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Ono R, Sakamoto K, Doi T, Yanagisawa R, Morimoto A, Kanegane H, Nakazawa Y, Shioda Y. Dexamethasone palmitate as an etoposide-free treatment for children with hemophagocytic lymphohistiocytosis after hematopoietic cell transplantation. Bone Marrow Transplant 2023; 58:1286-1288. [PMID: 37644136 DOI: 10.1038/s41409-023-02098-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Rintaro Ono
- Department of Pediatrics, St. Luke's International Hospital, Tokyo, Japan
| | - Kenichi Sakamoto
- Department of Pediatrics, Shiga University of Medical Science, Shiga, Japan.
| | - Takehiko Doi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Ryu Yanagisawa
- Division of Blood Transfusion, Shinshu University Hospital, Matsumoto, Japan
| | - Akira Morimoto
- Department of Pediatrics, Jichi Medical University School of Medicine, Tochigi, Japan
- Department of Pediatrics, Showa Inan Hospital, Komagane, Japan
| | - Hirokazu Kanegane
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yozo Nakazawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoko Shioda
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
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2
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Benevenuta C, Mussinatto I, Orsi C, Timeus FS. Secondary hemophagocytic lymphohistiocytosis in children (Review). Exp Ther Med 2023; 26:423. [PMID: 37602304 PMCID: PMC10433411 DOI: 10.3892/etm.2023.12122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 06/16/2023] [Indexed: 08/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition characterized by hyperinflammation in an uncontrolled and ineffective immune response. Despite great improvement in diagnosis and treatment, it still represents a challenge in clinical management, with poor prognosis in the absence of an aggressive therapeutic approach. The present literature review focuses on secondary HLH at pediatric age, which represents a heterogeneous group in terms of etiology and therapeutic approach. It summarizes the most recent evidence on epidemiology, pathophysiology, diagnosis, treatment and prognosis, and provides a detailed description and comparison of the major subtypes of secondary HLH. Finally, it addresses the open questions with a focus on diagnosis and new treatment insights.
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Affiliation(s)
- Chiara Benevenuta
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Ilaria Mussinatto
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Cecilia Orsi
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Fabio S. Timeus
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
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3
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Hines MR, Knight TE, McNerney KO, Leick MB, Jain T, Ahmed S, Frigault MJ, Hill JA, Jain MD, Johnson WT, Lin Y, Mahadeo KM, Maron GM, Marsh RA, Neelapu SS, Nikiforow S, Ombrello AK, Shah NN, Talleur AC, Turicek D, Vatsayan A, Wong SW, Maus MV, Komanduri KV, Berliner N, Henter JI, Perales MA, Frey NV, Teachey DT, Frank MJ, Shah NN. Immune Effector Cell-Associated Hemophagocytic Lymphohistiocytosis-Like Syndrome. Transplant Cell Ther 2023; 29:438.e1-438.e16. [PMID: 36906275 PMCID: PMC10330221 DOI: 10.1016/j.jtct.2023.03.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/20/2023] [Accepted: 03/04/2023] [Indexed: 03/11/2023]
Abstract
T cell-mediated hyperinflammatory responses, such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), are now well-established toxicities of chimeric antigen receptor (CAR) T cell therapy. As the field of CAR T cells advances, however, there is increasing recognition that hemophagocytic lymphohistiocytosis (HLH)-like toxicities following CAR T cell infusion are occurring broadly across patient populations and CAR T cell constructs. Importantly, these HLH-like toxicities are often not as directly associated with CRS and/or its severity as initially described. This emergent toxicity, however ill-defined, is associated with life-threatening complications, creating an urgent need for improved identification and optimal management. With the goal of improving patient outcomes and formulating a framework to characterize and study this HLH-like syndrome, we established an American Society for Transplantation and Cellular Therapy panel composed of experts in primary and secondary HLH, pediatric and adult HLH, infectious disease, rheumatology and hematology, oncology, and cellular therapy. Through this effort, we provide an overview of the underlying biology of classical primary and secondary HLH, explore its relationship with similar manifestations following CAR T cell infusions, and propose the term "immune effector cell-associated HLH-like syndrome (IEC-HS)" to describe this emergent toxicity. We also delineate a framework for identifying IEC-HS and put forward a grading schema that can be used to assess severity and facilitate cross-trial comparisons. Additionally, given the critical need to optimize outcomes for patients experiencing IEC-HS, we provide insight into potential treatment approaches and strategies to optimize supportive care and delineate alternate etiologies that should be considered in a patient presenting with IEC-HS. By collectively defining IEC-HS as a hyperinflammatory toxicity, we can now embark on further study of the pathophysiology underlying this toxicity profile and make strides toward a more comprehensive assessment and treatment approach.
