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Mori S, Guo M, Rivera-Robles N, Edgar CM, Mcvey CP, Yi F, Ahmad S, Patel RD, Varela JC. Evaluation of different pharmacokinetically guided IV busulfan exposure ranges on adult patient outcomes after hematopoietic stem cell transplantation. Ann Hematol 2023; 102:181-190. [PMID: 36462061 DOI: 10.1007/s00277-022-05042-z] [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: 04/18/2022] [Accepted: 11/08/2022] [Indexed: 12/04/2022]
Abstract
Conditioning intensity contributes significantly to outcomes in allogeneic hematopoietic stem cell transplantation (allo-HSCT). We evaluated two myeloablative conditioning dosing ranges of intravenous (IV) busulfan (Bu) in combination with fludarabine in 70 patients. In 2015, our practice changed to target busulfan area under the curve (AUC) of ≥ 19.7 mg*h/L. We assessed responses in patients receiving busulfan AUCs of < 19.7 mg*h/L (Low-Bu) and ≥ 19.7 mg*h/L (High-Bu). At 18-month median follow-up, no differences in overall survival (OS) and relapse-free survival (RFS) were found between Low-Bu and High-Bu groups (p = 0.35 and p = 0.29, respectively). Relapses occurred in 25.7% of patients. No differences in median time to relapse were noted. Minimal residual disease (MRD)-positive patients had a shorter median OS and RFS than MRD-negative patients. No differences were found in OS and RFS between Low-Bu and High-Bu groups in MRD-positive patients (p = 0.86 and p = 0.83, respectively), or MRD-negative patients (p = 0.56 and p = 0.38, respectively). Non-relapsed mortality (NRM) at 100 days was 3.4% vs. 4.1% in the Low-Bu vs. High-Bu groups. There were no significant differences in the incidence of acute-graft-versus-host disease (aGVHD) (71.4% vs. 63.4%) or chronic GVHD (cGVHD) (48.3% vs. 43.9%) between the groups. The cumulative incidence of grades III-IV aGVHD was 24.1% in Low-Bu group and 22.4% in High-Bu group. In conclusion, targeting a busulfan AUC of > 19.7 mg*h/L with fludarabine does not appear to add an advantage in OS and RFS.
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Affiliation(s)
- Shahram Mori
- Blood and Marrow Transplant Center, AdventHealth Cancer Institute, AdventHealth Cancer Institute/AHMG, 2415 N. Orange Ave., Suite 601, Orlando, FL, 32804, USA.
| | - Mengni Guo
- Department of Internal Medicine, AdventHealth, Orlando, USA
| | | | - Cory Mical Edgar
- Blood and Marrow Transplant Center, AdventHealth Cancer Institute, AdventHealth Cancer Institute/AHMG, 2415 N. Orange Ave., Suite 601, Orlando, FL, 32804, USA
| | - Courtney Paige Mcvey
- Blood and Marrow Transplant Center, AdventHealth Cancer Institute, AdventHealth Cancer Institute/AHMG, 2415 N. Orange Ave., Suite 601, Orlando, FL, 32804, USA
| | | | - Sarfraz Ahmad
- Gynecologic Oncology Program, AdventHealth Cancer Institute, Orlando, FL, 32804, USA
| | - Rushang D Patel
- Blood and Marrow Transplant Center, AdventHealth Cancer Institute, AdventHealth Cancer Institute/AHMG, 2415 N. Orange Ave., Suite 601, Orlando, FL, 32804, USA
| | - Juan Carlos Varela
- Blood and Marrow Transplant Center, AdventHealth Cancer Institute, AdventHealth Cancer Institute/AHMG, 2415 N. Orange Ave., Suite 601, Orlando, FL, 32804, USA
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Ohwada C, Yamazaki S, Shono K, Kayamori K, Hino Y, Oshima-Hasegawa N, Muto T, Tsukamoto S, Mitsukawa S, Takeda Y, Mimura N, Takeuchi M, Iseki T, Onoda M, Yokota A, Suzuki T, Ishii I, Nakaseko C, Sakaida E. Pharmacokinetically guided, once-daily intravenous busulfan in combination with fludarabine for elderly AML/MDS patients as a conditioning regimen for allogeneic stem cell transplantation. Int J Hematol 2021; 114:664-673. [PMID: 34523110 DOI: 10.1007/s12185-021-03188-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/24/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
The efficacy of pharmacokinetically (PK) guided, once-daily administration of busulfan (BU) was evaluated in elderly patients with acute myeloid leukemia/myelodysplastic syndrome (AML/MDS). Twenty-one patients (median age 61) received 30 mg/m2 fludarabine for 6 days and BU for 4 days, starting from 3.2 mg/m2 and subsequently adjusted to the target area under the curve (AUC) of 6000 µmol-min/L. The median AUC of day 1 (AUC1), AUC4, and their average were 4871.3, 6021.0, and 5368.1 µmol-min/L, respectively. Veno-occlusive disease/sinusoidal obstructive syndrome (VOD/SOS) occurred in five patients (24%) but all recovered well. Four patients (20%) had non-infectious pulmonary complications (NIPCs). Patients with high AUC1 had frequent gastrointestinal adverse events, but similar incidence of VOD/SOS and NIPCs. Two-year overall survival (OS), non-relapse mortality (NRM), and relapse rates were 44.4%, 28.6%, and 29.1%, respectively. Patients with high AUC1 had significantly high NRM (57.1% vs. 14.3%, P = 0.04) and inferior OS (14.3% vs. 60.1%, P = 0.002), while patients with high AUC4 had a significantly low relapse rate (8.3% vs. 55.6%, P = 0.02). In conclusion, once-daily BU and a PK-guided dose intensification were beneficial for reducing relapse in elderly patients with AML/MDS. However, caution should be exercised as rapid BU dose elevation may contribute to NRM.
