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Randhawa B, Blosser N, Daly A, Storek J, Shaheen AA, Jamani K. Chronic liver disease after allogeneic hematopoietic cell transplantation. Cytotherapy 2024:S1465-3249(24)00772-2. [PMID: 39046389 DOI: 10.1016/j.jcyt.2024.07.002] [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: 05/05/2024] [Revised: 06/23/2024] [Accepted: 07/01/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND AIMS There are few descriptions of the epidemiology of chronic liver disease (CLD) after allogeneic hematopoietic stem cell transplantation (allo-HCT). Among those transplanted before 2000, viral hepatitis was the dominant cause of CLD. Recently, the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD, previously known as nonalcoholic fatty liver disease) is increasing in the general population. In addition, survivors of allo-HCT are known to be at increased risk of metabolic syndrome. We set out to describe the epidemiology of CLD in a modern cohort of allo-HCT recipients. We hypothesized that MASLD would be the most common cause of CLD in the cohort. METHODS We undertook a retrospective cohort and nested case-control study of 2-year survivors of allo-HCT in Alberta transplanted between 2008 and 2018. RESULTS Among 392 2-year survivors of allo-HCT between 2008 and 2018, the prevalence of CLD was 41.8% and MASLD was identified in 56% of those with CLD, followed by iron overload in 47% of those with CLD. The prevalence of MASLD among the entire cohort was 46%. Although most patients developed CLD before 2 years post-transplant, there was a 13% cumulative incidence of new CLD after 2 years posttransplant. Grade 2-4 acute graft-versus-host disease and/or moderate-to-severe chronic graft-versus-host disease and pretransplant CLD were strongly associated with CLD. In the case-control study examining the association between cardiovascular risk factors and CLD, type 2 diabetes was associated with CLD. Cirrhosis developed in 1.5% of survivors, and MASLD was an underlying etiology in one half of these cases. There was no difference in overall survival and non-relapse mortality between those who did and did not develop CLD. CONCLUSIONS MASLD is the main cause of CLD in recent long-term survivors of allo-HCT and may be associated with post-transplant corticosteroid exposure and type 2 diabetes. We note a shift in the underlying etiology of CLD post-HCT: previous studies describe viral hepatitis as the most common cause of CLD. The high prevalence of MASLD in allo-HCT recipients has important implications for survivorship care.
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Affiliation(s)
- Baljit Randhawa
- Alberta Blood & Marrow Transplant Program, Tom Baker Cancer Centre, Calgary, Alberta, Canada; Division of Hematology & Hematologic Malignancies, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nikki Blosser
- Alberta Blood & Marrow Transplant Program, Tom Baker Cancer Centre, Calgary, Alberta, Canada; Division of Hematology & Hematologic Malignancies, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Daly
- Alberta Blood & Marrow Transplant Program, Tom Baker Cancer Centre, Calgary, Alberta, Canada; Division of Hematology & Hematologic Malignancies, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jan Storek
- Alberta Blood & Marrow Transplant Program, Tom Baker Cancer Centre, Calgary, Alberta, Canada; Division of Hematology & Hematologic Malignancies, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abdel-Aziz Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kareem Jamani
- Alberta Blood & Marrow Transplant Program, Tom Baker Cancer Centre, Calgary, Alberta, Canada; Division of Hematology & Hematologic Malignancies, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Diaz ACMB, Witkin SS, de Almeida C, Mendrone A, Rocha V, Costa SF, Ramos JF, Mendes-Correa MC. Prevalence and clinical consequences of Hepatitis C virus infection in patients undergoing hematopoietic stem cell transplantation. Rev Inst Med Trop Sao Paulo 2024; 66:e11. [PMID: 38324877 PMCID: PMC10846481 DOI: 10.1590/s1678-9946202466011] [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: 09/26/2023] [Accepted: 12/20/2023] [Indexed: 02/09/2024] Open
Abstract
Hepatitis C virus (HCV) infection is a significant cause of morbidity and mortality among hematopoietic stem cell transplant (HCT) recipients. In Brazil, its occurrence in HCT recipients remains undetermined. We now report on HCV prevalence in HCT recipients and its clinical consequences. The medical records of all HCT recipients seen at Hospital das Clinicas, Sao Paulo University Medical School, from January 2010 to January 2020 were reviewed to determine HCV serostatus. A retrospective analysis of medical charts was undertaken on all seropositive cases to determine HCV genotype, presence of liver fibrosis, co-infections with other viruses, previous treatments, and clinical evolution of liver pathology after HCT. Of the 1,293 HCT recipients included in the study, seven (0.54%) were HCV antibody-positive and five (0.39%) were also viremic for HCV-RNA. Four of these individuals had moderate to severe liver fibrosis (METAVIR F2/F3) and one was cirrhotic. Two of the viremic patients developed acute liver dysfunction following transplantation. All patients had their acute episode of liver dysfunction resolved with no further complications. Four of the viremic patients were treated for HCV infection with direct acting agents (DAA). Information regarding HCV treatment was lacking for one of the viremic HCV patients due to loss of follow up. Sustained anti-virologic responses were observed in three cases after the use of DAA. The detection of HCV in hematological adults undergoing HCT and its successful treatment with DAA highlight the necessity of testing for HCV both prior to and following transplantation.
