Low Body Mass Index Is Associated with Increased Risk of Acute GVHD after Umbilical Cord Blood Transplantation in Children and Young Adults with Acute Leukemia: A Study on Behalf of Eurocord and the EBMT Pediatric Disease Working Party

The impact of pre-transplantation diabetes and obesity on acute graft-versus-host disease, relapse and death after allogeneic hematopoietic cell transplantation: a study from the EBMT Transplant Complications Working Party

Obesity and diabetes can modulate immune responses, which may impact allogeneic HCT outcomes and GvHD. From the EBMT registry, we included 36,539 adult patients who underwent allogeneic HCT for a hematological malignancy between 2016 and 2020. Of these, 5228 (14%) had obesity (BMI ≥ 30 kg/m2), 1415 (4%) had diabetes (requiring treatment with insulin or oral hypoglycemics), and 688 (2%) had obesity + diabetes pre-transplantation. Compared with patients without diabetes or obesity, the hazard ratio (HR) of grade II-IV acute GvHD was 1.00 (95% confidence interval [CI] 0.94-1.06, p = 0.89) for patients with obesity, 0.95 (CI 0.85-1.07, p = 0.43) for patients with diabetes, and 0.96 (CI 0.82-1.13, p = 0.63) for patients with obesity + diabetes. Non-relapse mortality was higher in patients with obesity (HR 1.08, CI 1.00-1.17, p = 0.047), diabetes (HR 1.40, CI 1.24-1.57, p < 0.001), and obesity + diabetes (HR 1.38, CI 1.16-1.64, p < 0.001). Overall survival after grade II-IV acute GvHD was lower in patients with diabetes (HR 1.46, CI 1.25-1.70, p < 0.001). Pre-transplantation diabetes and obesity did not influence the risk of developing acute GvHD, but pre-transplantation diabetes was associated with poorer survival after acute GvHD.

The Promise of Precision Nutrition for Modulation of the Gut Microbiota as a Novel Therapeutic Approach to Acute Graft-versus-host Disease

Acute graft-versus-host disease (aGVHD) is a severe side effect of allogeneic hematopoietic stem cell transplantation (aHSCT) that has complex phenotypes and often unpredictable outcomes. The current management is not always able to prevent aGVHD. A neglected actor in the management of aGVHD is the gut microbiota. Gut microbiota dysbiosis after aHSCT is caused by many factors and may contribute to the development of aGVHD. Diet and nutritional status modify the gut microbiota and a wide range of products are now available to manipulate the gut microbiota (pro-, pre-, and postbiotics). New investigations are testing the effect of probiotics and nutritional supplements in both animal models and human studies, with encouraging results. In this review, we summarize the most recent literature about the probiotics and nutritional factors able to modulate the gut microbiota and we discuss the future perspective in developing new integrative therapeutic approaches to reducing the risk of graft-versus-host disease in patients undergoing aHSCT.

The impact of malnutrition on mortality and complications of hematopoietic stem cell transplantation in patients with acute leukemia

BACKGROUND & AIMS

Malnutrition is common in hematopoietic stem cell transplantation (HSCT) patients. However, there are few studies on the association between malnutrition and post-transplant outcomes, with inconsistent results. No standard screening tool has been established for malnutrition in these patients. Previous research suggests the Global Leadership Initiative on Malnutrition (GLIM) criteria is effective in predicting outcomes in other cancers. This study investigates the link between malnutrition based on the GLIM criteria with mortality and complications following allogeneic HSCT.

METHODS

This single-center, observational, longitudinal, and prospective study of 98 adult leukemia patients at the Hematology Center of Shariati Hospital in Tehran, Iran, monitored patients before transplantation until 100 days after the procedure, focusing on overall survival and mortality as a primary outcome, and secondary endpoints including oral mucositis, acute GVHD, infection during hospitalization, and readmission rates.

