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Madsen K, Pelletier K, Côté G, Kitchlu A, Chen S, Mattsson J, Pasic I. Acute kidney injury within 100 days post allogeneic hematopoietic cell transplantation is associated with increased risk of post-transplant complications and poor transplant outcomes. Bone Marrow Transplant 2022; 57:1411-1420. [PMID: 35752740 DOI: 10.1038/s41409-022-01744-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 06/01/2022] [Accepted: 06/14/2022] [Indexed: 11/09/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) offers cure for some patients with hematological diseases but is associated with significant risk of morbidity and mortality. We investigated the incidence of AKI and its impact on transplant outcomes among 408 patients transplanted at Princess Margaret Hospital Cancer Centre, Toronto, Canada. The overall incidence of AKI at 100 days was 64.2%. Compared to those with no AKI, patients who developed AKI had inferior 2-y overall survival (OS), 44.7% vs. 62.4% (P = 0.0004), higher 2-y transplant related mortality (TRM) 36.8% vs. 18.7% (P = 0.0003), lower 2-y graft-vs-host disease (GVHD)- and relapse-free survival (GRFS), 21.0% vs. 39.8% (P = 0.0002), and higher 100-day grade 3-4 acute GVHD (aGVHD), 12.4% vs. 6.3% (P = 0.01). There was no difference in 2-y incidence of relapse between the AKI and non-AKI groups, 24.2% vs. 24.3% (P = 0.84), 100-day grade 2-4 aGVHD, 27.7% vs. 25.7 (P = 0.41) or 2-y moderate-severe chronic GVHD, 24.0% vs. 21.6% (P = 0.79). Patients who develop AKI within 100 days of HCT have inferior OS and GRFS with higher rates of TRM and grade 3-4 aGVHD. These results highlight the importance of close monitoring of renal function, multidisciplinary collaboration, and implementation of protective strategies throughout HCT to optimize transplant and kidney outcomes.
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Affiliation(s)
- Kayla Madsen
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Karyne Pelletier
- Division of Nephrology, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Gabrielle Côté
- Division of Nephrology, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Abhijat Kitchlu
- Division of Nephrology, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Shiyi Chen
- Biostatistics Department, Princess Margaret Cancer Center, University Health Network, Toronto, Canada
| | - Jonas Mattsson
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Gloria and Seymour Epstein Chair in Cell Therapy and Transplantation, Toronto, Canada
| | - Ivan Pasic
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada. .,Department of Medicine, University of Toronto, Toronto, Canada.
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Jodele S, Sabulski A. Transplant-associated thrombotic microangiopathy: elucidating prevention strategies and identifying high-risk patients. Expert Rev Hematol 2021; 14:751-763. [PMID: 34301169 DOI: 10.1080/17474086.2021.1960816] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (TA-TMA) is a severe complication of transplant. TA-TMA is a multifactorial disease where generalized endothelial dysfunction leads to microangiopathic hemolytic anemia, intravascular platelet activation, and formation of microthrombi leading to end-organ injury. It is essential to identify patients at risk for this complication and to implement early interventions to improve TA-TMA associated transplant outcomes. AREAS COVERED Recognition of TA-TMA and associated multi-organ injury, risk predictors, contributing factors, differential diagnosis and targeting complement pathway in TA-TMA by summarizing peer reviewed manuscripts. EXPERT OPINION TA-TMA is an important transplant complication. Diagnostic and risk criteria are established in children and young adults and risk-based targeted therapies have been proposed using complement blockers. The immediate goal is to extend this work into adult stem cell transplant recipients by implementing universal TA-TMA screening practices. This will facilitate early TA-TMA diagnosis and targeted interventions, which will further improve survival. While complement blocking therapy is effective, about one third of patients are refractory to treatment and those patients commonly die. The next hurdle for the field is identifying reasons for failure, optimizing strategies for complement modifying therapy and searching for additional targetable pathways of endothelial injury.
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Affiliation(s)
- Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Anthony Sabulski
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Sagou K, Fukushima N, Ukai S, Goto M, Ozeki K, Kohno A. Intrapatient variability in concentration/dose ratio of tacrolimus predicts transplant-associated thrombotic microangiopathy. Int J Hematol 2020; 113:63-72. [PMID: 32876853 DOI: 10.1007/s12185-020-02986-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/20/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
Tacrolimus (TAC) is essential for prophylaxis of acute graft-versus-host disease (aGVHD) after allogeneic hematopoietic cell transplantation (allo-HSCT). We have sometimes observed large fluctuations in TAC concentration. However, links between the variability in the concentration or the concentration/dose (C/D) ratio of TAC and clinical complications remain ambiguous. To clarify relationships between various parameters of TAC and early complications such as pre-engraftment immune reactions/engraftment syndrome, aGVHD, and transplant-associated thrombotic microangiopathy (TA-TMA), a total of 146 patients who underwent allo-HSCT were included. Intrapatient variabilities in the concentration and C/D ratio of TAC were estimated by intrapatient mean absolute deviation (iMAD). The mean concentration and C/D ratio of TAC were not significantly different between with and without complications. A strong association was observed between greater iMAD for TAC C/D ratio from days 15 to 21 and the development of TA-TMA. iMAD values for TAC C/D ratio of 11.4 or greater was a risk factor for TA-TMA and the cumulative incidence of nonrelapse mortality (NRM) was significantly higher in patients with iMAD values for TAC C/D ratio of 11.4 or greater. Intrapatient variability in the C/D ratio of TAC was associated with the incidence of TA-TMA and NRM and might be useful for predicting TA-TMA.
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Affiliation(s)
- Ken Sagou
- Department of Hematology and Oncology, JA Aichi Konan Kosei Hospital, 137, Omatsubara, Takaya-cho, Konan, Aichi, 483-8704, Japan. .,Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Nobuaki Fukushima
- Department of Hematology and Oncology, JA Aichi Konan Kosei Hospital, 137, Omatsubara, Takaya-cho, Konan, Aichi, 483-8704, Japan
| | - Shun Ukai
- Department of Hematology and Oncology, JA Aichi Konan Kosei Hospital, 137, Omatsubara, Takaya-cho, Konan, Aichi, 483-8704, Japan
| | - Miyo Goto
- Department of Hematology and Oncology, JA Aichi Konan Kosei Hospital, 137, Omatsubara, Takaya-cho, Konan, Aichi, 483-8704, Japan
| | - Kazutaka Ozeki
- Department of Hematology and Oncology, JA Aichi Konan Kosei Hospital, 137, Omatsubara, Takaya-cho, Konan, Aichi, 483-8704, Japan
| | - Akio Kohno
- Department of Hematology and Oncology, JA Aichi Konan Kosei Hospital, 137, Omatsubara, Takaya-cho, Konan, Aichi, 483-8704, Japan
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