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Nabarrete JM, Pereira AZ, Garófolo A, Seber A, Venancio AM, Grecco CES, Bonfim CMS, Nakamura CH, Fernandes D, Campos DJ, Oliveira FLC, Cousseiro FK, Rossi FFP, Gurmini J, Viani KHC, Guterres LF, Mantovani LFAL, Darrigo LG, Albuquerque MIBPE, Brumatti M, Neves MA, Duran N, Villela NC, Zecchin VG, Fernandes JF. Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: children and adolescents. EINSTEIN-SAO PAULO 2021; 19:eAE5254. [PMID: 34909973 PMCID: PMC8664291 DOI: 10.31744/einstein_journal/2021ae5254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 12/10/2020] [Indexed: 11/28/2022] Open
Abstract
The Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Children and Adolescents was developed by dietitians, physicians, and pediatric hematologists from 10 Brazilian reference centers in hematopoietic stem cell transplantation. The aim was to emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to patient´s nutritional assessment. This consensus is intended to improve and standardize nutrition therapy during hematopoietic stem cell transplantation. The consensus was approved by the Brazilian Society of Bone Marrow Transplantation.
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Affiliation(s)
- Juliana Moura Nabarrete
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Andrea Z Pereira
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Adriana Garófolo
- Universidade Federal de São PauloInstituto de Oncologia PediátricaSão PauloSPBrazilInstituto de Oncologia Pediátrica, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Adriana Seber
- Universidade Federal de São PauloSão PauloSPBrazilUniversidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Angela Mandelli Venancio
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Carlos Eduardo Setanni Grecco
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoHospital das ClínicasRibeirão PretoSPBrazilHospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
| | - Carmem Maria Sales Bonfim
- Universidade Federal do ParanáHospital de ClínicasCuritibaSPBrazilHospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Claudia Harumi Nakamura
- Universidade Federal de São PauloInstituto de Oncologia PediátricaSão PauloSPBrazilInstituto de Oncologia Pediátrica, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Daieni Fernandes
- Santa Casa de Misericórdia de Porto AlegrePorto AlegreRSBrazilSanta Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.
| | - Denise Johnsson Campos
- Universidade Federal do ParanáHospital de ClínicasCuritibaSPBrazilHospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Fernanda Luisa Ceragioli Oliveira
- Universidade Federal de São PauloEscola Paulista de MedicinaSão PauloSPBrazilEscola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Flávia Krüger Cousseiro
- Santa Casa de Misericórdia de Porto AlegrePorto AlegreRSBrazilSanta Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.
| | - Flávia Feijó Panico Rossi
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Jocemara Gurmini
- Universidade Federal do ParanáHospital de ClínicasCuritibaSPBrazilHospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Karina Helena Canton Viani
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilInstituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Luciana Fernandes Guterres
- Santa Casa de Misericórdia de Porto AlegrePorto AlegreRSBrazilSanta Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.
| | | | - Luiz Guilherme Darrigo
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoHospital das ClínicasRibeirão PretoSPBrazilHospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
| | - Maria Isabel Brandão Pires e Albuquerque
- Instituto Nacional de Câncer José Alencar Gomes da SilvaRio de JaneiroRJBrazilInstituto Nacional de Câncer José Alencar Gomes da Silva - INCA, Rio de Janeiro, RJ, Brazil.
| | - Melina Brumatti
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Mirella Aparecida Neves
- Universidade Federal do ParanáHospital de ClínicasCuritibaSPBrazilHospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Natália Duran
- Hospital de Câncer de BarretosBarretosSPBrazilHospital de Câncer de Barretos, Barretos, SP, Brazil.
| | - Neysimelia Costa Villela
- Hospital de Câncer de BarretosBarretosSPBrazilHospital de Câncer de Barretos, Barretos, SP, Brazil.
