1
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Neurological complications in adult allogeneic hematopoietic stem cell transplant patients: Incidence, characteristics and long-term follow-up in a multicenter series. Bone Marrow Transplant 2022; 57:1133-1141. [PMID: 35513485 DOI: 10.1038/s41409-022-01690-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 12/20/2022]
Abstract
Neurological complications (NCs) represent a diagnostic and clinical challenge in allogeneic hematopoietic stem cell transplant (alloHSCT) patients. We retrospectively analyzed NC incidence, etiology, timing, characteristics, outcome, and long-term effects in 2384 adult patients transplanted in seven Italian institutions between January 2007 and December 2019. Ninety-three (3.9%) patients were affected by 96 NCs that were infectious (29.2%), immune/inflammatory (26%), drug-related (12.5%), cerebrovascular (5.2%), metabolic (3.1%), related to central nervous system disease relapse (11.5%) and malignancy (3.1%), or undefined (9.4%). Six patients (6.4%) had neurological manifestations of chronic graft-versus-host disease (GVHD). NCs occurred on average at day +128 (from -5 to +4063). Early (< day +120) and late NCs had similar frequencies (46.9% vs 53.1%, p = 0.39). Thirty-one patients (33.3%) were affected by acute or chronic GVHD at the NC onset. With a median follow-up of 25.4 (0.4-163) months, the overall mortality due to NCs was 22.6%. The median time between NC onset and death was 36 (1-269) days. Infectious NCs were the main cause (61.9%) of NC-related mortality. A persistent neurological impairment occurred in 20.4% patients, 57.9% of whom being affected by immune/inflammatory NCs. This study highlights the rare, yet severe impact of alloHSCT-associated NCs on patient survival and long-term functional ability.
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2
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Balaguer-Rosello A, Bataller L, Piñana JL, Montoro J, Lorenzo I, Villalba A, Freiria C, Santiago M, Sevilla T, Muelas N, Guerreiro M, Carretero C, Gómez I, Solves P, Sanz MÁ, Sanz G, Sanz J. Noninfectious Neurologic Complications after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:1818-1824. [PMID: 31132454 DOI: 10.1016/j.bbmt.2019.05.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/18/2019] [Accepted: 05/21/2019] [Indexed: 12/19/2022]
Abstract
Although allogeneic hematopoietic stem cell transplantation (allo-HSCT) can be associated with neurologic complications, data on noninfectious etiologies are scanty. Therefore, we analyzed the incidence, clinical characteristics, risk factors, and influence on outcomes of noninfectious neurologic complications (NCs) in 971 consecutive patients with hematologic malignancies undergoing allo-HSCT at our center between January 2000 and December 2016. We evaluated NCs affecting the central nervous system (CNS) and peripheral nervous system (PNS). The median duration of follow-up of survivors was 71 months (range, 11 to 213 months). A total of 467 patients received a matched sibling donor (MSD) transplant, 381 received umbilical cord blood (UCB), 74 received a haploidentical transplant, and 49 received a matched unrelated donor (MUD) transplant. One hundred forty-nine (15.3%) NCs were documented at a median of 78 days after transplantation (range, 5 days before to 3722 days after). The cumulative incidence risk of developing NC was 7.5% (95% confidence interval, 6% to 8.2%) at day +90 and 13% at 5 years. The 5-year cumulative incidence of NCs was 10.8% after MSD allo-HSCT and 15.3% after alternative donor (UCB, MUD, haploidentical) allo-HSCT (P = .004). There were 101 (68%) CNS complications, including encephalopathy, n = 46 (31%); headache, n = 20 (13%); stroke, n = 15 (10%); seizures, n = 9 (6%), posterior reversible encephalopathy syndrome, n = 6 (4%), and myelopathy, n = 5 (3%). PNS complications (32%) included neuropathies, n = 25 (17%), and myopathies and neuromuscular junction disorders, n = 23 (17%), with 17% of the total PNS complications being immune-related. In multivariable analysis, donor type other than MSD, age ≥40 years, development of acute graft-versus-host disease (GVHD) grade II-IV (hazard ratio [HR], 3.3; P < .00001), and extensive chronic GVHD (HR, 3.2; P = .0002) were independently associated with increased risk of NCs. The 5-year overall survival (OS) was 21% in patients who developed NCs and 41% for those who did not (P < .0001). This difference in OS was observed in patients developing CNS NCs, but not in those developing PNS complications. In conclusion, our study reveals NCs as a frequent and heterogeneous complication that, when affecting CNS, is associated with poor prognosis following allo-HSCT.