RESULTS

This study involved 98 allogeneic HSCT patients with a median age of 38 years old, 64.3 % with acute myeloid leukemia (AML), and 35.7 % with acute lymphoblastic leukemia (ALL). Among them, 26.5 % were categorized as malnourished based on GLIM criteria. During 100 days of follow-up, 13 patients died, but there was no significant difference in overall survival and mortality between malnourished and well-nourished patients. Malnourished patients demonstrated a noticeable upward trend in the incidence of oral mucositis, hospital readmission, and infection during their hospitalization. It is important to highlight that although this observed trend is discernible, it did not attain statistical significance in statistical analyses (P > 0.05).

CONCLUSION

The current study determined that, when assessed using the GLIM criteria, malnutrition did not exert a statistically significant influence on survival, mortality, or complications within the specified age range of 18-55 years, underscoring its limited impact on this cohort of younger patients.

Comparison of three malnutrition screening tools prior to allogeneic hematopoietic stem-cell transplantation

Background

Previous studies have shown that malnutrition before hematopoietic stem cell transplantation (HSCT) is associated with poor patient prognoses. There is inconsistency among studies on which nutritional status screening tool is appropriate for malnutrition diagnosis before allo-HSCT. The present study aimed to compare nutritional screening tools in patients with leukemia before allo-HSCT.

Methods

An observational, cross-sectional, and single-center study was conducted in Tehran, Iran. One hundred four adults allo-HSCT candidates aged 18-55 years with leukemia were selected sequentially. Malnutrition assessment was done using three tools, the Global Leadership Initiative on Malnutrition (GLIM), nutritional risk screening 2002 (NRS-2002) and European Society for Clinical Nutrition and Metabolism (ESPEN) criteria. The agreement between malnutrition assessment tools was evaluated with Cohen's kappa.

Results

The agreement between GLIM and NRS-2002 was perfect (κ = 0.817, p < 0.001), while the agreement between GLIM and ESPEN was fair (κ = 0.362, p < 0.001). The agreement between NRS-2002 and ESPEN was fair (κ = 0.262, p < 0.001). We also found a moderate agreement for all tools (κ = 0.489, p < 0.001).

Conclusion

NRS-2002 is an accepted tool for screening malnutrition in hospitalized patients. In the current study, the GLIM criterion perfectly agreed with the NRS-2002. Further studies in the HSCT setting are needed to introduce a valid tool.

Evaluation of Children with Malignancies for Blood and Marrow Transplantation: A Report from the ASTCT Committee on Practice Guidelines

Evaluation of a candidate for hematopoietic cell transplantation (HCT) is a complex process with substantial intercenter variability. Although literature providing guidance for evaluating the eligibility of adults is well established, similar guidance for children is lacking. To address gaps between adult recommendations and the specific needs of children, we convened a panel of pediatric HCT experts from a wide geographic range of American Society of Transplantation and Cellular Therapy (ASTCT) member institutions to offer recommendations for pediatric-focused pre-HCT evaluation. In this report from the ASTCT Committee on Practice Guidelines, we present a practical framework for evaluating children with malignancies who are candidates for HCT. We also highlight key differences from adults and emphasize areas of unmet need that require additional research to delineate best practices.

Expanded HCT-CI Definitions Capture Comorbidity Better for Younger Patients of Allogeneic HCT for Nonmalignant Diseases

Allogeneic hematopoietic cell transplantation (HCT) can cure many nonmalignant conditions, but concern for morbidity and mortality remains. To help physicians estimate patient-specific transplant mortality risk, the HCT comorbidity index (HCT-CI) is used. However, pediatric physicians use the HCT-CI less frequently than adult counterparts. We used the Center for International Blood and Marrow Transplant Research database to expand the HCT-CI comorbidity definitions to be more inclusive of children and adolescent and young adult (AYA) patients, adding history of mechanical ventilation, history of invasive fungal infection, assessment of chronic kidney disease (CKD) by estimated glomerular filtration rate, expanding the definition of obesity, and adding an underweight category. A total of 2815 children and AYAs (<40 years old) who received first allogeneic HCT for nonmalignant diseases from 2008 to 2017 were included to create an expanded youth nonmalignant HCT-CI (expanded ynHCT-CI) and a simplified non-malignant (simplified ynHCT-CI) HCT-CI. The expanded comorbidities occurred frequently-history of mechanical ventilation (9.6%), history of invasive fungal infection (5.9%), mild CKD (12.2%), moderate/severe CKD (2.1%), obesity (10.9%), and underweight (14.5%). Thirty-nine percent of patients had an increase in their comorbidity score using the expanded ynHCT-CI, leading to a redistribution of scores: ynHCT-CI score 0 (35%), 1-2 (36.4%), and ≥3 (28.6%). Patients with an increase in their comorbidity score had an increased hazard of mortality compared to those whose score remained the same (hazard ratio = 1.41; 95% confidence interval, 1.01-1.98). Modifications to the HCT-CI can benefit children and AYA patients with nonmalignant diseases, creating a risk assessment tool that is clinically relevant and better captures comorbidity in this younger population.

