Engraftment syndrome after nonmyeloablative allogeneic hematopoietic stem cell transplantation: incidence and effects on survival

Plerixafor-based mobilization and mononuclear cell counts in graft increased the risk of engraftment syndrome after autologous hematopoietic stem cell transplantation

Engraftment syndrome (ES) is one of the most common complications in the early phase after autologous hematopoietic stem cell transplantation (ASCT), and we aimed to evaluate the incidence and risk factors for ES patients receiving ASCT in the era of plerixafor-based mobilization. A total of 294 were enrolled, and 16.0% (n = 47) experienced ES after ASCT. The main clinical manifestations were fever (100%), diarrhea (78.7%), skin rash (23.4%), and hypoxemia/pulmonary edema (12.8%). Plerixafor-based mobilization was associated with higher counts of CD3+ cells, CD4+ cells, and CD8+ cells in grafts. In univariate analysis of the total cohort, age ≥60 years, receiving ASCT at complete remission (CR), higher number of mononuclear cell (MNC), CD3+ cell counts, CD4+ cells as well as CD8+ cells transfused and plerixafor-based mobilization were associated with ES after ASCT. Multivariate analysis showed that age ≥60 years (P = .0014), receiving ASCT at CR (P = .002), and higher number of MNC transfused (P = .026) were associated with ES in total cohort. In plasma cell disease subgroup, age ≥60 years (P = .013), plerixafor-based mobilization (P = .036), and receiving ASCT at CR (P = .002) were associated with ES. Patients with more risk factors had a higher risk of ES. The 1-year probabilities of relapse, non-relapse mortality, and survival were comparable between patients with and without ES. Thus, plerixafor-based mobilization may influence the composition of T lymphocytes in grafts and increase the risk of ES, particularly in patients with plasma cell disease.

Engraftment syndrome after allogeneic stem cell transplantation: a systematic review and meta-analysis

Engraftment syndrome (ES) is associated with neutrophil recovery after stem cell transplantation (SCT). It is associated with autologous and allogeneic SCT. However, a literature review has shown that allogeneic SCT (allo-SCT) is associated with ES without conclusive data on risk factors or effects on outcomes. This meta-analysis was undertaken to estimate the cumulative incidence of ES following allo-SCT, and to evaluate the risk factors and outcomes among patients with ES following allo-SCT. Current literature was searched using electronic databases, and manually. Studies with ES after allo-SCT were selected, and a meta-analysis of proportion was performed using the Freeman-Tukey Double Arcsine transformation, random-effects model to calculate the cumulative incidence of ES. Donor type, source of haematopoetic stem cells, graft vs. host disease (GvHD) prophylaxes, and conditioning regimens' intensity were evaluated for risk factors for ES. Association of acute GvHD (aGvHD), chronic GvHD (cGvHD), relapse, nonrelapse mortality (NRM), and overall survival (OS) between the ES and no ES groups were assessed using the odds ratio (OR). Eighteen studies were included comprising 3620 patients receiving allo-SCT and 774 of them had developed ES with a cumulative incidence of 35.4%. The odds of aGvHD (OR 2.5, p < 0.001), cGvHD (OR 4.5, p = 0.021), and NRM (OR 1.8, p = 0.01) were higher among patients who developed ES. The odds of relapse were significantly less (OR = 0.679, p = 0.011) among the ES group. OS (OR = 0.72, p < 0.001) was reduced in the ES group. Myeloablative conditioning was found to be a significant risk factor for ES development. In conclusion, ES after allo-SCT is common with higher odds of developing aGvHD, cGvHD, and NRM and lower odds of OS.

Early vascular endothelial complications after hematopoietic cell transplantation: Role of the endotheliopathy in biomarkers and target therapies development

This work aims to review the role of endothelial dysfunction underlying the main complications appearing early after autologous and allogeneic hematopoietic cell transplantation (HCT). The endothelial damage as the pathophysiological substrate of sinusoidal obstruction syndrome (SOS) is well established. However, there is growing evidence of the involvement of endothelial dysfunction in other complications, such as acute graft-versus-host disease (aGVHD) and transplant-associated thrombotic microangiopathy (TA-TMAs). Moreover, HCT-related endotheliopathy is not only limited to the HCT setting, as there is increasing evidence of its implication in complications derived from other cellular therapies. We also review the incidence and the risk factors of the main HCT complications and the biological evidence of the endothelial involvement and other linked pathways in their development. In addition, we cover the state of the art regarding the potential use of the biomarkers of endotheliopathy in the prediction, the early diagnosis, and the follow-up of the HCT complications and summarize current knowledge points to the endothelium and the other linked pathways described as potential targets for the prevention and treatment of HCT-complications. Lastly, the endothelium-focused therapeutic strategies that are emerging and might have a potential impact on the survival and quality of life of post-HCT-patients are additionally reviewed.

Outcome of Acute Respiratory Failure Secondary to Engraftment in Children After Hematopoietic Stem Cell Transplant

Introduction: Respiratory complications due to engraftment syndrome (ES) in the post-hematopoietic stem cell transplant (HSCT) setting can lead to acute respiratory failure (ARF). Outcomes of children developing ARF due to engraftment are unknown.

Methods: We conducted a retrospective analysis of 1,527 pediatric HSCT recipients and identified children who developed ARF due to ES over a 17-year period. Thirty patients that developed ARF and required invasive mechanical ventilation (IMV) due to ES were included in this study.

Results: The survival rate for our cohort was 80% [alive at intensive care unit (ICU) discharge]. The most common underlying primary disease was hematologic malignancy, and 67% of children underwent allogeneic HSCT. Further, 73% required vasopressor drips and 23% underwent dialysis. Survivors had a shorter median ICU length of stay than did non-survivors (15 vs. 40 days, respectively, p = 0.01). Survivors had a significantly lower median cumulative fluid overload % on days 4 and 5 after initiation of IMV than did non-survivors (2.8 vs. 14.0 ml/kg, p = 0.038 on day 4, and 1.8 vs. 14.9 ml/kg, p = 0.044 on day 5, respectively).

