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Janscak M, Stelmes A, van den Berg J, Heim D, Halter J, Drexler B, Arranto C, Passweg J, Medinger M. Influence of comorbidities on outcome in 1102 patients with an allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2024:10.1038/s41409-024-02395-z. [PMID: 39138337 DOI: 10.1038/s41409-024-02395-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 07/29/2024] [Accepted: 08/06/2024] [Indexed: 08/15/2024]
Abstract
The hematopoietic comorbidity risk index (HCT-CI) is a pre-transplant risk assessment tool used to qualify comorbidities to predict non-relapse mortality (NRM) of patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT). HSCT procedures continue to improve. Therefore, the predictive value of HCT-CI needs to be re-evaluated. Our study is a retrospective analysis of pre-existing comorbidities assessing the relevance of the HCT-CI on the outcome of consecutive patients (n = 1102) undergoing allo-HSCT from 2006-2021. HCT-CI was classified as low (HCT-CI 0), intermediate (HCT-CI 1-2) and high-risk (HCT-CI ≥ 3). At 10 years, NRM for low, intermediate, and high-risk HCT-CI group was 21.0%, 26.0%, and 25.8% (p = 0.04). NRM difference was significant between low to intermediate (p < 0.001), but not between intermediate to high-risk HCT-CI (p = 0.22). Overall survival (OS) at 10 years differed significantly with 49.9%, 39.8%, and 31.1%, respectively (p < 0.001). In multivariate analysis of HCT-CI organ subgroups, cardiac disease was most strongly associated with NRM (HR = 1.73, p = 0.02) and OS (HR = 1.77, p < 0.001). All other individual organ comorbidities influenced NRM to a lesser extent. Further, donor (HR = 2.20, p < 0.001 for unrelated and HR = 2.17, p = 0.004 for mismatched related donor), disease status (HR = 1.41, p = 0.03 for advanced disease) and previous HSCT (HR = 1.55, p = 0.009) were associated with NRM. Improvement in transplant techniques and supportive care may have improved outcome with respect to comorbidities.
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Affiliation(s)
- Marie Janscak
- Division of Hematology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Anne Stelmes
- Division of Hematology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Jana van den Berg
- Division of Hematology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Dominik Heim
- Division of Hematology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Joerg Halter
- Division of Hematology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Beatrice Drexler
- Division of Hematology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Jakob Passweg
- Division of Hematology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Michael Medinger
- Division of Hematology, University Hospital Basel, Basel, Switzerland.
- University of Basel, Basel, Switzerland.
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2
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Nikoloudis A, Buxhofer-Ausch V, Aichinger C, Binder M, Hasengruber P, Kaynak E, Wipplinger D, Milanov R, Strassl I, Stiefel O, Machherndl-Spandl S, Petzer A, Weltermann A, Clausen J. Impact of early cyclosporine A levels on acute graft-versus-host disease in allogeneic hematopoietic stem cell transplantation using in vivo T-cell depletion. Cytotherapy 2024; 26:490-497. [PMID: 38385908 DOI: 10.1016/j.jcyt.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/25/2024] [Accepted: 02/08/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND AIMS Cyclosporin A (CsA) remains a major component of immunosuppressive regimens applied in allogeneic hematopoietic stem cell transplantation (HSCT). The impact of CsA trough levels during the first weeks after HSCT has not yet been investigated specifically in anti-T-lymphocyte globulin (ATLG)-based HSCT from matched related and unrelated donors. METHODS To address this issue, we have retrospectively examined 307 consecutive matched related (n = 145) and unrelated (n = 162) HSCTs, using peripheral blood stem cells or bone marrow. HSCTs for active, uncontrolled malignancies were excluded. The initial three weeks' average mean CsA trough levels were analyzed in landmark and multi-state models, using a cut-off of 200 ng/mL. RESULTS CsA levels >200 ng/mL were associated with a reduced risk of acute graft-versus-host disease (GVHD) grade 3-4 at the first-week landmark (subdistribution hazard ratio [SHR] 0.59, P = 0.03) and the second-week landmark (SHR 0.48, P = 0.004), whereas there was no impact at the third-week landmark (HR 0.87, P = 0.69). This was supported by a multi-state model, in which week 1 (hazard ratio [HR] 0.53, P = 0.006) and week 2 (HR 0.48, P = 0.003), but not week 3 (HR 0.80, P = 0.44) CsA levels >200 ng/mL were associated with a reduced acute GVHD 3-4 risk. Relapse incidence was not significantly affected by week 1 through 3 CsA levels. Despite ATLG's inherent GVHD-preventive properties, week 1 CsA trough levels >200 ng/mL following ATLG-based HSCT (n = 220) were associated with a significantly reduced risk of non-relapse mortality (SHR 0.52, P = 0.02) and improved overall survival (HR 0.61, P = 0.02). CONCLUSIONS Our findings emphasize the continuing importance of ensuring CsA levels ≥200 ng/mL immediately post-transplant in the setting of ATLG-based HSCT.