| | - Victor Gottardello Zecchin
- Universidade Federal de São PauloInstituto de Oncologia PediátricaSão PauloSPBrazilInstituto de Oncologia Pediátrica, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Juliana Folloni Fernandes
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Dang BN, Wilhalme H, Ch'ng J, De Oliveira S, Bowles L, Moore TB. Pediatric hematopoietic cell transplantation: Longitudinal trends in body mass index and outcomes. Pediatr Transplant 2020; 24:e13844. [PMID: 32997423 DOI: 10.1111/petr.13844] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/02/2020] [Accepted: 08/24/2020] [Indexed: 01/23/2023]
Abstract
Pediatric recipients of HCT may have a high susceptibility for overweight and obesity, and obesity may negatively impact post-transplant mortality and survival. This is a single-center retrospective analysis of 297 pediatric patients who received HCT between 2005 and 2018. Patients were classified as UW, NW, OW, or OB based on age-adjusted BMI. A mixed-effects linear regression model controlling for patient, disease, and transplant-related characteristics was used to trend weight longitudinally. Comparisons were made between weight category and post-transplant outcomes. In the pretransplant period, 5.4%, 54.5%, 22.2%, and 17.8% of patients were UW, NW, OW, and OB, respectively. Five years post-transplantation, those numbers were 10.6%, 48.2%, 16.5%, and 24.7%. Overall, BMI increased 0.00094 ± 0.0001 kg/m2 each day post-transplant (P < .001), with older individuals demonstrating greater rates of increase. Further, there was a larger BMI increase in patients without TBI compared with those who received TBI (1.29 ± 0.49, P = .008). Rates of acute GVHD, chronic GVHD, and viral infections, in addition to time to platelet and neutrophil engraftment and 5-year survival estimates, were not significantly different based on pretransplant BMI. Overweight and obese individuals had poorer 5-year survival based on 100-day post-transplant BMI (P = .02). Overall, pediatric HCT recipients are at risk of developing obesity, which is associated with decreased survival. Adolescents and young adults demonstrate the highest risk of weight gain, representing a vulnerable population that requires close monitoring, additional interventions, and further research.
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Affiliation(s)
- Brian Norman Dang
- Division of Pediatric Hematology and Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Holly Wilhalme
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, California, USA
| | - James Ch'ng
- Division of Pediatric Hematology and Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Satiro De Oliveira
- Division of Pediatric Hematology and Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - LaVette Bowles
- Division of Pediatric Hematology and Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Theodore Bruce Moore
- Division of Pediatric Hematology and Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
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Lawitschka A, Schwarze P, Rovelli A, Badoglio M, Socie G, Tichelli A, Bauer D, Rovo A, Basak G, Schoemans H, Peters C, Salooja N. Management of growth failure and growth hormone deficiency after pediatric allogeneic HSCT: Endocrinologists are of importance for further guidelines and studies. Pediatr Hematol Oncol 2019; 36:494-503. [PMID: 31633441 DOI: 10.1080/08880018.2019.1670764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Growth failure (GF) is a frequent problem after pediatric allogeneic hematopoietic stem cell transplantation (HSCT). Growth hormone deficiency (GHD) occurs in 20 to 85%, but published data on the efficacy of growth hormone treatment (GHT) are conflicting. Currently, there are no recommendations on screening for and treatment of GHD after HSCT. We aimed to describe the management of endocrine follow-up (FU)and details of GHT within European Society for Blood and Marrow Transplantation (EBMT) centers.In a retrospective questionnaire study, all EBMT centers performing pediatric HSCT were invited. Results were evaluated in correlation with the structure of endocrine aftercare (HSCT-clinicians and endocrinologists).The majority of centers (80%) reported endocrine FU by an endocrinologist - either within the HSCT-center or in a separate endocrine clinic. Fifty-four percent reported FU outside of the HSCT-center. As diagnostic tests the insulin-like growth factor IGF-I and insulin-like growth factor binding protein IGFBP3, insulin tolerance test and arginine stimulation test were most frequently used. Sixty-four percent of centers performed GHT and endocrinologists were more likely to prescribe GH (74%) compared to HSCT-clinicians (33%). The most frequent indication for GHT was GHD in 60%, with a distinct different approach of endocrinologists in comparison with HSCT-clinicians.Our study reveals substantial variation in practice and emphasizes the need for endocrine aftercare performed by dedicated endocrinologists in close collaboration with the HSCT-center. Our results indicate that the management of GHT depends on the structure of endocrine aftercare, which is important for the future development and distribution of studies and guidelines.