Conclusion: Our results suggest that children who develop ARF during engraftment have better ICU survival rates than do those with other etiologies of ARF post-HSCT. Furthermore, fluid overload contributes to mortality in these children; therefore, strategies to prevent and address fluid overload should be considered.

Prophylactic corticosteroid use prevents engraftment syndrome in patients after autologous stem cell transplantation

Engraftment syndrome (ES) following autologous stem cell transplantation (ASCT) at the time of neutrophil recovery may comprise fever, rash, pulmonary edema, or diarrhea. Usually, ES is easily manageable using corticosteroids but may prolong hospitalization. In two consecutive cohorts of subsequent patients with myeloma, lymphomas, and testicular/germ cell cancer, we assessed the benefit of corticosteroid use to prevent incidence and severity of ES following ASCT. Whereas Cohort A (82 patients) received no prophylactic corticosteroids, corticosteroids (4 mg dexamethasone oral daily) were started in Cohort B (60 patients) at day +9 until day +13 following ASCT. Steroid prophylaxis significantly reduced the incidence of ES (6/60; 10% vs. 33/82; 40%; p < 0.001). Hospitalization duration was longer in patients with ES than in patients without ES within both cohorts (in Cohort A: p = 0.007; and B: p = 0.011), but did not differ significantly between cohorts A and B. Finally, in Cohort A, there was a trend to an inferior 2-year overall survival rate in patients without ES compared to patients with ES (p = 0.067), but definite conclusions are not yet allowed. Our results suggest that corticosteroid prophylaxis from days +9 to +13 following ASCT significantly reduces the risk of ES and shortens hospitalization duration.

Allogeneic reactivity-mediated endothelial cell complications after HSCT: a plea for consensual definitions

Endothelial cell (EC) activation has been suspected of triggering a group of rare and dismal complications that can occur after allogeneic hematopoietic stem cell transplantation (HSCT). Capillary leak syndrome, engraftment syndrome, transplant-associated microangiopathy, diffuse alveolar hemorrhage, and idiopathic pneumonia syndrome are the main nosological entities. Post-HSCT endotheliitis can be triggered by chemotherapy, infections, and calcineurin inhibitors, but allogeneic reactivity is claimed to be the common denominator. Endothelial damages are thought to activate several deleterious pathways (proapoptotic, procoagulant, proinflammatory) and can lead to multiorgan failure; however, clinical manifestations of each syndrome overlap, and their relationship with graft-versus-host disease could be minimal. The lack of well-defined diagnostic criteria does not allow for a clear-cut comparison in the current literature. Therapeutic efforts have been made to intercept the pathogenic mechanisms leading to EC dysfunction, but remission rates and survival remain mostly unsatisfactory. In this article, we have reviewed the incidence, clinical features, and treatment approaches of EC activation syndromes, and we plead for the development of internationally accepted standard definitions.

Noninfectious pulmonary complications of haematopoietic stem cell transplantation

Haematopoietic stem cell transplantation (HSCT) is an established treatment for a variety of malignant and nonmalignant conditions. Pulmonary complications, both infectious and noninfectious, are a major cause of morbidity and mortality in patients who undergo HSCT. Recent advances in prophylaxis and treatment of infectious complications has increased the significance of noninfectious pulmonary conditions. Acute lung injury associated with idiopathic pneumonia syndrome remains a major acute complication with high morbidity and mortality. On the other hand, bronchiolitis obliterans syndrome is the most challenging chronic pulmonary complication facing clinicians who are taking care of allogeneic HSCT recipients. Other noninfectious pulmonary complications following HSCT are less frequent. This review provides a clinical update of the incidence, risk factors, pathogenesis, clinical characteristics and management of the main noninfectious pulmonary complications following HSCT.

Noninfectious pulmonary complications following haematopoietic stem cell transplantation is a major cause of morbidity and mortality in this patient population. There are recent advances in the diagnosis and management of these conditions.http://bit.ly/2FgsIYG

Chemotherapy-induced pulmonary complications in cancer: Significance of clinicoradiological correlation

Chemotherapy while revolutionizing cancer management by improving survival and quality of life; is also associated with several adverse effects. Lung is the most common organ affected in chemotherapy-related complications, due to either drug toxicity or more commonly due to infections caused by immunosuppression and less commonly due to immune-mediated injury. Radiology, when used in combination with clinical and lab data, can help reach the specific diagnosis or narrow down the differentials. The common radiological patterns of drug toxicity include pulmonary interstitial and airway infiltrates, diffuse alveolar damage, nonspecific interstitial pneumonia, eosinophilic pneumonia, cryptogenic organizing pneumonia, pulmonary hemorrhage, edema and hypertension. Cancer patients are immunosuppressed due to the underlying malignancy itself or due to therapy and are prone to a gamut of opportunistic infections including viral, bacterial, fungal and mycobacterial pathogens. Immune reconstitution inflammatory syndrome (IRIS), a well-known complication in HIV, is now being increasingly recognized in non-HIV patients with immunosuppression. Engraftment syndrome is specifically seen following hematopoietic stem cell transplant during neutrophil recovery phase. Pulmonary involvement is frequent, causing a radiological picture of noncardiogenic pulmonary edema. Thus, radiology in combination with clinical background and lab parameters helps in detecting and differentiating various causes of pulmonary complications. This approach can help alter potentially toxic treatment and initiate early treatment depending on the diagnosis.

Engraftment Syndrome and Acute Graft-versus-Host Disease: A Meta-Analysis

Engraftment syndrome (ES) has been associated with the surge of neutrophils and cytokines, which is similar to the presumed underlying pathophysiology behind acute graft-versus-host disease (aGVHD). However, there has been no meta-analysis to evaluate the association; therefore, the team attempted to verify an association between ES and aGVHD through meta-analysis. The team searched for titles of articles in MEDLINE (PubMed), the Cochrane Library, and the EMBASE database up until December 2018 that evaluated the association between ES and aGVHD and conducted a random effect meta-analysis of 8 studies involving a total of 1,945 participants to report the pooled odds ratio (OR) for association of ES and aGVHD. The team found a significantly increased odds of developing aGVHD in patients with ES with the pooled OR of 2.76 (95% confidence interval [CI]: 1.64-4.63) and an I²⁼ 64.5%. In conclusion, patients with ES have significantly higher odds of developing aGVHD compared to patients without ES.