Adapting the HCT-CI Definitions for Children, Adolescents, and Young Adults with Hematologic Malignancies Undergoing Allogeneic Hematopoietic Cell Transplantation

Allogeneic hematopoietic cell transplantation is a curative procedure for hematologic malignancies but is associated with a significant risk of non-relapse mortality (NRM). The Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI) is a prognostic tool that discriminates this risk in all age groups. A recent survey of transplant physicians demonstrated that 79% of pediatric providers used the HCT-CI infrequently, and most reported concerns about its applicability in the younger population. We conducted a retrospective study using the Center for International Blood and Marrow Transplant Research database to examine the impact of expanded HCT-CI definitions on NRM in pediatric and young adult patients with hematologic malignancies. We included 5790 patients <40 years old receiving allogeneic transplants between 2008 and 2017 to examine broader definitions of comorbidities in the HCT-CI, including history of mechanical ventilation and fungal infection, estimated glomerular filtration rate, and body mass index (BMI) percentiles. Multivariable Fine-Gray models were created to determine the effect of each HCT-CI defining comorbidity and its modification on NRM and were used to develop 2 novel risk scores. We next developed the expanded HCT-CI for children and young adults (youth with malignancies; expanded ymHCT-CI), where 23% patients had an increased comorbidity score, compared to the HCT-CI. Comorbidities with hazard ratio < 1.2 were then removed to create the simplified HCT-CI for children and young adults (youth with malignancies; simplified ymHCT-CI), which demonstrated higher scores corresponded to a greater risk of NRM (P < .001). These novel comorbidity indexes with broader definitions are more relevant to pediatric and young adult patients, and prospective studies are needed to validate these in the younger patient population. It remains to be seen whether the development of these pediatric-specific and practical risk indexes increases their use by the pediatric transplant community.

The emerging role of nutritional support in the supportive care of pediatric patients undergoing hematopoietic stem cell transplantation

Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) represents a potentially curative strategy for many oncological, hematological, metabolic, and immunological diseases in children. The continuous effort in ameliorating supportive care represents one of the cornerstones in the improvement of outcome in these patients. Nowadays, more than ever nutritional support can be considered a key feature. Oral feeding in the early post-transplant period is severely impaired because of mucositis due to conditioning regimen, characterized by, mainly by vomiting, anorexia, and diarrhea. Gastrointestinal acute graft-versus-host-disease (GvHD), infections and associated treatments, and other medications, such as opioids and calcineurin inhibitors, have also been correlated with decreased oral intake. The consequent reduction in caloric intake combined with the catabolic effect of therapies and transplantation-related complications with consequent extended immobilization, results in a rapid deterioration of nutritional status, which is associated with decreased overall survival and higher complication rates during treatment. Thus, nutritional support during the early post-transplantation period becomes an essential and challenging issue for allo-HSCT recipients. In this context, the role of nutrition in the modulation of the intestinal flora is also emerging as a key player in the pathophysiology of the main complications of HSCT. The pediatric setting is characterized by less evidence, considering the challenge of addressing nutritional needs in this specific population, and many questions are still unanswered. Thus, we perform a narrative review regarding all aspects of nutritional support in pediatric allo-HSCT recipients, addressing the assessment of nutritional status, the relationship between nutritional status and clinical outcomes and the evaluation of the nutritional support, ranging from specific diets to artificial feeding.