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Affiliation(s)
- Melissa R Hines
- Department of Pediatric Medicine, Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Tristan E Knight
- Pediatric Hematology and Oncology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, Washington
| | - Kevin O McNerney
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Mark B Leick
- Cellular Immunotherapy Program and Blood and Marrow Transplant Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Tania Jain
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Sairah Ahmed
- Departments of Lymphoma and Myeloma and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew J Frigault
- Cellular Immunotherapy Program and Blood and Marrow Transplant Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Joshua A Hill
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - William T Johnson
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yi Lin
- Division Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Rochester, Minnesota
| | - Kris M Mahadeo
- Pediatric Transplantation and Cellular Therapy, Duke University, Durham, North Carolina
| | - Gabriela M Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, and Department of Pediatrics, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee
| | - Rebecca A Marsh
- University of Cincinnati, and Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sattva S Neelapu
- Departments of Lymphoma and Myeloma and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah Nikiforow
- Division of Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Amanda K Ombrello
- Inflammatory Disease Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Nirav N Shah
- Bone Marrow Transplant and Cellular Therapy Program, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee and Department of Pediatrics, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee
| | - David Turicek
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Anant Vatsayan
- Division of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Sandy W Wong
- UCSF Health Division of Hematology and Oncology and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | - Marcela V Maus
- Cellular Immunotherapy Program and Blood and Marrow Transplant Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Krishna V Komanduri
- UCSF Health Division of Hematology and Oncology and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | | | - Jan-Inge Henter
- Division of Pediatric Oncology and Surgery, Department of Women's and Children's Health, Karolinska Institute, and Department of Paediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Noelle V Frey
- Division of Hematology-Oncology, Abramson Cancer Center and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David T Teachey
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew J Frank
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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4
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Hemophagocytic Lymphohistiocytosis and Graft Failure Following Unrelated Umbilical Cord Blood Transplantation in Children. J Pediatr Hematol Oncol 2020; 42:e440-e444. [PMID: 32287100 DOI: 10.1097/mph.0000000000001795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) following hematopoietic stem cell transplantation is closely correlated with graft failure and poor prognosis. Because of its rarity, the incidence, risk factors, and optimal treatment strategy are unclear. We analyzed data from cases of HLH following umbilical cord blood transplantation (UCBT) performed for pediatric patients at our center. Among 66 UCBT recipients, 5 developed HLH and imminent graft failure. The median time of diagnosis of HLH was 22 (range, 19 to 30) days after UCBT, and the cumulative incidence of HLH was 7.6% (95% confidence interval, 2.8-15.7) at day 60. In univariate analysis, the cumulative incidence of HLH was significantly higher in patients with infused CD34 cells <1.0×10/kg than in patients with higher CD34 cells. Patients with preengraftment infection showed a trend toward higher incidence of HLH compared with patients without any infection. All 5 patients with HLH received corticosteroids and low-dose etoposide (VP-16), with or without high-dose intravenous immunoglobulin. Following these treatments, successful engraftment was observed in 2 patients. Corticosteroids and low-dose VP-16 may be worthy of a trial before attempting salvage hematopoietic stem cell transplantation. Further analyses are required to identify risk factors and to develop methods for prophylaxis, diagnosis, and treatment of HLH.