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Affiliation(s)
- Ana Claudia Marques Barbosa Diaz
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo, Laboratório de Investigação Médica em Virologia (LIM-52), São Paulo, São Paulo, Brazil
| | - Steven Sol Witkin
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo, Laboratório de Investigação Médica em Virologia (LIM-52), São Paulo, São Paulo, Brazil
- Weill Cornel Medicine, Department of Obstetrics and Gynecology New York, New York, USA
| | - Cesar de Almeida
- Fundação Pró-Sangue, Hemocentro de São Paulo, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Disciplina de Ciências Médicas, São Paulo, São Paulo, Brazil
| | - Alfredo Mendrone
- Fundação Pró-Sangue, Hemocentro de São Paulo, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Hematologia, Laboratório de Investigação Médica em Patogênese e Terapia Dirigida em Onco-Imuno-Hematologia (LIM-31), São Paulo, São Paulo, Brazil
| | - Vanderson Rocha
- Fundação Pró-Sangue, Hemocentro de São Paulo, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Hematologia, Laboratório de Investigação Médica em Patogênese e Terapia Dirigida em Onco-Imuno-Hematologia (LIM-31), São Paulo, São Paulo, Brazil
| | - Silvia Figueiredo Costa
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo, Laboratorio de Investigação Médica em Virologia (LIM-49, São Paulo, São Paulo, Brazil
| | - Jessica Fernandes Ramos
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, São Paulo, Brazil
| | - Maria Cassia Mendes-Correa
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo, Laboratório de Investigação Médica em Virologia (LIM-52), São Paulo, São Paulo, Brazil
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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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Liver Transplantation After Hematopoietic Stem Cell Transplant for the Treatment of Sickle Cell Disease: A Case Report. Transplant Proc 2022; 54:1394-1397. [PMID: 35659126 DOI: 10.1016/j.transproceed.2022.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/13/2022] [Indexed: 11/23/2022]
Abstract
Sickle cell anemia is the most common of the hemoglobinopathies, in which the abnormal hemoglobin formed in deoxygenation states undergoes a polymerization process with consequent erythrocyte deformation and vaso-occlusive events. The need for multiple blood transfusions, prolonged ineffective erythropoiesis, hemolysis, and increased iron absorption can cause iron overload in the liver, leading to liver fibrosis. Hematopoietic stem cell transplantation (HSCT) is currently the only treatment with a curative potential for this disease and can establish normal complete or partial donor-derived erythropoiesis and stabilize or restore function in affected organs, preventing further deterioration of function. However, it does not reverse preexisting liver fibrosis and siderosis. One of the possible complications of patients who undergo HSCT is chronic liver disease, which has a multifactorial cause, with iron overload being an important factor. In the long term, the prevalence of chronic liver disease in HSCT patients, including cirrhosis and its complications, can be significant. Solid organ transplantation after allogeneic hematopoietic cell transplantation for end-organ failure remains a very rare event. It may offer a valuable treatment strategy in selected recipients, although it is associated with significant morbidity and mortality. We report the case of a patient with sickle cell anemia who underwent HSCT and developed severe liver dysfunction requiring liver transplantation 13 years after the procedure. We found no previous report in the literature of orthotopic liver transplant after HCT for the treatment of sickle cell disease.