Nutritional status and prognosis in children with immunodeficiencies undergoing hematopoietic stem cell transplantation

BACKGROUND

Primary immunodeficiencies (PID) are diseases resulting from genetic dysfunctions in the immune system, which can result in recurrent infections, autoimmunity and even malignancy. It is estimated that approximately one-third of the PID described have gastrointestinal components or symptoms involved and may present an increased risk of weight loss and failure to thrive. It is also known that, in patients with other diagnoses, malnutrition may be associated with worse outcomes after hematopoietic stem cell transplantation (HSCT).

OBJECTIVE

to characterize the nutritional status of pediatric patients with PID at the time of admission for HSCT and to establish the relationship between baseline nutritional status measures and post-HSCT clinical outcomes.

METHODS

a retrospective analytical observational study, based on data from pediatric patients, of both sexes and all ethnicities, with PID, submitted to HSCT in the period from 2004 to 2019. The risk factors analyzed were the Z-scores of weights for age (W/A), height for age (H/A), BMI for age (BMI/A) and Sum score, obtained by through the sum of the W/A and H/A scores. The primary outcomes were overall survival at 6 months, occurrence of acute Graft Versus Host Disease (aGVHD) at 6 months, and occurrence of chronic Graft Versus Host Disease (cGVHD) at 1 year. Secondary outcomes were occurrence and degree of mucositis, length of stay, and total number of infectious episodes. As statistical analysis, the ANOVA model, the Tukey test, ROC curves and Kaplan Meier and Log-Rank analysis were used. Multivariate survival and logistic regression models were also performed.

RESULTS

The study showed important indicators of malnutrition in patients with PID, especially those diagnosed with Severe Combined Immunodeficiency Syndrome (SCID) and Hemophagocytic Syndromes (HS). Among those with SCID, 60% had low or very low weight for their age, 52% had low or very short stature for their age, and 44% were classified as being thin or very thin. Among patients with HS, 75% had short or very short stature for their age. Multivariate analysis only demonstrated association between W/A score with extensive cGVHD, controlling for diagnosis, compatibility, conditioning and immunoprophylaxis. Lower W/A values were associated with higher occurrences of these events. Although W/A was only associated with cGVHD and H/A had no association with chronic or acute GVHD, when Sum scores were used, the lower values the higher rates of severe aGVHD and total cGVHD according to multivariate controlled models for diagnosis, compatibility, conditioning and immunoprophylaxis.

CONCLUSIONS

Our study characterized the nutritional status of children with PID undergoing HSCT and found alarming rates of underweight and short stature in patients with SCID and HS. We also demonstrated a relationship between anthropometric parameters and outcomes such as mortality, the occurrence of GVHD and severe mucositis after HSCT. In this sense, W/A and Sum score measures would be good prognostic methods for these outcomes. Henceforth, prospective studies are needed to confirm these findings and establish new nutritional assessment criteria for this population.

Weight-adjusted urinary creatinine excretion predicts transplant outcomes in adult patients with acute myeloid leukemia in complete remission

Sarcopenia is a prognostic factor for cancer. Because creatinine is formed from creatine phosphate in muscle tissue, urinary creatinine excretion (UCE) serves as an index of muscle volume. However, as of yet, there are no studies assessing the clinical impact of UCE or weight- adjusted urinary creatinine excretion (WA-UCE) on allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. We analyzed the association between pre-transplant WA-UCE and transplant outcomes among 164 adult patients with acute myeloid leukemia in complete remission who underwent their first allo-HSCT at our center. The patients were classified into a high (n = 106) and a low WA-UCE group (n = 58) for predicting overall survival (OS) based on the receiver operating characteristics curve. On multivariate analysis, low WA-UCE was associated with poor OS, progression-free survival and a high incidence of non-relapse mortality. WA-UCE has the potential to be an objective biomarker for predicting transplant outcomes, especially the incidence of infection-related death.

Allogeneic hematopoietic stem cell transplantation in infants is associated with significant morbidity and mortality

BACKGROUND

Infants are subjected to hematopoietic stem cell transplantation (HSCT) due to malignant and non-malignant diseases. However, specific data concerning the outcome and transplantation-related complications in infants, as a separate age group, are limited. Our aim was to evaluate the impact of infancy on the outcome, toxicity, and complications after HSCT.