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Affiliation(s)
| | - Luis Bataller
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - José Luis Piñana
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Juan Montoro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ignacio Lorenzo
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ana Villalba
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Carmen Freiria
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Marta Santiago
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Teresa Sevilla
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Nuria Muelas
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Manuel Guerreiro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Carlos Carretero
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Inés Gómez
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pilar Solves
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Miguel Ángel Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Guillermo Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
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3
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Sakellari I, Gavriilaki E, Papagiannopoulos S, Gavriilaki M, Batsis I, Mallouri D, Vardi A, Constantinou V, Masmanidou M, Yannaki E, Smias C, Geroukis T, Kazis D, Kimiskidis V, Anagnostopoulos A. Neurological adverse events post allogeneic hematopoietic cell transplantation: major determinants of morbidity and mortality. J Neurol 2019; 266:1960-1972. [PMID: 31087160 DOI: 10.1007/s00415-019-09372-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/06/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Despite advances in the field, diagnosis and management of the wide spectrum of neurological events post allogeneic hematopoietic cell transplantation (alloHCT) remain challenging. Therefore, we investigated their incidence, diagnosis, management and long-term prognosis in alloHCT recipients. METHODS We retrospectively recorded data from consecutive alloHCT recipients with or without neurological complications in our center. RESULTS Among 758 alloHCT recipients, 127 (16.8%) presented with neurological complications. Complications developed in central nervous system (89.7%) during the late post-transplant period. Neurological adverse events included a wide spectrum of infectious and non-infectious etiologies. With a median follow-up of 11.4 months, incidence of chronic graft-versus-host disease (GVHD) was 52.8%, relapse mortality 48.6%, transplant-related mortality 39.1% and 5-year overall survival (OS) 25.8% in patients with neurological complications. Timing of appearance of neurological complications, early or late, was associated only with acute and chronic graft-versus-host-disease/GVHD. Independent pre-transplant risk factors of neurological complications in the multivariate model were unrelated or alternative donors, ALL diagnosis and non-myeloablative conditioning. In multivariate analysis of post-alloHCT events, favorable OS was independently associated with resolution of neurological syndromes, absence of chronic GVHD and sibling transplantation. In our cohort, 10-year OS was significantly lower in patients with neurological complications and independently associated with acute and chronic GVHD, relapse, fungal and bacterial infections and neurological complications. CONCLUSIONS Our large study with long-term follow-up highlights the wide spectrum of neurological complications in alloHCT. Accurate recognition is required for adequate management, a major determinant of survival. Thus, long-term increased awareness and collaboration between expert physicians is warranted.
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Affiliation(s)
- Ioanna Sakellari
- BMT Unit, Hematology Department, G. Papanicolaou Hospital, Thessaloníki, Greece
| | - Eleni Gavriilaki
- BMT Unit, Hematology Department, G. Papanicolaou Hospital, Thessaloníki, Greece
| | | | - Maria Gavriilaki
- School of Medicine, University Campus, Aristotle University of Thessaloniki, 54124, Thessaloníki, Greece.
