: 10.1080/14787210.2016.1245613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Due to increasing intensity and complexity of therapies and longer survivorship, many patients with haematologic malignancy (HM) are at risk of invasive fungal disease (IFD). Mortality from IFD is high and treatment of an episode of IFD results in an excess length of hospital stay and costs and delays delivery of curative therapy of the underlying haematologic condition. Therefore, prevention and early recognition and treatment of IFD are crucial. Areas covered: Risk factors particular to certain HMs and haematopoietic stem cell transplantation, as well as those risk factors universal to all HM groups are examined. Expert commentary: Risk stratification identifies those patients who would benefit most from mould active versus yeast active prophylaxis and those who can be safely managed with monitoring and clinically driven interventions for IFD. This approach aids in antifungal stewardship.
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Affiliation(s)
- Abby P Douglas
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , Melbourne , VIC , Australia
| | - Monica A Slavin
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , Melbourne , VIC , Australia.,b Victorian Infectious Diseases Service , Royal Melbourne Hospital , Melbourne , VIC , Australia.,c Department of Medicine , University of Melbourne , Melbourne , VIC , Australia
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63
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Gao L, Sun Y, Meng F, Han M, Huang H, Wu D, Yu L, Ren H, Huang X, Zhang X. Antifungal prophylaxis of patients undergoing allogenetic hematopoietic stem cell transplantation in China: a multicenter prospective observational study. J Hematol Oncol 2016; 9:97. [PMID: 27663309 PMCID: PMC5035465 DOI: 10.1186/s13045-016-0305-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 08/24/2016] [Indexed: 11/28/2022] Open
Abstract
Background Antifungal prophylaxis is currently regarded as the gold standard in situations with allo-genetic hematopoietic stem cell transplantation (allo-HSCT). However, the epidemiological information regarding prophylaxis of invasive fungal diseases (IFDs) is not clear in China. Methods We report the first large-scale (1053 patients) observational study of the prophylaxis and management of IFDs among patients with allo-HSCT in China. Results The incidence rates of IFD after primary antifungal prophylaxis (PAP), secondary antifungal prophylaxis (SAP), and non-prophylaxis were 22.7 vs. 38.6 vs. 68.6 %, respectively (P = 0.0000). The median time from transplantation to IFD was 45 days in PAP patients, 18 days in SAP patients, and 12 days in non-prophylaxis patients. Aspergillus spp. represents the most common type of fungal infection. Independent risk factors for IFD in allo-HSCT patients with PAP were age, having human leukocyte antigen (HLA)-haploidentical or matched unrelated donor, decreased albumin levels, and the use of itraconazole as the prophylactic antifungal agent. Among SAP transplant recipients, there was no significant risk factor for IFDs. The incidence rates of overall survival (OS) in the PAP, SAP, and no prophylaxis groups were 85.07, 78.80, and 74.82, respectively (P = 0.01). Conclusions This observational study indicates that prophylaxis of IFD is helpful to reduce the incidence of IFDs and improve the OS of patients after allo-HSCT.
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Affiliation(s)
- Lei Gao
- Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Yuqian Sun
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Fanyi Meng
- Nanfang Hospital, Nanfang Medical University, Guangzhou, China
| | - Mingzhe Han
- Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, Tianjin, China
| | - He Huang
- The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, China
| | - Depei Wu
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Li Yu
- Chinese PLA General Hospital (301 Hospital), Beijing, China
| | - Hanyun Ren
- The First Hospital of Peking University, Beijing, China
| | - Xiaojun Huang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Xi Zhang
- Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
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Pagano L, Busca A, Candoni A, Cattaneo C, Cesaro S, Fanci R, Nadali G, Potenza L, Russo D, Tumbarello M, Nosari A, Aversa F. Risk stratification for invasive fungal infections in patients with hematological malignancies: SEIFEM recommendations. Blood Rev 2016; 31:17-29. [PMID: 27682882 DOI: 10.1016/j.blre.2016.09.002] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 09/05/2016] [Accepted: 09/09/2016] [Indexed: 11/17/2022]
Abstract
Invasive fungal infections (IFIs) are an important cause of morbidity and mortality in immunocompromised patients. Patients with hematological malignancies undergoing conventional chemotherapy, autologous or allogeneic hematopoietic stem cell transplantation are considered at high risk, and Aspergillus spp. represents the most frequently isolated micro-organisms. In the last years, attention has also been focused on other rare molds (e.g., Zygomycetes, Fusarium spp.) responsible for devastating clinical manifestations. The extensive use of antifungal prophylaxis has reduced the infections from yeasts (e.g., candidemia) even though they are still associated with high mortality rates. This paper analyzes concurrent multiple predisposing factors that could favor the onset of fungal infections. Although neutropenia is common to almost all hematologic patients, other factors play a key role in specific patients, in particular in patients with AML or allogeneic HSCT recipients. Defining those patients at higher risk of IFIs may help to design the most appropriate diagnostic work-up and antifungal strategy.