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Bardi E, Mulder RL, van Dalen EC, Bhatt NS, Ruble KA, Burgis J, Castellino SM, Constine LS, den Hoed CM, Green DM, Koot BGP, Levitt G, Szonyi L, Wallace WH, Skinner R, Hudson MM, Kremer LCM, Effinger KE, Bresters D. Late hepatic toxicity surveillance for survivors of childhood, adolescent and young adult cancer: Recommendations from the international late effects of childhood cancer guideline harmonization group. Cancer Treat Rev 2021; 100:102296. [PMID: 34571378 DOI: 10.1016/j.ctrv.2021.102296] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Survivors of childhood, adolescent and young adult (CAYA) cancer may develop treatment-induced chronic liver disease. Surveillance guidelines can improve survivors' health outcomes. However, current recommendations vary, leading to uncertainty about optimal screening. The International Late Effects of Childhood Cancer Guideline Harmonization Group has developed recommendations for the surveillance of late hepatotoxicity after CAYA cancer. METHODS Evidence-based methods based on the GRADE framework were used in guideline development. A multidisciplinary guideline panel performed systematic literature reviews, developed evidence summaries, appraised the evidence, and formulated recommendations on the basis of evidence, clinical judgement, and consideration of benefits versus the harms of the surveillance while allowing for flexibility in implementation across different health care systems. RESULTS The guideline strongly recommends a physical examination and measurement of serum liver enzyme concentrations (ALT, AST, gGT, ALP) once at entry into long-term follow-up for survivors treated with radiotherapy potentially exposing the liver (moderate- to high-quality evidence). For survivors treated with busulfan, thioguanine, mercaptopurine, methotrexate, dactinomycin, hematopoietic stem cell transplantation (HSCT), or hepatic surgery, or with a history of chronic viral hepatitis or sinusoidal obstruction syndrome, similar surveillance for late hepatotoxicity once at entry into LTFU is reasonable (low-quality evidence/expert opinion, moderate recommendation). For survivors who have undergone HSCT and/or received multiple red blood cell transfusions, surveillance for iron overload with serum ferritin is strongly recommended once at long-term follow-up entry. CONCLUSIONS These evidence-based, internationally-harmonized recommendations for the surveillance of late hepatic toxicity in cancer survivors can inform clinical care and guide future research of health outcomes for CAYA cancer survivors.
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Affiliation(s)
- Edit Bardi
- St. Anna Children's Hospital, Vienna, Austria; Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria.
| | - Renée L Mulder
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | | | - Neel S Bhatt
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Kathy A Ruble
- Division of Pediatric Oncology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer Burgis
- Division of Pediatric Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Sharon M Castellino
- Department of Pediatrics at Emory University School of Medicine, and Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Caroline M den Hoed
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Daniel M Green
- Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Bart G P Koot
- Pediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Gill Levitt
- Department of Paediatric Oncology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - László Szonyi
- Semmelweis University, I. Pediatric Department, Budapest, Hungary
| | - W Hamish Wallace
- Department of Paediatric Haematology and Oncology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Roderick Skinner
- Department of Paediatric and Adolescent Haematology/Oncology, Great North Children's Hospital and Translational and Clinical Research Institute, Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Melissa M Hudson
- Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Karen E Effinger
- Department of Pediatrics at Emory University School of Medicine, and Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Dorine Bresters
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
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El Jurdi N, Fair C, Rogosheske J, Shanley R, Arora M, Bachanova V, Betts B, He F, Holtan S, Janakiram M, Maakaron J, Rashidi A, Warlick E, Weisdorf D, Brunstein CG. Effect of Keratinocyte Growth Factor on Hospital Readmission and Regimen-Related Toxicities after Autologous Hematopoietic Cell Transplantation for Lymphoma. Transplant Cell Ther 2020; 27:179.e1-179.e4. [PMID: 33830033 DOI: 10.1016/j.jtct.2020.11.005] [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: 09/23/2020] [Revised: 11/02/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
Regimen-related toxicities with high-dose therapy followed by hematopoietic cell rescue leads to considerable patient distress, morbidity, and high readmission rates. Palifermin is a recombinant keratinocyte growth factor that is Food and Drug Administration-approved to decrease severe oral mucositis (OM) associated with autologous hematopoietic cell transplantation (ASCT) for hematologic malignancies. We added palifermin as a supportive care measure for patients with lymphoma undergoing ASCT with BEAM conditioning. We compared patients receiving palifermin (n = 35) with historical controls (n = 38) for toxicity and readmission outcomes. The cumulative incidence of OM of any grade was 23% in the palifermin-treated patients and 42% in the control group. Patients receiving palifermin were less likely to be readmitted (57% versus 82%; P = .04), had fewer hospital readmission days (median, 4 days versus 7 days; P < .01), and had fewer total days in the hospital through day +30 after ASCT (median, 12 days versus 15 days; P = .05). Fewer patients in the palifermin group had >20 days in the hospital through day +30 (9% in the palifermin group versus 23% of controls). Adverse events associated with palifermin were mild and transient. The addition of palifermin limits severe regimen-related toxicities and decreases readmissions and duration of hospital stay. This and other measures are needed to identify comprehensive and cost-effective approaches, possibly including palifermin, to prevent severe regimen-related toxicities and decrease health care resource utilization.