| | - Ioannis Batsis
- BMT Unit, Hematology Department, G. Papanicolaou Hospital, Thessaloníki, Greece
| | - Despina Mallouri
- BMT Unit, Hematology Department, G. Papanicolaou Hospital, Thessaloníki, Greece
| | - Anna Vardi
- BMT Unit, Hematology Department, G. Papanicolaou Hospital, Thessaloníki, Greece
| | | | - Marianna Masmanidou
- BMT Unit, Hematology Department, G. Papanicolaou Hospital, Thessaloníki, Greece
| | - Evangelia Yannaki
- BMT Unit, Hematology Department, G. Papanicolaou Hospital, Thessaloníki, Greece
| | - Christos Smias
- BMT Unit, Hematology Department, G. Papanicolaou Hospital, Thessaloníki, Greece
| | | | - Dimitrios Kazis
- 3rd Department of Neurology, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Vasileios Kimiskidis
- School of Medicine, University Campus, Aristotle University of Thessaloniki, 54124, Thessaloníki, Greece.,Laboratory of Clinical Neurophysiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
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4
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Lin TA, Gau JP, Liu YC, Ko PS, Wang HY, Chien SH, Liu CJ, Hsiao LT, Chiou TJ, Liu JH. Cerebrovascular disease after allogeneic hematopoietic stem cell transplantation: incidence, risk, and clinical outcome. Int J Hematol 2019; 109:584-592. [PMID: 30864116 DOI: 10.1007/s12185-019-02624-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 11/30/2022]
Abstract
Cerebrovascular complications after hematopoietic stem cell transplantation (HSCT) cause serious morbidity and often contribute to mortality. The incidence, risk factors, and outcome of cerebrovascular disease (CVD) after allogeneic HSCT remain poorly defined. We retrospectively evaluated 459 adult patients who underwent allogeneic HSCT at a tertiary medical center between January 2003 and December 2015. A total of 20 patients (4.4%) developed post-transplant CVD. All cerebrovascular accidents occurred in the first two years post-transplant. The two-year incidences of post-transplant CVD, intracranial hemorrhage, and cerebrovascular infarction were 6.1%, 3.2%, and 3.2%, respectively. The incidence rate of CVD within two years after HSCT was 34.7 (95% CI 22.3 to - 53.7) per 1000 person-years, which was about tenfold higher than the general Taiwanese population. The only significant risk factor associated with post-transplant CVD is prior exposure to three or more courses of high-dose cytarabine. Post-transplant CVD is associated with dismal outcome and early mortality. The median overall survival of patients with post-transplant CVD was markedly reduced compared with those without CVD (8.0 vs. 60.6 months). Most patients with post-transplant CVD died within two months after the CVD events. Our study demonstrates that CVD remains a devastating complication after allogeneic HSCT in the modern era.
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Affiliation(s)
- Ting-An Lin
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan
| | - Jyh-Pyng Gau
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yao-Chung Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan. .,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Po-Shen Ko
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hao-Yuan Wang
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Sheng-Hsuan Chien
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Transfusion Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Jen Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Liang-Tsai Hsiao
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tzeon-Jye Chiou
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Transfusion Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jin-Hwang Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Hematology and Oncology, Department of Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
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5
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Gavriilaki E, Sakellari I, Batsis I, Mallouri D, Bousiou Z, Vardi A, Yannaki E, Constantinou V, Tsompanakou A, Vadikoliou C, Kaloyannidis P, Bamihas G, Anagnostopoulos A. Transplant-associated thrombotic microangiopathy: Incidence, prognostic factors, morbidity, and mortality in allogeneic hematopoietic cell transplantation. Clin Transplant 2018; 32:e13371. [DOI: 10.1111/ctr.13371] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 07/20/2018] [Accepted: 07/29/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Eleni Gavriilaki
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Ioanna Sakellari
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Ioannis Batsis
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Despina Mallouri
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Zoi Bousiou
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Anna Vardi
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Evangelia Yannaki
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | | | - Aliki Tsompanakou
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | | | | | - Gerasimos Bamihas
- Nephrology Department; G. Papanicolaou Hospital; Thessaloniki Greece
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6
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Neurologic complications after allogeneic hematopoietic stem cell transplantation: risk factors and impact. Bone Marrow Transplant 2017; 53:199-206. [PMID: 29131150 DOI: 10.1038/bmt.2017.239] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/08/2017] [Accepted: 09/12/2017] [Indexed: 01/16/2023]
Abstract
Neurologic complications (NCs) may be a significant source of morbidity and mortality after hematopoietic cell transplantation (HCT). We performed a retrospective study of 263 consecutive patients undergoing allogeneic HCT for hematological malignancies to determine the incidence, risk factors and clinical impact of NCs in the first 5 years after HCT. We determined the incidence of central nervous system (CNS) infection, intracranial hemorrhage, ischemic stroke, metabolic encephalopathy, posterior reversal encephalopathy syndrome, seizure and peripheral neuropathy. In all, 50 patients experienced 63 NCs-37 early (⩽day +100), 21 late (day +101 to 2 years) and 5 very late (2 to 5 years). The 1- and 5-year cumulative incidences of all NCs were 15.6% and 19.2%, respectively, and of CNS complication (CNSC; all of the above complications except peripheral neuropathy) were 12.2 and 14.5%. Risk factors for CNSC were age (hazard ratio (HR)=1.06 per year, P=0.0034), development of acute GvHD grade III-IV (HR=2.78, P=0.041), transfusion-dependent thrombocytopenia (HR=3.07, P=0.025) and delayed platelet engraftment (>90th centile; HR=2.77, P=0.043). CNSCs negatively impacted progression-free survival (HR=2.29, P=0.0001), overall survival (HR=2.63, P<0.0001) and non-relapse mortality (HR=8.51, P<0.0001). NCs after HCT are associated with poor outcomes, and usually occur early after HCT.