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Affiliation(s)
- Chikako Ohwada
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan.
- Department of Hematology, International University of Health and Welfare Narita Hospital, Narita, Japan.
| | - Shingo Yamazaki
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Katsuhiro Shono
- Department of Hematology, Aoba Municipal Hospital, Chiba, Japan
| | - Kensuke Kayamori
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
| | - Yutaro Hino
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
| | - Nagisa Oshima-Hasegawa
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
| | - Tomoya Muto
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
| | - Shokichi Tsukamoto
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
| | - Shio Mitsukawa
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
- Department of Transfusion Medicine and Cell Therapy, Chiba University Hospital, Chiba, Japan
| | - Yusuke Takeda
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
| | - Naoya Mimura
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
- Department of Transfusion Medicine and Cell Therapy, Chiba University Hospital, Chiba, Japan
| | | | - Tohru Iseki
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
- Department of Transfusion Medicine and Cell Therapy, Chiba University Hospital, Chiba, Japan
| | - Masahiro Onoda
- Department of Hematology, Aoba Municipal Hospital, Chiba, Japan
| | - Akira Yokota
- Department of Hematology, Aoba Municipal Hospital, Chiba, Japan
| | - Takaaki Suzuki
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Itsuko Ishii
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Chiaki Nakaseko
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Department of Hematology, International University of Health and Welfare Narita Hospital, Narita, Japan
| | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Blood and Marrow Transplant Center, Chiba University Hospital, Chiba, Japan
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Comparison of clonazepam and levetiracetam in children for prevention of busulfan-induced seizure in hematopoietic stem cell transplantation. Int J Hematol 2019; 111:463-466. [DOI: 10.1007/s12185-019-02795-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/05/2019] [Accepted: 12/06/2019] [Indexed: 11/25/2022]
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Akiyama K, Kume T, Fukaya M, Shiki I, Enami T, Tatara R, Shino M, Ikeda T. Comparison of levetiracetam with phenytoin for the prevention of intravenous busulfan-induced seizures in hematopoietic cell transplantation recipients. Cancer Chemother Pharmacol 2018; 82:717-721. [PMID: 30083882 PMCID: PMC6132870 DOI: 10.1007/s00280-018-3659-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 08/01/2018] [Indexed: 11/20/2022]
Abstract
Purpose Busulfan is used as a conditioning regimen for hematopoietic stem cell transplantation and is known to cause seizures as a side effect. As various anticonvulsant drugs have been reported, we conducted a retrospective investigation regarding the preventive effects and adverse events associated with different anticonvulsants administered alongside intravenous busulfan (ivBu) in our institution. Methods We targeted 104 patients who received ivBu at our institution from May 1, 2010 to April 30, 2017. We investigated the seizure prevention rate and adverse events rate under anticonvulsant prophylaxis. Results There were 70 cases (67.3%) of phenytoin administration and 34 cases (32.7%) of levetiracetam administration for anticonvulsant therapy. The seizure prevention rate was 98.6% for phenytoin and 100% for levetiracetam; seizures occurred in one out of 104 patients. There were no significant differences in the seizure prevention rate depending on the type of anticonvulsant. Further, there were no differences in adverse events. Conclusions Anticonvulsant prophylaxis is considered necessary for safe conditioning with ivBu. Adverse events associated with the use of levetiracetam are within an acceptable range. Further, levetiracetam is considered useful as a preventive drug against seizures during ivBu administration because it is easy to administer and has ideal pharmacokinetics for supportive care.
