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Gopalappa R, Lee M, Kim G, Jung ES, Lee H, Hwang HY, Lee JG, Kim SJ, Yoo HJ, Sung YH, Kim D, Baek IJ, Kim HH. In vivo adenine base editing rescues adrenoleukodystrophy in a humanized mouse model. Mol Ther 2024; 32:2190-2206. [PMID: 38796705 PMCID: PMC11286820 DOI: 10.1016/j.ymthe.2024.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/14/2024] [Accepted: 05/23/2024] [Indexed: 05/28/2024] Open
Abstract
X-linked adrenoleukodystrophy (ALD), an inherited neurometabolic disorder caused by mutations in ABCD1, which encodes the peroxisomal ABC transporter, mainly affects the brain, spinal cord, adrenal glands, and testes. In ALD patients, very-long-chain fatty acids (VLCFAs) fail to enter the peroxisome and undergo subsequent β-oxidation, resulting in their accumulation in the body. It has not been tested whether in vivo base editing or prime editing can be harnessed to ameliorate ALD. We developed a humanized mouse model of ALD by inserting a human cDNA containing the pathogenic variant into the mouse Abcd1 locus. The humanized ALD model showed increased levels of VLCFAs. To correct the mutation, we tested both base editing and prime editing and found that base editing using ABE8e(V106W) could correct the mutation in patient-derived fibroblasts at an efficiency of 7.4%. Adeno-associated virus (AAV)-mediated systemic delivery of NG-ABE8e(V106W) enabled robust correction of the pathogenic variant in the mouse brain (correction efficiency: ∼5.5%), spinal cord (∼5.1%), and adrenal gland (∼2%), leading to a significant reduction in the plasma levels of C26:0/C22:0. This established humanized mouse model and the successful correction of the pathogenic variant using a base editor serve as a significant step toward treating human ALD disease.
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Affiliation(s)
- Ramu Gopalappa
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - MinYoung Lee
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; Brain Korea 21 Plus Project for Medical Sciences, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Globinna Kim
- ConveRgence mEDIcine research cenTer (CREDIT), ASAN Institute for Life Sciences, ASAN Medical Center, Seoul 05505, Republic of Korea; Department of Cell and Genetic Engineering, ASAN Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Eul Sik Jung
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; JES Clinic, Incheon 21550, Republic of Korea
| | - Hanahrae Lee
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; Brain Korea 21 Plus Project for Medical Sciences, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hye-Yeon Hwang
- Department of Precision Medicine, Sungkyunkwan University School of Medicine, Suwon 16419, Republic of Korea
| | - Jong Geol Lee
- ConveRgence mEDIcine research cenTer (CREDIT), ASAN Institute for Life Sciences, ASAN Medical Center, Seoul 05505, Republic of Korea
| | - Su Jung Kim
- ConveRgence mEDIcine research cenTer (CREDIT), ASAN Institute for Life Sciences, ASAN Medical Center, Seoul 05505, Republic of Korea
| | - Hyun Ju Yoo
- ConveRgence mEDIcine research cenTer (CREDIT), ASAN Institute for Life Sciences, ASAN Medical Center, Seoul 05505, Republic of Korea
| | - Young Hoon Sung
- ConveRgence mEDIcine research cenTer (CREDIT), ASAN Institute for Life Sciences, ASAN Medical Center, Seoul 05505, Republic of Korea; Department of Cell and Genetic Engineering, ASAN Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Daesik Kim
- Department of Precision Medicine, Sungkyunkwan University School of Medicine, Suwon 16419, Republic of Korea
| | - In-Jeoung Baek
- ConveRgence mEDIcine research cenTer (CREDIT), ASAN Institute for Life Sciences, ASAN Medical Center, Seoul 05505, Republic of Korea; Department of Cell and Genetic Engineering, ASAN Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea.
| | - Hyongbum Henry Kim
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; Brain Korea 21 Plus Project for Medical Sciences, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; Center for Nanomedicine, Institute for Basic Science, Seoul 03722, Republic of Korea; Graduate Program of Nano Biomedical Engineering, Advanced Science Institute, Yonsei University, Seoul 03722, Republic of Korea; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; Woo Choo Lee Institute for Precision Drug Development, Yonsei University College of Medicine, Seoul 03722, Republic of Korea.
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Farina M, Scaini MC, Facchinetti A, Leoni A, Bernardi S, Catoni C, Morello E, Radici V, Frioni F, Campodonico E, Traverso G, Cavallaro G, Olivieri A, Galieni P, Renzo ND, Patriarca F, Carluccio P, Skert C, Maffini E, Pellizzeri S, Campisi G, Re F, Benedetti E, Rosato A, Almici C, Chiusolo P, Peccatori J, Malagola M, Poggiana C, Russo D. Evaluation of Circulating Endothelial Cells as Direct Marker of Endothelial Damage in Allo-Transplant Recipients at High Risk of Hepatic Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome. Transplant Cell Ther 2024; 30:580.e1-580.e14. [PMID: 38582286 DOI: 10.1016/j.jtct.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/28/2024] [Accepted: 03/19/2024] [Indexed: 04/08/2024]
Abstract
Sinusoidal obstruction syndrome (SOS), also known as veno-occlusive disease (VOD), is a rare but potentially fatal complication following allogenic hematopoietic cell transplantation (allo-HCT). Timely identification of SOS/VOD to allow for prompt treatment is critical, but identifying a VOD-predictive biomarker remains challenging. Given the pivotal role of endothelial dysfunction in SOS/VOD pathophysiology, the CECinVOD study prospectively evaluated levels of circulating endothelial cells (CECs) in patients undergoing allo-HCT with a myeloablative conditioning (MAC) regimen to investigate the potential of CEC level in predicting and diagnosing SOS/VOD. A total of 150 patients from 11 Italian bone marrow transplantation units were enrolled. All participants were age >18 years and received a MAC regimen, putting them at elevated risk of developing SOS/VOD. Overall, 6 cases of SOS/VOD (4%) were recorded. CECs were detected using the Food and Drug Administration-approved CellSearch system, an immunomagnetic selection-based platform incorporating ferrofluid nanoparticles and fluorescent-labeled antibodies, and were defined as CD146+, CD105+, DAPI+, or CD45-. Blood samples were collected at the following time points: before (T0) and at the end of conditioning treatment (T1), at neutrophil engraftment (T2), and at 7 to 10 days postengraftment (T3). For patients who developed VOD, additional samples were collected at any suspected or proven VOD onset (T4) and weekly during defibrotide treatment (T5 to T8). A baseline CEC count >17/mL was associated with an elevated risk of SOS/VOD (P = .04), along with bilirubin level >1.5 mg/mL and a haploidentical donor hematopoietic stem cell source. Postconditioning regimen (T1) CEC levels were elevated (P = .02), and levels were further increased at engraftment (P < .0001). Additionally, patients developing SOS/VOD after engraftment, especially those with late-onset SOS/VOD, showed a markedly higher relative increase (>150%) in CEC count. Multivariate analysis supported these findings, along with a high Endothelial Activation and Stress Index (EASIX) score at engraftment (T2). Finally, CEC kinetics corresponded with defibrotide treatment. After the start of therapy (T4), CEC levels showed an initial increase in the first week (T5), followed by a progressive decrease during VOD treatment (T6 and T7) and a return to pre-SOS/VOD onset levels at resolution of the complication. This prospective multicenter study reveals a low incidence of SOS/VOD in high-risk patients compared to historical data, in line with recent reports. The results from the CECinVOD study collectively confirm the endothelial injury in allo-HCT and its role in in the development of SOS/VOD, suggesting that CEC level can be a valuable biomarker for diagnosing SOS/VOD and identifying patients at greater risk of this complication, especially late-onset SOS/VOD. Furthermore, CEC kinetics may support treatment strategies by providing insight into the optimal timing for discontinuing defibrotide treatment.