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Affiliation(s)
- A Lawitschka
- St. Anna Children's Hospital, Vienna Medical University, Vienna, Austria
| | - P Schwarze
- Department of General Pediatrics, Hematology/Oncology, University Children's Hospital, Tuebingen, Germany
| | - A Rovelli
- MBBM Foundation, Bone Marrow Transplantation Unit, Pediatric Department of Milano-Bicocca University, Monza, Italy
| | - M Badoglio
- Department of Haematology, EBMT Paris Study Office, Saint Antoine Hospital, Paris, France
| | - G Socie
- Department of Hematology, Hôpital Saint Louis, Paris, France
| | - A Tichelli
- Department for Haematology, University Hospital Basel, Basel, Switzerland
| | - D Bauer
- St. Anna Children's Hospital, Vienna Medical University, Vienna, Austria
| | - A Rovo
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern
| | - G Basak
- Department of Hematology, Oncology, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - H Schoemans
- Department of Hematology, University Hospital Leuven and KU Leuven, Leuven, Belgium
| | - C Peters
- St. Anna Children's Hospital, Vienna Medical University, Vienna, Austria
| | - N Salooja
- Centre for Haematology, Imperial College London, London, UK
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Wei C, Crowne E. The impact of childhood cancer and its treatment on puberty and subsequent hypothalamic pituitary and gonadal function, in both boys and girls. Best Pract Res Clin Endocrinol Metab 2019; 33:101291. [PMID: 31327697 DOI: 10.1016/j.beem.2019.101291] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Childhood cancer survivors (CCS) are at an increased risk of endocrine disorders. Disorders of the hypothalamic-pituitary-gonadal (HPG) axis are a particular concern because of their impact on pubertal development and future fertility and may be of central (hypothalamic or pituitary damage) or primary (gonadal) origin. Hypogonadism may present as pubertal disorders during adolescence and subsequent infertility in adulthood but should be anticipated to ensure appropriate surveillance is in place to address these issues at an appropriate age. Those at risk of HPG axis dysfunction include those with tumours primarily affecting the hypothalamus, pituitary or gonads themselves or due to their treatment with surgery, radiotherapy and chemotherapy. CCS who have had cranial irradiation of more than 30 Gy are at risk of gonadotrophin deficiency. Those who have had gonadotoxic chemotherapy, especially alkylating agents or radiotherapy to the gonads are at risk of primary gonadal failure. HSCT survivors who have had chemotherapy and total body irradiation are at risk of primary gonadal failure but may also have gonadotrophin deficiency. Understanding those at risk is essential to appropriate counselling and long-term follow-up. This chapter gives an overview on the impact of childhood cancer and its treatment on puberty, gonadal function and fertility in childhood cancer survivors.
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Affiliation(s)
- Christina Wei
- St George's University Hospital, NHS Foundation Trust, London, UK
| | - Elizabeth Crowne
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
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Long-term and late treatment consequences: endocrine and metabolic effects. Curr Opin Support Palliat Care 2018; 11:205-213. [PMID: 28661901 DOI: 10.1097/spc.0000000000000289] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Cancer therapies often result in the 'late effect of cancer treatment' whereby secondary health complications emerge years after radiotherapy and chemotherapy. This review focuses on endocrine and metabolic consequences in adult cancer survivors as late treatment effects. RECENT FINDINGS Endocrine and metabolic disorders are among the most common late effects. Endocrine disorders include hypopituitarism, which leads to growth hormone deficiency, hypogonadism, adrenal insufficiency and hypothyroidism and related clinical manifestations. Hypogonadism in particular is associated with a wide range of health complications requiring input from the like of endocrine and fertility specialists. Immune checkpoint inhibitors are novel anticancer agents, some of which are uniquely associated with hypophysitis which requires early recognition and management, including steroid replacement. Metabolic syndrome, a significant risk for cardiovascular disease, is highly prevalent. Although the effects of cranial irradiation on the hypothalamic-pituitary system are more apparent, the relationship between chemotherapy and endocrine/metabolic disorders remains to be elucidated. There exist published guidelines for monitoring endocrine and cardiometabolic risk in cancer survivors, but the extent of monitoring appears insufficient. SUMMARY Regular monitoring and early management of endocrine/metabolic disorders is required to prevent the elevated rates of health complications after cancer treatment, and thereby improve cancer survivorship.
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Crowne E, Gleeson H, Benghiat H, Sanghera P, Toogood A. Effect of cancer treatment on hypothalamic-pituitary function. Lancet Diabetes Endocrinol 2015; 3:568-76. [PMID: 25873572 DOI: 10.1016/s2213-8587(15)00008-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 02/06/2015] [Indexed: 12/31/2022]
Abstract
The past 30 years have seen a great improvement in survival of children and young adults treated for cancer. Cancer treatment can put patients at risk of health problems that can develop many years later, most commonly affecting the endocrine system. Patients treated with cranial radiotherapy often develop dysfunction of the hypothalamic-pituitary axis. A characteristic pattern of hormone deficiencies develops over several years. Growth hormone is disrupted most often, followed by gonadal, adrenal, and thyroid hormones, leading to abnormal growth and puberty in children, and affecting general wellbeing and fertility in adults. The severity and rate of development of hypopituitarism is determined by the dose of radiotherapy delivered to the hypothalamic-pituitary axis. Individual growth hormone deficiencies can develop after a dose as low as 10 Gy, whereas multiple hormone deficiencies are common after 60 Gy. New techniques in radiotherapy aim to reduce the effect on the hypothalamic-pituitary axis by minimising the dose received. Patients taking cytotoxic drugs do not often develop overt hypopituitarism, although the effect of radiotherapy might be enhanced. The exception is adrenal insufficiency caused by glucocorticosteroids which, although transient, can be life-threatening. New biological drugs to treat cancer can cause autoimmune hypophysitis and hypopituitarism; therefore, oncologists and endocrinologists should be vigilant and work together to optimise patient outcomes.