Engraftment Syndrome: A Retrospective Analysis of the Experience at a Tertiary Care Institute

Engraftment syndrome (ES) is a clinical syndrome that occurs in the early neutrophil recovery phase following hematopoietic stem cell transplant (HSCT). Although also described for allogenic HSCT, it is basically diagnosed in the context of autologous HSCT. We retrospectively reviewed 171 consecutive HSCTs performed between January 2013 and January 2015 in our Bone Marrow Transplant (BMT) unit and analyzed all cases of noninfectious fever and strong clinical features suggestive of ES in the peri-engraftment period for up to 7 days. We observed the incidence of ES to be 12.3% (16/130) in the autologous and 4.8% (2/41) in the allogeneic cohort. Among plasma cell disorders, which constitute 50% of our study population, the incidence of ES was 19.7%. Among the ES cases of autologous transplants, 81.2% (13/16) patients satisfied the Maiolino criteria (MC) and 87.5% (14/16) patients the Spitzer diagnostic criteria (SC). A total of 68.7% (11/16) patients satisfied both MC and SC, and two patients (12.5%) did not satisfy either (MC− SC−). There was no significant difference in days of hospitalization and usage of supportive care between ES and non-ES patients, and there was no mortality due to ES. On univariate analysis, female patients (p < 0.013) and those with diagnosis of a plasma cell disorder (p < 0.03) had higher risk of ES. In conclusion, the incidence of ES in our study population is consistent with that of many others, but severity evaluation needs exploration in larger cohorts with pragmatically modified diagnostic criteria.

Dermatologic Conditions of the Early Post-Transplant Period in Hematopoietic Stem Cell Transplant Recipients

Hematopoietic stem cell transplants (HSCTs) are used to treat a variety of conditions, including hematologic malignancies, bone marrow failure syndromes, and immunodeficiencies. Over 60,000 HSCTs are performed annually worldwide, and the numbers continue to increase. Indeed, as new conditioning regimens develop, more and more individuals, including those of older age, will be eligible for transplants. Nevertheless, although HSCTs are clearly a life-saving and necessary treatment for thousands of patients per year, there is still substantial morbidity and mortality associated with the procedure. Of note, skin eruptions in the post-HSCT period are frequent and often significantly reduce quality of life in recipients. Moreover, these cutaneous findings sometimes herald an underlying systemic condition, presenting possible opportunities for timelier intervention. Dermatologists therefore play a vital role in distinguishing life-threatening conditions from benign issues and prompting recognition of critical complications earlier in their course. This article aims to review the major dermatologic conditions occurring in the early post-HSCT period.

Cytokine Profile of Engraftment Syndrome in Pediatric Hematopoietic Stem Cell Transplant Recipients

The biology of engraftment syndrome is poorly understood, and the degree of overlap with acute graft-versus-host disease (GVHD) is unclear. To understand engraftment syndrome better, plasma cytokine profiles were evaluated in 56 pediatric allogeneic bone marrow transplant recipients before transplant, on the day of stem cell infusion, and weekly until day +100. Patients were divided into 4 groups: those with isolated engraftment syndrome (n = 8), acute GVHD (n = 12), both engraftment syndrome and acute GVHD (n = 4), and neither engraftment syndrome nor acute GVHD (n = 32). Engraftment syndrome was observed a median of 13.5 days (range, 10 to 28) after transplant, whereas acute GVHD was diagnosed a median of 55 days (range, 19 to 95) after transplant. Four patients developed both engraftment syndrome at a median of 10.5 days (range, 10 to 11) and acute GVHD at a median of 35 days (range, 23 to 56) after stem cell infusion. Median plasma levels of IL-1β, IL-6, IL-12, IL-4, and IL-13 were significantly elevated in patients with isolated engraftment syndrome when compared with isolated acute GVHD. A rise of proinflammatory cytokines (IL-1β, IL-6, and IL-12) was followed by surge in anti-inflammatory cytokines (IL-4 and IL-13) in patients with isolated engraftment syndrome. The observation of elevated IL-1β suggests that engraftment syndrome could be an inflammasome mediated phenomenon.

Infusion-related febrile reaction after haploidentical stem cell transplantation in children is associated with higher rates of engraftment syndrome and acute graft-versus-host disease

The clinical significance and prognostic impact of IRFR in pediatric recipients of haploidentical SCT are not clearly understood. Therefore, we attempted to determine how IRFR affects clinical outcomes in children. Clinical data from 100 consecutive pediatric patients (60 boys and 40 girls; median age, 12 yr [range, 2-18 yr] after haploidentical SCT between January 2010 and December 2012 were collected retrospectively. IRFR was described as unexplained fever (>38 °C) within 24 h after the infusion of haploidentical PBSCs. Thirty-eight (38.0%) cases met the criteria for IRFR. ES was found in 24 (63.2%) of the 38 children with IRFR, with the median time of developing ES of +9 (7-16) days, while only 15 (25.4%) of the 59 children without IRFR were found with ES (p < 0.001). Similarly, the cumulative incidence rates of grade II-IV aGVHD were 50.0% in the IRFR group and 29.3% (p = 0.012) in the non-febrile group. Multivariate analysis identified IRFR as the risk factor for ES and aGVHD. In the haploidentical setting, IRFR is associated with the development of ES and aGVHD. We attempted to determine how IRFR affects clinical outcomes in children after haploidentical SCT. Thirty-eight children comprised the IRFR group, and 59 were in the control (non-IRFR) group. High incidence of ES was observed in children with the occurrence of IRFR. Similarly, the incidence of stage I-IV and II-IV aGVHD was significantly higher in the febrile group. Multivariate analysis showed IRFR to be the risk factor for ES and aGVHD.

The association between platelet transfusion and idiopathic pneumonia syndrome is unaffected by platelet product type

BACKGROUND

Methods used to produce platelet (PLT) components, pooling of PLT-rich plasma (PRP-PLT) and apheresis (AP-PLT), may variably contribute to the pathogenesis and severity of idiopathic pneumonia syndrome (IPS).