METHODS

We retrospectively analyzed data of 55 infants that underwent HSCT in our unit from May 1997 until February 2020, emphasizing on the probability of overall survival (OS) and the cumulative incidence (CI) of transplantation-related mortality (TRM) and complications.

RESULTS

We report a probability of OS of 61%, a CI of TRM at day 100 and 365 post transplantation of 22% and 30%, respectively, and additionally a CI of graft failure, acute graft-versus-host disease (GvHD), and infectious complications, 18%, 44%, and 39%, respectively. No statistically significant association was detected between the above mentioned parameters and diagnosis, the use of myeloablative or non-myeloablative/reduced toxicity conditioning regimens or the type of donor.

CONCLUSIONS

We conclude that HSCT in infancy is associated with significant mortality and morbidity. This is possibly attributed to endogenous, age-related factors. More specifically, infants may be at a higher risk of toxicities due to the immaturity of developing vital organs and the deficiency of the newly adopted immune system that predisposes them to infectious complications. The development of GvHD further augments the danger of infections, in a potential vice-versa relationship. Moreover, there are few data on pharmacokinetics of chemotherapy agents, making safe and efficacious drug administration hard.

Association of obesity with mortality and clinical outcomes in children and adolescents with transplantation: A systematic review and meta-analysis

Obesity might be associated with mortality and clinical outcomes following transplantation; however, the direction of this relationship has not been well-recognized in youth. The aim of this systematic review and meta-analysis was to investigate the association of obesity with post-transplant mortality and clinical outcomes in children and adolescents. Following a systematic search of observational studies published by December 2018 in PubMed, Scopus, Embase, and Cochrane library, 15 articles with total sample size of 50,498 patients were included in the meta-analysis. The main outcome was mortality and secondary outcomes included acute graft versus host disease (GVHD), acute rejection, and overall graft loss. The pooled data analyses showed significantly higher odds of long term mortality (OR 1.30, 95% CI 1.15-1.48, P < 0.001, I² = 50.3%), short term mortality (OR 1.79, 95% CI 1.19-2.70, P = 0.005, I² = 59.6%), and acute GVHD (OR 2.13, 95% CI 1.5-3.02, P < 0.001, I² = 1.7%) in children with obesity. There were no significant differences between patients with and without obesity in terms of acute rejection (OR 1.07, 95% CI 0.98-1.16, P = 0.132, I² = 7.5%) or overall graft loss (OR 1.04, 95% CI 0.84-1.28, P = 0.740, I² = 51.6%). This systematic review and meta-analysis has stated higher post-transplant risk of short and long term mortality and higher risk of acute GVHD in children with obesity compared to those without obesity. Future clinical trials are required to investigate the effect of pre-transplant weight management on post-transplant outcomes to provide insights into the clinical application of these findings. This may in turn lead to establish guidelines for the management of childhood obesity in transplantations.

Risk Factors for Graft-Versus-Host Disease and Survival in Pediatric Hematopoietic Stem Cell Transplant Recipients: A Single-Center Experience

OBJECTIVES

Graft-versus-host disease is still one of the most important complications after hematopoietic stem cell transplantation. The risk factors remain unclear, with effects of graft-versus-host disease on survival varying among different centers. We aimed to determine risk factors that may affect development of graft-versus-host disease and the corresponding patient survival rates at a single pediatric hematopoietic stem cell transplant unit.

METHODS

Our study included 104 of 118 pediatric patients who underwent allogeneic hematopoietic stem cell transplant at our institute between 2005 and 2018. Patient characteristics, clinical information, pretransplant and posttransplant factors, and laboratory parameters were obtained from the database.

RESULTS

Acute graft-versus-host disease was seen in 19 pediatric patients. Chronic graft-versus-host disease, which was seen in 13 of our pediatric study patients, occurred more often in those with peripheral blood stem cell than in those with bone marrow transplant (odds ratio of 9.969; 95% CI, 1.040-95.547; P = .046). Female donor-to-male recipient transplant was significantly associated with incidence of chronic graft-versus-host disease (odds ratio of 8.51; 95% CI, 1.323-54.843; P = .024). Later neutrophil engraftment was associated with incidence of acute graft-versus-host disease (odds ratio of 1.107; 95% CI, 1.012-1.212; P = .02).