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Affiliation(s)
- Elizabeth Crowne
- Department of Paediatric Diabetes and Endocrinology, Bristol Royal Hospital for Children, Bristol, UK
| | - Helena Gleeson
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHSFT, Birmingham, UK
| | - Helen Benghiat
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, University Hospitals Birmingham NHSFT, Birmingham, UK
| | - Paul Sanghera
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, University Hospitals Birmingham NHSFT, Birmingham, UK
| | - Andrew Toogood
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHSFT, Birmingham, UK.
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Inaba H, Yang J, Kaste SC, Hartford CM, Motosue MS, Chemaitilly W, Triplett BM, Shook DR, Pui CH, Leung W. Longitudinal changes in body mass and composition in survivors of childhood hematologic malignancies after allogeneic hematopoietic stem-cell transplantation. J Clin Oncol 2012; 30:3991-7. [PMID: 23032628 DOI: 10.1200/jco.2011.40.0457] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To measure longitudinal changes in body mass and composition in survivors of childhood hematologic malignancies after allogeneic hematopoietic stem-cell transplantation (HSCT). PATIENTS AND METHODS Body mass index (BMI) was analyzed in 179 survivors by category (underweight, healthy-weight, overweight, and obese) and by z score. Fat and lean body mass measured by dual-energy x-ray absorptiometry was analyzed as z scores. RESULTS Over a median 6.6 years of follow-up, BMI z scores diminished significantly (0.32 pre-HSCT v -0.60 at 10 years post-HSCT; P < .001). Mean z scores for fat mass stayed within population norms, but those for lean mass remained below normal levels and diminished significantly over time (P = .018). Pre-HSCT BMI category and/or z score were strongly predictive of post-HSCT BMI (P < .001) and of fat and lean mass z scores (both P < .001). Survivors with extensive chronic graft-versus-host disease were more likely than others to have low BMI (P = .004) and low lean mass (P < .001) post-HSCT. Older age at HSCT (P = .015) and T-cell-depleted graft (P = .018) were predictive of lower post-HSCT BMI. Female patients had higher body fat (P = .002) and lower lean mass (P = .013) z scores than male patients, and black patients had higher fat mass z scores than white patients (P = .026). CONCLUSION BMI declines significantly after allogeneic HSCT for childhood hematologic malignancies, reflecting primarily a substantial decrease in lean mass but not fat mass. Monitoring and preservation of BMI and lean mass are vital, especially in those with the identified risk factors.
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Affiliation(s)
- Hiroto Inaba
- Department of Bone Marrow Transplantation and Cellular Therapy, MS 1130, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678, USA
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Frangoul H, Najjar J, Simmons J, Domm J. Long-term follow-up and management guidelines in pediatric patients after allogenic hematopoietic stem cell transplantation. Semin Hematol 2012; 49:94-103. [PMID: 22221789 DOI: 10.1053/j.seminhematol.2011.10.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Over the past 50 years there has been considerable progress and success in the field of allogeneic hematopoietic stem cell transplant (HSCT) in children. In addition there has been significant improvement in transplant outcomes for both malignant and nonmalignant indications. These improved outcomes have resulted in many long-term survivors who are experiencing substantial long-term morbidities. There are limited data examining the long-term complications of transplant on the various organs. This issue is complicated by the fact that children receive their transplant at different stages of their growth and development (ie, infant, toddler, child, adolescent, and young adult). Each of these developmental stages has different sensitivities to treatment and can result in different sets of complications. We summarize the long-term side effects of allogeneic HSCT in children.
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Affiliation(s)
- Haydar Frangoul
- Pediatric Stem Cell Transplant and Pediatric Endocrinology, Vanderbilt University, Nashville, TN 37232-2573, USA.
