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Li Y, Vader DT, Oganisian A, Boge CLK, Hayes M, Newman A, Olson T, Freedman J, Elgarten CW, Fisher BT. Effect of cytomegalovirus infection on post-transplant hospitalization days among children undergoing allogeneic hematopoietic cell transplantation: A marginal structural model approach. Pediatr Transplant 2024; 28:e14526. [PMID: 37550269 DOI: 10.1111/petr.14526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) commonly reactivates after allogeneic hematopoietic cell transplant (HCT), potentially leading to CMV disease and significant morbidity and mortality. To reduce morbidity and mortality, many centers conduct weekly CMV blood polymerase chain reaction (PCR) surveillance testing with subsequent initiation of antiviral therapy upon CMV DNAemia detection. However, the impact of CMV DNAemia on subsequent hospitalization risk has not been assessed using models accounting for the time-varying nature of the exposure, outcome, and confounders. METHODS All allogeneic HCTs at the Children's Hospital of Philadelphia from January 2004-April 2017 were considered for inclusion. Patients were monitored with CMV surveillance via PCR testing for up to 105 days after HCT receipt. We estimated the association between CMV DNAemia and rate of hospitalization using marginal structural models (MSM). RESULTS There were 343 allogeneic HCT episodes in 330 with CMV surveillance; median age was 9.0 (range: 0.1-26.2) and 46.5% were female. And 24.1% of HCT patients had at least one positive CMV blood PCR during the follow-up period. Median time to CMV DNAemia detection was 19 days (range: 4-97). The MSM estimated the incidence rate ratios for an association of CMV DNAemia with hospitalization to be 1.24, (95% confidence interval: 1.04-1.47). CONCLUSIONS CMV DNAemia was associated with an increased hospitalization in the post-HCT period. The MSM accounted for time-varying nature of the outcome, exposure and confounders. The findings support prevention of CMV DNAemia in this population. We recommend further investigation into the effectiveness and safety of prophylaxis versus pre-emptive CMV prevention approaches.
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Affiliation(s)
- Yun Li
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Pediatric IDEAS Research Group of Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel T Vader
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Pediatric IDEAS Research Group of Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Arman Oganisian
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Craig L K Boge
- Pediatric IDEAS Research Group of Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Molly Hayes
- Antimicrobial Stewardship Program, Center for Healthcare Quality & Analytics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anders Newman
- Division of Pediatric Infectious Disease, Benioff Children's Hospital, University of California San Francisco, San Francisco, California, USA
| | - Tim Olson
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Oncology, Cellular Therapy and Transplant Section, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jason Freedman
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Oncology, Cellular Therapy and Transplant Section, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Caitlin W Elgarten
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Oncology, Cellular Therapy and Transplant Section, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brian T Fisher
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Pediatric IDEAS Research Group of Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Abstract
Mesenchymal stromal cells (MSC) are multipotent precursor cells that can be derived from a variety of tissue sources, with a working definition based on immunophenotyping and cell differentiation capacity. Despite historical roots in the field of tissue engineering, they have generated great interest as cell therapies for their immune regulatory function, which has led to numerous clinical trials for a range of inflammatory and autoimmune conditions. Importantly, due to the lack of traditional MHC expression and their expression of other immune regulatory proteins, they can be used from third party donors without generating a dangerous alloreactivity. After 20 years of clinical trials, they have earned themselves an excellent safety record but are currently only approved for use in Canada, New Zealand, Japan, South Korea and Europe due to a lack of consistent efficacy data. In the United States, the indication that has seen the most progress is steroid refractory acute graft-versus-host disease (SR-aGVHD). Issues with early clinical trials can be attributed to both challenges with defining optimal patient populations and trial design as well as limitations related to commercial manufacturing. Earlier this year, the encouraging data for a repeat Phase III trial in pediatric patients with SR-aGVHD was published. This review provides information on the proposed mechanism of action of MSCs, clinical utilization of MSCs with focus on SR-aGVHD and potential modalities that can improve the efficacy of MSCs.
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Affiliation(s)
- Holly Wobma
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA 02115, USA
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, NY, 10032, USA.