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Possible role of low-dose etoposide therapy for hemophagocytic lymphohistiocytosis by COVID-19. Int J Hematol 2020; 112:122-124. [PMID: 32399895 PMCID: PMC7216850 DOI: 10.1007/s12185-020-02888-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 04/28/2020] [Accepted: 05/01/2020] [Indexed: 12/19/2022]
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6
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Successful salvage treatment with antithymocyte globulin for patients with early-onset hemophagocytic lymphohistiocytosis refractory to steroid and etoposide therapy following allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2020; 55:1479-1482. [PMID: 31992843 DOI: 10.1038/s41409-020-0802-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/15/2019] [Accepted: 01/16/2020] [Indexed: 01/12/2023]
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7
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Vatsayan A, Pateva I, Cabral L, Dalal J, Abu-Arja R. Post-hematopoietic stem cell transplant hemophagocytic lymphohistiocytosis or an impostor: Case report and review of literature. Pediatr Transplant 2018; 22:e13174. [PMID: 29577525 DOI: 10.1111/petr.13174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2018] [Indexed: 11/29/2022]
Abstract
HLH occurring after HSCT is a relatively rare disease. Many conditions may mimic or trigger HLH in post-HSCT period (eg, cytokine release syndrome, engraftment syndrome, graft rejection/failure, acute graft-vs-host disease, infections systemic inflammatory response syndrome/sepsis, and thrombotic microangiopathy). Moreover, this period is usually marked by febrile illness, cytopenia, and a "cytokine storm" leading to elevation of inflammatory biomarkers like ferritin and sCD25. These parameters overlap with the diagnostic criteria for HLH. Such confounding factors make the management of post-HSCT HLH quite challenging. We illustrate this critical issue with case report of a patient who was diagnosed with HLH after allogeneic HSCT for tAML. He received MP and CsA for HLH but VP-16 was not administered due to fear of severe myelosuppression. Fortunately, he responded well to treatment and remains in remission to date. We recommend caution while using HLH-94/HLH-2004 guidelines for the diagnosis and management of post-HSCT HLH. In this article, we pinpoint these issues with a brief review of all the pediatric cases and clinical studies of post-HSCT HLH along with a critical evaluation of its various diagnostic criteria. Finally, based on the limitations of current diagnostic criteria, we suggest a need for formulating disease-specific diagnostic criteria for post-HSCT HLH.
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Affiliation(s)
- Anant Vatsayan
- Department of Pediatric Hematology/Oncology, UH Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Irina Pateva
- Department of Pediatric Hematology/Oncology, UH Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Linda Cabral
- Department of Pediatric Hematology/Oncology, UH Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Jignesh Dalal
- Department of Pediatric Hematology/Oncology, UH Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Rolla Abu-Arja
- Department of Pediatric Hematology Oncology and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA
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8
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Morimoto A, Nakazawa Y, Ishii E. Hemophagocytic lymphohistiocytosis: Pathogenesis, diagnosis, and management. Pediatr Int 2016; 58:817-25. [PMID: 27289085 DOI: 10.1111/ped.13064] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/03/2016] [Accepted: 06/09/2016] [Indexed: 12/14/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that is classified into primary and secondary HLH. Primary HLH consists of monogenic disorders that mainly affect the perforin-mediated cytotoxicity of cytotoxic T lymphocytes and natural killer cells. Secondary HLH occurs as a complication in various settings such as infection, malignancy, autoimmune disease, and post-allogeneic hematopoietic stem cell transplantation. Both primary and secondary HLH are characterized by uncontrolled hypercytokinemia that results in myelosuppression and vascular endothelium damage. More than 10% of patients with HLH die within 2 months of diagnosis due to bleeding in the visceral organs, opportunistic infection due to neutropenia, or multiple organ failure. The most obvious presentations of HLH are persistent fever refractory to antimicrobial agents and hyperferritinemia due to hypersecretion of various cytokines. The first rule is not to overlook signs of hypercytokinemia and to settle the hyperactivated immunological state as soon as possible. In addition, to improve outcome, it is essential to identify the disorders underlying HLH and provide disorder-appropriate treatment.