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Tomita Y, Ishiguro H, Yasuda Y, Hyodo H, Koike T, Shimizu T, Morimoto T, Hattori K, Matsumoto M, Inoue H, Yabe H, Yabe M, Shinohara O, Kojima S, Minemura T, Kato S. High incidence of fatty liver and insulin resistance in long-term adult survivors of childhood SCT. Bone Marrow Transplant 2010; 46:416-25. [PMID: 20562924 DOI: 10.1038/bmt.2010.144] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Overweight/obesity among adult survivors of childhood SCT has been considered to be predictive of eventual development of metabolic abnormalities. Fatty liver is increasingly recognized as a major cause of liver-related morbidity and mortality in the general population. However, the real incidence of fatty liver in adult survivors of SCT has not been fully elucidated. We determined whether adult survivors are at risk for overweight/obesity, metabolic abnormalities and fatty liver and whether these risks are associated with cranial radiotherapy (CRT) before SCT. Among the 51 patients (30 males), only two male patients were overweight/obese at the last evaluation. On the other hand, 9 male (30%) and 15 female (71%) patients were underweight. Fatty liver was diagnosed in 11 male (37%) and 10 female (48%) patients during the follow-up period, although patients who had fatty liver did not tend to be overweight/obese. Significantly more patients who received CRT before SCT developed fatty liver with insulin resistance than those who did not (P<0.05). Even patients who are not overweight/obese may develop fatty liver and metabolic abnormalities. We recommend that healthcare professionals recognize these risks and give life-long attention to detecting, preventing and treating late complications after SCT.
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Affiliation(s)
- Y Tomita
- Department of Pediatrics, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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Baker KS, Bresters D, Sande JE. The burden of cure: long-term side effects following hematopoietic stem cell transplantation (HSCT) in children. Pediatr Clin North Am 2010; 57:323-42. [PMID: 20307723 DOI: 10.1016/j.pcl.2009.11.008] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Children who survive hematopoietic stem cell transplantation (HSCT) are at risk for an inordinate number of long-term side effects. Late effects can be secondary to the underlying diagnosis for which the transplant is performed, prior treatment of the disease, the transplant preparative regimen, treatment of the complications of transplant, and immunologic interactions between the graft and the host. This article describes the risks and manifestations of the most commonly reported late effects in survivors of pediatric HSCT.
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Affiliation(s)
- K Scott Baker
- Survivorship Program, Fred Hutchinson Cancer Research Center, University of Washington, 1100 Fairview Avenue N, Mailstop D5-280, PO Box 19024, Seattle, WA 98109-1024, USA.
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11
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Ishiguro H, Yasuda Y, Hyodo H, Tomita Y, Koike T, Shinagawa T, Shimizu T, Morimoto T, Hattori K, Matsumoto M, Inoue H, Yabe H, Yabe M, Shinohara O, Kato S. Growth and Endocrine Function in Long-term Adult Survivors of Childhood Stem Cell Transplant. Clin Pediatr Endocrinol 2009; 18:1-14. [PMID: 24790374 PMCID: PMC4004878 DOI: 10.1297/cpe.18.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 09/29/2008] [Indexed: 12/02/2022] Open
Abstract
The number of long-term surviving stem cell transplant (SCT) recipients has
increased steadily, and attention has now extended to the late complications of this
procedure. The objective of this study was to investigate relationship among growth and
endocrine functions in long-term adult survivors of childhood SCT. The inclusion criteria
of this study were survival at least 5 yr after SCT and achievement of adult height.
Fifty-four patients (39 males) fulfilled these criteria and were included in this study.
Growth was mainly evaluated by height standard deviation score (SDS) and individual
longitudinal growth curves. Among the 54 patients, those that received SCT before 10 yr of
age showed significantly greater reductions in changes in height SDS (mean –1.75, range
–4.80 to –0.10) compared with those that received SCT at or after 10 yr of age (mean
–0.50, range –1.74 to 1.20; P<0.001). The mean loss of height for all patients who
received SCT during childhood was estimated to be approximately 1 SDS/6.5 yr (r=0.517).
Individual longitudinal growth curves indicated that a significant growth spurt was absent
in severe short stature patients during the pubertal period without severe endocrine
dysfunctions including GH deficiency. The incidence of growth disorder in long-term adult
survivors depends on the age at SCT and whether they received radiation therapy. Life-long
follow-up is necessary for survivors to detect, prevent and treat the late endocrine
complications in SCT survivors.