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Affiliation(s)
- Alexander Nikoloudis
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria; Medical Faculty, Johannes Kepler University, Linz, Austria.
| | - Veronika Buxhofer-Ausch
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria; Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Christoph Aichinger
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria
| | - Michaela Binder
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria
| | - Petra Hasengruber
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria
| | - Emine Kaynak
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria
| | - Dagmar Wipplinger
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria
| | - Robert Milanov
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria
| | - Irene Strassl
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria; Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Olga Stiefel
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria; Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Sigrid Machherndl-Spandl
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria; Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Andreas Petzer
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria; Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Ansgar Weltermann
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria; Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Johannes Clausen
- Department of Internal Medicine I: Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz - Elisabethinen, Linz, Austria; Medical Faculty, Johannes Kepler University, Linz, Austria
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3
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Och K, Turki AT, Götz KM, Selzer D, Brossette C, Theobald S, Braun Y, Graf N, Rauch J, Rohm K, Weiler G, Kiefer S, Schwarz U, Eisenberg L, Pfeifer N, Ihle M, Grandjean A, Fix S, Riede C, Rissland J, Smola S, Beelen DW, Kaddu‐Mulindwa D, Bittenbring J, Lehr T. A dynamic time-to-event model for prediction of acute graft-versus-host disease in patients after allogeneic hematopoietic stem cell transplantation. Cancer Med 2024; 13:e6833. [PMID: 38132807 PMCID: PMC10807572 DOI: 10.1002/cam4.6833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/26/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Acute graft-versus-host disease (aGvHD) is a major cause of death for patients following allogeneic hematopoietic stem cell transplantation (HSCT). Effective management of moderate to severe aGvHD remains challenging despite recent advances in HSCT, emphasizing the importance of prophylaxis and risk factor identification. METHODS In this study, we analyzed data from 1479 adults who underwent HSCT between 2005 and 2017 to investigate the effects of aGvHD prophylaxis and time-dependent risk factors on the development of grades II-IV aGvHD within 100 days post-HSCT. RESULTS Using a dynamic longitudinal time-to-event model, we observed a non-monotonic baseline hazard overtime with a low hazard during the first few days and a maximum hazard at day 17, described by Bateman function with a mean transit time of approximately 11 days. Multivariable analysis revealed significant time-dependent effects of white blood cell counts and cyclosporine A exposure as well as static effects of female donors for male recipients, patients with matched related donors, conditioning regimen consisting of fludarabine plus total body irradiation, and patient age in recipients of grafts from related donors on the risk to develop grades II-IV aGvHD. Additionally, we found that higher cumulative hazard on day 7 after allo-HSCT are associated with an increased incidence of grades II-IV aGvHD within 100 days indicating that an individual assessment of the cumulative hazard on day 7 could potentially serve as valuable predictor for later grades II-IV aGvHD development. Using the final model, stochastic simulations were performed to explore covariate effects on the cumulative incidence over time and to estimate risk ratios. CONCLUSION Overall, the presented model showed good descriptive and predictive performance and provides valuable insights into the interplay of multiple static and time-dependent risk factors for the prediction of aGvHD.