STUDY DESIGN AND METHODS

We performed a retrospective cohort study of 906 allogeneic hematopoietic cell transplant recipients to examine associations between PLT product type and risks of developing IPS and dying after IPS onset. Proportional hazards models included separate terms for the sum of all PLT transfusions and the sum of PRP-PLT units received in the 3 or 7 days before IPS onset. Similarly constructed models analyzed the outcome of time to death after IPS onset. All analyses were adjusted for known IPS risk factors.

RESULTS

Patients received a median of three PRP-PLT transfusions (interquartile range [IQR], 0-6) and five AP-PLT transfusions (IQR, 1-13) while at risk for IPS. Seventy-five patients (8%) developed IPS by Posttransplant Day 120. The proportion of PRP-PLT transfusions was not associated with risk of developing IPS (3-day hazard ratio [HR] 0.98, 95% CI 0.74-1.29, p = 0.86; 7-day HR 1.00, 95% CI 0.86-1.15, p = 0.95) or dying after IPS onset (3-day HR 0.99, 95% CI 0.75-1.31, p = 0.97; 7-day HR 0.98, 95% CI 0.78-1.12, p = 0.47).

CONCLUSION

The association between PLT transfusions and risk of developing IPS or dying after IPS onset does not differ according to PLT product type. Further research is required to identify potentially modifiable steps in PLT component production that contribute to IPS.

Engraftment syndrome in hematopoietic stem cell transplantations

Hematopoietic stem cell transplantation (HSCT) is an increasingly common treatment option for malignant and nonmalignant diseases, but it has significant associated morbidity and mortality. Nurses caring for HSCT recipients must be aware of all potential complications, including engraftment syndrome (ES). Previous nursing literature has included little information on this syndrome, which often presents with noninfectious fever, skin rash, and pulmonary infiltrates, and ES may be fatal if left unidentified and treatment is not initiated promptly. Reports of the risk factors, incidence, clinical manifestations, diagnosis, treatment, and outcomes have much variation, likely from a lack of definite diagnostic criteria and inconsistency in the terminology associated with ES. The purpose of this article is to provide an overview of ES and the implications for nursing practice and research.

Engraftment syndrome after allogeneic hematopoietic cell transplantation predicts poor outcomes

Engraftment syndrome (ES), characterized by fever, rash, pulmonary edema, weight gain, liver and renal dysfunction, and/or encephalopathy, occurs at the time of neutrophil recovery after hematopoietic cell transplantation (HCT). In this study, we evaluated the incidence, clinical features, risk factors, and outcomes of ES in children and adults undergoing first-time allogeneic HCT. Among 927 patients, 119 (13%) developed ES at a median of 10 days (interquartile range 9 to 12) after HCT. ES patients experienced significantly higher cumulative incidence of grade 2 to 4 acute GVHD at day 100 (75% versus 34%, P < .001) and higher nonrelapse mortality at 2 years (38% versus 19%, P < .001) compared with non-ES patients, resulting in lower overall survival at 2 years (38% versus 54%, P < .001). There was no significant difference in relapse at 2 years (26% versus 31%, P = .772). Suppression of tumorigenicity 2, interleukin 2 receptor alpha, and tumor necrosis factor receptor 1 plasma biomarker levels were significantly elevated in ES patients. Our results illustrate the clinical significance and prognostic impact of ES on allogeneic HCT outcomes. Despite early recognition of the syndrome and prompt institution of corticosteroid therapy, outcomes in ES patients were uniformly poor. This study suggests the need for a prospective approach of collecting clinical features combined with correlative laboratory analyses to better characterize ES.

Engraftment syndrome after allogeneic hematopoietic cell transplantation in adults

We performed a retrospective study of the engraftment syndrome (ES) as defined by the Spitzer Criteria in adult patients undergoing allogeneic hematopoietic cell transplantation (HCT) for various hematological malignancies at a single institution, over a decade, and analyzed its relationship to acute GVHD; 217 patients underwent either myeloablative (38.7%) or reduced intensity (61.3%) HCT; 22.1% met the criteria for ES. Acute GVHD prophylaxis (P = 0.006) and transplants prior to 2006 (P < 0.0001) were significantly associated with a risk of ES in univariable analysis. Early aGVHD within 4 weeks of engraftment was significantly more common in the ES compared to the non ES cohort (21 vs. 8.3% respectively, P = 0.02). ES did not predict for future GVHD, as at day +180, the cumulative incidences of grades II-IV aGVHD (31 vs. 23%, P = 0.19) and of chronic GVHD at 2 years of engraftment (42 vs. 36%, P = 0.28) were not significantly different between the ES and non ES groups, respectively. No significant differences in NRM, overall survival and progression-free survival were observed between the two groups. Although predictive of early aGVHD, ES occurred independently of GVHD in 79% of the patients. Survival outcomes should be evaluated in a larger randomized study to investigate if there is a correlation with ES.

Pulmonary manifestations of the pre-engraftment syndrome after umbilical cord blood transplantation

Pre-engraftment syndrome (PES) is a condition occurring after umbilical cord blood transplantation (UCBT) characterized by fever and erythematous skin rash prior to neutrophil engraftment. We sought to determine the incidence and characterize the pulmonary manifestations of PES. A retrospective review of patients who underwent UCBT at the University of Kansas Medical Center over a 5-year period was performed. Data collected included patient baseline characteristics, presence of PES, pulmonary findings, treatments, and survival. Forty-four patients underwent UCBT with 22 of those patients developing PES. Full-intensity myeloablative conditioning regimen was found to be a risk factor for development of PES. Of those 22 patients, 13 had resting hypoxemia. The most common radiographic findings included diffuse ground glass opacities with pleural effusions. Fifteen patients with PES received corticosteroids, of which 12 had improvement in fevers and rash. These patients had a trend toward worse mortality than those not receiving corticosteroids. There was a nonsignificant trend toward worse survival in patients with PES and hypoxemia compared to those without hypoxemia. PES is a common complication following cord blood transplantation, with hypoxemia being present in over half of patients with PES. Hypoxemia with PES and treatment with corticosteroids may portend a worse prognosis.