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Affiliation(s)
- Hiroyuki Ishiguro
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Yukiharu Yasuda
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiromi Hyodo
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Yuichiro Tomita
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Takashi Koike
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Tsuyoshi Shinagawa
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Takashi Shimizu
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Tsuyoshi Morimoto
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Kinya Hattori
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Masae Matsumoto
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiroyasu Inoue
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiromasa Yabe
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan ; Department of Cell Transplantation & Regenerative Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Miharu Yabe
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Osamu Shinohara
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Shunichi Kato
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan ; Department of Cell Transplantation & Regenerative Medicine, Tokai University School of Medicine, Kanagawa, Japan
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Perkins JL, Kunin-Batson AS, Youngren NM, Ness KK, Ulrich KJ, Hansen MJ, Petryk A, Steinberger J, Anderson FS, Baker KS. Long-term follow-up of children who underwent hematopoeitic cell transplant (HCT) for AML or ALL at less than 3 years of age. Pediatr Blood Cancer 2007; 49:958-63. [PMID: 17474113 DOI: 10.1002/pbc.21207] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hematopoeitic cell transplantation (HCT) in childhood has been associated with late complications including endocrine, neurocognitive, and cardiopulmonary abnormalities. Little is known about the complications of transplantation in infants. PROCEDURE Eligible subjects underwent HCT for acute lymphoblastic leukemia (ALL) or acute myelogenous leukemia (AML) at less than 3 years of age. Seventeen out of 33 eligible patients were evaluated, transplanted between 1981-2000. Eleven patients had AML, 11 were female. Preparative regimen included total body irradiation (TBI) for eleven. Age at HCT ranged from 0.58 to 2.97 years, and survival 3.25 to 22.33 years. Patients underwent physical and laboratory evaluation, dual-energy X-ray absorptiometry (DXA) scan, bone age X-ray, neuropsychological, and quality of life (QOL) evaluation. RESULTS Identified abnormalities included: growth hormone deficiency (59%), hypothyroidism (35%), osteochondromas (24%), decreased bone mineral density (24%), and dyslipidemias (59%). Two patients developed a second malignancy. Neuropsychological testing revealed average intelligence quotient (IQ) with attention deficits and other weaknesses for most patients. There were no overall differences between QOL in these children when compared to population norms. CONCLUSIONS Of the survivors evaluated, typical late effects seen after radiation exposure are common, yet most subjects were doing well without major ongoing medical issues. Dyslipidemias affect more than half of patients and may be associated with metabolic syndrome, placing patients at increased risk for early cardiovascular disease. Even in this group of patients where the majority was exposed to TBI at a very young age, most are functioning at an average or above-average level.
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Affiliation(s)
- Joanna L Perkins
- Department of Pediatric Hematology/Oncology, Children's Hospitals and Clinics, Minneapolis, Minnesota 55404, USA.
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Yoshihara T, Morimoto A, Kuroda H, Imamura T, Ishida H, Tsunamoto K, Naya M, Hibi S, Todo S, Imashuku S. Allogeneic stem cell transplantation in children with acute lymphoblastic leukemia after isolated central nervous system relapse: our experiences and review of the literature. Bone Marrow Transplant 2006; 37:25-31. [PMID: 16247416 DOI: 10.1038/sj.bmt.1705202] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The prognosis of patients with acute lymphoblastic leukemia (ALL) and central nervous system (CNS) relapse has historically been very poor. Although chemo-radiotherapy has improved outcomes, some patients still have a poor prognosis after CNS relapse. Therefore, allogeneic hematopoietic stem cell transplantation (allo-SCT) has recently become an option for treatment of CNS leukemia; however, information, particularly on the long-term outcome of transplant recipients, is limited. We performed allo-SCT in eight pediatric patients with ALL (n=7) or T-cell type non-Hodgkin's lymphoma (n=1), who had isolated CNS relapse. All patients survived for a median of 70.5 (range, 13-153) months after SCT. Sequelae developed late in some patients: mental retardation (IQ=47) in one patient, severe alopecia in two patients, limited chronic graft-versus-host-disease in three patients, and amenorrhea and/or hypothyroidism in three patients. Except for a pre-school child with post transplant CNS relapse, six out of seven patients show normal school/social performance. Our results clearly indicate a high cure rate of isolated CNS relapse by allo-SCT in pediatric lymphoid malignancies; however, there needs to be further studies to determine which are the appropriate candidates for transplantation and what is the best transplant regimen to achieve high cure rate and maintain good quality of life.
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Affiliation(s)
- T Yoshihara
- Department of Pediatrics, Matsushita Memorial Hospital, Osaka, Japan.