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Affiliation(s)
- Najla El Jurdi
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota.
| | - Christina Fair
- Department of Pharmacy, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - John Rogosheske
- Department of Pharmacy, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Ryan Shanley
- Biostatistics and Informatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Mukta Arora
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Veronika Bachanova
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Brian Betts
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Fiona He
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Shernan Holtan
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Murali Janakiram
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Joseph Maakaron
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Armin Rashidi
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Erica Warlick
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Weisdorf
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
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Retrospective Evaluation of Relationship Between Iron Overload and Transplantation Complications in Pediatric Patient Who Underwent Allogeneic Stem Cell Transplantation Due to Acute Leukemia and Myelodysplastic Syndrome. J Pediatr Hematol Oncol 2020; 42:e315-e320. [PMID: 32427707 DOI: 10.1097/mph.0000000000001829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) is a curative therapy option for hematologic malignancies. Iron overload is common in this patient group and can impact short-term and long-term nonrelapse mortality. STUDY DESIGN Retrospective observational cohort study. AIMS To evaluate the effect of iron load on early and late HSCT outcomes in patients with acute leukemia and myelodysplasia to assess the necessity of reducing iron load. PATIENTS AND METHODS Sixty patients who underwent HSCT in pediatric stem cell transplantation unit between 2000 and 2012 were evaluated retrospectively. The patients were divided into those with pretransplantation serum ferritin levels above and below the median value of 1299 ng/mL. RESULTS Forty-two (70%) of the patients were male, mean ages of the low and high ferritin groups were 85.43±9.42 and 118.56±10.04 months, respectively. Acute graft-versus-host disease (GVHD) within the first 100 days and acute liver GVHD were significantly more common in the high ferritin group (P<0.011 for both). Ferritin level was not associated with rates of engraftment syndrome, veno-occlusive disease, early/late infection, relapse, or overall and disease-free survival. CONCLUSIONS In our study, significant result especially in terms of acute liver GVHD, was important to emphasize the need to be more careful in terms of acute liver GVHD risk in early liver pathologies in patients with high levels of ferritin after transplantation. In future large studies may be helpful to explain the relationship between acute liver GVHD and high ferritin levels.
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Brissot E, Bernard DG, Loréal O, Brissot P, Troadec MB. Too much iron: A masked foe for leukemias. Blood Rev 2020; 39:100617. [DOI: 10.1016/j.blre.2019.100617] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/20/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
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Modi D, Ye JC, Surapaneni M, Singh V, Chen W, Jang H, Deol A, Ayash L, Alavi A, Ratanatharathorn V, Uberti JP. Liver Graft-Versus-Host Disease is associated with poor survival among allogeneic hematopoietic stem cell transplant recipients. Am J Hematol 2019; 94:1072-1080. [PMID: 31292984 DOI: 10.1002/ajh.25575] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/03/2019] [Accepted: 07/07/2019] [Indexed: 12/17/2022]
Abstract
Liver Graft-versus-host disease (GVHD) is common in patients with post-transplant liver dysfunction following allogeneic hematopoietic stem cell transplantation (AHSCT). Oftentimes, the diagnosis is made clinically, and liver biopsy is deferred. Our objective was to evaluate the risk factors and clinical outcomes of liver GVHD among patients who developed post-transplant liver dysfunction. Additionally, we evaluated the feasibility of liver biopsy in this population. We compared outcomes between liver GVHD and a "non-liver GVHD" group, which consisted of other etiologies of post-transplant liver dysfunction. Between January 2003 and December 2010, 249 patients developed post-transplant liver dysfunction following AHSCT: 124 patients developed liver GVHD and 125 were in the "non-liver GVHD" group. The incidence of acute and chronic liver GVHD at one year was 15.7% and 31.0%, respectively. The competing risk analysis revealed full intensity conditioning regimen (Hazard ratio [HR], 1.76; P = .008) and related donor (HR, 1.68; P = .004) as independent risk factors for liver GVHD. The time-varying covariate Cox regression analysis with competing risk event, demonstrated that liver GVHD was independently associated with higher non-relapse mortality, and adverse relapse-free and overall survival. A total of 112 liver biopsies were performed in 100 patients. No major complications were observed. Liver biopsy confirmed prebiopsy hypotheses in 49% of cases, and led to treatment modification in 49% of patients. Our study shows that liver GVHD is associated with adverse survival. Liver biopsy is safe and often helps directing care in this setting.