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Affiliation(s)
- Mirko Farina
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy.
| | - Maria Chiara Scaini
- Immunology and Molecular Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Italy
| | - Antonella Facchinetti
- Immunology and Molecular Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Italy; Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, 35128 Padua, Italy
| | - Alessandro Leoni
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Simona Bernardi
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Cristina Catoni
- Immunology and Molecular Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Italy.
| | - Enrico Morello
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Vera Radici
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Filippo Frioni
- Hematology Section, Department of Radiologic and Hematologic Sciences, Università Cattolica del Sacro Cuore, Rome; Department of Diagnostic Imaging, Radiotherapy, Oncology, and Hematology, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Edoardo Campodonico
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Ginevra Traverso
- Hematology Unit, Azienda Ospedaliero Universitana Pisana, Pisa, Italy
| | - Gianluca Cavallaro
- Hematology and Bone Marrow Transplantation Unit, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Attilio Olivieri
- Clinica di Ematologia e Clinica Medica, Università Politecnica delle Marche, Ancona, Italy
| | - Piero Galieni
- UOC Ematologia e Terapia cellulare, Ospedale C. e G. Mazzoni, Ascoli Piceno, Italy
| | | | - Francesca Patriarca
- Hematology and Bone Marrow Transplantation Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Paola Carluccio
- Unit of Hematology and Stem Cell Transplantation, AOUC Policlinico, Bari, Italy
| | - Cristina Skert
- Unit of Haematology and Bone Marrow Transplantation, "Ospedale Dell'Angelo", Venezia Mestre, Italy
| | - Enrico Maffini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna; Istituto "L. e A. Seràgnoli", Bologna, Italy
| | - Simone Pellizzeri
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Giovanni Campisi
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Federica Re
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Edoardo Benedetti
- Hematology Unit, Azienda Ospedaliero Universitana Pisana, Pisa, Italy
| | - Antonio Rosato
- Immunology and Molecular Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Italy; Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, 35128 Padua, Italy
| | - Camillo Almici
- Laboratory for Stem Cells Manipulation and Cryopreservation, Department of Transfusion Medicine, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Patrizia Chiusolo
- Hematology Section, Department of Radiologic and Hematologic Sciences, Università Cattolica del Sacro Cuore, Rome; Department of Diagnostic Imaging, Radiotherapy, Oncology, and Hematology, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Michele Malagola
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Cristina Poggiana
- Immunology and Molecular Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Italy
| | - Domenico Russo
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
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Phansalkar R, Kambham N, Charu V. Liver Pathology After Hematopoietic Stem Cell Transplantation. Surg Pathol Clin 2023; 16:519-532. [PMID: 37536886 DOI: 10.1016/j.path.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Hematopoietic stem cell transplantation is used to treat a variety of hematologic malignancies and autoimmune conditions. The immunosuppressive medications as well as other therapies used both before and after transplantation leave patients susceptible to a wide spectrum of complications, including liver injury. Causes for liver damage associated with stem cell transplantation include sinusoidal obstruction syndrome, graft-versus-host disease, iron overload, and opportunistic infection. Here, the authors review the clinical and pathological findings of these etiologies of liver injury and provide a framework for diagnosis.
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Affiliation(s)
- Ragini Phansalkar
- Department of Pathology, Lane Building, L235, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Neeraja Kambham
- Department of Pathology, Lane Building, L235, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Vivek Charu
- Department of Pathology, Lane Building, L235, 300 Pasteur Drive, Stanford, CA 94305, USA; Department of Medicine, Quantitative Sciences Unit, Stanford, CA, USA.
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Dezan MGF, Cavalcante LN, Cotrim HP, Lyra AC. Hepatobiliary disease after bone marrow transplant. Expert Rev Gastroenterol Hepatol 2023; 17:129-143. [PMID: 36655915 DOI: 10.1080/17474124.2023.2169671] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Bone marrow transplantation (BMT) is the standard treatment for several hematologic pathologies. Post-BMT patients may develop hepatobiliary complications that impact morbidity and mortality. The differential diagnosis may include drug-induced liver injury (DILI), sepsis-associated liver injury (SALI), sinusoidal obstruction syndrome (SOS), graft-versus-host disease (GVHD), viral hepatitis, ischemic and fulminant hepatitis, among others. AREA COVERED Defining the etiology of hepatobiliary injury is challenging due to the overlapping symptoms. Thus, it is necessary to be aware of and understand the clinical characteristics of these hepatobiliary complications and provide adequate management with possible better outcomes. We reviewed the scientific literature focused on early hepatobiliary complications associated with BMT. We searched the PubMed database using the following descriptors: hepatic complications, drug-induced liver disease, graft-versus-host disease, cholestasis, sepsis, sinusoidal obstruction syndrome, cytomegalovirus, viral hepatitis, bone marrow transplantation, and hematopoietic stem cell transplantation. EXPERT OPINION Post-BMT hepatobiliary complications comprise several differential diagnoses and are challenges for the hepatologist's clinical practice. When evaluating these patients, it is necessary to consider the temporality between the use of certain medications, the increase in liver enzymes, and the presence of infection, in addition to applying diagnostic criteria and complementary tests for a specific diagnosis.
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Affiliation(s)
- Maria Gabriela Fernandes Dezan
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
| | - Lourianne Nascimento Cavalcante
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
| | - Helma Pinchemel Cotrim
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
| | - Andre Castro Lyra
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
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Endothelial Dysfunction Syndromes after Allogeneic Stem Cell Transplantation. Cancers (Basel) 2023; 15:cancers15030680. [PMID: 36765638 PMCID: PMC9913851 DOI: 10.3390/cancers15030680] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only therapy with a curative potential for a variety of malignant and non-malignant diseases. The major limitation of the procedure is the significant morbidity and mortality mainly associated with the development of graft versus host disease (GVHD) as well as with a series of complications related to endothelial injury, such as sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD), transplant-associated thrombotic microangiopathy (TA-TMA), etc. Endothelial cells (ECs) are key players in the maintenance of vascular homeostasis and during allo-HSCT are confronted by multiple challenges, such as the toxicity from conditioning, the administration of calcineurin inhibitors, the immunosuppression associated infections, and the donor alloreactivity against host tissues. The early diagnosis of endothelial dysfunction syndromes is of paramount importance for the development of effective prophylactic and therapeutic strategies. There is an urgent need for the better understanding of the pathogenetic mechanisms as well as for the identification of novel biomarkers for the early diagnosis of endothelial damage. This review summarizes the current knowledge on the biology of the endothelial dysfunction syndromes after allo-HSCT, along with the respective therapeutic approaches, and discusses the strengths and weaknesses of possible biomarkers of endothelial damage and dysfunction.
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A case of percutaneous transhepatic stomal varices embolization and partial splenic artery embolization for rectal cancer after CAPOX/BEV chemotherapy: the summary of the stomal varices related to oxaliplatin administration. Clin J Gastroenterol 2023; 16:54-62. [PMID: 36266604 PMCID: PMC9889487 DOI: 10.1007/s12328-022-01720-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/06/2022] [Indexed: 02/04/2023]
Abstract
Capecitabine and oxaliplatin (CAPOX) plus bevacizumab (BEV) therapy (CAPOX/BEV) is a standard treatment recommended as the first-line treatment for colorectal cancer recurrence. Recently, sinusoidal obstruction syndrome (SOS) and resulting portal hypertension have been reported as important side effects of oxaliplatin. We herein report a rectal cancer patient who underwent percutaneous transhepatic stoma variceal embolization (PTO) and partial splenic artery embolization (PSE) for stomal variceal bleeding and splenomegaly due to portal hypertension caused by SOS after CAPOX therapy. A 43-year-old man who underwent robot-assisted laparoscopic abdominoperineal resection for advanced lower rectal cancer was started on CAPOX/BEV therapy for early recurrence 1 month after surgery. In the sixth course, splenomegaly rapidly worsened, stomal varices appeared, and the stoma began bleeding. At 5 months after the appearance of stomal varices, the splenomegaly worsened, the frequency of stomal bleeding increased, and PTO was performed. Five months later, PSE was performed for splenomegaly and thrombocytopenia. At 5 months since the PSE, the stoma bleeding has not recurred, and the thrombocytopenia has been corrected. The patient has been able to continue chemotherapy. We suggest that staged treatment by PTO and PSE be considered an important treatment option for stomal varices and splenomegaly associated with SOS.