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Abstract
BACKGROUND Long-term survival rates among children diagnosed with severe aplastic anemia (SAA) are excellent due to the success of human leukocyte antigen (HLA)-identical related hematopoietic stem cell transplantation (HSCT), concurrent advances in immunosuppressive treatment (IST), and improved supportive care. The challenge in making treatment recommendations for children with SAA, therefore, is to balance the apparent chronicity and morbidity following IST, with the potential up-front toxicity and complications of HSCT. METHODS This review provides an update on the diagnosis and a risk-based treatment algorithm for children with acquired SAA. Recent experience using alternative donor HSCT and efforts to extend HSCT eligibility through advances in donor matching, de-escalation of conditioning regimens, and potential marrow graft engineering are highlighted. We discuss IST response rates, risks of relapse, and complications including clonal evolution. CONCLUSIONS While good treatment options exist for a majority of children diagnosed with SAA, novel non-transplantation treatments for unresponsive and relapsed patients without suitable transplant donors are needed. Further improvements in outcome will ultimately require a more complete understanding of the pathophysiology of aplastic anemia (AA).
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Affiliation(s)
- Peter Kurre
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239-3098, USA.
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15
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White M, Murphy AJ, Hastings Y, Shergold J, Young J, Montgomery C, Davies PSW, Lockwood L. Nutritional status and energy expenditure in children pre-bone-marrow-transplant. Bone Marrow Transplant 2005; 35:775-9. [PMID: 15765115 DOI: 10.1038/sj.bmt.1704891] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The aims of this study were to establish the nutritional status of children pre-BMT and to determine whether predictive methods of assessing nutritional status and resting energy expenditure (REE) are accurate in this population. We analysed the body cell mass (BCM) (n=26) and REE (n=24) in children undergoing BMT. BCM was adjusted for height (BCM/HT(p)) and expressed as a Z score to represent nutritional status. To determine whether body mass index (BMI) was indicative of nutritional status in children undergoing BMT, BMI Z scores were compared to the reference method of BCM/HT(p) Z scores. Schofield predictive equations of basal metabolic rate (BMR) were compared to measured REE to evaluate the accuracy of the predictive equations. The mean BCM/HT(p) Z score for the subject population was -1.09+/-1.28. There was no significant relationship between BCM/HT(p) Z score and BMI Z score (r=0.34; P>0.05); however there was minimal difference between measured REE and predicted BMR (bias=-11+/-149 kcal/day). The results of this study demonstrate that children undergoing BMT may have suboptimal nutritional status and that BMI is not an accurate indication of nutritional status in this population. However, Schofield equations were found to be suitable for representing REE in children pre-BMT.
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Affiliation(s)
- M White
- Department of Nutrition and Dietetics, Royal Children's Hospital, Herston, Qld, Australia.
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Robin M, Guardiola P, Dombret H, Baruchel A, Esperou H, Ribaud P, Devergie A, Gluckman E, Socié G. Allogeneic bone marrow transplantation for acute myeloblastic leukaemia in remission: risk factors for long-term morbidity and mortality. Bone Marrow Transplant 2003; 31:877-87. [PMID: 12748664 DOI: 10.1038/sj.bmt.1704027] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In this single-centre retrospective study, we analysed risk factors for nonrelapse long-term morbidity and mortality in patients with acute myeloblastic leukaemia (AML) who had undergone allogeneic transplantation. A total of 112 patients with de novo AML in first complete remission (CR1), n=90 or second complete remission (CR2, n=22) who received un-manipulated bone marrow grafts from human leukocyte antigen identical siblings between January 1985 and August 2000 were included. Of these, 97 patients alive and disease-free for at least 100 days after transplant were selected for the purpose of this long-term analysis. The use of an intensified conditioning regimen, Gram-negative bacteriaemia before transplantation, year of transplantation and number of pretransplant chemotherapy courses for patients in CR1 significantly affected the 7-year event-free survival which was 57%. 7-year transplant-related mortality TRM was 22%. Significant predictors for TRM were: bacterial infections before transplantation, major ABO blood group incompatibility, late severe bacterial infections, and chronic (graft-versus-host disease) GvHD. Predictive factors for late severe bacterial infections were infections before transplant, total body irradiation and GvHD. Incidence and risk factors for other late events including, chronic GvHD, late infections, osteonecrosis, cataract, endocrine- cardiac- and lung-complications, cancer and performance status at last follow-up were also studied. The analysis strongly suggests that the combination of pretransplant factors such as chemotherapy and conditioning, and posttransplant factors such as chronic GvHD had a major impact on late nonrelapse morbidity and mortality.