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Healthcare utilization and financial impact of acute-graft-versus host disease among children undergoing allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2019; 55:384-392. [PMID: 31537901 DOI: 10.1038/s41409-019-0688-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 01/31/2023]
Abstract
The impact of AGVHD on healthcare utilization and cost is not well described. In this retrospective single center cohort study of 240 pediatric patients, we analyzed cost, healthcare utilization and patient outcomes for the first year post-alloHCT. Costs were estimated from charges recorded in the Pediatric Health Information System database and the hospital's accounting system. The overall incidence of grade I-IV aGVHD was 40.4%. The incidence of grade I, grade II, and grade III-IV aGVHD was 6.6%, 16.2%, and 17.5%, respectively. The overall incidence of steroid refractory (SR)-aGVHD was 10.8%. The median number of days of hospitalization in the first year post-alloHCT was significantly higher for patients with aGVHD vs. no aGVHD: 113 days (range: 35-354 days) vs. 63 days (range: 25-298 days), p < 0.001. Patients with SR-aGVHD had increased hospitalization compared with the patients with steroid responsive aGVHD (152.8 ± 66.6days vs. 111.3 ± 59.3 days, p = 0.004), with associated increased alloHCT cost of ~$200,000. On multivariable analysis of risk factor for alloHCT cost, aGVHD, was associated with significantly higher cost ($141,094 [SE = 31247], p < 0.001). In summary, aGVHD and SR-aGVHD is associated with prolonged hospitalization and higher cost and inferior survival among children. Better aGVHD prevention strategies are desperately needed. Despite significant advances, lack of effective salvage regimens for SR-aGVHD remains a major concern.
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Rastogi S, Ricci A, Jin Z, Bhatia M, George D, Garvin JH, Hall M, Satwani P. Clinical and Economic Impact of Cytomegalovirus Infection among Children Undergoing Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:1253-1259. [DOI: 10.1016/j.bbmt.2018.11.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/26/2018] [Indexed: 02/07/2023]
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Furey A, Rastogi S, Prince R, Jin Z, Smilow E, Briamonte C, Kahn JM, Tanhehco Y, Patel N, George D, Garvin J, Bhatia M, Satwani P. Bone Marrow Harvest in Pediatric Sibling Donors: Role of Granulocyte Colony-Stimulating Factor Priming and CD34+ Cell Dose. Biol Blood Marrow Transplant 2018; 24:324-329. [DOI: 10.1016/j.bbmt.2017.10.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/14/2017] [Indexed: 10/18/2022]
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Heneghan C, Smilow E, Tanhehco Y, Jin Z, Cofnas P, Schwartz S, Patel N, Carberry D, Silverman J, Huynh P, Hagan B, Tobin K, Bhatia M, George D, Garvin J, Satwani P. Safety of hematopoietic cell infusion in children with malignant and non-malignant diseases. Pediatr Transplant 2017; 21. [PMID: 28845921 DOI: 10.1111/petr.13038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2017] [Indexed: 12/25/2022]
Abstract
HPC infusions have been associated with a variety of adverse events related to either patient or HPC product-related factors. Studies documenting infusion-related AEs in children are limited. We reviewed HPC infusion records in 354 children. Infusion-related adverse events were classified as follows: grade 0-absent, grade I-mild, grade II-moderate, grade III-severe, grade IV-life-threatening, and grade V-death. The percentage of patients with grade 0, I, and II-IV AEs was as follows: 0 = 67%, I = 23.4%, and II-V = 9.6% (one patient had fatal anaphylactic reaction to dimethyl sulfoxide). The incidence of grade II-IV hypertension was 7.1%. There was a higher incidence of AEs with infusion of allogeneic bone marrow versus allogeneic PBSCs (47.4% vs 25.3%, P = .001). Cryopreserved products had a lower incidence of infusion-associated AEs compared with fresh HPC products (24% vs 39.4%, P = .003). Allogeneic HPC infusion volume (>100 mL) was a significant risk factor for infusion-associated AEs (P < .001). Patients >10 years who received autologous HPC infusions had higher risk of AEs when compared to patients <10 years (P = .01). Our study demonstrated that despite a high incidence of infusion-associated hypertension, HPC infusion is relatively safe in children. Investigating strategies to optimize management of hypertension in the setting of HPC infusion is warranted.