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Affiliation(s)
- Livio Pagano
- Istituto di Ematologia, Università Cattolica S. Cuore, Roma, Italy.
| | - Alessandro Busca
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Anna Candoni
- Clinica Ematologica, Azienda Ospedaliero-Universitaria Santa Maria Misericordia, Udine, Italy
| | | | - Simone Cesaro
- Oncoematologia Pediatrica, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Rosa Fanci
- Unità Funzionale di Ematologia, Azienda Ospedaliero-Universitaria Careggi e Università di Firenze, Italy
| | - Gianpaolo Nadali
- Unità Operativa Complessa di Ematologia, Azienda Ospedaliera Universitaria Integrata di Verona, Italy
| | - Leonardo Potenza
- UOC Ematologia, Dipartimento di Scienze Mediche e Chirurgiche Materno Infantili e dell'Adulto, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Domenico Russo
- Cattedra di Ematologia, Unità di Malattie del Sangue e Trapianto di Midollo Osseo, Dipartimento di Scienze Cliniche e Sperimentali, Università di Brescia e ASST Spedali Civili, Brescia, Italy
| | - Mario Tumbarello
- Istituto di Malattie Infettive, Università Cattolica S. Cuore, Roma, Italy
| | - Annamaria Nosari
- Divisione di Ematologia e Centro Trapianti Midollo, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Franco Aversa
- Hematology and BMT Unit, Department of Clinical and Experimental Medicine, University of Parma, Italy
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Ji Y, Sun YQ, Huang H, Chen J, Zhang XY, Meng FY, Han MZ, Wu DP, Huang XJ. [Diagnostic and treatment cost of invasive fungal infections in patients with hematologic malignancies during hospitalization]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:819-822. [PMID: 27719729 PMCID: PMC7342107 DOI: 10.3760/cma.j.issn.0253-2727.2016.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Antifungal Therapy in Hematopoietic Stem Cell Transplant Recipients. Mediterr J Hematol Infect Dis 2016; 8:e2016039. [PMID: 27648202 PMCID: PMC5016011 DOI: 10.4084/mjhid.2016.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 07/20/2016] [Indexed: 11/08/2022] Open
Abstract
Invasive fungal infections (IFI) represent a major hindrance to the success of hematopoietic stem cell transplantation (HSCT), contributing substantially to morbidity and infection-related mortality. During the most recent years several reports indicate an overall increase of IFI among hematologic patients, in particular, invasive aspergillosis, that may be explained, at least partially, by the fact that diagnoses only suspected in the past, are now more easily established due to the application of serum biomarkers and early use of CT scan. Along with new diagnostic options, comes the recent development of novel antifungal agents that expanded the spectrum of activity over traditional treatments contributing to the successful management of fungal diseases. When introduced in 1959, Amphotericin B deoxycholate (d-AmB) was a life-saving drug, and the clinical experience over 50 years has proven that this compound is effective although toxic. Given the superior safety profile, lipid formulations of AmB have now replaced d-AmB in many circumstances. Similarly, echinocandins have been investigated as initial therapy for IA in several clinical trials including HSCT recipients, although the results were moderately disappointing leading to a lower grade of recommendation in the majority of published guidelines. Azoles represent the backbone of therapy for treating immunocompromised patients with IFI, including voriconazole and the newcomer isavuconazole; in addition, large studies support the use of mold-active azoles, namely voriconazole and posaconazole, as antifungal prophylaxis in HSCT recipients. The aim of the present review is to summarize the clinical application of antifungal agents most commonly employed in the treatment of IFI.