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7
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Chaudhary RK, Dhakal P, Aryal A, Bhatt VR. Central nervous system complications after allogeneic hematopoietic stem cell transplantation. Future Oncol 2017; 13:2297-2312. [PMID: 28984145 DOI: 10.2217/fon-2017-0274] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Allogenic hematopoietic stem cell transplant (alloSCT) is a potentially curative modality of treatment for patients with hematological malignancies. However, CNS complications following transplant pose a risk to survival of the patients. Early recognition and management of these complications are crucial to reduce morbidity and mortality of patients following transplant. Early CNS complications associated with alloSCT are infection, cerebrovascular events, chemotherapy and radiation-induced toxicities while late complications include post-transplant lymphoproliferative disorder, CNS relapse of underlying malignancy and viral and fungal infections. Development of graft-versus-host disease can further increase the risk of CNS complications and outcomes after alloSCT. Strategies aimed to reduce the risk of CNS complications and early management may ameliorate the morbidity and mortality in transplant recipients.
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Affiliation(s)
- Ranjit Kumar Chaudhary
- Department of Radiodiagnosis & Imaging, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Prajwal Dhakal
- Department of Medicine, Michigan State University, East Lansing, MI 48824, USA
| | - Aashrayata Aryal
- Department of Neurology, University of Nebraska Medical Center; Omaha, NE 68198, USA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology & Oncology, University of Nebraska Medical Center; Omaha, NE 68198, USA
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8
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Balaguer Rosello A, Bataller L, Lorenzo I, Jarque I, Salavert M, González E, Piñana JL, Sevilla T, Montesinos P, Iacoboni G, Muelas N, Romero S, Carretero C, Montoro J, Ibáñez-Juliá MJ, Sanz G, Sanz MÁ, Sanz J. Infections of the Central Nervous System after Unrelated Donor Umbilical Cord Blood Transplantation or Human Leukocyte Antigen-Matched Sibling Transplantation. Biol Blood Marrow Transplant 2016; 23:134-139. [PMID: 27794456 DOI: 10.1016/j.bbmt.2016.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 10/07/2016] [Indexed: 12/19/2022]
Abstract
We analyzed the incidence, clinical characteristics, prognostic factors, and outcome of central nervous system (CNS) infections in consecutive patients with receiving umbilical cord blood transplantation (UCBT) (n = 343) or HLA-matched sibling donor stem cell transplantation (MST) (n = 366). Thirty-four CNS infections were documented at a median time of 116 days after transplantation (range, 7 to 1161). The cumulative incidence (CI) risk of developing a CNS infection was .6% at day +30, 2.3% at day +90, and 4.9% at 5 years. The 5-year CI of CNS infection was 8.2% after UCBT and 1.7% after MST (P < .001). The causative micro-organisms of CNS infections were fungi (35%), virus (32%), Toxoplasma spp. (12%), and bacteria (12%). Fungal infections occurred in 11 patients after UCBT and 1 after MST and were due to Aspergillus spp. (n = 8), Cryptococcus neoformans (n = 2), Scedosporium prolificans (n = 1), and Mucor (n = 1). Except for 1 patient, all died from CNS fungal infection. Viral infections occurred in 9 patients after UCBT and 1 after MST and were due to human herpes virus 6 (n = 7), cytomegalovirus (n = 2), and varicella zoster virus (n = 1). CNS toxoplasmosis was diagnosed in 3 patients after UCBT and 1 after MST. Other pathogens were Staphylococcus spp, Nocardia spp, Streptococcus pneumoniae, and Mycobacterium tuberculosis. Twenty of the 34 patients (59%) died from the CNS infection. In multivariable analysis, UCBT and disease stage beyond first complete remission were independently associated with the risk of developing CNS infections. The 5-year overall survival was 19% in patients who developed a CNS and 39% for those who did not (P = .006). In conclusion, our study showed that CNS infections are a significant clinical problem after stem cell transplantation associated with poor survival. They were more frequent after UCBT compared to MST.