Pre-engraftment graft-versus-host disease after allogeneic hematopoietic cell transplantation for acute leukemia

OBJECTIVES

Acute graft-versus-host disease (GVHD) usually occurs with neutrophil engraftment following allogeneic hematopoietic cell transplantation (HCT), but it can also occur before engraftment. We intended to analyze the effects of timing of acute GVHD on leukemia relapse and mortality.

METHODS

The outcomes of pre- and postengraftment GVHD were investigated in 384 patients who underwent allogeneic HCT for acute leukemia.

RESULTS

Acute GVHD occurred in 100 patients, pre-engraftment in 22 and postengraftment in 78. Compared with postengraftment GVHD, pre-engraftment GVHD was more severe, as assessed by overall grade, with more frequent and more severe skin involvement and higher incidences of non-infectious fever, diarrhea, hepatic dysfunction, renal insufficiency, and weight gain. Compared with patients without acute GVHD, those with postengraftment GVHD had lower cumulative incidence of relapse [CIR; hazard ratio (HR), 0.470; P=0.006] and higher cumulative incidence of non-relapse mortality (CINRM; HR, 2.568; P<0.001), while those with pre-engraftment GVHD had similar CIR (HR, 0.815; P=0.059) and higher CINRM (HR, 2.872; P=0.036). Overall survival of patients with pre-engraftment GVHD was lower than that of those without acute GVHD (HR, 1.976; P=0.017), which was similar to that of those with postengraftment GVHD (HR, 0.969; P=0.878). Separate analyses of the effects of timing of acute GVHD on post-transplant outcomes in patients with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) showed similar trends.

CONCLUSION

Pre-engraftment GVHD might be a 'cytokine storm' type syndrome rather than 'real' GVHD, indicating the need for separate analyses of pre- and postengraftment GVHD in future trials.

An official American Thoracic Society research statement: noninfectious lung injury after hematopoietic stem cell transplantation: idiopathic pneumonia syndrome

RATIONALE

Acute lung dysfunction of noninfectious etiology, known as idiopathic pneumonia syndrome (IPS), is a severe complication following hematopoietic stem cell transplantation (HSCT). Several mouse models have been recently developed to determine the underlying causes of IPS. A cohesive interpretation of experimental data and their relationship to the findings of clinical research studies in humans is needed to better understand the basis for current and future clinical trials for the prevention/treatment of IPS.

OBJECTIVES

Our goal was to perform a comprehensive review of the preclinical (i.e., murine models) and clinical research on IPS.

METHODS

An ATS committee performed PubMed and OVID searches for published, peer-reviewed articles using the keywords "idiopathic pneumonia syndrome" or "lung injury" or "pulmonary complications" AND "bone marrow transplant" or "hematopoietic stem cell transplant." No specific inclusion or exclusion criteria were determined a priori for this review.

MEASUREMENTS AND MAIN RESULTS

Experimental models that reproduce the various patterns of lung injury observed after HSCT have identified that both soluble and cellular inflammatory mediators contribute to the inflammation engendered during the development of IPS. To date, 10 preclinical murine models of the IPS spectrum have been established using various donor and host strain combinations used to study graft-versus-host disease (GVHD). This, as well as the demonstrated T cell dependency of IPS development in these models, supports the concept that the lung is a target of immune-mediated attack after HSCT. The most developed therapeutic strategy for IPS involves blocking TNF signaling with etanercept, which is currently being evaluated in clinical trials.

CONCLUSIONS

IPS remains a frequently fatal complication that limits the broader use of allogeneic HSCT as a successful treatment modality. Faced with the clinical syndrome of IPS, one can categorize the disease entity with the appropriate tools, although cases of unclassifiable IPS will remain. Significant research efforts have resulted in a paradigm shift away from identifying noninfectious lung injury after HSCT solely as an idiopathic clinical syndrome and toward understanding IPS as a process involving aspects of both the adaptive and the innate immune response. Importantly, new laboratory insights are currently being translated to the clinic and will likely prove important to the development of future strategies to prevent or treat this serious disorder.

Clinical significance of hemophagocytosis in BM clot sections during the peri-engraftment period following allogeneic hematopoietic SCT

The effects of macrophage activation on the outcome of allogeneic hematopoietic SCT (allo-HSCT) have yet to be fully examined. A total of 70 adult patients who received a first allo-HSCT for hematological diseases were studied. We counted the number of hemophagocytic cells in BM clot sections on day +14±7, and analyzed its impact on subsequent outcome. In all, 23 patients were diagnosed as having increased numbers of hemophagocytic cells (HP group), whereas 47 were not (non-HP group). The HP group was not associated with an increased incidence of acute or chronic GVHD, but was associated with worse hematopoietic recovery than the non-HP group. The 2-year OS for the HP group and the non-HP group was 30 and 65% (P<0.01), respectively, and 2-year non-relapse mortality was 48% and 27% (P<0.01), respectively. Multivariate analysis confirmed that the HP group was associated with a lower OS (hazard ratio (HR)=2.3; 95% confidence interval (CI), 1.0-5.4; P=0.048) and higher non-relapse mortality (HR=4.0; 95% CI, 1.6-9.9; P<0.01). The HP group had higher incidences of death due to graft failure (P<0.01) and endothelial complications, such as sinusoidal obstruction syndrome and transplant-associated microangiopathy (P=0.01). Macrophage activation is a previously unrecognized complication with negative impact on outcome of allo-HSCT.

Intestinal damage determines the inflammatory response and early complications in patients receiving conditioning for a stem cell transplantation

Background

Stem cell transplantation (SCT) is still complicated by the occurrence of fever and inflammatory complications attributed to neutropenia and subsequent infectious complications. The role of mucosal barrier injury (MBI) of the intestinal tract therein has received little attention.

Methods

We performed a retrospective analysis in 163 SCT recipients of which data had been collected prospectively on intestinal damage (citrulline), inflammation (C-reactive protein), and neutrophil count. Six different conditioning regimens were studied; 5 myeloablative (MA) and 1 non-myeloablative (NMA). Linear mixed model multivariate and AUC analyses were used to define the role of intestinal damage in post-SCT inflammation. We also studied the relationship between the degree of intestinal damage and the occurrence of early post-SCT complications.