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Ballen K, Woo Ahn K, Chen M, Abdel-Azim H, Ahmed I, Aljurf M, Antin J, Bhatt AS, Boeckh M, Chen G, Dandoy C, George B, Laughlin MJ, Lazarus HM, MacMillan ML, Margolis DA, Marks DI, Norkin M, Rosenthal J, Saad A, Savani B, Schouten HC, Storek J, Szabolcs P, Ustun C, Verneris MR, Waller EK, Weisdorf DJ, Williams KM, Wingard JR, Wirk B, Wolfs T, Young JAH, Auletta J, Komanduri KV, Lindemans C, Riches ML. Infection Rates among Acute Leukemia Patients Receiving Alternative Donor Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1636-1645. [PMID: 27343716 DOI: 10.1016/j.bbmt.2016.06.012] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 06/06/2016] [Indexed: 12/16/2022]
Abstract
Alternative graft sources (umbilical cord blood [UCB], matched unrelated donors [MUD], or mismatched unrelated donors [MMUD]) enable patients without a matched sibling donor to receive potentially curative hematopoietic cell transplantation (HCT). Retrospective studies demonstrate comparable outcomes among different graft sources. However, the risk and types of infections have not been compared among graft sources. Such information may influence the choice of a particular graft source. We compared the incidence of bacterial, viral, and fungal infections in 1781 adults with acute leukemia who received alternative donor HCT (UCB, n= 568; MUD, n = 930; MMUD, n = 283) between 2008 and 2011. The incidences of bacterial infection at 1 year were 72%, 59%, and 65% (P < .0001) for UCB, MUD, and MMUD, respectively. Incidences of viral infection at 1 year were 68%, 45%, and 53% (P < .0001) for UCB, MUD, and MMUD, respectively. In multivariable analysis, bacterial, fungal, and viral infections were more common after either UCB or MMUD than after MUD (P < .0001). Bacterial and viral but not fungal infections were more common after UCB than MMUD (P = .0009 and <.0001, respectively). The presence of viral infection was not associated with an increased mortality. Overall survival (OS) was comparable among UCB and MMUD patients with Karnofsky performance status (KPS) ≥ 90% but was inferior for UCB for patients with KPS < 90%. Bacterial and fungal infections were associated with poorer OS. Future strategies focusing on infection prevention and treatment are indicated to improve HCT outcomes.
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Affiliation(s)
- Karen Ballen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Kwang Woo Ahn
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Min Chen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hisham Abdel-Azim
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Ibrahim Ahmed
- Department of Hematology, Oncology and Bone Marrow Transplantation, The Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center and Research, Riyadh, Saudi Arabia
| | - Joseph Antin
- Center for Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ami S Bhatt
- Stanford University School of Medicine, Stanford, California
| | - Michael Boeckh
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - George Chen
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | | | | | - Mary J Laughlin
- Medical Director, Cleveland Cord Blood Center, Cleveland, Ohio
| | - Hillard M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Margaret L MacMillan
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - David A Margolis
- Section of Hematology, Oncology and BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David I Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Maxim Norkin
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
| | | | - Ayman Saad
- Division of Hematology/Oncology Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bipin Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Harry C Schouten
- Department of Hematology, Academische Ziekenhuis, Maastricht, Netherlands
| | - Jan Storek
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Szabolcs
- Division of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Michael R Verneris
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Edmund K Waller
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Kirsten M Williams
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institute of Health, Bethesda, Maryland
| | - John R Wingard
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, Washington
| | - Tom Wolfs
- Division of Pediatrics, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Jo-Anne H Young
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey Auletta
- Host Defense Program, Divisions of Hematology/Oncology/Bone Marrow Transplant and Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Krishna V Komanduri
- Adult Stem Cell Transplantation Program, University of Miami, Miami, Florida
| | - Caroline Lindemans
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marcie L Riches
- Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Zhang XH, Wang QM, Zhang JM, Feng FE, Wang FR, Chen H, Zhang YY, Chen YH, Han W, Xu LP, Liu KY, Huang XJ. Desialylation is associated with apoptosis and phagocytosis of platelets in patients with prolonged isolated thrombocytopenia after allo-HSCT. J Hematol Oncol 2015; 8:116. [PMID: 26497387 PMCID: PMC4619537 DOI: 10.1186/s13045-015-0216-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prolonged isolated thrombocytopenia (PT) is a frequent complication in patients who undergo allogeneic hematopoietic stem cell transplantation (allo-HSCT), and it is associated with an adverse prognosis. In this study, we hypothesized that desialylation on platelet surfaces was associated with PT after allo-HSCT. The mechanisms participating in this process may include NEU1 translocation, platelet apoptosis, and phagocytosis by macrophages. METHODS PT was defined as a peripheral platelet count less than 100 × 10(9)/L without sustained anemia or leukopenia for more than 3 months after allo-HSCT. 34 patients were identified consecutively from a cohort of 255 patients who underwent allo-HSCT for hematologic malignancies between May and October 2014 at Peking University Institute of Hematology. Desialylation, enzyme expression, and phagocytosis were detected using flow cytometry, immunofluorescence, RT-PCR, Western blot, and so on. RESULTS Platelets from the PT patients had significantly fewer sialic acids (P = .001) and increased β-galactose exposure indicative of desialylation on the surface (P = .042), and serum from the PT patients showed a higher sialic acid concentration (8.400 ± 0.2209 μmol/L, P < .001). The sialidase NEU1 was over-expressed from mRNA to protein levels, and its catalytic activity was increased in platelets from the PT patients. Desialylation of GPIbα in the PT patients was correlated with changes in 14-3-3ζ distribution, which, relative to Bad activation, modulated the expression of Bcl-2 family proteins, depolarized the inner membrane of the mitochondria, and initiated the intrinsic mitochondria-dependent pathway of apoptosis. Macrophages derived from the THP-1 cell line preferred to phagocytize desialylated platelets from the PT patients in vitro. We also revealed that oseltamivir (400 μmol/L) could inhibit 50 % of the sialidase activity on platelets and could protect 20 % of platelets from phagocytosis in vitro. CONCLUSIONS Desialylation of platelets was associated with platelet apoptosis and phagocytosis, whereas oseltamivir could reduce platelet destruction in the periphery, indicating a potential novel treatment for PT after allo-HSCT.