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Affiliation(s)
- Akira Morimoto
- Department of Pediatrics, Jichi Medical University of Medicine, Shimotsuke, Tochigi, Japan.
| | - Yozo Nakazawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Eiichi Ishii
- Department of Pediatrics, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
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The minimum required level of donor chimerism in hereditary hemophagocytic lymphohistiocytosis. Blood 2016; 127:3281-90. [PMID: 27099148 DOI: 10.1182/blood-2015-12-684498] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 04/09/2016] [Indexed: 12/14/2022] Open
Abstract
Reduced-intensity conditioning has improved survival after hematopoietic stem cell transplantation (HSCT) for hemophagocytic lymphohistiocytosis (HLH) at the cost of more frequent mixed chimerism. The minimum level of donor chimerism (DC) required to prevent HLH reactivation in humans remains to be determined. In a multicenter retrospective study, 103 patients transplanted for hereditary HLH (2000-2013) and DC permanently or transiently <75% (overall, CD3(+), CD56(+)) were analyzed regarding DC, specific immunologic function, occurrence of systemic reactivations (≥5/8 HLH criteria), partial systemic flares (<5 criteria and HLH-directed treatment), isolated central nervous system reactivations, and management. Recurrence was reported in 18 patients (systemic reactivation n = 11, partial flare n = 3, isolated central nervous system reactivation n = 4). Ten events occurred during profound immune suppression before day 180 (median DC, 10%; range, 1-100%; CD3(+) if available, otherwise overall DC), which renders a differentiation between secondary post-HSCT HLH and HLH related to the genetic defect difficult. Eight events occurred between 0.5 and 6.7 years post-HSCT (median DC, 13%; range, 0-30%). In 5 patients, overall and lineage-specific DC were ≤10% for >6 months (median, 5.1; range, 1.1-10 years) without reactivation. A second HSCT was performed in 18 patients (median, DC 4%; range, 0-19%). Death from reactivation occurred in 4 patients (22% of recurrences). Six patients died of transplant complications following a second HSCT (33% of second HSCT). We conclude that a DC >20%-30% is protective against late reactivation. Lower levels do not, however, inescapably result in recurrences. The decision for or against second HSCT must be based on a thorough risk assessment.
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Seo JJ. Hematopoietic cell transplantation for hemophagocytic lymphohistiocytosis: recent advances and controversies. Blood Res 2015; 50:131-9. [PMID: 26457279 PMCID: PMC4595578 DOI: 10.5045/br.2015.50.3.131] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 09/16/2015] [Accepted: 09/16/2015] [Indexed: 01/09/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory clinical syndrome of uncontrolled immune response which results in hypercytokinemia due to underlying primary or secondary immune defect. A number of genetic defects in transport, processing and function of cytotoxic granules which result in defective granule exocytosis and cytotoxicity of cytotoxic T lymphocytes (CTL) and natural killer (NK) cells have been well identified at the cellular and molecular level. Important advances have been made during the last 20 years in the diagnosis and treatment of HLH. The Histiocyte Society has proposed diagnostic guideline using both clinical and laboratory findings in HLH-2004 protocol, and this has been modified partly in 2009. HLH used to be a fatal disease, but the survival of HLH patients has improved to more than 60% with the use of chemoimmunotherapy combined with hematopoietic cell transplantation (HCT) over the past 2 decades. However, HCT is still the only curative option of treatment for primary HLH and refractory/relapsed HLH after proper chemoimmunotherapy. The outcome of HCT for HLH patients was also improved steadily during last decades, but HCT for HLH still carries significant mortality and morbidity. Moreover, there remain ongoing controversies in various aspects of HCT including indication of HCT, donor selection, timing of HCT, conditioning regimen, and mixed chimerism after HCT. This review summarized the important practical issues which were proven by previous studies on HCT for HLH, and tried to delineate the controversies among them.