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Affiliation(s)
| | - Luis Bataller
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ignacio Lorenzo
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Isidro Jarque
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Miguel Salavert
- Department of Infectious Diseases, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Eva González
- Microbiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - José Luis Piñana
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Teresa Sevilla
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pau Montesinos
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Gloria Iacoboni
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Nuria Muelas
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Samuel Romero
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Carlos Carretero
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Juan Montoro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - Guillermo Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Medicine, Universidad de Valencia, Valencia, Spain
| | - Miguel Ángel Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Medicine, Universidad de Valencia, Valencia, Spain
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Medicine, Universidad de Valencia, Valencia, Spain
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9
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Hanajiri R, Kobayashi T, Yoshioka K, Watanabe D, Watakabe K, Murata Y, Hagino T, Seno Y, Najima Y, Igarashi A, Doki N, Kakihana K, Sakamaki H, Ohashi K. Central nervous system infection following allogeneic hematopoietic stem cell transplantation. Hematol Oncol Stem Cell Ther 2016; 10:22-28. [PMID: 27664550 DOI: 10.1016/j.hemonc.2016.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 07/21/2016] [Accepted: 08/29/2016] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE/BACKGROUND Here, we described the clinical characteristics and outcomes of central nervous system (CNS) infections occurring after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in a single institution over the previous 6 years. METHODS Charts of 353 consecutive allogeneic transplant recipients were retrospectively reviewed for CNS infection. RESULTS A total of 17 cases of CNS infection were identified at a median of 38 days (range, 10-1028 days) after allo-HSCT. Causative pathogens were human herpesvirus-6 (n=6), enterococcus (n=2), staphylococcus (n=2), streptococcus (n=2), varicella zoster virus (n=1), cytomegalovirus (n=1), John Cunningham virus (n=1), adenovirus (n=1), and Toxoplasma gondii (n=1). The cumulative incidence of CNS infection was 4.1% at 1 year and 5.5% at 5 years. CONCLUSION Multivariate analysis revealed that high-risk disease status was a risk factor for developing CNS infection (p=.02), and that overall survival at 3 years after allo-HSCT was 33% in patients with CNS infection and 53% in those without CNS infection (p=.04).
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Affiliation(s)
- Ryo Hanajiri
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takeshi Kobayashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kosuke Yoshioka
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Daisuke Watanabe
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kyoko Watakabe
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yutaka Murata
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takeshi Hagino
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yasushi Seno
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Aiko Igarashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazuhiko Kakihana
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hisashi Sakamaki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan.
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Bhatt VR, Balasetti V, Jasem JA, Giri S, Armitage JO, Loberiza FR, Bociek RG, Bierman PJ, Maness LJ, Vose JM, Fayad P, Akhtari M. Central Nervous System Complications and Outcomes After Allogeneic Hematopoietic Stem Cell Transplantation. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:606-11. [DOI: 10.1016/j.clml.2015.06.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 06/09/2015] [Accepted: 06/12/2015] [Indexed: 11/27/2022]
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11
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Chang L, Frame D, Braun T, Gatza E, Hanauer DA, Zhao S, Magenau JM, Schultz K, Tokala H, Ferrara JLM, Levine JE, Reddy P, Paczesny S, Choi SW. Engraftment syndrome after allogeneic hematopoietic cell transplantation predicts poor outcomes. Biol Blood Marrow Transplant 2014; 20:1407-17. [PMID: 24892262 PMCID: PMC4142041 DOI: 10.1016/j.bbmt.2014.05.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 05/22/2014] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Lawrence Chang
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan
| | - David Frame
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Thomas Braun
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Erin Gatza
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan
| | - David A Hanauer
- Department of Pediatrics, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan; Informatics Core of the Comprehensive Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Shuang Zhao
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan
| | - John M Magenau
- Department of Internal Medicine, Division of Hematology-Oncology, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan
| | - Kathryn Schultz
- Department of Pharmacy, Rush University Medical Center, Chicago, Illinois
| | - Hemasri Tokala
- Department of Internal Medicine, Michigan State University, East Lansing, Michigan
| | - James L M Ferrara
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan
| | - John E Levine
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan
| | - Pavan Reddy
- Department of Internal Medicine, Division of Hematology-Oncology, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan
| | - Sophie Paczesny
- Department of Pediatric Hematology-Oncology, Indiana University, Indianapolis, Indiana
| | - Sung Won Choi
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan.