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Affiliation(s)
- Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China.
| | - Qian-Ming Wang
- Peking University People's Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Jia-Min Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Fei-Er Feng
- Peking University People's Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Feng-Rong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Yuan-Yuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China.
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Deo SS, Gottlieb DJ. Adoptive T-cell therapy for fungal infections in haematology patients. Clin Transl Immunology 2015; 4:e40. [PMID: 26366286 PMCID: PMC4558438 DOI: 10.1038/cti.2015.16] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 07/09/2015] [Accepted: 07/09/2015] [Indexed: 02/01/2023] Open
Abstract
The prolonged immune deficiency resulting from haematopoietic stem cell transplant and chemotherapy predisposes to a high risk of invasive fungal infections. Despite the recent advances in molecular diagnostic testing, early initiation of pre-emptive antifungal therapy and the use of combination pharmacotherapy, mortality from invasive mould infections remain high among recipients of allogeneic stem cell transplant. The increasing incidences of previously rare and drug-resistant strains of fungi present a further clinical challenge. Therefore, there is a need for novel strategies to combat fungal infections in the immunocompromised. Adoptive therapy using in vitro-expanded fungus-specific CD4 cells of the Th-1 type has shown clinical efficacy in murine studies and in a small human clinical study. Several techniques for the isolation and expansion of fungus-specific T cells have been successfully applied. Here we discuss the incidence and changing patterns of invasive fungal diseases, clinical evidence supporting the role of T cells in fungal immunity, methods to expand fungus-specific T cells in the laboratory and considerations surrounding the use of T cells for fungal immunotherapy.
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Affiliation(s)
- Shivashni S Deo
- Centre for Cancer Research, Westmead Millennium Institute for Medical Research , Westmead, NSW, Australia ; Sydney Medical School, University of Sydney , Sydney, NSW, Australia
| | - David J Gottlieb
- Centre for Cancer Research, Westmead Millennium Institute for Medical Research , Westmead, NSW, Australia ; Sydney Medical School, University of Sydney , Sydney, NSW, Australia ; Blood and Marrow Transplant Unit, Department of Haematology, Westmead Hospital , Westmead, NSW, Australia ; Sydney Cell and Gene Therapy Laboratory, Westmead Hospital , Westmead, NSW, Australia
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70
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Fuji S, Einsele H, Savani BN, Kapp M. Systematic Nutritional Support in Allogeneic Hematopoietic Stem Cell Transplant Recipients. Biol Blood Marrow Transplant 2015; 21:1707-13. [PMID: 26172477 DOI: 10.1016/j.bbmt.2015.07.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 07/06/2015] [Indexed: 12/15/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) has become an established treatment modality for various hematological diseases. However, in allogeneic HSCT, patients often suffer from severe gastrointestinal complications caused by the conditioning regimen and acute/chronic graft-versus-host disease, which requires support by multidisciplinary nutritional support teams (NST). In addition, pretransplantation nutritional status can affect the clinical outcome after allogeneic HSCT. Therefore, it is important to refer the patient to a NST when becoming aware of nutritional problems before allogeneic HSCT. It is also important to follow nutritional status over the long term, as patients often suffer from various nutritional problems, such as malnutrition and metabolic syndrome, even late after allogeneic HSCT. In summary, NST can contribute to the improvement of nutritional status and possibly prognosis at every stage before and after allogeneic HSCT. Here, we aim to give a comprehensive overview of current understanding about nutritional support in allogeneic HSCT and try to provoke a constructive discussion to stimulate further investigation.
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Affiliation(s)
- Shigeo Fuji
- Department of Internal Medicine II, Division of Hematology, University Hospital of Würzburg, Würzburg, Germany; Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan.
| | - Hermann Einsele
- Department of Internal Medicine II, Division of Hematology, University Hospital of Würzburg, Würzburg, Germany
| | - Bipin N Savani
- Hematology and Stem Cell Transplantation Section, Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center and Veterans Affairs Medical Center, Nashville, Tennessee
| | - Markus Kapp
- Department of Internal Medicine II, Division of Hematology, University Hospital of Würzburg, Würzburg, Germany
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