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Affiliation(s)
- Jong Jin Seo
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Sawada A, Shimizu M, Isaka K, Higuchi K, Mayumi A, Yoshimoto Y, Kikuchi H, Kondo O, Koyama-Sato M, Yasui M, Kawa K, Inoue M. Feasibility of HLA-haploidentical hematopoietic stem cell transplantation with post-transplantation cyclophosphamide for advanced pediatric malignancies. Pediatr Hematol Oncol 2014; 31:754-64. [PMID: 25325678 DOI: 10.3109/08880018.2014.961214] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Patients with advanced malignancies in non-complete remission (CR) have a dismal prognosis after HLA-matched hematopoietic stem cell transplantation (HSCT). T-cell-replete HLA-haploidentical HSCT has remarkable anti-leukemia/tumor effects on these patients, but also a high risk of severe/extensive graft-versus-host disease (GHVD). Post-transplantation cyclophosphamide (PTCY) is regarded as a GVHD-specific immunosuppressant in adults, but its feasibility is unknown in children. METHODS We performed a prospective feasibility study of PTCY at 50 mg/kg on day 3 for children with advanced leukemias or malignant solid tumors: refractory to chemotherapy or relapsed after conventional allogeneic HSCT. Conditioning consisted of fludarabine (180 mg/m2) and melphalan (140-210 mg/m2). RESULTS Long-term engraftments were achieved in 11 patients (73.3%) after bone marrow transplantation (BMT, n = 13) or peripheral blood (PB) stem cell transplantation (n = 2). The incidence of severe acute GHVD was 25.0% and that of extensive chronic GVHD 0.0% after evaluable BMT. CR was achieved in 6/15 and partial response in 4/15 as the best response. Finally, 11/15 experienced disease progression/relapse, 2/15 suffered treatment-related mortality without evidence of disease, and 2/15 are alive in continuous CR. CONCLUSIONS PTCY is feasible in children; however, for a better outcome in such patients with advanced malignancies, some modifications are anticipated.
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Affiliation(s)
- Akihisa Sawada
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health , Izumi City, Osaka , Japan
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12
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Imashuku S. Hemophagocytic lymphohistiocytosis: Recent progress in the pathogenesis, diagnosis and treatment. World J Hematol 2014; 3:71-84. [DOI: 10.5315/wjh.v3.i3.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 05/09/2014] [Accepted: 06/18/2014] [Indexed: 02/05/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome that develops as a primary (familial/hereditary) or secondary (non-familial/hereditary) disease characterized in the majority of the cases by hereditary or acquired impaired cytotoxic T-cell (CTL) and natural killer responses. The molecular mechanisms underlying impaired immune homeostasis have been clarified, particularly for primary diseases. Familial HLH (familial hemophagocytic lymphohistiocytosis type 2-5, Chediak-Higashi syndrome, Griscelli syndrome type 2, Hermansky-Pudlak syndrome type 2) develops due to a defect in lytic granule exocytosis, impairment of (signaling lymphocytic activation molecule)-associated protein, which plays a key role in CTL activity [e.g., X-linked lymphoproliferative syndrome (XLP) 1], or impairment of X-linked inhibitor of apoptosis, a potent regulator of lymphocyte homeostasis (e.g., XLP2). The development of primary HLH is often triggered by infections, but not in all. Secondary HLH develops in association with infection, autoimmune diseases/rheumatological conditions and malignancy. The molecular mechanisms involved in secondary HLH cases remain unknown and the pathophysiology is not the same as primary HLH. For either primary or secondary HLH cases, immunosuppressive therapy should be given to control the hypercytokinemia with steroids, cyclosporine A, or intravenous immune globulin, and if primary HLH is diagnosed, immunochemotherapy with a regimen containing etoposide or anti-thymocyte globulin should be started. Thereafter, allogeneic hematopoietic stem-cell transplantation is recommended for primary HLH or secondary refractory disease (especially EBV-HLH).
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13
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Sawada A, Inoue M, Koyama-Sato M, Kondo O, Yamada K, Shimizu M, Isaka K, Kimoto T, Kikuchi H, Tokimasa S, Yasui M, Kawa K. Umbilical cord blood as an alternative source of reduced-intensity hematopoietic stem cell transplantation for chronic Epstein-Barr virus-associated T or natural killer cell lymphoproliferative diseases. Biol Blood Marrow Transplant 2013; 20:214-21. [PMID: 24188918 DOI: 10.1016/j.bbmt.2013.10.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 10/30/2013] [Indexed: 12/20/2022]
Abstract
Chronic Epstein-Barr virus-associated T/natural killer cell lymphoproliferative diseases represented by chronic active Epstein-Barr virus infection are lethal but are curable with several courses of chemotherapy and allogeneic hematopoietic stem cell transplantation (HSCT). Recently, we reported that reduced-intensity conditioning (RIC) provided better outcomes than myeloablative conditioning because RIC was less toxic. However, it was unclear whether cord blood transplantation (CBT) works in the context of RIC. We retrospectively analyzed 17 patients who underwent RIC followed by bone marrow transplantation (RIC-BMT) and 15 patients who underwent RIC followed by CBT (RIC-CBT). The representative regimen was fludarabine and melphalan based. The overall survival rates with RIC-BMT and RIC-CBT were 92.9% ± 6.9% and 93.3% ± 6.4%, respectively (P = .87). One patient died of lung graft-versus-host disease after RIC-BMT, and 1 patient died of multiple viral infections after RIC-CBT. Although cytotoxic chemotherapy was also immunosuppressive and might contribute to better donor cell engraftment after RIC-HSCT, the rate of engraftment failure after RIC-CBT was still higher than that after RIC-BMT (not significant); however, patients who had experienced graft failure were successfully rescued with a second HSCT. Unrelated cord blood can be an alternative source for RIC-HSCT if a patient has no family donor.