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MESH Headings
- Adolescent
- Adult
- Bacterial Infections/epidemiology
- Bone Marrow Transplantation/methods
- Child
- Child, Preschool
- Disease-Free Survival
- Female
- Follow-Up Studies
- Graft Survival/physiology
- Graft vs Host Disease/immunology
- Graft vs Host Disease/prevention & control
- HLA Antigens/immunology
- Humans
- Leukemia, Myeloid, Acute/classification
- Leukemia, Myeloid, Acute/epidemiology
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/therapy
- Living Donors
- Male
- Middle Aged
- Postoperative Complications/epidemiology
- Siblings
- Survival Analysis
- Time Factors
- Transplantation, Homologous/immunology
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Affiliation(s)
- M Robin
- Haematology Department, Bone Marrow Transplant Unit, Hospital Saint Louis, Paris, France
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Nysom K, Holm K, Michaelsen KF, Hertz H, Jacobsen N, Müller J, Mølgaard C. Degree of fatness after allogeneic BMT for childhood leukaemia or lymphoma. Bone Marrow Transplant 2001; 27:817-20. [PMID: 11477438 DOI: 10.1038/sj.bmt.1703012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2000] [Accepted: 02/13/2001] [Indexed: 11/09/2022]
Abstract
Excess fatness is frequent after childhood ALL treated without BMT. We measured the whole-body percent fat by dual-energy X-ray absorptiometry and the body-mass index (weight/height(2) (kg/m(2)), BMI) in 25 survivors of childhood leukaemia or lymphoma (21 with ALL) who had received TBI and allogeneic BMT a median of 8 years ago (range 4-13). Adjusted for sex and age, the mean BMI was slightly but significantly reduced (0.4 s.d. below predicted) and the whole-body percent fat was significantly increased compared with healthy controls (1.1 s.d. above predicted). Eleven of 25 patients had a percent fat above the 90 percentile of the reference values, which indicates excess fatness. Adjusted for sex and age, a higher percent fat was related to additional cranial irradiation. Controlled for this, the whole-body percent fat seemed to be unrelated to age at BMT, length of follow-up, and previous chemotherapy. Compared with untransplanted ALL survivors treated with cranial irradiation, BMT survivors had significantly reduced BMI but similar whole body percent fat. BMI was a poor measure of body fatness in these patients. In conclusion, survivors of BMT for childhood leukaemia or lymphoma are adipose and slightly underweight and consequently have a substantially reduced lean body mass.
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Affiliation(s)
- K Nysom
- Section of Paediatric Haematology and Oncology, The Juliane Marie Centre, Rigshospitalet, Denmark
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Couto-Silva AC, Trivin C, Esperou H, Michon J, Fischer A, Brauner R. Changes in height, weight and plasma leptin after bone marrow transplantation. Bone Marrow Transplant 2000; 26:1205-10. [PMID: 11149732 DOI: 10.1038/sj.bmt.1702718] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Short stature can be a severe side-effect of bone marrow transplantation (BMT). Because of the effect of weight changes on growth rate and on plasma insulin-like growth factor (IGF I), we analyzed changes in height and body mass index (BMI) in 53 patients given BMT. Group 1 (n = 22) was given 12 Gy total body irradiation (TBI) as six fractions, group 2 (n = 14) 10 Gy TBI (one dose), group 3 (n = 8) 6 Gy total lymphoid irradiation (one dose), and group 4 (n = 9) chemotherapy alone. At the first evaluation, 13/36 patients in groups 1 and 2 had low growth hormone (GH) peaks after stimulation. The mean plasma IGF I concentrations (z score) were similar in groups 1 (-2.9 +/- 0.3) and 2 (-2.5 +/- 0.3), and in groups 3 (-1.4 +/- 0.3) and 4 (-1.4 +/- 0.7), but those of group 1 were lower than those of groups 3 (P < 0.01) and 4 (P < 0.05), and those of group 2 than those of group 3 (P < 0.05). BMI during the 5 years after BMT did not change in groups 1 and 2, decreased in group 3, and increased in group 4. However, these changes were not significant. Most of the patients given TBI had BMI below the mean at 2 (66%) and 5 (57%) years later. Their BMI and leptin concentrations correlated positively with each other (P = 0.005), and negatively with GH peak (P = 0.02 for BMI and 0.007 for leptin). In conclusion, this study suggests that TBI actually decreases GH secretion and is followed by a persistent low BMI. The negative relationship between GH peak and leptin may indicate that both are markers of a TBI-induced hypothalamic-pituitary lesion.
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Affiliation(s)
- A C Couto-Silva
- Pediatric Endocrinology Department, Université René Descartes and H pital Necker-Enfants Malades, Paris, France
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Affiliation(s)
- S E Ball
- Department of Haematology, St George's Hospital Medical School, Cranmer Terrace, London, UK.
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