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Affiliation(s)
- Katharina Och
- Department of Clinical PharmacySaarland UniversitySaarbrückenGermany
| | - Amin T. Turki
- Department of Hematology and Stem Cell Transplantation, West‐German Cancer CenterUniversity Hospital EssenEssenGermany
| | - Katharina M. Götz
- Department of Clinical PharmacySaarland UniversitySaarbrückenGermany
| | - Dominik Selzer
- Department of Clinical PharmacySaarland UniversitySaarbrückenGermany
| | - Christian Brossette
- Department of Pediatric Oncology and HematologySaarland UniversityHomburgGermany
| | - Stefan Theobald
- Department of Pediatric Oncology and HematologySaarland UniversityHomburgGermany
| | - Yvonne Braun
- Department of Pediatric Oncology and HematologySaarland UniversityHomburgGermany
| | - Norbert Graf
- Department of Pediatric Oncology and HematologySaarland UniversityHomburgGermany
| | - Jochen Rauch
- Department of Biomedical Data & BioethicsFraunhofer Institute for Biomedical Engineering (IBMT)SulzbachGermany
| | - Kerstin Rohm
- Department of Biomedical Data & BioethicsFraunhofer Institute for Biomedical Engineering (IBMT)SulzbachGermany
| | - Gabriele Weiler
- Department of Biomedical Data & BioethicsFraunhofer Institute for Biomedical Engineering (IBMT)SulzbachGermany
| | - Stephan Kiefer
- Department of Biomedical Data & BioethicsFraunhofer Institute for Biomedical Engineering (IBMT)SulzbachGermany
| | - Ulf Schwarz
- Institute for Formal Ontology and Medical Information ScienceSaarland UniversitySaarbrückenGermany
| | - Lisa Eisenberg
- Department of Computer ScienceUniversity of TübingenTübingenGermany
| | - Nico Pfeifer
- Department of Computer ScienceUniversity of TübingenTübingenGermany
| | | | | | | | | | - Jürgen Rissland
- Institute of VirologySaarland University Medical CentreHomburgGermany
| | - Sigrun Smola
- Institute of VirologySaarland University Medical CentreHomburgGermany
- Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI)Saarland University CampusSaarbrückenGermany
| | - Dietrich W. Beelen
- Department of Hematology and Stem Cell Transplantation, West‐German Cancer CenterUniversity Hospital EssenEssenGermany
| | | | - Jörg Bittenbring
- Department of Internal Medicine 1University Hospital of the SaarlandHomburgGermany
| | - Thorsten Lehr
- Department of Clinical PharmacySaarland UniversitySaarbrückenGermany
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4
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Lisak M, Nicklasson M, Palmason R, Wichert S, Isaksson C, Andersson PO, Johansson JE, Lenhoff S, Brune M, Hansson M. Higher cyclosporine-A concentration increases the risk of relapse in AML following allogeneic stem cell transplantation from unrelated donors using anti-thymocyte globulin. Sci Rep 2023; 13:22777. [PMID: 38123675 PMCID: PMC10733303 DOI: 10.1038/s41598-023-50105-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
Cyclosporine-A (CsA) is used to prevent acute graft-versus-host disease (aGvHD). European Society for Blood and Marrow transplantation (EBMT) recommends a CsA target serum concentration of 200-300 µg/L during the first month after allogeneic hematopoietic stem cell transplantation (HSCT). With this study, we investigated whether a median CsA concentration > 200 µg/L (CsAhigh) the first month after HSCT, compared to ≤ 200 µg/L (CsAlow), increased the relapse risk of acute myloid leukemia (AML), using unrelated donors (URD) and antithymocyte globulin (ATG). Data was collected from 157 patients with AML, transplanted 2010-2016. The cumulative incidence of relapse (CIR) at 60 months was 50% in the CsAhigh versus 32% in the CsAlow group (p = 0.016). In univariate analysis, CsAhigh versus CsAlow (p = 0.028), 10-unit increase of CsA as a continuous variable (p = 0.017) and high risk disease (p = 0.003) were associated with higher CIR. The results remained after adjusting for disease risk. Death following relapse occurred more frequently in the CsAhigh group (p = 0.0076). There were no significant differences in rates of aGvHD, chronic GvHD (cGvHD), EBV/CMV-infections or overall survival (OS) between the two groups. In conclusion, we found that a median CsA concentration > 200 µg/L, the first month after HSCT, results in higher CIR of AML when combined with ATG.
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Affiliation(s)
- Mikael Lisak
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden.