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Affiliation(s)
- Akihisa Sawada
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan.
| | - Masami Inoue
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Maho Koyama-Sato
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Osamu Kondo
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Kayo Yamada
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Mariko Shimizu
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Kanako Isaka
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Tomiko Kimoto
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Hiroaki Kikuchi
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Sadao Tokimasa
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Masahiro Yasui
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Keisei Kawa
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
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14
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Kobayashi R, Tanaka J, Hashino S, Ota S, Torimoto Y, Kakinoki Y, Yamamoto S, Kurosawa M, Hatakeyama N, Haseyama Y, Sakai H, Sato K, Fukuhara T. Etoposide-containing conditioning regimen reduces the occurrence of hemophagocytic lymphohistiocytosis after SCT. Bone Marrow Transplant 2013; 49:254-7. [PMID: 24037021 DOI: 10.1038/bmt.2013.145] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/09/2013] [Accepted: 08/09/2013] [Indexed: 11/09/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening disease of severe hyperinflammation caused by uncontrolled proliferation of activated lymphocytes and macrophages that secrete high amounts of inflammatory cytokines. HLH occurring after SCT is difficult to diagnose. It is characterized by severe clinical manifestations and high mortality. Despite current therapeutic approaches, outcomes remain poor. We analyzed the incidence and risk factors of HLH after SCT and the response to treatment and prognosis of 554 patients with HLH after SCT. The cumulative incidence of HLH after SCT was 4.3% (24/554). Use of etoposide in the conditioning regimen was only factor that reduced HLH after SCT (P=0.027). All patients who received autologous transplantation were successfully treated. Patients with liver dysfunction (for example, high total bilirubin level, prolonged prothrombin time and high level of fibrinogen degradation products) had a poor response to treatment for HLH. Physicians should be cautious of HLH, while not using etoposide for conditioning regimen.
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Affiliation(s)
- R Kobayashi
- Department of Pediatrics, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - J Tanaka
- Stem Cell Transplantation Center, Hokkaido University Hospital, Sapporo, Japan
| | - S Hashino
- Stem Cell Transplantation Center, Hokkaido University Hospital, Sapporo, Japan
| | - S Ota
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Y Torimoto
- Third Department of Internal Medicine, Asahikawa Medical College, Asahikawa, Japan
| | - Y Kakinoki
- Department of Hematology, Asahikawa City Hospital, Asahikawa, Japan
| | - S Yamamoto
- Department of Hematology, Sapporo City General Hospital, Sapporo, Japan
| | - M Kurosawa
- Department of Hematology, National Hospital Organization Hokkaido Cancer Center, Sapporo, Japan
| | - N Hatakeyama
- Department of Pediatrics, Sapporo Medical College, Sapporo, Japan
| | - Y Haseyama
- Department of Hematology, KKR Sapporo Medical Center, Tonan Hospital, Sapporo, Japan
| | - H Sakai
- Department of Hematology, Teine Keijinkai Hospital, Sapporo, Japan
| | - K Sato
- Department of Hematology, Hokkaido P.W.F.A.C Asahikawa-Kosei General Hospital, Asahikawa, Japan
| | - T Fukuhara
- Department of Palliative Care Medicine, Hokkaido P.W.F.A.C Sapporo-Kosei General Hospital, Sapporo, Japan