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Yang AH, Han MAT, Samala N, Rizvi BS, Marchalik R, Etzion O, Wright EC, Patel R, Khan V, Kapuria D, Samala Venkat V, Kleiner DE, Koh C, Kanakry JA, Kanakry CG, Pavletic S, Williams KM, Heller T. Abnormal liver tests are not sufficient for diagnosis of hepatic graft-versus-host disease in critically ill patients. Hepatol Commun 2022; 6:2210-2220. [PMID: 35527712 PMCID: PMC9315132 DOI: 10.1002/hep4.1965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/25/2022] [Accepted: 03/22/2022] [Indexed: 11/11/2022] Open
Abstract
Hepatic graft-versus-host disease (HGVHD) contributes significantly to morbidity and mortality after hematopoietic stem cell transplantation (HSCT). Clinical findings and liver biomarkers are neither sensitive nor specific. The relationship between clinical and histologic diagnoses of HGVHD was assessed premortem and at autopsy. Medical records from patients who underwent HSCT at the National Institutes of Health (NIH) Clinical Center between 2000 and 2012 and expired with autopsy were reviewed, and laboratory tests within 45 days of death were divided into 15-day periods. Clinical diagnosis of HGVHD was based on Keystone Criteria or NIH Consensus Criteria, histologic diagnosis based on bile duct injury without significant inflammation, and exclusion of other potential etiologies. We included 37 patients, 17 of whom had a cholestatic pattern of liver injury and two had a mixed pattern. Fifteen were clinically diagnosed with HGVHD, two showed HGVHD on autopsy, and 13 had histologic evidence of other processes but no HGVHD. Biopsy or clinical diagnosis of GVHD of other organs during life did not correlate with HGVHD on autopsy. The diagnostic accuracy of the current criteria was poor (κ = -0.20). A logistic regression model accounting for dynamic changes included peak bilirubin 15 days before death, and an increase from period -30 (days 30 to 16 before death) to period -15 (15 days before death) showed an area under the receiver operating characteristic curve of 0.77. Infection was the immediate cause of death in 68% of patients. In conclusion, liver biomarkers at baseline and GVHD elsewhere are poor predictors of HGVHD on autopsy, and current clinical diagnostic criteria have unsatisfactory performance. Peak bilirubin and cholestatic injury predicted HGVHD on autopsy. A predictive model was developed accounting for changes over time. Further validation is needed.
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Affiliation(s)
- Alexander H Yang
- Liver Diseases BranchNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)BethesdaMarylandUSA
| | - Mai Ai Thanda Han
- Liver Diseases BranchNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)BethesdaMarylandUSA
| | - Niharika Samala
- Liver Diseases BranchNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)BethesdaMarylandUSA
| | - Bisharah S Rizvi
- Liver Diseases BranchNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)BethesdaMarylandUSA
| | - Rachel Marchalik
- Experimental Transplantation and Immunotherapy BranchNational Cancer Institute (NCI)BethesdaMarylandUSA
| | - Ohad Etzion
- Liver Diseases BranchNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)BethesdaMarylandUSA
| | - Elizabeth C Wright
- Office of the DirectorNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)BethesdaMarylandUSA
| | - Ruchi Patel
- Liver Diseases BranchNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)BethesdaMarylandUSA
| | - Vinshi Khan
- Liver Diseases BranchNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)BethesdaMarylandUSA
| | - Devika Kapuria
- Liver Diseases BranchNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)BethesdaMarylandUSA
| | - Vikramaditya Samala Venkat
- Liver Diseases BranchNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)BethesdaMarylandUSA
| | - David E Kleiner
- Laboratory of PathologyNational Cancer Institute (NCI)BethesdaMarylandUSA
| | - Christopher Koh
- Liver Diseases BranchNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)BethesdaMarylandUSA
| | - Jennifer A Kanakry
- Experimental Transplantation and Immunotherapy BranchNational Cancer Institute (NCI)BethesdaMarylandUSA
| | - Christopher G Kanakry
- Experimental Transplantation and Immunotherapy BranchNational Cancer Institute (NCI)BethesdaMarylandUSA
| | - Steven Pavletic
- Immune Deficiency Cellular Therapy ProgramNational Cancer Institute (NCI)BethesdaMarylandUSA
| | - Kirsten M Williams
- Department of PediatricsAflac Cancer and Blood Disorders CenterChildren's Healthcare of Atlanta, Emory UniversityAtlantaGeorgiaUSA
| | - Theo Heller
- Liver Diseases BranchNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)BethesdaMarylandUSA
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Debureaux PE, Bourrier P, Rautou PE, Zagdanski AM, De Boutiny M, Pagliuca S, Sutra Del Galy A, Robin M, Peffault de Latour R, Plessier A, Sicre de Fontbrune F, Xhaard A, de Lima Prata PH, Valla D, Socié G, Michonneau D. Elastography improves accuracy of early hepato-biliary complications diagnosis after allogeneic stem cell transplantation. Haematologica 2021; 106:2374-2383. [PMID: 32732366 PMCID: PMC8409044 DOI: 10.3324/haematol.2019.245407] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Indexed: 12/15/2022] Open
Abstract
Significant morbidity and mortality have been associated with liver complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Causes and consequences of these hepato-biliary complications are various and might be life-threatening. A high misdiagnosis rate has been reported because of a weak correlation between clinical, laboratory and imaging data. Liver elastography, a liver stiffness measure, is able to assess liver fibrosis and portal hypertension in most liver diseases, but data after allo-HSCT are scarce. Our aim was to determine the interest of sequential liver stiffness measurements for the diagnosis of early hepatic complications after allo-HSCT. Over a 2-year time period, 161 consecutive adult patients were included and 146 were analyzed. Ultrasonography and elastography measurements were performed before transplantation, at day+7 and day+14 by three different experienced radiologists unaware of the patients’ clinical status. Eightyone (55%) patients had liver involvements within the first 100 days after allo-HSCT. Baseline elastography was not predictive for the occurrence of overall liver abnormalities. A significant increase in two-dimensional real-time shearwave elastography (2D-SWE) was found in patients with sinusoidal obstruction syndrome (SOS). Fifteen patients (10%) fulfilled European Society for Blood and Marrow Transplantation (EBMT) score criteria and twelve (8%) reached Baltimore criteria for SOS diagnosis, but only six (4%) had a confirmed SOS. 2D-SWE at day+14 allowed early detection of SOS (AUROC=0.84, P=0.004) and improved sensibility (75%), specificity (99%) and positive predictive value (60%) over the Seattle, Baltimore or EBMT scores. A 2D-SWE measurement above 8.1 kPa at day+14 after allo-HSCT seems a promising, non-invasive, and reproducible tool for early and accurate diagnosis of SOS.
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Affiliation(s)
| | | | - Pierre-Emmanuel Rautou
- DHU Unit, Pole des Maladies de Appareil Digestif, Service d'Hepatologie, Centre de Reference
| | | | | | - Simona Pagliuca
- Hematology and transplantation unit, Saint Louis Hospital, APHP, Paris, France
| | | | - Marie Robin
- Hematology and transplantation unit, Saint Louis Hospital, APHP, Paris, France
| | | | - Aurélie Plessier
- DHU Unit, Pole des Maladies Appareil Digestif, Service d'Hepatologie, Centre de Reference
| | | | - Aliénor Xhaard
- Hematology and transplantation unit, Saint Louis Hospital, APHP, Paris, France
| | | | - Dominique Valla
- DHU Unit, Pole des Maladies de Appareil Digestif, Service d'Hepatologie, Centre de Reference
| | - Gérard Socié
- Hematology and transplantation unit, Saint Louis Hospital, APHP, Paris, France
| | - David Michonneau
- Hematology and transplantation unit, Saint Louis Hospital, APHP, Paris, France
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9
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Pereira M, Lee NT, Noonan J, Willcox AEH, Calvello I, Georgy SR, Selan C, Chia JS, Hauw W, Wang X, Peter K, Robson SC, Nandurkar HH, Sashindranath M. Early Endothelial Activation in a Mouse Model of Graft vs Host Disease Following Chemotherapy. Front Immunol 2021; 12:708554. [PMID: 34421913 PMCID: PMC8374081 DOI: 10.3389/fimmu.2021.708554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/20/2021] [Indexed: 11/28/2022] Open
Abstract
Allogenic hematopoietic stem cell transplant (allo-HSCT) can lead to sinusoidal obstruction syndrome (SOS) and graft-versus-host disease (GvHD) in some individuals. GvHD is characterised by an immune triggered response that arises due to donor T cells recognizing the recipient tissue as “foreign”. SOS results in impaired liver function due to microvascular thrombosis and consequent obstruction of liver sinusoids. Endothelial damage occurs following chemotherapy and allo-HSCT and is strongly associated with GvHD onset as well as hepatic SOS. Animal models of GvHD are rarely clinically relevant, and endothelial dysfunction remains uncharacterised. Here we established and characterised a clinically relevant model of GvHD wherein Balb/C mice were subjected to myeloablative chemotherapy followed by transplantation of bone marrow (BM) cells± splenic T-cells from C57Bl6 mice, resulting in a mismatch of major histocompatibility complexes (MHC). Onset of disease indicated by weight loss and apoptosis in the liver and intestine was discovered at day 6 post-transplant in mice receiving BM+T-cells, with established GvHD detectable by histology of the liver within 3 weeks. Together with significant increases in pro-inflammatory cytokine gene expression in the liver and intestine, histopathological signs of GvHD and a significant increase in CD4+ and CD8+ effector and memory T-cells were seen. Endothelial activation including upregulation of vascular cell adhesion molecule (VCAM)- 1 and downregulation of endothelial nitric oxide synthase (eNOS) as well as thrombosis in the liver indicated concomitant hepatic SOS. Our findings confirm that endothelial activation is an early sign of acute GvHD and SOS in a clinically relevant mouse model of GvHD based on myeloablative chemotherapy. Preventing endothelial activation may be a viable therapeutic strategy to prevent GvHD.