CONCLUSIONS

Although there are some known risk factors for graft-versus-host disease in adult patients, little is known about risk factors in children. In our comprehensive study in pediatric patients, we found that peripheral blood stem cell transplant, female-tomale transplant, and later neutrophil engraftment were associated with incidence of graft-versus-host disease. Although peripheral blood as a source of stem cells and female-to-male transplant are known risk factors, later neutrophil engraftment was a new finding as a possible risk factor for acute graft-versushost disease. This finding requires further verification in future prospective studies.

Outcomes of Adolescents and Young Adults Compared with Children with Acute Leukemia after Single-Unit Unrelated Cord Blood Transplantation Using Myeloablative Conditioning without Antithymocyte Globulin

BACKGROUND

Although the use of cord blood transplantation (CBT) is becoming more frequent in acute leukemia, considering the relationship between the low stem cell dose and graft failure, whether use of CBT for adolescents and young adults (AYAs) is appropriate remains uncertain.

METHODS

A retrospective registry-based analysis of clinical outcomes and immune reconstitution was conducted for 105 AYAs and 187 children with acute leukemia who underwent single-unit CBT using myeloablative conditioning (MAC) without antithymocyte globulin (ATG).

RESULTS

Outcomes were similar between AYAs and children, except for nonrelapse mortality (NRM) and recovery rates of neutrophils and platelets. The 30-day cumulative incidence of neutrophil engraftment was similar between AYAs and children, but children had faster rates of neutrophil and platelet recovery than AYAs. The median time to neutrophil engraftment was earlier in children than in AYAs (AYAs, 19 days, 95% confidence interval [CI] 17.3-21.7; children, 16 days, 95% CI 13.1-19.5, p = 0.00003). The incidence of platelet recovery on day 120 was higher in children than in AYAs (AYAs, 80%, 95% CI 71-81%; children, 88%, 95% CI 82-92%, p = 0.037). CD34+ cell dose was the only independent factor influencing both neutrophil and platelet recovery. The cumulative incidence of NRM at 2 years was higher among AYAs than among children (AYAs, 27.5%, 95% CI 20-37%; children, 15%, 95% CI 10-21%, p = 0.008). Conditioning regimen was an independent factor influencing NRM. With respect to immune reconstitution, natural killer cell counts quickly recovered to normal levels 1-month post-CBT in both children and AYAs. CD8+ T-cell counts were higher in children than in AYAs at 1 and 3 months post-CBT. CD4+ T-cell counts were similar in both children and AYAs after CBT.

CONCLUSION

AYAs with acute leukemia have outcomes of single-unit CBT using MAC without ATG that are as good as those of children. Thus, single-unit CBT using modified MAC without ATG is an acceptable choice for both AYAs and children who do not have a suitable donor.

Current Prophylaxis and Treatment Approaches for Acute Graft-Versus-Host Disease in Haematopoietic Stem Cell Transplantation for Children With Acute Lymphoblastic Leukaemia

Acute graft-versus-host disease (aGvHD) continues to be a leading cause of morbidity and mortality following allogeneic haematopoietic stem cell transplantation (HSCT). However, higher event-free survival (EFS) was observed in patients with acute lymphoblastic leukaemia (ALL) and grade II aGvHD vs. patients with no or grade I GvHD in the randomised, controlled, open-label, international, multicentre Phase III For Omitting Radiation Under Majority age (FORUM) trial. This finding suggests that moderate-severity aGvHD is associated with a graft-versus-leukaemia effect which protects against leukaemia recurrence. In order to optimise the benefits of HSCT for leukaemia patients, reduction of non-relapse mortality-which is predominantly caused by severe GvHD-is of utmost importance. Herein, we review contemporary prophylaxis and treatment options for aGvHD in children with ALL and the key challenges of aGvHD management, focusing on maintaining the graft-versus-leukaemia effect without increasing the severity of GvHD.