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15
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Asano T, Kogawa K, Morimoto A, Ishida Y, Suzuki N, Ohga S, Kudo K, Ohta S, Wakiguchi H, Tabuchi K, Kato S, Ishii E. Hemophagocytic lymphohistiocytosis after hematopoietic stem cell transplantation in children: a nationwide survey in Japan. Pediatr Blood Cancer 2012; 59:110-4. [PMID: 22038983 DOI: 10.1002/pbc.23384] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 09/09/2011] [Indexed: 11/12/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is associated with hypercytokinemia in children. Although HLH can be also observed after hematopoietic stem cell transplantation (HSCT), the incidence and clinical features of HLH after HSCT remain obscure. PROCEDURE The clinical features of HLH after HSCT (post-HSCT HLH) were investigated in children with malignancies, immune deficiencies, or aplastic anemia. The HLH/Langerhans Cell Histiocytosis (LCH) Committee of the Japanese Society of Pediatric Hematology (JSPH) sent questionnaires to hospitals with JPSH members asking for details of cases in which HLH occurred after HSCT between 1998 and 2008. RESULTS Among 42 children who were diagnosed with post-HSCT HLH between 1998 and 2008 in Japan, 37 fulfilled our inclusion criteria; of these, 26 were classified as early-onset (onset <30 days after HSCT) and 11 were classified as late-onset (onset >30 days after HSCT). In the early-onset group, the presence of respiratory symptoms, high levels of total bilirubin, and triglycerides at onset and the lack of control of GVHD with tacrolimus were significantly associated with non-resolution of HLH (P < 0.05). The survival rate was significantly higher in patients with resolution of HLH than in those without resolution (59% vs. 14%, P < 0.05). CONCLUSIONS These findings suggest that early-onset post-HSCT HLH is a specific entity of HLH, and appropriate diagnosis and prompt management need to be established.
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Affiliation(s)
- Takeshi Asano
- Department of Pediatrics, Nippon Medical School, Chiba Hokusoh Hospital, Inzai City, Chiba, Japan.
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16
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Nishiwaki S, Nakayama T, Murata M, Nishida T, Sugimoto K, Saito S, Kato T, Mizuno H, Imahashi N, Seto A, Ozawa Y, Goto T, Koyama D, Yokohata E, Kubota N, Kamoshita S, Miyamura K, Matsumoto K, Ito M, Naoe T. Dexamethasone palmitate successfully attenuates hemophagocytic syndrome after allogeneic stem cell transplantation: macrophage-targeted steroid therapy. Int J Hematol 2012; 95:428-33. [PMID: 22351164 DOI: 10.1007/s12185-012-1023-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 01/30/2012] [Accepted: 01/31/2012] [Indexed: 11/28/2022]
Abstract
Hemophagocytic syndrome (HPS) induced by uncontrolled macrophage activation and subsequent graft failure is a frequent and prominent complication after allogeneic stem cell transplantation (allo-SCT), a cause of severe morbidity and death, and a therapeutic challenge. Liposome-incorporated dexamethasone, dexamethasone palmitate (DP), shows greater efficacy against macrophages as compared to dexamethasone sodium phosphate (DSP). Based on our findings that DP achieves significantly larger decrease than DSP on the viability of primary human macrophages compared in vitro, we tested the effects of DP in patients with HPS. A decrease in number of macrophages in the bone marrow and prevention of engraftment failure were observed in all patients without any severe complications. In conclusion, these data provide a rationale for testing DP as a first-line treatment for patients with HPS after allo-SCT.