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Affiliation(s)
- Melrine Pereira
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Alfred Hospital, Melbourne VIC, Australia
| | - Natasha Ting Lee
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Alfred Hospital, Melbourne VIC, Australia
| | - Jonathan Noonan
- Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC, Australia.,Department of Immunology, Monash University, Melbourne, VIC, Australia
| | - Abbey E H Willcox
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Alfred Hospital, Melbourne VIC, Australia
| | - Ilaria Calvello
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Alfred Hospital, Melbourne VIC, Australia
| | - Smitha Rose Georgy
- Department of Anatomic Pathology, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Werribee, VIC, Australia
| | - Carly Selan
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Alfred Hospital, Melbourne VIC, Australia
| | - Joanne S Chia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Alfred Hospital, Melbourne VIC, Australia
| | - Wayne Hauw
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Alfred Hospital, Melbourne VIC, Australia
| | - Xiaowei Wang
- Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC, Australia
| | - Simon C Robson
- Harvard Medical School, Department of Medicine, Division of Gastroenterology, Boston, MA, United States
| | - Harshal H Nandurkar
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Alfred Hospital, Melbourne VIC, Australia
| | - Maithili Sashindranath
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Alfred Hospital, Melbourne VIC, Australia
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10
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Bonifazi F, Sica S, Angeletti A, Marktel S, Prete A, Iori AP, Olivari D, Rossetti G, Bertaina A, Botti S, Busca A, Carella AM, Cerretti R, Gargiulo G, Grassi A, Gualandi F, Irrera G, Milone G, Risitano AM, Santarone S, Vassallo E, Zecca M, Ciceri F, Pomponio G. Veno-occlusive Disease in HSCT Patients: Consensus-based Recommendations for Risk Assessment, Diagnosis, and Management by the GITMO Group. Transplantation 2021; 105:686-694. [PMID: 33273315 DOI: 10.1097/tp.0000000000003569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Variation in clinical practice affects veno-occlusive disease management, mainly in patients who undergo allogeneic hematopoietic stem cell transplantation. Disputes about diagnostic criteria, treatment, and prophylaxis, due to the lack of high-quality data, are at the base of this variability. With the aim of limiting inconsistency in clinical care, thus improving both patient outcomes and data collection reliability, the Italian Society of Stem cell transplant (Gruppo Italiano Trapianto Midollo Osseo e Terapia Cellulare) launched a collaborative effort to formulate recommendations based on integration of available evidence and expert's consensus. A systematic method, according to US National Institute of Health guidelines and Italian National System for Guidelines, was used. Twenty-nine recommendations were approved with a strong (20) or weak (9) level of agreement, while 26 were rejected. In particular, the panel pointed out the need to achieve an early diagnosis, encouraging the adoption of European Society for Blood and Marrow Transplantation criteria and the prompt use of ultrasonography. Moreover, our experts strongly recommended in favor of prophylactic use of ursodeoxycholic acid. As soon as a veno-occlusive disease diagnosis is established, treatment with defibrotide should be started for at least 21 days. A number of areas of uncertainty, particularly concerning risk stratification and use of diagnostic tools such as elastography has been identified and discussed.
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Affiliation(s)
- Francesca Bonifazi
- IRCCS Azienda Ospedaliero-Universitaria, Istituto di Ematologia "L. e A. Seràgnoli", Bologna, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico A. Gemelli IRCCS, Roma, Italia
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italia
| | | | - Sarah Marktel
- Unità di Ematologia e Trapianto di Midollo Osseo IRCCS, Istituto Scientifico Ospedale San Raffaele, Milano, Italia
| | - Arcangelo Prete
- Dipartimento di Oncologia ed Ematologia Pediatrica, Università di Bologna, Ospedale S. Orsola-Malpighi, Bologna, Italia
| | - Anna Paola Iori
- Dipartimento di Oncologia ed Ematologia Pediatrica IRCCS, Ospedale Bambino Gesu', Roma, Italia
| | - Diletta Olivari
- Clinica Medica, Università Politecnica delle Marche, Ancona, Italia
| | - Giulia Rossetti
- Clinica Medica, Università Politecnica delle Marche, Ancona, Italia
| | - Alice Bertaina
- Division of Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA
| | - Stefano Botti
- Unità di Ematologia, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italia
| | - Alessandro Busca
- Dipartimento di Oncologia ed Ematologia, AOU Citta' della Salute e della Scienza, Torino, Italia
| | - Angelo Michele Carella
- Unità di Trapianto di Midollo Osseo, Dipartimento di Oncoematologia, Fondazione IRCCS "Casa Sollievo della Sofferenza" San Giovanni Rotondo, Foggia, Italia
| | - Raffaella Cerretti
- UOC Ematologia, Unità di Trapianto di Cellule Staminali, Ospedale Tor Vergata, Roma, Italia
| | - Gianpaolo Gargiulo
- Dipartimento di Oncologia ed Ematologia, Azienda Ospedaliero Universitaria Federico II, Napoli, Italia
| | - Anna Grassi
- UOS Trapianto di Midollo USC Ematologia, ASST PG23 Bergamo, Italia
| | - Francesca Gualandi
- Divisione di Ematologia e Unità di Trapianto di Cellule Staminali, Policlinico San Martino IRCCS, Genova, Italia
| | - Giuseppe Irrera
- Centro Trapianti Cellule Staminali e Terapie Cellulari "A.Neri," Grande Ospedale Metropolitano, Reggio Calabria, Italia
| | - Giuseppe Milone
- Unità di Trapianto Emopoietico, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele," San Marco, Catania, Italia
| | - Antonio Maria Risitano
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II Napoli, Napoli, Italia
| | - Stella Santarone
- Terapia Intensiva Ematologica, Dipartimento Oncologico Ematologico Ospedale Civile, Pescara, Italia
| | - Elena Vassallo
- Dipartimento di Oncoematologia, Centro Trapianti Cellule Staminali e Terapia Cellulare, Ospedale Infantile Regina Margherita, Torino, Italia
| | - Marco Zecca
- Oncoematologia Pediatrica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italia
| | - Fabio Ciceri
- Unità di Ematologia e Trapianto di Midollo Osseo IRCCS, Istituto Scientifico Ospedale San Raffaele, Milano, Italia
- Università Vita-Salute San Raffaele, Milano, Italia
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11
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Omori I, Yamaguchi H, Hirakawa T, Inai K, Onai D, Marumo A, Yamanaka S, Sakaguchi M, Fujiwara Y, Wakita S, Okamoto M, Tamai H, Nakayama K, Yui S, Inokuchi K. Outcomes of Patients with Early Hyperbilirubinemia after Allogeneic Hematopoietic Stem Cell Transplantation. J NIPPON MED SCH 2020; 87:142-152. [PMID: 32009070 DOI: 10.1272/jnms.jnms.2020_87-404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Because the cause of liver dysfunction after allogeneic hematopoietic stem cell transplantation (HSCT) is difficult to identify in the early stages, treatment may be delayed. Therefore, early factors associated with unfavorable outcomes of liver dysfunction must be identified. The objective of this study was to identify unfavorable prognostic factors for liver dysfunction during the early period after transplantation. METHODS We defined liver dysfunction as elevated liver or biliary enzyme levels (corresponding to Grade 2 in the Common Terminology Criteria for Adverse Events version 4.0) within 30 days of transplantation and retrospectively investigated data from 82 patients who had undergone allogeneic HSCT at our center. RESULTS Elevated liver or biliary enzyme levels were observed in almost half of the patients studied (n=40, 48.7%). Elevated total bilirubin (T-Bil) level was the most frequently observed unfavorable prognostic factor and had the greatest effect on overall survival (OS), progression-free survival (PFS), and non-relapse mortality (NRM) (probability of unfavorable outcome in patients without and with elevated T-Bil level: OS, 58.9% vs. 15.4%, p < 0.001; PFS, 46.4% vs. 15.4%, p < 0.001; NRM, 10.7% vs. 53.8%, p < 0.001). Moreover, the probability of an unfavorable outcome increased in relation to the degree of T-Bil elevation and absence of improvement over time in T-Bil level. CONCLUSION Elevated T-Bil level was an important marker of outcomes for liver dysfunction after allogeneic HSCT.