Results

In the 5 MA regimen there was a striking pattern of inflammatory response that coincided with the occurrence of severe intestinal damage. This contrasted with a modest inflammatory response seen in the NMA regimen in which intestinal damage was limited. With linear mixed model analysis the degree of intestinal damage was shown the most important determinant of the inflammatory response, and both neutropenia and bacteremia had only a minor impact. AUC analysis revealed a strong correlation between citrulline and CRP (Pearson correlation r = 0.96). Intestinal damage was associated with the occurrence of bacteremia and acute lung injury, and influenced the kinetics of acute graft-versus-host disease.

Conclusion

The degree of intestinal damage after myeloablative conditioning appeared to be the most important determined the inflammatory response following SCT, and was associated with inflammatory complications. Studies should explore ways to ameliorate cytotoxic therapy-induced intestinal damage in order to reduce complications associated with myeloablative conditioning therapy.

Syngeneic donor hematopoietic stem cell transplantation is associated with high rates of engraftment syndrome

Engraftment syndrome (ES), typically characterized by noninfectious fever, rash, and/or noncardiogenic pulmonary edema, is a complication of autologous and allogeneic hematopoietic stem cell transplantation (HSCT). There are no data on ES after syngeneic HSCT. We retrospectively analyzed syngeneic HSCT outcomes and determined ES incidence, risk factors, and prognostic impact. Thirty-two adult patients with a median age of 46 years (range: 22-60) underwent syngeneic HSCT at our institution between July 1986 and April 2009, primarily for hematologic malignancies (65% lymphoid-including 15% plasma cell; 31% myeloid). The median duration of follow-up was 6.1 years (range: 3.7 months to 18.1 years). Five-year progression-free and overall survival (PFS, OS) was 52% and 67%, respectively. Five-year overall cumulative incidence of relapse and nonrelapse mortality (NRM) was 37.6% and 10.2%, respectively; with increased relapse incidence of 76.3% in myeloid disease (P = .002). Fifteen patients (47%) met diagnostic criteria for ES, 10 (67%) of whom received systemic steroids. Five-year PFS was 47% in patients with ES versus 56% in those without (P = .37). Five-year OS was 63% with ES versus 71% without (P = .80). Five-year cumulative incidence of NRM was 21% with ES versus 0% without (P = .06). Five-year cumulative incidence of relapse was 32% with ES and 44% without (P = .68). Older age (P = .05) and possibly total body irradiation-based conditioning (P = .09) were risk factors for developing ES. In multivariable Cox models only diagnosis (myeloid disease) impaired OS and PFS. In summary, we document a high incidence of ES after syngeneic HSCT. The trend of increased NRM after ES requires reevaluation in a larger syngeneic HSCT cohort.

Engraftment syndrome following allogeneic hematopoietic stem cell transplantation in children

ES is a complication that occurs immediately before or at the timing of neutrophil engraftment following autologous or allogeneic SCT. It is characterized by fever, skin rash, and non-cardiac pulmonary infiltrates. We evaluated the incidence, risk factors, and outcomes of ES following allogeneic SCT in children. Of 100 pediatric patients, 20 (20%) developed ES occurring at a median of 14 days (range 8-27 days) post-transplant. Patients presented with fever (100%), skin rash (100%), diffuse pulmonary infiltration (25%), and body weight gain (85%). On multivariate analysis, significant risk factors for ES included younger age (<8 yr old) and human leukocyte antigen disparity between donors and recipients. Univariate analysis showed that patients with ES had a higher incidence of developing chronic graft-versus-host disease and ES was not associated with other complications. Event-free survival did not significantly differ between patients with and without ES regardless of the presence of malignant or non-malignant diseases.

Pre-engraftment syndrome after double-unit cord blood transplantation: a distinct syndrome not associated with acute graft-versus-host disease

Pre-engraftment syndrome (PES) occurring after cord blood transplantation (CBT) is poorly characterized. We reviewed 52 consecutive double-unit CBT recipients treated for high-risk hematologic malignancies. PES was defined as unexplained fever >38.3 degrees C (101 degrees F) not associated with infection and unresponsive to antimicrobials, and/or unexplained rash occurring before or at neutrophil recovery. CBT recipients (median age, 38 years; range, 3-66 years) received either myeloablative (MA; n=36) or nonmyeloablative (NMA; n=16) conditioning. Sixteen patients (31%) fulfilled PES criteria: 15 with fever (median at onset, 39 degrees C [102.2 degrees F]), 13 of whom also had rash, and 1 with rash alone. The median onset was 9 days (range, 5-12 days) posttransplantation (a median of 14 days before neutrophil recovery). Sixteen patients (14 with PES and 2 with infection and possible PES) received intravenous methylprednisolone (median dose, 1mg/kg; median duration, 3 days); 15 (94%) experienced resolution of fever within 24 hours. Recurrent PES (n=3) resolved with retreatment. There was no association between the development of PES and the likelihood of sustained donor engraftment, speed of neutrophil recovery, grade II-IV acute graft-versus-host disease (aGVHD), day-180 treatment-related mortality (TRM), or survival. PES is common after CBT, precedes neutrophil recovery, is distinct from and does not predict for aGVHD, and responds promptly to short-course corticosteroid therapy.

Low toxicity of a conditioning with 8-Gy total body irradiation, fludarabine and cyclophosphamide as preparative regimen for allogeneic hematopoietic stem cell transplantation in pediatric hematological malignancies

We here report the efficacy and toxicity of a conditioning regimen with fractionated 8-Gy TBI, fludarabine, and cyclophosphamide in allogeneic HSCT for pediatric hematological malignancies. Among 22 children who received related or unrelated HSCT, nine were transplanted with refractory disease and/or from HLA two or more loci-mismatched family donors. None of the patients developed graft failure. The Seattle grading system revealed that 18 patients had no RRT, and the remaining patients had grade I gastrointestinal toxicity alone. The estimated overall survival and leukemia-free survival at two yr were 57.1% and 48.0%, respectively, in 10 patients with acute lymphoblastic leukemia; 91.7% and 71.3%, respectively, in 12 patients with myeloid leukemia. The incidence of TRM was 4.8% at two yr. The rates of RRT above grade II and TRM in an 8-Gy TBI-containing regimen were significantly lower than the data of historical control patients who underwent 12-Gy TBI and cyclophosphamide with or without etoposide. The intermediate-dose TBI-based conditioning regimen may confer successful engraftment combined with minimized RRT, although its efficacy should be further evaluated.