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
| | - Malin Nicklasson
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
| | - Robert Palmason
- Department of Hematology, Skane University Hospital, Lund, Sweden
| | - Stina Wichert
- Department of Hematology, Skane University Hospital, Lund, Sweden
| | - Cecila Isaksson
- Department of Hematology, Norrland University Hospital, Umeå, Sweden
| | - Per-Ola Andersson
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jan-Erik Johansson
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Stig Lenhoff
- Department of Hematology, Skane University Hospital, Lund, Sweden
| | - Mats Brune
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Markus Hansson
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Hematology, Skane University Hospital, Lund, Sweden
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5
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Feng H, Wang X, Zheng W, Liu S, Jiang H, Lin Y, Qiu H, Chan TF, Huang M, Li Y, Mo X, Li J. Initial dosage optimisation of cyclosporine in Chinese paediatric patients undergoing allogeneic haematopoietic stem cell transplantation based on population pharmacokinetics: a retrospective study. BMJ Paediatr Open 2023; 7:e002003. [PMID: 37643815 PMCID: PMC10465907 DOI: 10.1136/bmjpo-2023-002003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/13/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE Improved understanding of cyclosporine A (CsA) pharmacokinetics in children undergoing allogeneic haematopoietic stem cell transplantation (allo-HSCT) is crucial for effective prevention of acute graft-versus-host disease and medication safety. The aim of this study was to establish a population pharmacokinetic (Pop-PK) model that could be used for individualised therapy to paediatric patients undergoing allo-HSCT in China. DESIGN, SETTING AND PARTICIPANTS A retrospective analysis of 251 paediatric HSCT patients who received CsA intravenously in the early post transplantation period at Women and Children's Medical Center in Guangzhou was conducted. ANALYSIS MEASURES The model building dataset from 176 children was used to develop and analyse the CsA Pop-Pk model by using the nonlinear mixed effect model method. The basic information was collected by the electronic medical record system. Genotype was analysed by matrix-assisted time-of-flight mass spectrometry. The stability and predictability of the final model were verified internally, and a validation dataset of 75 children was used for external validation. Monte Carlo simulation is used to adjust and optimise the initial dose of CsA in paediatric allo-HSCT patients. RESULTS The typical values for clearance (CL) and volume of distribution ([Formula: see text]) were 14.47 L/hour and 2033.53 L, respectively. The body weight and haematocrit were identified as significant variables for V, while only body weight had an impact on CL. The simulation based on the final model suggests that paediatrics with HSCT required an appropriate intravenous dose of 5 mg/kg/day to reach the therapeutic trough concentration. CONCLUSIONS The CsA Pop-PK model established in this study can quantitatively describe the factors influencing pharmacokinetic parameters and precisely predict the intrinsic exposure to CsA in children. In addition, our dosage simulation results can provide evidence for the personalised medications TRIAL REGISTRATION NUMBER: ChiCTR2000040561.
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Affiliation(s)
- Huanwen Feng
- Institute of Clinical Pharmacology, Sun Yat-Sen University School of Pharmaceutical Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, Sun Yat-Sen University School of Pharmaceutical Sciences, Guangzhou, Guangdong, China
| | - Xianggui Wang
- Institute of Clinical Pharmacology, Sun Yat-Sen University School of Pharmaceutical Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, Sun Yat-Sen University School of Pharmaceutical Sciences, Guangzhou, Guangdong, China
| | - Wei Zheng
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Sha Liu
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hua Jiang
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yuxian Lin
- Department of Pharmacy, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Haojie Qiu
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Teng Fong Chan
- Institute of Clinical Pharmacology, Sun Yat-Sen University School of Pharmaceutical Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, Sun Yat-Sen University School of Pharmaceutical Sciences, Guangzhou, Guangdong, China
| | - Min Huang
- Institute of Clinical Pharmacology, Sun Yat-Sen University School of Pharmaceutical Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, Sun Yat-Sen University School of Pharmaceutical Sciences, Guangzhou, Guangdong, China
| | - Yan Li
- Guangzhou Cord Blood Bank, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xiaolan Mo
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jiali Li
- Institute of Clinical Pharmacology, Sun Yat-Sen University School of Pharmaceutical Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, Sun Yat-Sen University School of Pharmaceutical Sciences, Guangzhou, Guangdong, China
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6
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Kero AE, Taskinen M, Volin L, Löyttyniemi E, Itälä-Remes M, Lähteenmäki PM. Cardiovascular morbidity following conventional therapy versus allogeneic hematopoietic stem cell transplantation after childhood, adolescent, and young adult leukemia in Finland. Int J Cancer 2023; 152:2292-2302. [PMID: 36760204 DOI: 10.1002/ijc.34469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 11/29/2022] [Accepted: 12/15/2022] [Indexed: 02/11/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (aHSCT) represents a therapeutic choice for high-risk and relapsed leukemia at a young age. In this retrospective population-based study, we evaluated cardiovascular complications after aHSCT (N = 272) vs conventional therapy (N = 1098) among patients diagnosed with acute lymphoblastic or acute myeloid leukemia below 35 years between 1985 and 2004. Additionally, siblings from a prior comparison group served as population controls (N = 39 217). Childhood leukemia and aHSCT was associated with a 16-fold HR for developing arterial hypertension (HR 16.8, 95%CI 1.5-185.5) compared with conventional therapy. A 2-fold HR for any cardiovascular complication was observed after AYA leukemia and aHSCT vs conventional treatment (HR 2.7, 95% CI 1.4-5.1). After AYA leukemia and aHSCT, the HR of cardiac arrhythmia was significantly elevated vs conventional therapy (HR 14.4, 95% CI 1.5-125.2). Moreover, after aHSCT in childhood, elevated hazard ratios (HRs) were found for cardiomyopathy/ cardiac insufficiency (HR 105.0, 95% CI 10.0-1100.0), cardiac arrhythmia, and arterial hypertension (HR 20.1, 95%CI 2.5-159.7 and HR 20.0, 95%CI 4.1-97.4) compared with healthy controls. After adolescent and young adult (AYA) leukemia and aHSCT, markedly increased HRs were observed for cardiac arrhythmia (HR 29.2, 95%CI 6.6-129.2), brain vascular thrombosis/ atherosclerosis and cardiomyopathy/cardiac insufficiency (HR 23.4, 95%CI 7.1-77.4 and HR 19.2, 95%CI 1.5-245.2) compared with healthy controls. As the cumulative incidence for cardiovascular complications rose during the follow-up of childhood and AYA leukemia patients, long-term cardiovascular surveillance is warranted to optimize the quality of life after childhood and AYA leukemia following both conventional treatment and aHSCT.