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Affiliation(s)
- Dipenkumar Modi
- Department of OncologyKarmanos Cancer Institute/Wayne State University Detroit Michigan
| | - Jing Christine Ye
- Department of Internal Medicine, Division of Hematology Oncology, Rogel Cancer CenterUniversity of Michigan Ann Arbor Michigan
| | - Malini Surapaneni
- Department of OncologyKarmanos Cancer Institute/Wayne State University Detroit Michigan
| | - Vijendra Singh
- Department of OncologyKarmanos Cancer Institute/Wayne State University Detroit Michigan
| | - Wei Chen
- Department of OncologyKarmanos Cancer Institute/Wayne State University Detroit Michigan
| | - Hyejeong Jang
- Department of OncologyKarmanos Cancer Institute/Wayne State University Detroit Michigan
| | - Abhinav Deol
- Department of OncologyKarmanos Cancer Institute/Wayne State University Detroit Michigan
| | - Lois Ayash
- Department of OncologyKarmanos Cancer Institute/Wayne State University Detroit Michigan
| | - Asif Alavi
- Department of OncologyKarmanos Cancer Institute/Wayne State University Detroit Michigan
| | | | - Joseph P. Uberti
- Department of OncologyKarmanos Cancer Institute/Wayne State University Detroit Michigan
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Mulder RL, Bresters D, Van den Hof M, Koot BGP, Castellino SM, Loke YKK, Post PN, Postma A, Szőnyi LP, Levitt GA, Bardi E, Skinner R, van Dalen EC. Hepatic late adverse effects after antineoplastic treatment for childhood cancer. Cochrane Database Syst Rev 2019; 4:CD008205. [PMID: 30985922 PMCID: PMC6463806 DOI: 10.1002/14651858.cd008205.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Survival rates have greatly improved as a result of more effective treatments for childhood cancer. Unfortunately, the improved prognosis has been accompanied by the occurrence of late, treatment-related complications. Liver complications are common during and soon after treatment for childhood cancer. However, among long-term childhood cancer survivors, the risk of hepatic late adverse effects is largely unknown. To make informed decisions about future cancer treatment and follow-up policies, it is important to know the risk of, and associated risk factors for, hepatic late adverse effects. This review is an update of a previously published Cochrane review. OBJECTIVES To evaluate all the existing evidence on the association between antineoplastic treatment (that is, chemotherapy, radiotherapy involving the liver, surgery involving the liver and BMT) for childhood cancer and hepatic late adverse effects. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2018, Issue 1), MEDLINE (1966 to January 2018) and Embase (1980 to January 2018). In addition, we searched reference lists of relevant articles and scanned the conference proceedings of the International Society of Paediatric Oncology (SIOP) (from 2005 to 2017) and American Society of Pediatric Hematology/Oncology (ASPHO) (from 2013 to 2018) electronically. SELECTION CRITERIA All studies, except case reports, case series, and studies including fewer than 10 patients that examined the association between antineoplastic treatment for childhood cancer (aged 18 years or less at diagnosis) and hepatic late adverse effects (one year or more after the end of treatment). DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection and 'risk of bias' assessment. The 'risk of bias' assessment was based on earlier checklists for observational studies. For the original version of the review, two review authors independently performed data extraction. For the update of the review, the data extraction was performed by one reviewer and checked by another reviewer. MAIN RESULTS Thirteen new studies were identified for the update of this review. In total, we included 33 cohort studies including 7876 participants investigating hepatic late adverse effects after antineoplastic treatment (especially chemotherapy and radiotherapy) for different types of childhood cancer, both haematological and solid malignancies. All studies had methodological limitations. The prevalence of hepatic late adverse effects, all defined in a biochemical way, varied widely, between 0% and 84.2%. Selecting studies where the outcome of hepatic late adverse effects was well-defined as alanine aminotransferase (ALT) above the upper limit of normal, indicating cellular liver injury, resulted in eight studies. In this subgroup, the prevalence of hepatic late adverse effects ranged from 5.8% to 52.8%, with median follow-up durations varying from three to 23 years since cancer diagnosis in studies that reported the median follow-up duration. A more stringent selection process using the outcome definition of ALT as above twice the upper limit of normal, resulted in five studies, with a prevalence ranging from 0.9% to 44.8%. One study investigated biliary tract injury, defined as gamma-glutamyltransferase (γGT) above the upper limit of normal and above twice the upper limit of normal and reported a prevalence of 5.3% and 0.9%, respectively. Three studies investigated disturbance in biliary function, defined as bilirubin