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Pruitt AA, Graus F, Rosenfeld MR. Neurological complications of transplantation: part I: hematopoietic cell transplantation. Neurohospitalist 2013; 3:24-38. [PMID: 23983885 DOI: 10.1177/1941874412455338] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Hematopoietic cell transplantation (HCT) is the preferred treatment for an expanding range of neoplastic and nonmalignant conditions. Increasing numbers of solid organ transplantations (SOTs) add an additional population of immunosuppressed patients with multiple potential neurological problems. While the spectrum of neurological complications varies with conditioning procedure and hematopoietic cell or solid organ source, major neurological complications occur with all transplantation procedures. This 2 part review emphasizes a practical consultative approach to central and peripheral nervous system problems related to HCT or SOT with clinical and neuroimaging examples from the authors' institutional experience with the following conditions: the diversity of manifestations of common infections such as varicella zoster virus, Aspergillus, and progressive multifocal leukoencephalopathy (PML), drug therapy-related complications, stroke mechanisms, the spectrum of graft versus host disease (GVHD), and neurologically important syndromes of immune reconstitution inflammatory syndrome (IRIS), posterior reversible encephalopathy syndrome (PRES), and posttransplantation lymphoproliferative disorder (PTLD). These complications preferentially occur at specific intervals after HCT and SOT, and neurological consultants must recognize an extensive spectrum of syndromes in order to effect timely diagnosis and expedite appropriate treatment.
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Affiliation(s)
- Amy A Pruitt
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
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13
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Zhang XH, Xu LP, Liu DH, Chen H, Han W, Chen YH, Wang FR, Wang JZ, Wang Y, Zhao T, Chen Y, Fu HX, Liu KY, Huang XJ. Epileptic seizures in patients following allogeneic hematopoietic stem cell transplantation: a retrospective analysis of incidence, risk factors, and survival rates. Clin Transplant 2012; 27:80-9. [PMID: 22938074 DOI: 10.1111/ctr.12000] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Xiao-hui Zhang
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Lan-ping Xu
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Dai-hong Liu
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Huan Chen
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Wei Han
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Yu-hong Chen
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Feng-rong Wang
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Jing-zhi Wang
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Yu Wang
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Ting Zhao
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Yao Chen
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Hai-xia Fu
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Kai-yan Liu
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
| | - Xiao-jun Huang
- Peking University People's Hospital; Peking University Institute of Hematology; Beijing; China
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14
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15
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Koh KN, Park M, Kim BE, Im HJ, Seo JJ. Early central nervous system complications after allogeneic hematopoietic stem cell transplantation in children. THE KOREAN JOURNAL OF HEMATOLOGY 2010; 45:164-70. [PMID: 21120204 PMCID: PMC2983044 DOI: 10.5045/kjh.2010.45.3.164] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 08/04/2010] [Accepted: 09/02/2010] [Indexed: 11/17/2022]
Abstract
BACKGROUND Central nervous system (CNS) complications after allogeneic hematopoietic stem cell transplantation (HSCT) have not been well characterized in the pediatric population. METHODS We retrospectively analyzed data of 202 consecutive children who underwent allogeneic HSCT (60 from matched related donors, 9 from mismatched related donors, and 133 from unrelated donors) at Asan Medical Center between 1998 and 2009. RESULTS Twenty-seven children (13.5%) developed CNS complications within 6 months after HSCT. Calcineurin inhibitor (CNI)-associated neurotoxicity was the most common CNS complication (n=16), followed by CNS infection (n=2), cerebrovascular events (n=2), thrombotic microangiopathy-associated events (n=2), metabolic encephalopathy (n=2), irradiation/chemotherapy injury (n=1), and encephalopathy/myelopathy of unknown causes (n=2). Univariate analysis showed that a transplant from an alternative donor and the occurrence of acute graft-versus-host disease (GVHD) (>grade 2) were associated with a significantly increased risk of CNS complications. In the multivariate analysis, acute GVHD >grade 2 was identified as an independent risk factor for early CNS complications. The 5-year overall survival rate was significantly lower in patients with CNS complications (52.1% vs. 64.9%, P=0.014), whereas CNI-associated neurotoxicity did not affect the survival outcome. CONCLUSION CNS complications are frequent among children undergoing HSCT, contributing to early death after transplant. More attention should be paid to the development of CNS complications for recipients of alternative donor transplants and patients with severe acute GVHD who are at increased risk for CNS complications.