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Affiliation(s)
- Andreina E Kero
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, and Turku University, Turku, Finland
| | - Mervi Taskinen
- New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Liisa Volin
- Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland
| | | | - Maija Itälä-Remes
- Department of Internal Medicine, Turku University Hospital, Turku, Finland
| | - Päivi M Lähteenmäki
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, and Turku University, Turku, Finland
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7
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Song L, Huang CR, Pan SZ, Zhu JG, Cheng ZQ, Yu X, Xue L, Xia F, Zhang JY, Wu DP, Miao LY. A model based on machine learning for the prediction of cyclosporin A trough concentration in Chinese allo-HSCT patients. Expert Rev Clin Pharmacol 2023; 16:83-91. [PMID: 36373407 DOI: 10.1080/17512433.2023.2142561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cyclosporin A is a calcineurin inhibitor which has a narrow therapeutic window and high interindividual variability. Various population pharmacokinetic models have been reported; however, professional software and technical personnel were needed and the variables of the models were limited. Therefore, the aim of this study was to establish a model based on machine learning to predict CsA trough concentrations in Chinese allo-HSCT patients. METHODS A total of 7874 cases of CsA therapeutic drug monitoring data from 2069 allo-HSCT patients were retrospectively included. Sequential forward selection was used to select variable subsets, and eight different algorithms were applied to establish the prediction model. RESULTS XGBoost exhibited the highest prediction ability. Except for the variables that were identified by previous studies, some rarely reported variables were found, such as norethindrone, WBC, PAB, and hCRP. The prediction accuracy within ±30% of the actual trough concentration was above 0.80, and the predictive ability of the models was demonstrated to be effective in external validation. CONCLUSION In this study, models based on machine learning technology were established to predict CsA levels 3-4 days in advance during the early inpatient phase after HSCT. A new perspective for CsA clinical application is provided.
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Affiliation(s)
- Lin Song
- Department of Pharmacy, the First Affiliated Hospital of Soochow University, Suzhou, China.,College of Pharmaceutical Sciences, Soochow University, Suzhou, China
| | - Chen-Rong Huang
- Department of Pharmacy, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shi-Zheng Pan
- Department of Pharmacy, the First Affiliated Hospital of Soochow University, Suzhou, China.,College of Pharmaceutical Sciences, Soochow University, Suzhou, China
| | - Jian-Guo Zhu
- Department of Pharmacy, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zong-Qi Cheng
- Department of Pharmacy, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xun Yu
- Department of Pharmacy, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ling Xue
- Department of Pharmacy, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Fan Xia
- Department of Pharmacy, the First Affiliated Hospital of Soochow University, Suzhou, China
| | | | - De-Pei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Li-Yan Miao
- Department of Pharmacy, the First Affiliated Hospital of Soochow University, Suzhou, China.,College of Pharmaceutical Sciences, Soochow University, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
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8
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Saillard C, Legal PH, Furst S, Bisbal M, Servan L, Sannini A, Gonzalez F, Faucher M, Vey N, Blaise D, Chow-Chine L, Mokart D. Feasibility of Cyclosporine Prophylaxis Withdrawal in Critically Ill Allogenic Hematopoietic Stem Cell Transplant Patients Admitted to the Intensive Care Unit With No GVHD. Transplant Cell Ther 2022; 28:783.e1-783.e10. [DOI: 10.1016/j.jtct.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 11/12/2022]
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9
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Optimized cyclosporine starting dose may reduce risk of acute GvHD after allogeneic hematopoietic cell transplantation: a single-center cohort study. Bone Marrow Transplant 2022; 57:613-619. [PMID: 35132203 PMCID: PMC8993684 DOI: 10.1038/s41409-022-01598-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 11/19/2022]
Abstract
Cyclosporine A (CsA) is commonly used for Graft versus Host Disease (GvHD) prophylaxis at a recommended starting dose of 3 mg/kg/d: Evidence for the effect of different CsA starting doses on GvHD risk is limited. We therefore estimated the association of 5 mg/kg/d (CsA5) and 3 mg/kg/d (CsA3) CsA starting doses with GvHD risk in two consecutive cohorts of allogeneic hematopoietic cell transplantation (allo-HCT) patients, exploring potential risk factors for incident acute GvHD, with a focus on CsA starting dose. We analyzed 519 patients within CsA5 (n = 153) and CsA3 (n = 366). The cumulative incidence function of acute GvHD grade ≥2 was higher in the CsA3 compared to the CsA5 group (41% vs. 33%, respectively; p = 0.043), without impacting chronic GvHD. In multivariable analysis, a CsA starting dose of 3 mg/kg/d, no ATG use, unrelated donor and high to very high disease risk index were significantly associated with acute GvHD grade ≥2. A higher CsA starting dose of 5 mg/kg/d was independently associated with lower acute GvHD risk, and higher CsA levels in the early period after allo-HCT were reached.