above the upper limit of normal and reported prevalences ranging from 0% to 8.7%. Two studies showed that treatment with radiotherapy involving the liver (especially after a high percentage of the liver irradiated), higher BMI, and longer follow-up time or older age at evaluation increased the risk of cellular liver injury in multivariable analyses. In addition, there was some suggestion that busulfan, thioguanine, hepatic surgery, chronic viral hepatitis C, metabolic syndrome, use of statins, non-Hispanic white ethnicity, and higher alcohol intake (> 14 units per week) increase the risk of cellular liver injury in multivariable analyses. Chronic viral hepatitis was shown to increase the risk of cellular liver injury in six univariable analyses as well. Moreover, one study showed that treatment with radiotherapy involving the liver, higher BMI, higher alcohol intake (> 14 units per week), longer follow-up time, and older age at cancer diagnosis increased the risk of biliary tract injury in a multivariable analysis. AUTHORS' CONCLUSIONS The prevalence of hepatic late adverse effects among studies with an adequate outcome definition varied considerably from 1% to 53%. Evidence suggests that radiotherapy involving the liver, higher BMI, chronic viral hepatitis and longer follow-up time or older age at follow-up increase the risk of hepatic late adverse effects. In addition, there may be a suggestion that busulfan, thioguanine, hepatic surgery, higher alcohol intake (>14 units per week), metabolic syndrome, use of statins, non-Hispanic white ethnicity, and older age at cancer diagnosis increase the risk of hepatic late adverse effects. High-quality studies are needed to evaluate the effects of different therapy doses, time trends, and associated risk factors after antineoplastic treatment for childhood cancer.
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Affiliation(s)
- Renée L Mulder
- Princess Máxima Center for Pediatric OncologyHeidelberglaan 25UtrechtNetherlands3584 CS
- Emma Children's Hospital, Amsterdam UMC, University of AmsterdamDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Dorine Bresters
- Princess Máxima Center for Pediatric OncologyHeidelberglaan 25UtrechtNetherlands3584 CS
- Leiden University Medical CenterWillem Alexander Children's HospitalPO Box 9600LeidenNetherlands2300 RC
| | - Malon Van den Hof
- Emma Children's Hospital, Amsterdam UMC, University of AmsterdamDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Bart GP Koot
- Emma Children's Hospital, Amsterdam UMC, University of AmsterdamDepartment of Paediatric Gastroenterology and NutritionP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Sharon M Castellino
- Emory School of MedicineDepartment of Pediatrics, Division Hematology/OncologyAtlanta, GAUSA
| | | | - Piet N Post
- Dutch Institute for Healthcare Improvement CBOPO Box 20064UtrechtNetherlands3502 LB
| | - Aleida Postma
- University Medical Center Groningen and University of Groningen, Beatrix Children's HospitalDepartment of Paediatric OncologyPostbus 30.000GroningenNetherlands9700 RB
| | - László P Szőnyi
- King Feisal Specialist HospitalOrgan Transplant CentreRiyadhSaudi Arabia11211
| | - Gill A Levitt
- Great Ormond Street Hospital for Children NHS Foundation TrustOncologyGt Ormond StLondonUK
| | - Edit Bardi
- Kepler UniversitätsklinikumMed Campus IV26‐30 KrankenhausstraßeLinzAustria4020
| | - Roderick Skinner
- Great North Children’s HospitalDepartment of Paediatric and Adolescent Haematology / OncologyQueen Victoria RoadNewcastle upon TyneUKNE1 4LP
| | - Elvira C van Dalen
- Princess Máxima Center for Pediatric OncologyHeidelberglaan 25UtrechtNetherlands3584 CS
- Emma Children's Hospital, Amsterdam UMC, University of AmsterdamDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
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11
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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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12
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Vanishing Bile Ducts in the Long Term after Pediatric Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:2250-2258. [DOI: 10.1016/j.bbmt.2018.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/08/2018] [Indexed: 01/28/2023]
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13
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Abstract
BACKGROUND Patients transfused with packed red blood cells (PRBC), including childhood cancer survivors (CCS), experience complications. We describe iron overload (ferritin>500 ng/mL) prevalence and identify risk factors in CCS. OBSERVATIONS Of 116 participants, 3 (2.6%) had elevated ferritin. All were teenagers at cancer diagnosis and received >8000 mL PRBC. Total PRBC volume correlated best with elevated ferritin (r=0.74; P<0.0001). PRBC (8000 mL) had the best positive and negative predictive value (75% and 100%, respectively) for iron overload. CONCLUSIONS CCS may have iron overload. Overall prevalence is low. At-risk include teenagers at diagnosis and those receiving higher total PRBC volumes.