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Affiliation(s)
- Kyung Nam Koh
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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High fludarabine exposure and relationship with treatment-related mortality after nonmyeloablative hematopoietic cell transplantation. Bone Marrow Transplant 2010; 46:20-6. [PMID: 20383215 PMCID: PMC2904846 DOI: 10.1038/bmt.2010.53] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Despite its common use in nonmyeloablative preparative regimens, the pharmacokinetics of fludarabine are poorly characterized in hematopoietic cell transplantation (HCT) recipients and exposure-response relationships remain undefined. Our objective of this study was to evaluate the association between plasma F-ara-A exposure, the systemically circulating moiety of fludarabine, and engraftment, acute graft vs host disease (GVHD), treatment-related mortality (TRM) and survival after HCT. The preparative regimen consisted of cyclophosphamide 50 mg/kg/day i.v. day −6; plus fludarabine 30-40 mg/m2/day i.v. on days −6 to −2 and TBI 200 cGy on day −1. F-ara-A pharmacokinetics were performed with the first dose of fludarabine in 87 adult patients. Median (range) F-ara-A AUC (0-∞) was 5.0 ug*hr/mL (2.0-11.0), clearance 15.3 L/hour (6.2-36.6), Cmin 55 ng/mL (17-166), and concentration on dayzero 16.0 ng/mL (0.1-144.1). Despite dose reductions, patients with renal insufficiency had higher F-ara-A exposures. There was strong association between high plasma concentrations of F-ara-A and increased risk of TRM and reduced overall survival. Patients with an AUC(0-∞) greater than 6.5 ug*hr/mL had 4.56 greater risk of TRM and significantly lower survival. These data suggest that clinical strategies are needed to optimize dosing of fludarabine to prevent overexposure and toxicity in HCT.
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Current world literature. Curr Opin Oncol 2010; 22:155-61. [PMID: 20147786 DOI: 10.1097/cco.0b013e32833681df] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Barba P, Piñana JL, Valcárcel D, Querol L, Martino R, Sureda A, Briones J, Delgado J, Brunet S, Sierra J. Early and Late Neurological Complications after Reduced-Intensity Conditioning Allogeneic Stem Cell Transplantation. Biol Blood Marrow Transplant 2009; 15:1439-46. [DOI: 10.1016/j.bbmt.2009.07.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Accepted: 07/11/2009] [Indexed: 10/20/2022]
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Abstract
Human stem cells are in evaluation in clinical stem cell trials, primarily as autologous bone marrow studies, autologous and allogenic mesenchymal stem cell trials, and some allogenic neural stem cell transplantation projects. Safety and efficacy are being addressed for a number of disease state applications. There is considerable data supporting safety of bone marrow and mesenchymal stem cell transplants but the efficacy data are variable and of mixed benefit. Mechanisms of action of many of these cells are unknown and this raises the concern of unpredictable results in the future. Nevertheless there is considerable optimism that immune suppression and anti-inflammatory properties of mesenchymal stem cells will be of benefit for many conditions such as graft versus host disease, solid organ transplants and pulmonary fibrosis. Where bone marrow and mesenchymal stem cells are being studied for heart disease, stroke and other neurodegenerative disorders, again progress is mixed and mostly without significant benefit. However, correction of multiple sclerosis, at least in the short term is encouraging. Clinical trials on the use of embryonic stem cell derivatives for spinal injury and macular degeneration are beginning and a raft of other clinical trials can be expected soon, for example, the use of neural stem cells for killing inoperable glioma and embryonic stem cells for regenerating beta islet cells for diabetes. The change in attitude to embryonic stem cell research with the incoming Obama administration heralds a new co-operative environment for study and evaluation of stem cell therapies. The Californian stem cell initiative (California Institute for Regenerative Medicine) has engendered global collaboration for this new medicine that will now also be supported by the US Federal Government. The active participation of governments, academia, biotechnology, pharmaceutical companies, and private investment is a powerful consortium for advances in health.
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Affiliation(s)
- Alan Trounson
- California Institute for Regenerative Medicine, 210 King Street, San Francisco, CA 94107, USA.
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