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10
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Stutz L, Halter JP, Heim D, Passweg JR, Medinger M. Low Incidence of hepatic sinusoidal obstruction syndrome/veno-occlusive disease in adults undergoing allogenic stem cell transplantation with prophylactic ursodiol and low-dose heparin. Bone Marrow Transplant 2022; 57:391-398. [PMID: 34980902 PMCID: PMC8907064 DOI: 10.1038/s41409-021-01546-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/21/2021] [Accepted: 11/13/2021] [Indexed: 11/09/2022]
Abstract
Hepatic sinusoidal obstruction syndrome (SOS)/veno-occlusive disease (VOD) is a complication after allogenic hematopoietic stem-cell transplantation (allo-HSCT) with high mortality. The purpose of this study was to assess the incidence and outcome of SOS in patients after allo-HSCT with the impact of ursodeoxycholic acid (UDCA) and low-dose heparin as SOS prophylaxis. Out of 1016 patients, 23 developed SOS, with a cumulative incidence of 2.3% (95% CI 1.3-3.3) 6 months after HSCT. Approximately one quarter of these patients (26.1%) had late-onset SOS. A high proportion were very severe SOS cases (74%), and 83% of the patients were treated with defibrotide (DF). In multivariate analysis, advanced disease (p = 0.003), previous HSCT (p = 0.025) and graft versus host disease (GvHD) prophylaxis by post-transplant cyclophosphamide (PTCy) (p = 0.055) were associated with the development of SOS. The 1-year overall survival (OS) was significantly lower in the SOS group compared to patients without SOS (13% versus 70%, p = 0.0001). In conclusion, we found a low incidence of SOS in patients receiving low-dose heparin and UDCA prophylactically, but among SOS patients, a high mortality. Low-dose heparin and UDCA might be a prophylactic approach for SOS.
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Affiliation(s)
- Lina Stutz
- grid.410567.1Division of Hematology, University Hospital Basel,, Basel, Switzerland ,grid.6612.30000 0004 1937 0642University of Basel, Basel, Switzerland
| | - Jörg P. Halter
- grid.410567.1Division of Hematology, University Hospital Basel,, Basel, Switzerland ,grid.6612.30000 0004 1937 0642University of Basel, Basel, Switzerland
| | - Dominik Heim
- grid.410567.1Division of Hematology, University Hospital Basel,, Basel, Switzerland ,grid.6612.30000 0004 1937 0642University of Basel, Basel, Switzerland
| | - Jakob R. Passweg
- grid.410567.1Division of Hematology, University Hospital Basel,, Basel, Switzerland ,grid.6612.30000 0004 1937 0642University of Basel, Basel, Switzerland
| | - Michael Medinger
- Division of Hematology, University Hospital Basel,, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
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11
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Leclerc V, Ducher M, Ceraulo A, Bertrand Y, Bleyzac N. A Clinical Decision Support Tool to Find the Best Initial Intravenous Cyclosporine Regimen in Pediatric Hematopoietic Stem Cell Transplantation. J Clin Pharmacol 2021; 61:1485-1492. [PMID: 34105165 DOI: 10.1002/jcph.1924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/04/2021] [Indexed: 12/20/2022]
Abstract
To optimize cyclosporine A (CsA) dosing regimen in pediatric patients undergoing hematopoietic stem cell transplantation (HSCT), we aimed to provide clinicians with a validated decision support tool for determining the most suitable first dose of intravenous CsA. We used a 10-year monocentric data set of pediatric patients undergoing HSCT. Discretization of all variables was performed according to literature or thanks to algorithms using Shannon entropy (from information theory) or equal width intervals. The first 8 years were used to build the Bayesian network model. This model underwent a 10-fold cross-validation, and then a prospective validation with data of the last 2 years. There were 3.3% and 4.1% of missing values in the training and the validation data set, respectively. After prospective validation, the Tree-Augmented Naïve Bayesian network shows interesting prediction performances with an average area under the receiver operating characteristic curve of 0.804, 32.8% of misclassified patients, a true-positive rate of 0.672, and a false-positive rate of 0.285. This validated model allows good predictions to propose an optimized and personalized initial CsA dose for pediatric patients undergoing HSCT. The clinical impact of its use should be further evaluated.