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14
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Leitch HA, Fibach E, Rachmilewitz E. Toxicity of iron overload and iron overload reduction in the setting of hematopoietic stem cell transplantation for hematologic malignancies. Crit Rev Oncol Hematol 2017; 113:156-170. [PMID: 28427505 DOI: 10.1016/j.critrevonc.2017.03.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/13/2017] [Accepted: 03/04/2017] [Indexed: 01/19/2023] Open
Abstract
Iron is an essential element for key cellular metabolic processes. However, transfusional iron overload (IOL) may result in significant cellular toxicity. IOL occurs in transfusion dependent hematologic malignancies (HM), may lead to pathological clinical outcomes, and IOL reduction may improve outcomes. In hematopoietic stem cell transplantation (SCT) for HM, IOL may have clinical importance; endpoints examined regarding an impact of IOL and IOL reduction include transplant-related mortality, organ function, infection, relapse risk, and survival. Here we review the clinical consequences of IOL and effects of IOL reduction before, during and following SCT for HM. IOL pathophysiology is discussed as well as available tests for IOL quantification including transfusion history, serum ferritin level, transferrin saturation, hepcidin, labile plasma iron and other parameters of iron-catalyzed oxygen free radicals, and organ IOL by imaging. Data-based recommendations for IOL measurement, monitoring and reduction before, during and following SCT for HM are made.
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Affiliation(s)
- Heather A Leitch
- Division of Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada.
| | - Eitan Fibach
- Hematology Branch, Hadassah - Hebrew University Medical Center, Ein-Kerem, Jerusalem, Israel
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15
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Abstract
A 59-year-old female received a matched related donor stem cell transplant for chronic myelogenous leukemia. After being successfully treated with prednisone for chronic graft versus host disease that initially started 50 days posttransplant, she developed hepatic dysfunction during the steroid taper on day 531, as evidenced by jaundice, elevated liver enzymes, and increased bilirubin. Liver biopsy showed histology suggestive of autoimmune-like hepatitis, which is a rare manifestation of chronic “hepatitic” graft versus host disease.
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Affiliation(s)
- Nick M. Baniak
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Rani Kanthan
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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16
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Efficacy and safety of deferasirox in non-thalassemic patients with elevated ferritin levels after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2015; 51:89-95. [DOI: 10.1038/bmt.2015.204] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/18/2015] [Accepted: 07/23/2015] [Indexed: 12/22/2022]
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17
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Torres HA, Chong PP, De Lima M, Friedman MS, Giralt S, Hammond SP, Kiel PJ, Masur H, McDonald GB, Wingard JR, Gambarin-Gelwan M. Hepatitis C Virus Infection among Hematopoietic Cell Transplant Donors and Recipients: American Society for Blood and Marrow Transplantation Task Force Recommendations. Biol Blood Marrow Transplant 2015; 21:1870-82. [PMID: 26256943 DOI: 10.1016/j.bbmt.2015.07.033] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 07/31/2015] [Indexed: 02/08/2023]
Affiliation(s)
- Harrys A Torres
- The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Pearlie P Chong
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marcos De Lima
- University Hospitals Case Medical Center and University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | | | - Sergio Giralt
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sarah P Hammond
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Patrick J Kiel
- Indiana University Simon Cancer Center, Indianapolis, Indiana
| | - Henry Masur
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - George B McDonald
- University of Washington and Fred Hutchinson Cancer Research Center, Seattle, Washington
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18
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Vallejo C, Batlle M, Vázquez L, Solano C, Sampol A, Duarte R, Hernández D, López J, Rovira M, Jiménez S, Valcárcel D, Belloch V, Jiménez M, Jarque I. Phase IV open-label study of the efficacy and safety of deferasirox after allogeneic stem cell transplantation. Haematologica 2014; 99:1632-7. [PMID: 24997153 PMCID: PMC4181261 DOI: 10.3324/haematol.2014.105908] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 07/02/2014] [Indexed: 01/19/2023] Open
