Post-transplant ferritin level predicts outcomes after allogeneic hematopoietic stem cell transplant, independent from pre-transplant ferritin level

Association between the pre-transplantation serum ferritin level and outcomes of hematopoietic stem cell transplantation: A systematic review and meta-analysis

Background

Iron overload, as indicated by evaluated serum ferritin (SF) level, occurs commonly in patients with hematological diseases. To evaluate the association between pre-transplant SF level and outcomes of hematopoietic stem cell transplantation (HSCT), we performed this systematic review and meta-analysis.

Methods

PubMed, Embase, Web of Science and the Cochrane Library electronic database were searched from inception to August 2023, and 56 studies with 14149 patients were found to be eligible.

Results

An elevated pre-transplantation SF level was associated with inferior overall survival (hazard ratio [HR],1.77; 95 % confidence interval [CI],1.61-1.96) and disease-free survival (HR, 1.86; 95 % CI, 1.58-2.19), and increased risk of non-relapse mortality (HR, 1.73; 95 % CI, 1.49-2.02), and relapse (HR, 1.46; 95 % CI, 1.29-1.65). However, no meaningful association was observed between SF levels and acute graft-versus-host disease (GVHD) (risk ratio [RR], 1.09; 95 % CI, 0.96-1.24), or chronic GVHD (RR, 0.95; 95 % CI, 0.79-1.16). Furthermore, an elevated pre-transplantation SF level was associated with a higher risk of fungal infection (RR, 1.56; 95 % CI, 1.16-2.10), but not with bacterial infection (RR, 1.09; 95 % CI, 0.80-1.50). Moreover, an elevated pre-transplantation SF level was related to a higher risk of death due to relapse/disease progression (RR, 1.72; 95 % CI, 1.33-2.23) and infection (RR, 2.21; 95 % CI, 1.55-3.15), but not death due to GVHD (RR, 1.18; 95 % CI, 0.79-1.77).

Conclusions

A higher pre-transplantation SF level was significantly associated with a higher risk of relapse/disease progression and infections, which contributed to worse survival in patients undergoing HSCT. In particular, a higher SF level was related to a higher risk of fungal infection, indicating that patients with a higher pre-transplantation SF level require more attention regarding the risk of fungal infection after HSCT.

Lack of RBC transfusion independence by Day 30 following allogeneic hematopoietic stem cell transplant strongly predicts inferior survival and high non-relapse mortality in acute myeloid leukemia patients

BACKGROUND

Studies have suggested that acute myeloid leukemia (AML) patients with incomplete hematologic recovery undergoing allogeneic stem cell transplantation (allo-HSCT) had inferior overall survival (OS).

STUDY DESIGN AND METHODS

This single-center, retrospective study of AML patients evaluated the relationship between red blood cell (RBC) and platelet (PLT) transfusion requirements during the first 30 days and long-term outcomes after allo-HSCT through multivariate analyses.

RESULTS

A total of 692 AML patients received peripheral blood stem cells (89.2%), marrow (5.6%), or umbilical cord (5.2%) from matched related (37.4%), unrelated (49.1%), or haploidentical (8.2%) donors in 2011-2017. Transfusion requirements during the first 30 days for RBC (89.5% transfused, median 3, range 1-18 units) or PLT (98.2% transfused, median 6, range 1-144 units) were variable. By Day 30, 56.7% (95% confidence interval [CI]: 52.8-60.3%) and 86.1% (95% CI: 83.2-88.5%) had achieved RBC and PLT transfusion independence, respectively. Median follow-up among survivors (n = 307) was 7.1 years (range: 2.7-11.8). Lack of RBC transfusion independence by Day 30 was strongly and independently associated with worse 5-year OS (39.2% vs. 59.6%, adjusted hazard ratio [HR] 1.83, 95% CI: 1.49-2.25), leukemia-free survival (35.8% vs. 55.5%, HR = 1.75, 95% CI: 1.43-2.14), and NRM (29.7% vs. 13.7%, HR = 2.05, 95% CI: 1.45-2.89) (p < .001). There was no difference in relapse rates among patients who achieved or did not achieve RBC (p = .34) or PLT (p = .64) transfusion independence.

CONCLUSION

Prolonged RBC dependence predicted worse survival and NRM rates, but not increased relapse. Posttransplant surveillance of such patients should be adjusted with more attention to non-relapse complications.

Multiple roles of wheat ferritin genes during stress treatment and TaFER5D-1 as a positive regulator in response to drought and salt tolerance

Ferritin not only regulates the plant's iron content but also plays a significant role in the plant's development and resistance to oxidative damage. However, the role of the FER family in wheat has not been systematically elucidated. In this study, 39 FERs identified from wheat and its ancestral species were clustered into two subgroups, and gene members from the same group contain relatively conservative protein models. The structural analyses indicated that the gene members from the same group contained relatively conserved protein models. The cis-acting elements and expression patterns analysis suggested that TaFERs might play an important role combating to abiotic and biotic stresses. In the transcriptional analysis, the TaFER5D-1 gene was found to be significantly up-regulated under drought and salt stresses and was, therefore, selected to further explore the biological functions Moreover, the GFP expression assay revealed the subcellular localization of TaFER5D-1 proteins in the chloroplast, nucleus, membrane and cytoplasm. Over-expression of TaFER5D-1 in transgenic Arabidopsis lines conferred greater tolerance to drought and salt stress. According to the qRT-PCR data, TaFER5D-1 gene over-expression increased the expression of genes related to root development (Atsweet-17 and AtRSL4), iron storage (AtVIT1 and AtYSL1), and stress response (AtGolS1 and AtCOR47). So it is speculated that TaFER5D-1 could improve stress tolerance by promoting root growth, iron storage, and stress-response ability. Thus, the current study provides insight into the role of TaFER genes in wheat.