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Affiliation(s)
- Ikuko Omori
- Department of Hematology, Nippon Medical School
| | | | | | - Kazuki Inai
- Department of Hematology, Nippon Medical School
| | - Daishi Onai
- Department of Hematology, Nippon Medical School
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12
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Giaccone L, Felicetti F, Butera S, Faraci D, Cerrano M, Dionisi Vici M, Brunello L, Fortunati N, Brignardello E, Bruno B. Optimal Delivery of Follow-Up Care After Allogeneic Hematopoietic Stem-Cell Transplant: Improving Patient Outcomes with a Multidisciplinary Approach. J Blood Med 2020; 11:141-162. [PMID: 32523389 PMCID: PMC7237112 DOI: 10.2147/jbm.s206027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/02/2020] [Indexed: 01/05/2023] Open
Abstract
The increasing indications for allogeneic stem-cell transplant in patients with hematologic malignancies and non-malignant diseases combined with improved clinical outcomes have contributed to increase the number of long-term survivors. However, survivors are at increased risk of developing a unique set of complications and late effects, besides graft-versus-host disease and disease relapse. In this setting, the management capacity of a single health-care provider can easily be overwhelmed. Thus, to provide appropriate survivorship care, a multidisciplinary approach for the long-term follow-up is essential. This review aims at summarizing the most relevant information that a health-care provider should know to establish a follow-up care plan, in the light of individual exposures and risk factors, that includes all organ systems and considers the psychological burden of these patients.
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Affiliation(s)
- Luisa Giaccone
- Division of Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, University of Torino, Torino, Italy
| | - Francesco Felicetti
- Transition Unit for Childhood Cancer Survivors, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Sara Butera
- Division of Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, University of Torino, Torino, Italy
| | - Danilo Faraci
- Division of Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, University of Torino, Torino, Italy
| | - Marco Cerrano
- Division of Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, University of Torino, Torino, Italy
| | - Margherita Dionisi Vici
- Transition Unit for Childhood Cancer Survivors, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Lucia Brunello
- Division of Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, University of Torino, Torino, Italy
| | - Nicoletta Fortunati
- Transition Unit for Childhood Cancer Survivors, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Enrico Brignardello
- Transition Unit for Childhood Cancer Survivors, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Benedetto Bruno
- Division of Hematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, University of Torino, Torino, Italy
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13
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Bonifazi F, Barbato F, Ravaioli F, Sessa M, Defrancesco I, Arpinati M, Cavo M, Colecchia A. Diagnosis and Treatment of VOD/SOS After Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2020; 11:489. [PMID: 32318059 PMCID: PMC7147118 DOI: 10.3389/fimmu.2020.00489] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 03/03/2020] [Indexed: 12/27/2022] Open
Abstract
Hepatic veno-occlusive disease (VOD) or sinusoidal obstruction syndrome (SOS) is a rare complication characterized by hepatomegaly, right-upper quadrant pain, jaundice, and ascites, occurring after high-dose chemotherapy, hematopoietic stem cell transplantation (HSCT) and, less commonly, other conditions. We review pathogenesis, clinical appearance and diagnostic criteria, risk factors, prophylaxis, and treatment of the VOD occurring post-HSCT. The injury of the sinusoidal endothelial cells with loss of wall integrity and sinusoidal obstruction is the basis of development of postsinusoidal portal hypertension responsible for clinical syndrome. Risk factors associated with the onset of VOD and diagnostic tools have been recently updated both in the pediatric and adult settings and here are reported. Treatment includes supportive care, intensive management, and specific drug therapy with defibrotide. Because of its severity, particularly in VOD with associated multiorgan disease, prophylaxis approaches are under investigation. During the last years, decreased mortality associated to VOD/SOS has been reported being it attributable to a better intensive and multidisciplinary approach.
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Affiliation(s)
- Francesca Bonifazi
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Francesco Barbato
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mariarosaria Sessa
- Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum-Bologna University School of Medicine S. Orsola's University Hospital, Bologna, Italy
| | - Irene Defrancesco
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Mario Arpinati
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Michele Cavo
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy.,Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum-Bologna University School of Medicine S. Orsola's University Hospital, Bologna, Italy
| | - Antonio Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Gastroenterology Unit, Borgo Trento University Hospital, Verona, Italy
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14
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Acar S, Gencdal G, Kirimlioglu H, Polat KY, Cagatay AA, Akyildiz M. Varicella-Zoster Virus-Induced Hepatitis in a Liver Transplant Recipient: A Case Report. Transplant Proc 2019; 51:1193-1195. [PMID: 30981408 DOI: 10.1016/j.transproceed.2019.01.092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 01/30/2019] [Indexed: 10/27/2022]
Abstract
Infections after solid organ transplantation are a major cause of mortality and morbidity. Varicella-zoster virus (VZV) infection after solid organ transplantation is rare. Here we present a case presenting with acute hepatitis and shingles after a liver transplantation (LT). A 36-year-old male patient underwent a liver transplantation; 7 months later his liver function tests increased. An examination and test results revealed that he had VZV-induced hepatitis. After VZV treatment, his test results returned to normal levels. Hepatic involvement of VZV infection is rare, but it may be fatal in immunocompromised individuals. Early diagnosis and early initiation of antiviral therapy is important in the control of hepatitis and rare hepatotropic viruses in immunocompromised individuals.
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Affiliation(s)
- S Acar
- Department of Gastroenterology and Organ Transplantation Center, Sakarya University School of Medicine, Sakarya, Turkey.
| | - G Gencdal
- Department of Gastroenterology and Organ Transplantation Center, Memorial Atasehir Hospital, Istanbul, Turkey
| | - H Kirimlioglu
- Department of Pathology, Acibadem University School of Medicine and Nisantasi Pathology Center, Istanbul, Turkey
| | - K Y Polat
- Department of General Surgery and Organ Transplantation Center, Memorial Atasehir Hospital, Istanbul, Turkey
| | - A A Cagatay
- Department of Infectious Disease, Istanbul University School of Medicine, Istanbul, Turkey
| | - M Akyildiz
- Department of Gastroenterology and Organ Transplantation Center, Koc University School of Medicine, Istanbul, Turkey
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15
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Ruggiu M, Bedossa P, Rautou PE, Bertheau P, Plessier A, Peffault de Latour R, Robin M, Sicre de Fontbrune F, Pagliuca S, Villate A, Xhaard A, Socié G, Michonneau D. Utility and Safety of Liver Biopsy in Patients with Undetermined Liver Blood Test Anomalies after Allogeneic Hematopoietic Stem Cell Transplantation: A Monocentric Retrospective Cohort Study. Biol Blood Marrow Transplant 2018; 24:2523-2531. [DOI: 10.1016/j.bbmt.2018.07.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/21/2018] [Indexed: 12/19/2022]
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16
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Miyata T, Tajima H, Hirata M, Nakanuma SI, Makino I, Hayashi H, Oyama K, Miyashita T, Takamura H, Ninomiya I, Fushida S, Iseki S, Harada SI, Wakayama T, Ohta T. Phosphodiesterase III inhibitor attenuates rat sinusoidal obstruction syndrome through inhibition of platelet aggregation in Disse's space. J Gastroenterol Hepatol 2018; 33:950-957. [PMID: 28960464 DOI: 10.1111/jgh.14004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 09/10/2017] [Accepted: 09/13/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIM Sinusoidal obstruction syndrome (SOS) is a serious drug-induced liver injury. However, the pathophysiology of the disease remains unclear. This study investigated the effects of cilostazol (CZ), a phosphodiesterase III inhibitor, in a monocrotaline (MCT)-induced rat model of SOS. METHODS Male Wistar rats were administrated MCT to induce SOS. Rats were divided into control, MCT, and MCT + CZ groups. In the MCT + CZ group, CZ was administered at 48 h, 24 h, and 30 min prior to and 8 h and 24 h after MCT administration. The MCT group was treated with water instead of CZ. At 48 h after MCT administration, blood and liver samples were collected to assess biochemistry and liver histology. Expression of rat endothelial cell antigen, CD34, CD41, P-selectin, and caspase-3 in the liver were analyzed. Plasminogen activator inhibitor-1 (PAI-1) in hepatocytes was analyzed using western blotting and polymerase chain reaction. RESULTS In the MCT group, macroscopic findings showed a dark-red liver surface. Histological findings showed sinusoidal dilatation, coagulative necrosis of hepatocytes, and endothelial damage of the central vein. These changes were attenuated in the MCT + CZ group. Elevated serum transaminase and decreased platelet counts were observed in the MCT + CZ group compared with those in the MCT group. Treatment with CZ reduced MCT-induced damage to the liver sinusoidal endothelial cells, inhibited extravasated platelet aggregation, and suppressed hepatocyte apoptosis around the central vein. CZ attenuated hepatic PAI-1 protein and mRNA levels. CONCLUSIONS Cilostazol attenuated MCT-induced SOS by preventing damage to liver sinusoidal endothelial cells and extravasated platelet aggregation. Hepatic PAI-1 levels were suppressed with CZ treatment.