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Affiliation(s)
- Vincent Leclerc
- Targeted Therapies in Oncology, Faculté de Médecine et de Maïeutique Lyon-Sud Charles Mérieux, Université Claude Bernard Lyon 1, Oullins, France.,Pharmacy Department, Hôpital Pierre Garraud, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Michel Ducher
- Targeted Therapies in Oncology, Faculté de Médecine et de Maïeutique Lyon-Sud Charles Mérieux, Université Claude Bernard Lyon 1, Oullins, France.,Pharmacy Department, Hôpital Pierre Garraud, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Antony Ceraulo
- Institute of Pediatric Hematology and Oncology (IHOPe), Hematology Unit, Hospices Civils de Lyon and Claude Bernard University, Lyon, France
| | - Yves Bertrand
- Institute of Pediatric Hematology and Oncology (IHOPe), Hematology Unit, Hospices Civils de Lyon and Claude Bernard University, Lyon, France
| | - Nathalie Bleyzac
- Targeted Therapies in Oncology, Faculté de Médecine et de Maïeutique Lyon-Sud Charles Mérieux, Université Claude Bernard Lyon 1, Oullins, France
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12
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Wölfl M, Qayed M, Benitez Carabante MI, Sykora T, Bonig H, Lawitschka A, Diaz-de-Heredia C. Current Prophylaxis and Treatment Approaches for Acute Graft-Versus-Host Disease in Haematopoietic Stem Cell Transplantation for Children With Acute Lymphoblastic Leukaemia. Front Pediatr 2021; 9:784377. [PMID: 35071133 PMCID: PMC8771910 DOI: 10.3389/fped.2021.784377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Acute graft-versus-host disease (aGvHD) continues to be a leading cause of morbidity and mortality following allogeneic haematopoietic stem cell transplantation (HSCT). However, higher event-free survival (EFS) was observed in patients with acute lymphoblastic leukaemia (ALL) and grade II aGvHD vs. patients with no or grade I GvHD in the randomised, controlled, open-label, international, multicentre Phase III For Omitting Radiation Under Majority age (FORUM) trial. This finding suggests that moderate-severity aGvHD is associated with a graft-versus-leukaemia effect which protects against leukaemia recurrence. In order to optimise the benefits of HSCT for leukaemia patients, reduction of non-relapse mortality-which is predominantly caused by severe GvHD-is of utmost importance. Herein, we review contemporary prophylaxis and treatment options for aGvHD in children with ALL and the key challenges of aGvHD management, focusing on maintaining the graft-versus-leukaemia effect without increasing the severity of GvHD.
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Affiliation(s)
- Matthias Wölfl
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Children's Hospital, Würzburg University Hospital, Würzburg, Germany
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Maria Isabel Benitez Carabante
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Tomas Sykora
- Haematopoietic Stem Cell Transplantation Unit, Department of Pediatric Haematology and Oncology, Comenius University Children's Hospital, Bratislava, Slovakia
| | - Halvard Bonig
- Institute for Transfusion Medicine and Immunohematology, Goethe-University Frankfurt/Main, Frankfurt, Germany.,German Red Cross Blood Service BaWüHe, Frankfurt, Germany
| | - Anita Lawitschka
- Department of Pediatrics, St. Anna Kinderspital and Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - Cristina Diaz-de-Heredia
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
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13
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Małyszko J, Bamias A, Danesh FR, Dębska-Ślizień A, Gallieni M, Gertz MA, Kielstein JT, Tesarova P, Wong G, Cheung M, Wheeler DC, Winkelmayer WC, Porta C. KDIGO Controversies Conference on onco-nephrology: kidney disease in hematological malignancies and the burden of cancer after kidney transplantation. Kidney Int 2020; 98:1407-1418. [PMID: 33276867 DOI: 10.1016/j.kint.2020.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 06/02/2020] [Accepted: 07/02/2020] [Indexed: 01/01/2023]
Abstract
The bidirectional relationship between cancer and chronic kidney disease (CKD) is complex. Patients with cancer, particularly those with hematological malignancies such as multiple myeloma and lymphoma, are at increased risk of developing acute kidney injury and CKD. On the other hand, emerging evidence from large observational registry analyses have consistently shown that cancer risk is increased by at least 2- to 3-fold in kidney transplant recipients, and the observed increased risk occurs not only in those who have received kidney transplants but also in those on dialysis and with mild- to moderate-stage CKD. The interactions between cancer and CKD have raised major therapeutic and clinical challenges in the management of these patients. Given the magnitude of the problem and uncertainties, and current controversies within the existing evidence, Kidney Disease: Improving Global Outcomes (KDIGO) assembled a global panel of multidisciplinary clinical and scientific expertise for a controversies conference on onco-nephrology to identify key management issues in nephrology relevant to patients with malignancy. This report covers the discussed controversies in kidney disease in hematological malignancies, as well as cancer after kidney transplantation. An overview of future research priorities is also discussed.