Impact of iron overload in hematopoietic stem cell transplantation

Iron overload (IOL) is a common condition in patients with hematological malignancies(HMs) undergoing hematopoietic stem cell transplantation (HSCT). Pathophysiologically, IOL results in iron-induced toxicity in HSCT by producing reactive oxygen species (ROS), which leads to detrimental effects on hematopoiesis, clonal evolution, and immunosuppression. IOL, therefore, may have a negative impact on the clinical outcomes of HSCT. For patients at a higher risk of developing IOL before HSCT, it is necessary to monitor red blood cell transfusion units, serum ferritin (SF) levels and MRI image of organs, and initiate iron removal therapy as soon as possible. Iron chelating therapy (ICT) might be safe and efficient in the post-HSCT period. We provide an overview of results from experimental and clinical evidence on the current understanding of IOL in patients with HMs undergoing HSCT, involving the underlying pathophysiological and clinical impact of IOL, as well as the significance of iron reduction therapy.

Erythroferrone and hepcidin as mediators between erythropoiesis and iron metabolism during allogeneic hematopoietic stem cell transplant

Hematopoietic cell transplantation (HCT) brings important alterations in erythropoiesis and iron metabolism. Hepcidin, which regulates iron metabolism, increases in iron overload or inflammation and decreases with iron deficiency or activated erythropoiesis. Erythroferrone (ERFE) is the erythroid regulator of hepcidin. We investigated erythropoiesis and iron metabolism after allogeneic HCT in 70 patients randomized between erythropoietin (EPO) treatment or no EPO, by serially measuring hepcidin, ERFE, CRP (inflammation), soluble transferrin receptor (sTfR, erythropoiesis), serum iron and transferrin saturation (Tsat; iron for erythropoiesis) and ferritin (iron stores). We identified biological and clinical factors associated with serum hepcidin and ERFE levels. Serum ERFE correlated overall with sTfR and reticulocytes and inversely with hepcidin. Erythroferrone paralleled sTfR levels, dropping during conditioning and recovering with engraftment. Inversely, hepcidin peaked after conditioning and decreased during engraftment. Erythroferrone and hepcidin were not significantly different with or without EPO. Multivariate analyses showed that the major determinant of ERFE was erythropoiesis (sTfR, reticulocytes or serum Epo). Pretransplant hepcidin was associated with previous RBC transfusions and ferritin. After transplantation, the major determinants of hepcidin were iron status (ferritin at all time points and Tsat at day 56) and erythropoiesis (sTfR or reticulocytes or ERFE), while the impact of inflammation was less clear and clinical parameters had no detectable influence. Hepcidin remained significantly higher in patients with high compared to low pretransplant ferritin. After allogeneic HCT with or without EPO therapy, significant alterations of hepcidin occur between pretransplant and day 180, in correlation with iron status and inversely with erythroid ERFE.

ABO Mismatch in Allogeneic Hematopoietic Stem Cell Transplant: Effect on Short- and Long-term Outcomes

Supplemental Digital Content is available in the text.

Background.

The impact of ABO incompatibility (ABO-I) on hematopoietic stem cell transplant outcomes is still debated.

Methods.

We retrospectively investigated 432 consecutive transplants performed at our center (2012–2020). All patients but 6 were affected by hematologic malignancies. The effect of different ABO match combinations on engraftment rate, transfusion support, acute and chronic graft-versus-host disease incidences, nonrelapse mortality (NRM), disease-free survival, and overall survival was assessed in univariate and multivariate analysis. Significance was set at P < 0.05.

Results.

ABO match distribution among transplants was as follows: 223 ABO-compatible, 94 major ABO-I, 82 minor ABO-I, and 33 bidirectional ABO-I. At univariate analysis, major ABO-I delayed the engraftment of neutrophils, platelets, and erythroid cells. At multivariate analysis, major ABO-I transplants displayed delayed erythroid engraftment (odds ratio [OR], 0.51; 95% confidence intervals [CIs], 0.38-0.70; P < 0.0001) and hindered transfusion independence for both red blood cells (OR, 0.52; 95% CI, 0.37-0.72; P = 0.0001) and platelets (0.60; 95% CI, 0.45-0.86; P = 0.0048). Moreover, major ABO-I transplants received greater amounts of blood products (P < 0.0001 for red blood cells and P = 0.0447 for platelets). In comparison with other ABO matches, major ABO-I was associated with an increased NRM (OR, 1.67; 95% CI, 1.01-2.75; P = 0.0427). No effects of ABO-mismatch were found on graft-versus-host disease, disease-free survival, and overall survival.

Conclusions.

Major ABO mismatch delays multilineage engraftment hinders transfusion independence and increases NRM. The prognostic impact of transfusion burden in hematopoietic stem cell transplantation deserves to be explored.