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Affiliation(s)
- Takashi Miyata
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Hidehiro Tajima
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Miki Hirata
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Shin-Ichi Nakanuma
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Isamu Makino
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Hironori Hayashi
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Katsunobu Oyama
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Tomoharu Miyashita
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Hiroyuki Takamura
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Itasu Ninomiya
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Sachio Fushida
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Shoichi Iseki
- Department of Histology and Embryology, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Shin-Ichi Harada
- Center for Biomedical Research, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Tomohiko Wakayama
- Department of Histology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Tetsuo Ohta
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
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17
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Bajwa RPS, Mahadeo KM, Taragin BH, Dvorak CC, McArthur J, Jeyapalan A, Duncan CN, Tamburro R, Gehred A, Lehmann L, Richardson P, Auletta JJ, Woolfrey AE. Consensus Report by Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplantation Consortium Joint Working Committees: Supportive Care Guidelines for Management of Veno-Occlusive Disease in Children and Adolescents, Part 1: Focus on Investigations, Prophylaxis, and Specific Treatment. Biol Blood Marrow Transplant 2017; 23:1817-1825. [PMID: 28754544 DOI: 10.1016/j.bbmt.2017.07.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/20/2017] [Indexed: 12/13/2022]
Abstract
Veno-occlusive disease (VOD) is a common and potentially fatal complication in children undergoing hematopoietic cell transplantation (HCT). It occurs in about one-third of all patients undergoing transplantation and is fatal in 50% of patients with severe disease. Early intervention and specific treatment with defibrotide are associated with improved outcomes. However, there is a lack of supportive care guidelines for management of the multiorgan dysfunction seen in most cases. There is high variability in the management of VOD, which may contribute to the increased morbidity and mortality. Although there is ample research in the specific treatment of VOD, there is paucity of literature regarding the management of ascites, transfusions requirements, fluids and electrolyte dysfunction, delirium, and investigations in children with VOD. The joint working committees of the Pediatric Acute Lung Injury and Sepsis Investigators and the Pediatric Blood and Marrow Transplantation Consortium collaborated to develop a series of evidence-based supportive care guidelines for management of VOD. The quality of evidence was rated and recommendations were made using Grading of Recommendations, Assessment, Development and Evaluation criteria. This manuscript is part 1 of the series and focuses on the need to develop these guidelines; methodology used to establish the guidelines; and investigations needed for diagnosis, prophylaxis, and treatment of VOD in children.
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Affiliation(s)
- Rajinder P S Bajwa
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio.
| | - Kris M Mahadeo
- Division of Pediatric Blood and Marrow Transplantation, The University of Texas, MD Anderson Children's Cancer Hospital, Houston, Texas
| | - Benjamin H Taragin
- Department of Pediatric Radiology, Children's Hospital at Montefiore, Bronx, New York
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Jennifer McArthur
- Department of Pediatric Critical Care Medicine St Jude Children's Research Hospital, Memphis, Tennessee
| | - Asumthia Jeyapalan
- Division of Pediatric Critical Care Medicine, University of Miami- Miller School of Medicine, Miami, Florida
| | - Christine N Duncan
- Division of Pediatric Stem Cell Transplant, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert Tamburro
- Division of Pediatric Critical Care Medicine, Pennsylvania University, Penn State Hershey Children's Hospital, Hershey, PA
| | - Alison Gehred
- Medical Library division, Nationwide Children's Hospital, Columbus, Ohio
| | - Leslie Lehmann
- Division of Pediatric Stem Cell Transplant, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Paul Richardson
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jeffery J Auletta
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio; Division of Infectious Diseases, Nationwide Children's Hospital, Columbus
| | - Ann E Woolfrey
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, Washington
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18
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How I treat hepatitis C virus infection in patients with hematologic malignancies. Blood 2016; 128:1449-57. [PMID: 27443290 DOI: 10.1182/blood-2016-05-718643] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 07/12/2016] [Indexed: 12/20/2022] Open
Abstract
Hepatitis C virus (HCV) infection is not uncommon in cancer patients. Over the past 5 years, treatment of chronic HCV infection in patients with hematologic malignancies has evolved rapidly as safe and effective direct-acting antivirals (DAAs) have become the standard-of-care treatment. Today, chronic HCV infection should not prevent a patient from receiving cancer therapy or participating in clinical trials of chemotherapy because most infected patients can achieve virologic cure. Elimination of HCV from infected cancer patients confers virologic, hepatic, and oncologic advantages. Similar to the optimal therapy for HCV-infected patients without cancer, the optimal therapy for HCV-infected patients with cancer is evolving rapidly. The choice of regimens with DAAs should be individualized after thorough assessment for potential hematologic toxic effects and drug-drug interactions. This study presents clinical scenarios of HCV-infected patients with hematologic malignancies, focusing on diagnosis, clinical and laboratory presentations, complications, and DAA therapy. An up-to-date treatment algorithm is presented.
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Correlation of Pain and Fluoride Concentration in Allogeneic Hematopoietic Stem Cell Transplant Recipients on Voriconazole. Biol Blood Marrow Transplant 2015; 22:579-83. [PMID: 26524731 DOI: 10.1016/j.bbmt.2015.10.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 10/26/2015] [Indexed: 11/23/2022]
Abstract
Supportive care guidelines recommend antimold prophylaxis in hematopoietic stem cell transplant (HSCT) recipients deemed to have high risk for invasive fungal infection, leading to long-term use of voriconazole after allogeneic HSCT in patients who remain immunocompromised. Voriconazole has been associated with periostitis, exostoses, and fluoride excess in patients after solid organ transplantation, HSCT, and leukemia therapy. The aims of this study were to describe the frequency and clinical presentation of patients presenting with pain and fluoride excess among allogeneic HSCT patients taking voriconazole, to identify when a plasma fluoride concentration was measured with respect to voriconazole initiation and onset of pain, and to describe the outcomes of patients with fluoride excess in the setting of HSCT. A retrospective review was conducted of all adult allogeneic HSCT patients receiving voriconazole at Mayo Clinic in Rochester, Minnesota, between January 1, 2009 and July 31, 2012. Of 242 patients included, 32 had plasma fluoride measured to explore the etiology of musculoskeletal pain. In 31 patients with fluoride measurement while on voriconazole, 29 (93.5%) had elevated levels. The median plasma fluoride was 11.1 μmol/L (range, 2.4 to 24.7). The median duration of voriconazole was 163 days (range, 2 to 1327). The median time to fluoride measurement was 128 days after voriconazole initiation (range, 28 to 692). At 1 year after the start of voriconazole after HSCT, 15.3% of patients had developed pain associated with voriconazole use and 35.7% developed pain while on voriconazole after 2 years. Of the patients with an elevated fluoride level, 22 discontinued voriconazole; pain resolved or improved in 15, stabilized in 3, and worsened in 4 patients. Ten patients continued voriconazole; pain resolved or improved in 7, was attributable to alternative causes in 2, and undefined in 1. Serum creatinine, estimated glomerular filtration rate, alkaline phosphatase, and voriconazole concentration did not predict for fluoride excess and associated pain. Periostitis due to fluoride excess is a common adverse effect of voriconazole that should be considered in patients presenting with pain and is often reversible after drug discontinuation. Alternative antifungal agents with a lower risk for fluoride excess should be considered in patients receiving voriconazole who develop fluoride excess and pain.