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Affiliation(s)
- Kana Akiyama
- Department of Pharmacy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Tetsuo Kume
- Department of Pharmacy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Masafumi Fukaya
- Division of Hematology and Stem Cell Transplantation, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Ikue Shiki
- Division of Hematology and Stem Cell Transplantation, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Terukazu Enami
- Division of Hematology and Stem Cell Transplantation, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Raine Tatara
- Division of Hematology and Stem Cell Transplantation, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Michihiro Shino
- Department of Pharmacy, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Takashi Ikeda
- Division of Hematology and Stem Cell Transplantation, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
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5
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Safety and Efficacy of Once-Daily Intravenous Busulfan in Allogeneic Transplantation: A Matched-Pair Analysis. Biol Blood Marrow Transplant 2018; 24:2139-2144. [PMID: 29680515 DOI: 10.1016/j.bbmt.2018.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/11/2018] [Indexed: 12/26/2022]
Abstract
Compared with 4-times-daily infusion of intravenous busulfan (ivBU4), the safety and efficacy of once-daily infusion of ivBU (ivBU1) has not been fully clarified. We have been routinely using ivBU1 in a conditioning regimen in adult patients with myeloid malignancy who undergo allogeneic hematopoietic stem cell transplantation. In this study, a total of 91 patients who received ivBU1 for 2 days (n = 18) or 4 days (n = 73) in our institutions were compared with 273 control patients who received ivBU4, who were matched for age, sex, performance status, disease risk, conditioning regimen, and donor type, selected from the database of the Japanese Society for Hematopoietic Cell Transplantation using optimal matching algorithms. One-year overall survival (56.8% versus 57.1%, P = .94), disease-free survival (51.6% versus 50.8%, P = .73), relapse rate (28.5% versus 26.2%, P = .94), nonrelapse mortality (19.9% versus 23.0%, P = .71), and the incidence of graft-versus-host disease were not significantly different between the ivBU1 and ivBU4 groups. In patients who received ivBU1, neutrophil recovery was slower (median days: 22 versus 17, P = .001), and the incidence of veno-occlusive disease was lower (2.6% versus 17.4%, P = .04). In conclusion, ivBU1 can be safely administered with clinical outcomes similar to those with ivBU4.
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Pasquini MC, Le-Rademacher J, Zhu X, Artz A, DiPersio J, Fernandez HF, Mineishi S, Kamishohara M, Mehta J, Nakamura Y, Ratanatharathorn V, Sobecks R, Burkart J, Bredeson C. Intravenous Busulfan-Based Myeloablative Conditioning Regimens Prior to Hematopoietic Cell Transplantation for Hematologic Malignancies. Biol Blood Marrow Transplant 2016; 22:1424-1430. [PMID: 27154848 DOI: 10.1016/j.bbmt.2016.04.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/14/2016] [Indexed: 11/19/2022]
Abstract
Busulfan (Bu)-containing regimens are commonly used in myeloablative conditioning regimens before allogeneic hematopoietic cell transplantation (HCT). Yet, there is considerable variability on how Bu is administered related to frequency (4 times a day [Q6] or daily [Q24]) and combinations with other chemotherapeutic agents (cyclophosphamide [Cy] or fludarabine [Flu]). We performed a prospective cohort study of recipients of Bu-based conditioning according to contemporary practices to compare different approaches (BuCy Q6, n = 495; BuFlu Q24, n = 331; BuCy Q24, n = 96; BuFlu Q6, n = 91) in patients with myeloid malignancies between 2009 and 2011. BuFlu Q24 recipients were more likely to be older and tended to have worse performance status and a higher comorbid burden. The cumulative incidences of hepatic veno-occlusive disease (P = .40), idiopathic pneumonia (P = .50), and seizures (P = .50) did not differ across groups. One-year HCT-related mortality ranged from 12% to 16% (P = .80), 3-year relapse incidence ranged from 32% to 36% (P = .80), and 3-year overall survival ranged from 51% to 58% (P = .20) across groups. This study demonstrates that HCT conditioning regimens using i.v. Bu Q6 or Q24 alone or in combination with Cy or Flu have similar outcomes in the myeloablative setting for treatment of myeloid malignancies.