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Affiliation(s)
- Jolanta Małyszko
- Department of Nephrology, Dialysis, and Internal Medicine, Medical University of Warsaw, Poland
| | - Aristotelis Bamias
- Second Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Greece
| | - Farhad R Danesh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alicja Dębska-Ślizień
- Clinical Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, Luigi Sacco Department of Biomedical and Clinical Sciences, Università di Milano, Milan, Italy
| | - Morie A Gertz
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jan T Kielstein
- Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Petra Tesarova
- Department of Oncology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Germaine Wong
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | | | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK; George Institute for Global Health, Sydney, Australia
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Camillo Porta
- Department of Internal Medicine and Therapeutics, University of Pavia and Division of Translational Oncology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy.
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14
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Pasic I, Lipton JH, Kim DD, Viswabandya A, Kumar R, Lam W, Law AD, Mattsson J, Michelis FV. Post-transplant cyclophosphamide combined with anti-thymocyte globulin for graft-vs-host disease prophylaxis improves survival and lowers non-relapse mortality in older patients undergoing allogeneic hematopoietic cell transplantation. Ann Hematol 2020; 99:1377-1387. [DOI: 10.1007/s00277-020-04033-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/10/2020] [Indexed: 12/19/2022]
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15
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Prophylaxis and management of graft versus host disease after stem-cell transplantation for haematological malignancies: updated consensus recommendations of the European Society for Blood and Marrow Transplantation. LANCET HAEMATOLOGY 2020; 7:e157-e167. [PMID: 32004485 DOI: 10.1016/s2352-3026(19)30256-x] [Citation(s) in RCA: 291] [Impact Index Per Article: 72.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 01/02/2023]
Abstract
Graft-versus-host disease (GVHD) is a major factor contributing to mortality and morbidity after allogeneic stem-cell transplantation. Because of the small number of results from well designed, large-scale, clinical studies there is considerable variability in the prevention and treatment of GVHD worldwide. In 2014, to standardise treatment approaches the European Society of Blood and Marrow Transplantation published recommendations on the management of GVHD in the setting of HLA-identical sibling or unrelated donor transplantation in adult patients with haematological malignancies. Here we update these recommendations including the results of study published after 2014. Evidence was searched in three steps: first, a widespread scan of published trials, meta-analyses, and systematic reviews; second, expert opinion was added for specific issues following several rounds of debate; and third, a refined search to target debated or rapidly updating issues. On the basis of this evidence and the 2014 recommendations, five members of the EBMT Transplant Complications Working Party created 38 statements on GVHD prophylaxis, drug management, and treatment of acute and chronic GVHD. Subsequently, they created the EBMT GVHD management recommendation expert panel by recruiting 20 experts with expertise in GVHD management. An email-based, two-round Delphi panel approach was used to manage the consensus. Modified National Comprehensive Cancer Network categories for evidence and consensus were applied to the approved statements. We reached 100% consensus for 29 recommendations and 95% consensus for nine recommendations. Key updates to these recommendations include a broader use of rabbit anti-T-cell globulin; lower steroid doses for the management of grade 2 acute GVHD with isolated skin or upper gastrointestinal tract manifestations; fluticasone, azithromycin, and montelukast should be used for bronchiolitis obliterans syndrome; and the addition of newer treatment options for resteroid-refractory acute and chronic GVHD. In addition, we discuss specific aspects of GVHD prophylaxis and management in the setting of haploidentical transplantation and in paediatric patients, but no formal recommendations on those procedures have been provided in this Review. The European Society of Blood and Marrow Transplantation proposes to use these recommendations as a basis for the routine management of GVHD during stem-cell transplantation.
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