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Affiliation(s)
- Chelsea Heneghan
- Department of Nursing, Morgan Stanly Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Elana Smilow
- Department of Nursing, Morgan Stanly Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Yvette Tanhehco
- Department of Pathology, Columbia University, New York, NY, USA
| | - Zhezhen Jin
- Department of Biostatistics, Columbia University, New York, NY, USA
| | - Paige Cofnas
- Department of Nursing, Morgan Stanly Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Sharon Schwartz
- Department of Nursing, Morgan Stanly Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Nita Patel
- Department of Pathology, Columbia University, New York, NY, USA
| | | | - Justin Silverman
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Paul Huynh
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Brittany Hagan
- Department of Nursing, Morgan Stanly Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Kim Tobin
- Department of Nursing, Morgan Stanly Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Monica Bhatia
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Diane George
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - James Garvin
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Prakash Satwani
- Department of Pediatrics, Columbia University, New York, NY, USA
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Satwani P, Freedman JL, Chaudhury S, Jin Z, Levinson A, Foca MD, Krajewski J, Sahdev I, Talekar MK, Gardenswartz A, Silverman J, Hayes M, Dvorak CC. A Multicenter Study of Bacterial Blood Stream Infections in Pediatric Allogeneic Hematopoietic Cell Transplantation Recipients: The Role of Acute Gastrointestinal Graft-versus-Host Disease. Biol Blood Marrow Transplant 2017; 23:642-647. [DOI: 10.1016/j.bbmt.2017.01.073] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 01/11/2017] [Indexed: 02/08/2023]
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Al-Sweedan S, Al-Seraihy A, Al-Ahmari A, Al-Jefri A, Mohammed V, Jafri R, Siddiqui K, Ayas M. Factors Determining the Outcome of Hematopoietic Stem Cell Transplantation in Patients With Acute Lymphoblastic Leukemia at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. J Pediatr Hematol Oncol 2017; 39:33-37. [PMID: 27906795 DOI: 10.1097/mph.0000000000000679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Medical records of 82 patients with acute lymphoblastic leukemia (ALL) who underwent hematopoietic cell transplantation (HCT) at our institution from 2005 to 2011 were reviewed. Forty-five patients were male (54.8%). The median age at HCT was 7.46 years (range, 0.98 to 14.31 y), the median time to HCT after diagnosis was 12.56 months. Ten patients were below the age of 1 year (12%). All patients were in complete remission at the time of HCT. In 83 transplants, 64 patients received HCT from human leukocyte antigen-identical-related donors and 19 from other donors. Stem cell source was bone marrow in 65 (78%) and cord blood in 18 (22%). Five-year overall survival was 58.8% and event-free survival was 54.3%. The cumulative incidence of acute graft versus host disease was 4.8%±2.3% and of chronic graft versus host disease was 8.9%±3.2%. The median time to absolute neutrophil count and platelet recovery was 17 days (range, 12 to 43 d) and 28 days (range, 15 to 98 d), respectively. One patient acquired CMV infection after transplant. No one developed venoocclusive disease, hemorrhagic cystitis, or other complication. Patient's age at diagnosis, sex, donor's human leukocyte antigen status and sex, source of transplant and complete remission status at HCT did not affect overall survival and event-free survival. Our results show a favorable outcome to HCT for acute lymphoblastic leukemia patients comparable to published data, and no single factor was associated with superior outcome.
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Affiliation(s)
- Suleimman Al-Sweedan
- *Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia †Jordan University of Science & Technology, Irbid, Jordan
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Rustia E, Violago L, Jin Z, Foca MD, Kahn JM, Arnold S, Sosna J, Bhatia M, Kung AL, George D, Garvin JH, Satwani P. Risk Factors and Utility of a Risk-Based Algorithm for Monitoring Cytomegalovirus, Epstein-Barr Virus, and Adenovirus Infections in Pediatric Recipients after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1646-1653. [PMID: 27252110 DOI: 10.1016/j.bbmt.2016.05.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/11/2016] [Indexed: 10/21/2022]
Abstract
Infectious complications, particularly viral infections, remain a significant cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (alloHCT). Only a handful of studies in children have analyzed the risks for and impact of viremia on alloHCT-related outcomes. We conducted a retrospective study of 140 pediatric patients undergoing alloHCT to investigate the incidence of and risk factors for cytomegalovirus (CMV), adenovirus (ADV), and Epstein-Barr virus (EBV) viremia and viral disease after alloHCT. Furthermore, we assessed the impact of viremia on days of hospitalization and develop an algorithm for routine monitoring of viremia. Patients were monitored before alloHCT and then weekly for 180 days after alloHCT. Patients were considered to have viremia if CMV were > 600 copies/mL, EBV were > 1000 copies/mL, or ADV were > 1000 copies/mL on 2 consecutive PCRs. The overall incidences of viremia and viral disease in all patients from day 0 to +180 after alloHCT were 41.4% (n = 58) and 17% (n = 24), respectively. The overall survival for patients with viremia and viral disease was significantly lower compared with those without viremia (58% versus 74.2%, P = .03) and viral disease (48.2% versus 71.2%, P = .024). We identified that pretransplantation CMV risk status, pre-alloHCT viremia, and use of alemtuzumab were associated with the risk of post-alloHCT viremia. The average hospitalization days in patients with CMV risk (P = .011), viremia (P = .024), and viral disease (P = .002) were significantly higher. The algorithm developed from our data can potentially reduce viral PCR testing by 50% and is being studied prospectively at our center. Improved preventative treatment strategies for children at risk of viremia after alloHCT are needed.
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Affiliation(s)
- Evelyn Rustia
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Leah Violago
- Department of Nursing, New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Marc D Foca
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Justine M Kahn
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Staci Arnold
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Jean Sosna
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Monica Bhatia
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Andrew L Kung
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Diane George
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - James H Garvin
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Prakash Satwani
- Department of Pediatrics, Columbia University Medical Center, New York, New York.
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