Pediatric hematopoietic cell transplantation: Longitudinal trends in body mass index and outcomes

Pediatric recipients of HCT may have a high susceptibility for overweight and obesity, and obesity may negatively impact post-transplant mortality and survival. This is a single-center retrospective analysis of 297 pediatric patients who received HCT between 2005 and 2018. Patients were classified as UW, NW, OW, or OB based on age-adjusted BMI. A mixed-effects linear regression model controlling for patient, disease, and transplant-related characteristics was used to trend weight longitudinally. Comparisons were made between weight category and post-transplant outcomes. In the pretransplant period, 5.4%, 54.5%, 22.2%, and 17.8% of patients were UW, NW, OW, and OB, respectively. Five years post-transplantation, those numbers were 10.6%, 48.2%, 16.5%, and 24.7%. Overall, BMI increased 0.00094 ± 0.0001 kg/m² each day post-transplant (P < .001), with older individuals demonstrating greater rates of increase. Further, there was a larger BMI increase in patients without TBI compared with those who received TBI (1.29 ± 0.49, P = .008). Rates of acute GVHD, chronic GVHD, and viral infections, in addition to time to platelet and neutrophil engraftment and 5-year survival estimates, were not significantly different based on pretransplant BMI. Overweight and obese individuals had poorer 5-year survival based on 100-day post-transplant BMI (P = .02). Overall, pediatric HCT recipients are at risk of developing obesity, which is associated with decreased survival. Adolescents and young adults demonstrate the highest risk of weight gain, representing a vulnerable population that requires close monitoring, additional interventions, and further research.

A Review on the Impact of Body Mass Index on Outcomes in Pediatric Leukemia

In the last decades, adults and pediatric obesity have become a major issue in developed countries. Considerable research has been conducted in patients with acute lymphoblastic (ALL) and myeloid leukemia (AML) with the aim of correlating body mass index (BMI) and outcomes in patients undergoing chemotherapy for hematological diseases. In adults, a high BMI has been associated with increased leukemia-related mortality. Whether a similar effect exists in the pediatric setting remains controversial. Some of the studies detailed in this review have reported no differences in outcomes according to BMI, whilst other reports have described higher treatment-related mortality, increased risk of relapse and death. Although the link between BMI and acute leukemia outcomes is controversial, a large number of studies describe poorer survival rates in children with AML or ALL with higher BMI. On the other hand, being underweight has been associated with higher treatment-related toxicity. Understanding more about the impact of BMI in pediatric leukemia is of utmost importance to provide prompt intervention and improve outcomes.

Computed tomography-defined sarcopenia: prognostic predictor of nonrelapse mortality after allogeneic hematopoietic stem cell transplantation: a multicenter retrospective study

We analyzed clinical cutoffs for defining computed tomography (CT) methods for sarcopenia and examined the prognostic value of CT for allogeneic hematopoietic stem cell transplantation (allo-HCST) outcomes of patients with myeloid malignancy. One hundred twenty-five adult patients with acute myeloid leukemia and myelodysplastic syndrome who underwent first allo-HSCT between 2000 and 2017 were included. Sarcopenia was assessed using CT-based skeletal muscle index (SMI) and mean muscle attenuation at L3. A statistical difference in SMI was confirmed between sarcopenia (n = 52) and nonsarcopenia (n = 73) patients. There were no significant correlations of muscularity with age, performance status, or other characteristics of HSCT. After 2 years, overall survival (OS) was 43.5% and 70.1%, disease-free survival was 52.9% and 68.6%, nonrelapse mortality (NRM) was 20.8% and 8.4%, incidence of acute GVHD (≥ grade 2) was 38.8% and 39.1%, that of chronic GVHD was 53.2% and 37.3%, and median duration of hospitalization was 88 days and 74 days (P = 0.026), respectively, in the sarcopenia and nonsarcopenia groups. Multivariate analysis showed that presence of sarcopenia is a novel adverse factor for high NRM and poor OS. Pretransplant CT-defined sarcopenia is correlated with decreased OS, increased NRM, and prolonged hospitalization.