Early pulmonary complications after hematopoietic stem cell transplantation in pediatric patients: association with cytomegalovirus infection

Pulmonary complications resulting in high morbidity and mortality occur in a substantial proportion of hematopoietic stem cell transplantation (HSCT) recipients. We investigated the incidence, causes, and risk factors of pulmonary complications, early after HSCT in pediatric patients, and patient outcomes by retrospective analysis of patients who underwent HSCT at Seoul National University Children's Hospital between September 2003 and June 2007. A total of 145 patients were evaluated of whom 15 (10.3%) developed pulmonary complications. Eight patients were suspected to have infection-related pulmonary complications and 7 had noninfectious causes. In a multivariate analysis of allogeneic transplantation recipients, detection of cytomegalovirus antigenemia was significantly associated with the development of both pulmonary complications and acute respiratory distress syndrome. Eleven (73.3%) of the 15 patients developed acute respiratory distress syndrome, required mechanical ventilation and eventually died. Early use of methylprednisolone in 3 patients decreased the oxygenation index. Sixteen patients died due to treatment-related complications early after HSCT, and pulmonary complications accounted for a substantial portion of the mortality. Thus, improvement of prophylaxis and management for pulmonary complications is crucial to improve the overall outcome of HSCT. More aggressive prophylaxis and treatment of cytomegalovirus infection and judicious use of methylprednisolone at the appropriate time could be the means for such improvement.

Respiratory complications after haematopoietic stem cell transplantation in a patient with chronic granulomatous disease

Chronic granulomatous disease (CGD) is an inherited immunodeficiency disorder caused by defects in NADPH oxidase and characterized by recurrent life-threatening bacterial and fungal infections. Although CGD has been considered to be a target for gene therapy, bone marrow transplantation (BMT) is now selected as the radical treatment in most cases. We performed BMT in a patient with CGD with severe infections and experienced respiratory complications of diffuse alveolar haemorrhage and/or infection-associated alveolar haemorrhage. We suggest that attention be paid to signs of onset of alveolar haemorrhage during BMT in CGD patients.

Vascular endothelium as 'novel' target of graft-versus-host disease

There is increasing evidence of the existence of an endothelial form of graft-versus-host disease (GvHD). The early endothelial injury syndromes - transplant-associated microangiopathy (TAM), veno-occlusive disease (VOD) of the liver, diffuse alveolar hemorrhage, engraftment syndrome, and capillary leak syndrome - all share common features with acute GvHD. They are more likely to occur after allogeneic hematopoietic stem-cell transplantation (HCT), in unrelated transplantation, or with non-T-cell-depleted grafts. In addition, acute GvHD is a risk factor for all these endothelial syndromes. Chronic GvHD leads to a rarefaction of microvessels caused by the infiltration of alloreactive cytotoxic T lymphocytes. Furthermore, late cardiovascular accidents are more likely to occur in patients treated with allogeneic than autologous HCT, suggesting that an immunological mechanism is involved in the development of atherosclerosis. Finally, biomarkers of endothelial injury show a close relationship with GvHD. These data support the notion that early endothelial damage syndromes, atherosclerosis, and vascular endothelial GvHD share a common denominator in patients treated with allogeneic HCT.

Characterization of acute graft-versus-host disease following reduced-intensity stem-cell transplantation from an HLA-identical related donor

To investigate clinical features of acute graft-versus-host disease (GVHD) following reduced intensity stem-cell transplantation (RIST), we retrospectively investigated medical records of 65 patients with hematologic malignancies who underwent RIST from a matched related donor. Preparative regimen comprised fludarabine 30 mg/m(2) (n = 53) or cladribine 0.11 mg/kg (n = 12) for 6 days plus busulfan 4 mg/kg for 2 days. Twelve patients received rabbit antithymocyte globulin 2.5 mg/kg/day for 2-4 consecutive days. Grade II to IV acute GVHD was diagnosed in 36 patients (55%). Its median onset was day 58 (range, 17-109), while it was bimodal, peaking day 15-29 (early-onset GVHD, n = 18) and day 75-89 days (late-onset GVHD, n = 18). Variables that were more common in early-onset GVHD than late-onset GVHD included skin rash (89% vs. 61%) and noninfectious fevers (33% vs. 11%). Desaturation, pulmonary infiltrates and hyperbilirubinemia (>2.0 mg/dL) were more common in late-onset GVHD (6% vs. 22%, 0% vs. 17%, and 6% vs. 33%, respectively). All of the patients with early-onset GVHD given corticosteroid responded to it, while 5 of the 18 patients with late-onset GVHD failed to respond it. Patients with either early-onset or late-onset GVHD tended to have better progression-free survival (PFS) than those without it; however, there was no significant difference in PFS between patients with early-onset GVHD and those with late-onset GVHD. This study suggests that several etiologies might have contributed to the development of acute GVHD following RIST.