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20
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Chen S, Osborn JD, Chen X, Boyer MW, McDonald GB, Hildebrandt GC. Subacute hepatic necrosis mimicking veno-occlusive disease in a patient with HFE H63D homozygosity after allogeneic hematopoietic cell transplantation with busulfan conditioning. Int J Hematol 2015; 102:729-31. [PMID: 26497867 DOI: 10.1007/s12185-015-1878-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 09/11/2015] [Accepted: 09/28/2015] [Indexed: 01/06/2023]
Abstract
Busulfan is a commonly used chemotherapeutic agent in myeloablative conditioning regimens for allogeneic hematopoietic cell transplantation (allo-HCT). It has been associated with sinusoidal-obstructive syndrome(SOS) as a life-threatening complication of myeloablative allo-HCT, yet it has not been found to cause severe hepatocellular injury, even in cases of significant accidental overdose.We report the case of a 31-year-old male with a history of high-risk myelodysplastic syndrome transitioning to acute myeloid leukemia, who in complete remission underwent allo-HCT using myeloablative busulfan–fludarabine conditioning, and who developed hepatic failure. While he met clinical criteria for SOS and was treated with defibrotide,liver biopsy demonstrated severe subacute hepatic necrosis and lacked characteristics of SOS. Further evaluation revealed that the patient was homozygous for the HFE H63D gene mutation, associated with hereditary hemochromatosis.Both Busulfan and iron overload related to HFE H63D homozygosity can cause oxidative stress resulting in cellular injury, and the cumulative effects of these risk factors are possibly responsible for the severe hepatocellular injury in this case, making our patient the first-known case of subacute hepatic necrosis related to busulfan administration.
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21
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Hopps SA, Borders EB, Hagemann TM. Prophylaxis and treatment recommendations for sinusoidal obstruction syndrome in adult and pediatric patients undergoing hematopoietic stem cell transplant: a review of the literature. J Oncol Pharm Pract 2015; 22:496-510. [PMID: 26126501 DOI: 10.1177/1078155215591387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sinusoidal obstruction syndrome, a complication occurring early after hematopoietic stem cell transplantation, is a concern for clinicians. There are no guidelines to direct clinicians on the optimal way to prevent and treat this disease. Newer data show that defibrotide is a promising drug both for prevention and treatment, although it is not yet FDA approved.
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Affiliation(s)
- Sarah A Hopps
- College of Pharmacy, University of Oklahoma, Oklahoma City, OK, USA
| | - Emily B Borders
- College of Pharmacy, University of Oklahoma, Oklahoma City, OK, USA
| | - Tracy M Hagemann
- College of Pharmacy, University of Oklahoma, Oklahoma City, OK, USA
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22
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Alexandrino H, Oliveira D, Cipriano MA, Ferreira L, Tralhão JG, Castro E Sousa F. Oxaliplatin toxicity presenting as a liver nodule - case report. BMC Cancer 2015; 15:247. [PMID: 25886004 PMCID: PMC4393578 DOI: 10.1186/s12885-015-1247-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Accepted: 03/24/2015] [Indexed: 12/12/2022] Open
Abstract
Background Oxaliplatin based chemotherapy is often used as adjuvant therapy in colon and rectal cancer. A reported side effect is Sinusoidal Obstruction Syndrome which is characterized by a spectrum of pathologic changes, from sinusoidal dilation, peri-sinusoidal haemorrhage, peliosis and nodular regenerative hyperplasia. Very rarely it can cause the development of liver nodules mimicking liver metastases. Herein, we report a case of Sinusoidal Obstruction Syndrome causing a liver nodule suspicious of liver metastasis on imaging. This is the third reported case of this complication of oxaliplatin toxicity, in which resection was performed and pathological diagnosis confirmed. Case presentation We report the case of a 59 year old man with stage III colon cancer who underwent sigmoidectomy followed by adjuvant chemotherapy with oxaliplatin. One year after surgery a liver nodule was detected and the patient underwent right hepatectomy. Pathology showed no liver nodule and diagnosed sinusoidal obstruction syndrome. Conclusion We describe the third reported case of a liver lesion mimicking a liver metastasis after oxaliplatin-based chemotherapy for colon cancer. We suggest that in patients heavily treated with oxaliplatin with de novo liver nodules, this differential diagnosis should be considered. In particular, in this population of patients an intense imagiologic evaluation and even a preoperative biopsy should be pursued to confirm the diagnosis of malignancy and avoid overtreatment.
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Affiliation(s)
- Henrique Alexandrino
- Department of General Surgery, Coimbra University Hospital, Coimbra, Portugal. .,Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
| | | | | | - Luís Ferreira
- Department of General Surgery, Coimbra University Hospital, Coimbra, Portugal.
| | - J Guilherme Tralhão
- Department of General Surgery, Coimbra University Hospital, Coimbra, Portugal. .,Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
| | - Francisco Castro E Sousa
- Department of General Surgery, Coimbra University Hospital, Coimbra, Portugal. .,Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
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Association between Plasma Endothelin-1, Transforming Growth Factor-β, Fibroblast Growth Factor, and Nitric Oxide Levels and Liver Injury in Hematopoietic Stem Cell Transplantation Recipients with Persistent Iron Overload after Transplantation. Biol Blood Marrow Transplant 2015; 21:948-53. [PMID: 25681034 DOI: 10.1016/j.bbmt.2015.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 02/03/2015] [Indexed: 01/19/2023]
Abstract
Graft-versus-host disease, iron overload, and infections are the major causes of liver dysfunction in allogeneic hematopoietic stem cell transplantation (AHSCT) recipients. We investigated the relationship between serum iron parameters and the levels of transforming growth factor-β (TGF-β), fibroblast growth factor (FGF), endothelin-1 (ET-1), and nitric oxide (NO) as predictors of chronic liver injury in 54 AHSCT recipients who survived at least a year after transplantation. Serum samples from patients were obtained for the evaluation of ET-1, TGF-β, FGF, NO, and nontransferrin bound iron at the first year follow-up visit using commercially available ELISA kits. Patients were categorized depending on serum ferritin and transferrin saturation levels. The parameters were compared between the groups, and survival analysis was also performed. Most of the AHSCT recipients (81.5%) were in complete remission during the study. After a median follow-up time of 73 months (range, 13 to 109 months), 72.2% of the patients were alive. Mean serum levels of ET-1, NO, TGF-β, and FGF were 81.54 ± 21.62 μmol/mL, 31.82 ± 26.42 μmol/mL, 2.56 ± 0.77 ng/mL, and 50.31 ± 32.69 pg/mL, respectively. Nineteen patients (35.2% of the cohort) had serum ferritin levels higher than 1000 ng/mL. Mean serum levels of ET-1, NO, TGF-β, and FGF were similar in patients with serum ferritin levels below or above 1000 ng/mL (P > .05). Serum ferritin levels were positively correlated with serum alanine aminotransferase (r = .284, P = .042) and γ-glutamyl transferase (r = .271, P = .05) levels and were negatively correlated with serum albumin levels (r = .295, P = .034). There was a significant positive correlation between serum transferrin saturation and alanine aminotransferase levels (r = .305, P = .03). Serum ET-1 level was positively correlated with alkaline phosphatase levels (r = .304, P = .026). In univariate Cox regression analysis serum levels of iron parameters, ET-1, NO, TGF-β, and FGF did not have an impact on overall survival (P > .05). The probability of progression-free survival was also similar in patients with ferritin levels above or below 1000 ng/mL (P = .275). The probability of survival was similar in patients with transferrin saturation ≥70% and <70% (P > .05). Serum iron parameters showed a positive correlation with liver injury. However, there was no correlation between fibrogenic cytokines and liver transaminases. Our results suggest that iron overload at least with the current levels of ferritin might have a relatively benign course. Prospective randomized trials will guide the actual role of iron chelation in the post-transplantation setting.
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24
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The Correlation Between Platelet Activation and Liver Injury by Conditioning and Bone Marrow Transplantation. Transplant Proc 2014; 46:1523-30. [DOI: 10.1016/j.transproceed.2014.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/16/2014] [Accepted: 02/27/2014] [Indexed: 11/22/2022]
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25
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Risk Factors Associated with Liver Injury and Impact of Liver Injury on Transplantation-Related Mortality in Pediatric Recipients of Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2013; 19:912-7. [DOI: 10.1016/j.bbmt.2013.02.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 02/26/2013] [Indexed: 11/20/2022]
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Anabtawi I, Abdelrahman F, Alomari A, Ba'ba' M, Al Masri M. Predictors of the development of surgical complications among hematopoietic stem cell transplantation recipients. World J Surg 2012; 36:1003-1010. [PMID: 22374543 DOI: 10.1007/s00268-012-1517-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study was designed to determine possible risk factors for the development of surgical complications after hematopoietic stem cell transplantation (HSCT). HSCT carries the possibility for the development of surgical morbidities and mortalities; certain populations of patients are at higher risk for developing complications. Defining those risk factors will help surgeons to anticipate and manage these complications. METHODS The records of 165 patients at King Hussein Cancer Center (KHCC) were reviewed from January 2007 to December 2008. Patients' characteristics, including age, source and type of transplant, behavior of disease, total body irradiation (TBI), immunity status, and intensity of conditioning were studied. RESULTS According to our data, abdominal complications were more common among patients who received TBI versus patients who did not, and in patients who received peripheral blood versus bone marrow and cord blood as the source of stem cells. Ear, nose, and throat (ENT) complications were found more in patients who underwent nonmyeloablation conditioning. Catheter-related complications were found more significantly in immune-compromised patients during the post-engraftment period. We also found that ENT complications were more frequent in patients with cord blood as the source of stem cells, although the results are inconclusive due to the small sample size. CONCLUSIONS Pretransplantation factors can be used as predictors for the development of surgical complications in HSCT recipients. Abdominal complications were significantly more common in patients who received total body irradiation as part of their conditioning regimen and when the peripheral blood was a source for stem cell transplantation.