Identifying risk factors associated with worse outcomes in adolescents and young adults undergoing hematopoietic stem cell transplantation

BACKGROUND

Adolescents and young adults (AYAs) undergoing allogeneic hematopoietic stem cell transplantation (HSCT) have unique risk factors and poor outcomes when compared to children, but this population has not been well studied. A hematopoietic stem cell transplantation-comorbidity index (HCT-CI) has been developed in adults to help predict outcomes, yet this index does not seem suitable for a younger population. Therefore, we sought to examine the prevalence of various risk factors in AYAs undergoing allogeneic HSCT and determine which factors had the greatest impact on overall survival (OS) and treatment-related mortality (TRM).

PROCEDURES

This was accomplished by retrospectively collecting data on 241 patients who received their first allogeneic HSCT at UCLA between 2005 and 2015. We investigated the effect of multiple predictors using the Cox proportional hazards model and Fine and Gray competing risk model for OS and TRM, respectively.

RESULTS

Our results showed that AYAs undergoing allogeneic HSCT had poor outcomes, with 5-year OS and NRM of 48% and 30%, respectively. We demonstrated that compared to a baseline model, the addition of the HCT-CI did not improve its ability to predict OS, while substituting individual comorbidities, that is, an unweighted comorbidity score, resulted in significant improvement in model performance. The factors associated with inferior outcomes were used to develop an AYA-specific risk score.

CONCLUSIONS

The comorbidities included in the HCT-CI as well as additional risk factors seen in younger populations need to be studied in prospective studies with the goal of validating and refining a risk score specific to AYA patients undergoing allogeneic HSCT.

The impact of pretransplant malnutrition on allogeneic hematopoietic stem cell transplantation outcomes

BACKGROUND

Malnutrition is a common finding in allogeneic hematopoietic stem cell transplantation (alloHSCT) patients, and there is some evidence that malnutrition might negatively affect the transplant outcomes.

METHOD

We performed a retrospective study with 148 patients aged 18-75 years, who underwent alloHSCT between 2011 and 2017. Patients were classified according to the body mass index (BMI) and the Subjective Global Assessment (SGA). The SGA was assessed on the day of hospitalization for the transplant, and classifies patients into three groups: A (well-nourished), B (moderately malnourished) and C (severely malnourished).

RESULTS

The SGA classified 49 (33%) patients as well-nourished, 54 (37%) as moderately malnourished, and 45 (30%) as severely malnourished. SGA-C was also associated with severe acute graft versus host disease (aGVHD) with a cumulative incidence (CI) of 31% vs. a CI of 14% for combined well-nourished or moderately malnourished group (SGA-A or -B, P = 0.017). In multivariate analysis, SGA-C compared to SGA-A or -B, remained as an independent risk factor for aGVHD (hazard ratio - HR 1.68, 95% confidence interval - 95% CI 1.02-2.74), and nonrelapse mortality (NRM - HR 3.63, 95% CI 1.76-7.46), worse progression free survival (HR 2.12, 95% CI 1.25-3.60), and worse overall survival (HR 3.27, 95% CI 1.90-5.64).

CONCLUSION

Malnutrition increases the risk of aGVHD and NRM and has a negative impact on survival.

The Prognostic Impact of Pretransplantation Inflammatory and Nutritional Status in Adult Patients after Myeloablative Single Cord Blood Transplantation

Markers of inflammatory and nutritional status, such as the Controlling Nutritional Status (CONUT) score, Prognostic Nutritional Index, Glasgow Prognostic Score, and C-reactive protein-albumin ratio (CAR) has been demonstrated to be associated with poor prognosis in patients with various cancers. Although the relatively low cell dose of a single cord blood unit restricts the indication for cord blood transplantation (CBT) to pediatric and relatively smaller and lighter adult patients, the impact of malnutrition on outcomes after CBT is unclear. We retrospectively analyzed 165 adult patients who underwent myeloablative single-unit CBT in our institute. In multivariate analysis, a higher CONUT score, which is indicative of poor inflammatory and nutritional status, was significantly associated with poor outcomes, including low neutrophil engraftment and development of extensive chronic graft-versus-host disease. A higher CAR, which is also suggestive of poor inflammatory and nutritional status, was significantly associated with poor neutrophil engraftment and higher overall mortality. Body mass index (BMI) was not associated with transplantation outcomes. These data suggest that poor pretransplantation inflammatory and nutritional status might be a more practical parameter than lower BMI, for predicting transplantation outcomes after single CBT for adults.