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Affiliation(s)
- Marcelo C Pasquini
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Jennifer Le-Rademacher
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Xiaochun Zhu
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrew Artz
- Section of Hematology/Oncology, University of Chicago School of Medicine, Chicago, Illinois
| | - John DiPersio
- Department of Hematology/Oncology, Barnes Jewish Hospital, St. Louis, Missouri
| | - Hugo F Fernandez
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Shin Mineishi
- Bone Marrow Transplant Program, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Jayesh Mehta
- Department of Hematology/ Oncology, Northwestern Memorial Hospital, Chicago, Illinois
| | | | - Voravit Ratanatharathorn
- Department of Clinical Arrangements, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan; J.P. McCarthy Cord Stem Cell Bank, Detroit, Michigan
| | - Ronald Sobecks
- Department of Hematopoietic Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Jeanne Burkart
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher Bredeson
- The Ottawa Hospital Blood and Marrow Transplant Program and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Watanabe E, Nishikawa T, Ikawa K, Yamaguchi H, Abematsu T, Nakagawa S, Kurauchi K, Kodama Y, Tanabe T, Shinkoda Y, Matsumoto K, Okamoto Y, Takeda Y, Kawano Y. Trough level monitoring of intravenous busulfan to estimate the area under the plasma drug concentration-time curve in pediatric hematopoietic stem cell transplant recipients. Int J Hematol 2015; 102:611-6. [PMID: 26243625 DOI: 10.1007/s12185-015-1853-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 07/28/2015] [Accepted: 07/28/2015] [Indexed: 12/23/2022]
Abstract
Optimizing systemic busulfan exposure, the area under the concentration-time curve (AUC), improves the outcomes for hematopoietic stem cell transplantation (HSCT). The AUC is conventionally calculated using six plasma concentrations (AUC(0-∞)) drawn after the first of 16 intravenous busulfan doses given as a 2-h infusion every 6 h. The aim of the present study was to develop limited sampling strategies using three or fewer busulfan concentrations to reliably calculate AUC(0-∞) in patients undergoing HSCT. We investigated the pharmacokinetics of busulfan 46 times in 29 pediatric patients receiving intravenous busulfan. Limited sampling strategies using one, two, or three plasma busulfan concentrations were developed by multiple linear regression that showed excellent agreement with AUC(0-∞). In single-point sampling strategies, the AUC(0-∞) predicted based on C(6) (trough level: busulfan plasma concentration 6 h after the start of the infusion) was significantly correlated with, and not statistically different from, actual values as follows: AUC(0-∞) = 2556.5 C6 + 320.9 (r(2) = 0.929, P < 0.0001, mean bias 0.282 %, precision 7.91 %). In contrast, the predicted AUCs derived from the other sampling single points did not meet the criteria. The trough level well correlated with actual AUC(0-∞), suggesting that this time-point is acceptable for busulfan monitoring.
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Affiliation(s)
- Erika Watanabe
- Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Takuro Nishikawa
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan.
| | - Kazuro Ikawa
- Department of Clinical Pharmacotherapy, Hiroshima University, Hiroshima, Japan
| | | | - Takanari Abematsu
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Shunsuke Nakagawa
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Koichiro Kurauchi
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Yuichi Kodama
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Takayuki Tanabe
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Yuichi Shinkoda
- Department of Pediatrics, Kagoshima City Hospital, Kagoshima, Japan
| | - Kazuaki Matsumoto
- Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yasuhiro Okamoto
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Yasuo Takeda
- Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yoshifumi Kawano
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
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