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Affiliation(s)
- Satoshi Nishiwaki
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
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17
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Redjoul R, Toma A, Hicheri Y, Maaroufi HE, Maertens J, Vigouroux S, Lioure B, Machaczka M, Pautas C, Bories D, Wagner-Ballon O, Gaulard P, Martin-Garcia N, Maury S, Cordonnier C. Hemophagocytic syndrome after allogeneic hematopoietic cell transplantation: more a graft rejection than an infectious process? Eur J Haematol 2012; 88:458-60. [DOI: 10.1111/j.1600-0609.2012.01757.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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18
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Koh H, Nakane T, Sakamoto E, Katayama T, Nakamae H, Ohsawa M, Hino M. Serum cytokine profiles in hemophagocytic syndrome following allogeneic hematopoietic stem cell transplantation. Acta Haematol 2012; 127:182-5. [PMID: 22353648 DOI: 10.1159/000335536] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 12/14/2011] [Indexed: 11/19/2022]
Affiliation(s)
- Hideo Koh
- Department of Hematology, Graduate School of Medicine, Osaka City University, Japan
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19
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Clinical significance of hemophagocytosis in BM clot sections during the peri-engraftment period following allogeneic hematopoietic SCT. Bone Marrow Transplant 2011; 47:387-94. [PMID: 21499316 DOI: 10.1038/bmt.2011.95] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The effects of macrophage activation on the outcome of allogeneic hematopoietic SCT (allo-HSCT) have yet to be fully examined. A total of 70 adult patients who received a first allo-HSCT for hematological diseases were studied. We counted the number of hemophagocytic cells in BM clot sections on day +14±7, and analyzed its impact on subsequent outcome. In all, 23 patients were diagnosed as having increased numbers of hemophagocytic cells (HP group), whereas 47 were not (non-HP group). The HP group was not associated with an increased incidence of acute or chronic GVHD, but was associated with worse hematopoietic recovery than the non-HP group. The 2-year OS for the HP group and the non-HP group was 30 and 65% (P<0.01), respectively, and 2-year non-relapse mortality was 48% and 27% (P<0.01), respectively. Multivariate analysis confirmed that the HP group was associated with a lower OS (hazard ratio (HR)=2.3; 95% confidence interval (CI), 1.0-5.4; P=0.048) and higher non-relapse mortality (HR=4.0; 95% CI, 1.6-9.9; P<0.01). The HP group had higher incidences of death due to graft failure (P<0.01) and endothelial complications, such as sinusoidal obstruction syndrome and transplant-associated microangiopathy (P=0.01). Macrophage activation is a previously unrecognized complication with negative impact on outcome of allo-HSCT.
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20
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Successful treatment with combined chemotherapy of two adult cases of hemophagocytic lymphohistiocytosis in recipients of umbilical cord blood cell transplantation. Int J Hematol 2011; 93:551-554. [DOI: 10.1007/s12185-011-0792-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 02/10/2011] [Accepted: 02/10/2011] [Indexed: 10/18/2022]
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21
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Takagi S, Masuoka K, Uchida N, Ishiwata K, Araoka H, Tsuji M, Yamamoto H, Kato D, Matsuhashi Y, Kusumi E, Ota Y, Seo S, Matsumura T, Matsuno N, Wake A, Miyakoshi S, Makino S, Ohashi K, Yoneyama A, Taniguchi S. High incidence of haemophagocytic syndrome following umbilical cord blood transplantation for adults. Br J Haematol 2009; 147:543-53. [PMID: 19709082 DOI: 10.1111/j.1365-2141.2009.07863.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Umbilical cord blood transplantation (CBT) is widely accepted, but one critical issue for adult patients is a low engraftment rate, of which one cause is haemophagocytic syndrome (HPS). We aimed to identify the contribution of HPS to engraftment failure after CBT, following preparative regimens containing fludarabine phosphate, in 119 patients (median age, 55 years; range; 17-69 years) with haematological diseases. Graft-versus-host disease prophylaxis comprised continuous infusion of a calcineurin inhibitor with or without mycophenolate mofetil. Of the 119 patients, 20 developed HPS within a median of 15 d (cumulative incidence; 16.8%) and 17 of them did so before engraftment. Donor-dominant chimaerism was confirmed in 16 of 18 evaluable patients with HPS. Despite aggressive interventions including corticosteroid, ciclosporin, high-dose immunoglobulin and/or etoposide, engraftment failed in 14 of 18 patients. Of these 14 patients, four received second rescue transplantation and all resulted in successful engraftment. Overall survival rates significantly differed between patients with and without HPS (15.0% vs. 35.4%; P < 0.01). Univariate and multivariate analysis identified having fewer infused CD34(+) cells as a significant risk factor for the development of HPS (P = 0.01 and 0.006, respectively). We concluded that engraftment failure closely correlated with HPS in our cohort, which negatively impacted overall survival after CBT.
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Ponticelli C, Alberighi ODC. Haemophagocytic syndrome--a life-threatening complication of renal transplantation. Nephrol Dial Transplant 2009; 24:2623-7. [PMID: 19525363 DOI: 10.1093/ndt/gfp282] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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