Incidence, predisposing factors, and outcome of engraftment syndrome in pediatric allogeneic stem cell transplant recipients

Engraftment syndrome (ES) has been recognized as an inflammatory condition during neutrophil recovery after hematopoietic stem cell transplantation (HSCT) characterized by noninfectious fever and skin rash. It has been reported to occur frequently after autologous HSCT in children and adults, and has been shown to be an independent risk factor for increased transplant-related mortality (TRM). However, virtually no data exist on its occurrence after allogeneic HSCT in children. To determine incidence, predisposing factors for, and complications of ES in a pediatric transplant cohort, we analyzed 61 consecutive recipients of a myeloablative allogeneic HSCT for the occurrence of ES. Diagnosis of ES was established when children presented with > or =2 of the following symptoms within 7 days before engraftment: (1) fever >38.0 degrees C, (2) skin rash, (3) weight gain and albumin drop, or (4) dyspnea, hypoxia, and pulmonary infiltrates. Incidence of ES in this cohort was 48% (29 of 61). In a univariate analysis, posttransplant granulocyte-colony stimulating factor (G-CSF) administration (P = .02), and high mononuclear cell count (MNC) (P = .002) were identified as significant risk factors predisposing for the development of ES. In a multiple logistic regression analysis, amphotericin B therapy (P = .009) and high MNC (P = .004) were significant explanatory variables for ES risk. There was a slight trend toward a higher rate of chronic GVHD (cGVHD) in patients with ES (P = .11). However, after a median follow-up of 9.5 years overall survival (OS) (P = .53) and TRM (P = .65) did not differ between the 2 groups. ES presenting with fever, rash, weight gain, and pulmonary symptoms should be recognized as a frequent complication of allogeneic HSCT after myeloablative conditioning in children. Treatment with G-CSF, amphotericin B, and a high nucleated cell count of the graft predisposed for the development of ES in this study. OS and TRM in this cohort were not affected by the occurrence of ES.

Bilateral Marginal Keratitis Associated With Engraftment Syndrome After Hematopoietic Stem Cell Transplantation

PURPOSE

To report the first case of bilateral marginal keratitis in the setting of engraftment syndrome in a patient who had undergone hematopoietic stem cell transplantation.

METHODS

A 63-year-old man with a history of myelodysplastic syndrome presented with a 5-day history of red eyes. Two weeks before presentation, the patient had received a matched unrelated donor peripheral blood stem cell transplant and subsequently developed engraftment syndrome with a rapid white blood cell count recovery, noninfectious fever, skin rash, and shortness of breath. Ocular symptoms coincided with the timing of the white blood cell recovery. On examination, vision was 20/20 OU with +1 conjunctival injection with bilateral corneal subepithelial infiltrates in the periphery, particularly in areas of corneal pannus from previously existing contact lens-related neovascularization. There was no evidence of blepharitis, meibomian gland dysfunction, or uveitis. Ocular bacterial and viral cultures were negative, and a conjunctival biopsy was negative for viral inclusions or ocular graft-versus-host disease.

RESULTS

The patient was initially treated with topical antibiotics for 2 days without any improvement and treated with topical corticosteroids 4 times daily. Examination 7 days after starting topical corticosteroids showed complete resolution of the marginal keratitis.

CONCLUSIONS

Engraftment syndrome is notable for a rapid recovery of the white blood cell count after hematopoietic stem cell transplantation. Patients who present with presumed conjunctivitis in the setting of autologous and allogeneic stem cell transplantation should be evaluated for engraftment syndrome-related marginal keratitis.

Hematopoietic stem cell transplantation: implications for critical care nurses

Hematopoietic stem cell transplantation (HSCT) is being used increasingly in the treatment of malignant and nonmalignant diseases. The treatment modality has been proven effective but is not without risks. Studies consistently have identified the need for advanced supportive care (e.g., multiple organ dysfunction, vasopressor use, mechanical ventilation) as a negative prognostic indicator in patients who have received HSCT. Among patients who have received HSCT, 15%-40% require critical care monitoring or advanced support. Nurses on intensive care units can positively impact outcomes for transplant recipients when they possess the specialized skills to recognize and promptly intervene when transplant-related complications arise. This article will provide a basic overview of the HSCT process and outline the complications that may necessitate transfer to a higher level of care for specialized skills and equipment in the intensive care setting.

A comparative investigation of methods for logistic regression with separated or nearly separated data

In logistic regression analysis of small or sparse data sets, results obtained by classical maximum likelihood methods cannot be generally trusted. In such analyses it may even happen that the likelihood meets the convergence criteria while at least one parameter estimate diverges to +/-infinity. This situation has been termed 'separation', and it typically occurs whenever no events are observed in one of the two groups defined by a dichotomous covariate. More generally, separation is caused by a linear combination of continuous or dichotomous covariates that perfectly separates events from non-events. Separation implies infinite or zero maximum likelihood estimates of odds ratios, which are usually considered unrealistic. I provide some examples of separation and near-separation in clinical data sets and discuss some options to analyse such data, including exact logistic regression analysis and a penalized likelihood approach. Both methods supply finite point estimates in case of separation. Profile penalized likelihood confidence intervals for parameters show excellent behaviour in terms of coverage probability and provide higher power than exact confidence intervals. General advantages of the penalized likelihood approach are discussed.

Overcoming graft rejection in heavily transfused and allo-immunised patients with bone marrow failure syndromes using fludarabine-based haematopoietic cell transplantation

Allogeneic haematopoietic cell transplantation (HCT) can cure a variety of non-malignant haematological disorders. Although transplant outcomes for selected patients with severe aplastic anaemia (SAA) and paroxysmal nocturnal haemoglobinuria (PNH) have improved, older age, allo-immunisation from transfusions, prior immunosuppressive therapy and a prolonged time from diagnosis to transplantation are associated with worse outcome. Because of its potent immunosuppressive effects, we investigated a fludarabine-based non-myeloablative conditioning regimen in patients with transfusion-dependent non-malignant haematological disorders at increased risk for graft rejection with conventional transplant conditioning. Twenty-six patients with transfusion dependent/anti-thymocyte globulin (ATG)-refractory SAA, PNH or pure red cell aplasia underwent HCT from a human leucocyte antigen (HLA)-compatible relative. Transplant conditioning consisted of cyclophosphamide (120 mg/kg) and fludarabine (125 mg/m2) with or without ATG. Ciclosporine, alone or combined with mycophenolate mofetil or methotrexate, was used as graft-versus-host disease (GVHD) prophylaxis. All patients achieved durable engraftment and transfusion-independence. Twenty-four of 26 patients are alive at a median of 21 months following transplantation. Although a high cumulative incidence of acute (65% grades II-IV, 54% grades III-IV) and chronic GVHD (56%) was observed, only one patient died from transplant-related causes (cumulative incidence 7%). These data show that HCT following fludarabine-based non-myeloablative conditioning results in durable engraftment and excellent survival in SAA and PNH patients at high risk for graft rejection.