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Affiliation(s)
- Iyad Anabtawi
- Department of Surgery, King Hussein Cancer Center, Queen Rania Street, P.O. Box 1269, Al-Jubeiha, Amman, 11941, Jordan
| | - Fawzi Abdelrahman
- Department of Bone Marrow and Stem Cell Transplantation Program, King Hussein Cancer Center, Amman, Jordan
| | - Ahamd Alomari
- Department of Surgery, King Hussein Cancer Center, Queen Rania Street, P.O. Box 1269, Al-Jubeiha, Amman, 11941, Jordan
| | - Murad Ba'ba'
- Department of Surgery, King Hussein Cancer Center, Queen Rania Street, P.O. Box 1269, Al-Jubeiha, Amman, 11941, Jordan
| | - Mahmoud Al Masri
- Department of Surgery, King Hussein Cancer Center, Queen Rania Street, P.O. Box 1269, Al-Jubeiha, Amman, 11941, Jordan.
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Wong KM, Atenafu EG, Kim D, Kuruvilla J, Lipton JH, Messner H, Gupta V. Incidence and risk factors for early hepatotoxicity and its impact on survival in patients with myelofibrosis undergoing allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 2012; 18:1589-99. [PMID: 22531490 DOI: 10.1016/j.bbmt.2012.04.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 04/17/2012] [Indexed: 11/30/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is commonly associated with hepatic complications. Patients with myelofibrosis (MF) often develop liver dysfunction in the early posttransplantation period; however, this has not yet been studied in a systematic fashion. We retrospectively evaluated 53 patients with MF who underwent HCT to assess the prevalence of acute liver toxicity and risk factors and the impact on survival. We compared the prevalence of acute hepatic complications in that group and a matched control group of 53 patients with myelodysplastic syndrome (MDS). In the MF group, during the first 6 weeks after HCT, the incidence of mild (34.2-102.6 μM), moderate (102.6-342 μM), and severe (>342 μM) hyperbilirubinemia was 34%, 40%, and 4%, respectively (normal, <22 μM). The incidence of mild/moderate transaminitis (2-10 times the upper limit of normal) was 23%, and that of severe transaminitis (>10 times the upper limit of normal) was 6%. Veno-occlusive disease as defined by the Baltimore criteria was observed in 19 patients (36%) in the MF group. Compared with MDS, MF was associated with a significantly higher incidence of moderate/severe hyperbilirubinemia (44% versus 21%; P = .02) and veno-occlusive disease (36% versus 19%; P = .05). A history of portal hypertension, biopsy-proven hepatic iron overload, or splanchnic vein thrombosis was a strong predictor of moderate/severe hyperbilirubinemia (P = .02). Acute hepatocellular injury with moderate/severe hyperbilirubinemia or transaminitis was associated with inferior survival at 12 months (P = .02) in the MF group. We conclude that patients with MF are at significant risk of early hepatotoxicity after HCT, which is associated with an adverse impact on survival.
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Affiliation(s)
- Kit Man Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Wang L, Wang X, Xie G, Wang L, Hill CK, DeLeve LD. Liver sinusoidal endothelial cell progenitor cells promote liver regeneration in rats. J Clin Invest 2012; 122:1567-73. [PMID: 22406533 DOI: 10.1172/jci58789] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Accepted: 01/25/2012] [Indexed: 12/28/2022] Open
Abstract
The ability of the liver to regenerate is crucial to protect liver function after injury and during chronic disease. Increases in hepatocyte growth factor (HGF) in liver sinusoidal endothelial cells (LSECs) are thought to drive liver regeneration. However, in contrast to endothelial progenitor cells, mature LSECs express little HGF. Therefore, we sought to establish in rats whether liver injury causes BM LSEC progenitor cells to engraft in the liver and provide increased levels of HGF and to examine the relative contribution of resident and BM LSEC progenitors. LSEC label-retaining cells and progenitors were identified in liver and LSEC progenitors in BM. BM LSEC progenitors did not contribute to normal LSEC turnover in the liver. However, after partial hepatectomy, BM LSEC progenitor proliferation and mobilization to the circulation doubled. In the liver, one-quarter of the LSECs were BM derived, and BM LSEC progenitors differentiated into fenestrated LSECs. When irradiated rats underwent partial hepatectomy, liver regeneration was compromised, but infusion of LSEC progenitors rescued the defect. Further analysis revealed that BM LSEC progenitors expressed substantially more HGF and were more proliferative than resident LSEC progenitors after partial hepatectomy. Resident LSEC progenitors within their niche may play a smaller role in recovery from partial hepatectomy than BM LSEC progenitors, but, when infused after injury, these progenitors engrafted and expanded markedly over a 2-month period. In conclusion, LSEC progenitor cells are present in liver and BM, and recruitment of BM LSEC progenitors is necessary for normal liver regeneration.
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Affiliation(s)
- Lin Wang
- Division of Gastrointestinal and Liver Disease and University of Southern California Research Center for Liver Disease, Los Angeles, California 90033, USA
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29
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Barba P, Martino R, Perez-Simón JA, Fernández-Avilés F, Piñana JL, Valcárcel D, Campos-Varela I, Lopez-Anglada L, Rovira M, Novelli S, Lopez-Corral L, Carreras E, Sierra J. Incidence, characteristics and risk factors of marked hyperbilirubinemia after allogeneic hematopoietic cell transplantation with reduced-intensity conditioning. Bone Marrow Transplant 2012; 47:1343-9. [PMID: 22388280 DOI: 10.1038/bmt.2012.25] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To analyze the incidence, characteristics and risk factors of hyperbilirubinemia after allogeneic hematopoietic cell transplantation with reduced-intensity conditioning (allo-RIC), we conducted a retrospective study in three Spanish centers. We analyzed 452 consecutive patients receiving allo-RIC. Of these, 92 patients (20%) developed marked hyperbilirubinemia (>4 mg/day or >68.4 μM) after allo-RIC. The main causes of marked hyperbilirubinemia after transplant were cholestasis due to GVHD or sepsis (n=57, 62%) and drug-induced cholestasis (n=13, 14%). A total of 22 patients with marked hyperbilirubinemia (24%) underwent liver biopsy. The most frequent histological finding was iron overload alone (n=6) or in combination with other features (n=6). In multivariate analysis, the risk factors for marked hyperbilirubinemia after allo-RIC were non-HLA-identical sibling donors (hazard ratio (HR) 2.2 (95% confidence interval (CI) 1.4-3.6) P=0.001), female donors to male recipients (HR 2.1 (95% CI 1.3-3.3) P=0.003) and high levels of bilirubin and γ-glutamyl transpeptidase before transplant (HR 4.5 (95% CI 2.5-8.4) P<0.001 and HR 4.6 (95% CI 2.6-8.1) P<0.001, respectively). Patients with marked hyperbilirubinemia showed higher 4-year nonrelapse mortality (HR 1.3 (95% CI 1-1.7), P=0.02) and lower 4-year OS (HR 1.4 (95%CI 1.3-1.7), P<0.001) than patients without. In conclusion, we confirm that marked hyperbilirubinemia is frequent and diverse after allo-RIC. Development of marked hyperbilirubinemia after allo-RIC is associated with worse outcome of the procedure.
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Affiliation(s)
- P Barba
- Department of Hematology, Hospital de la Santa Creu i Sant Pau de Barcelona, Barcelona, Spain.
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Abstract
Liver problems caused by infection, cholestasis and sinusoidal liver injury in the months following HCT have become less frequent because of preventive and pre-emptive strategies. When patients develop jaundice after transplant, the time to search for treatable causes is early in the course of jaundice, as the risk of mortality rises steeply with small increments of serum bilirubin above normal. Chronic hepatitis C, persistent GVHD, cirrhosis and hepatocellular carcinoma are significant liver problems in the longest-lived survivors of HCT.
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Affiliation(s)
- George B. McDonald
- Gastroenterology/Hepatology Section, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, Washington, U.S.A
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