Abstract
This is the first prospective study of deferasirox in adult allogeneic hematopoietic stem cell transplant recipients with transfusional iron overload in hematologic malignancies. Patients at least six months post transplant were treated with deferasirox at a starting dose of 10 mg/kg/day for 52 weeks or until serum ferritin was less than 400 ng/mL on two consecutive occasions. Thirty patients were enrolled and 22 completed the study. A significant reduction from baseline in median serum ferritin and in liver iron concentration at 52 weeks was observed in the overall population: from 1440 to 755.5 ng/mL (P=0.002) and from 14.5 to 4.6 mg Fe/g dw (P=0.0007), respectively. Reduction in serum ferritin in patients who did not discontinue deferasirox therapy was significantly greater than that found in those who prematurely discontinued the treatment (from 1541 to 581 ng/mL vs. from 1416 to 1486 ng/mL; P=0.008). Drug-related adverse events, reported in 17 patients (56.7%), were mostly mild to moderate in severity. There were no drug-related serious adverse events. Twelve patients (40.0%) showed an increase of over 33% in serum creatinine compared to baseline and greater than the upper limit of normal on two consecutive visits. Two patients (6.7%) with active graft-versus-host disease showed an increase in alanine aminotransferase exceeding 10 times upper limit of normal; both resolved. In this prospective study, deferasirox provided a significant reduction in serum ferritin and liver iron concentration over one year of treatment in allogeneic hematopoietic stem cell transplant recipients with iron overload. In addition, the majority of adverse events related to deferasirox were mild or moderate in severity. (clinicaltrials.gov identifier:01335035).
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Affiliation(s)
- Carlos Vallejo
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | - Carlos Solano
- Hospital Clínico Universitario-INCLIVA, Valencia, Spain
| | | | - Rafael Duarte
- Catalan Institute of Oncology-Idibell, L'Hospitalet de Llobregat, Spain
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19
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Hematopoietic stem cell transplantation: graft versus host disease and pathology of gastrointestinal tract, liver, and lung. Adv Anat Pathol 2014; 21:301-20. [PMID: 25105933 DOI: 10.1097/pap.0000000000000032] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Hematopoietic stem cell transplantation (HCT), formerly known as bone marrow transplantation, is an integral part of treatment for many hematological malignancies. HCT is associated with several complications and comorbidities with differential effects on a wide spectrum of organs and tissues. We present an update on HCT-associated complications such as graft versus host disease (GVHD) and infection, with focus on the surgical pathology of the gastrointestinal (GI) tract, liver, and lung. Although the grading system for GI tract acute GVHD was proposed 40 years ago, recent studies have shed light on minimal histologic criteria for diagnosis of GVHD, as well as its differential diagnosis, including histologic effects of various medications. GI dysfunction in autologous transplant recipients is increasingly appreciated and patients are often biopsied. Acute liver injury in HCT is often due to sinusoidal obstruction syndrome (previously known as venoocclusive disease), or acute GVHD. Liver dysfunction at later time posttransplantation may be associated with acute or chronic GVHD, iron overload, or other causes of hepatitis. Lung injury in HCT is multifactorial, and it remains crucially important to diagnose and treat pulmonary infections. The pulmonary biopsy yields clinically unsuspected diagnoses in the majority of cases and its utilization is likely to increase. The pathology of the skin and kidney in HCT patients are detailed in accompanying articles.
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20
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Norvell JP. Liver disease after hematopoietic cell transplantation in adults. Transplant Rev (Orlando) 2014; 29:8-15. [PMID: 25315987 DOI: 10.1016/j.trre.2014.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Revised: 08/10/2014] [Accepted: 08/22/2014] [Indexed: 01/22/2023]
Abstract
Liver-related complications constitute a large component of the overall morbidity and mortality associated with hematopoietic cell transplantation. Affecting up to 80% of allogeneic HCT recipients, prompt recognition and treatment are essential. The differential diagnosis is broad and is best categorized by time of onset after transplantation. Early complications include drug-induced liver injury, sinusoidal obstruction syndrome, and graft-versus-host disease. Late complications include infectious sequelae, cirrhosis, and hepatic malignancies. Patients being considered for hematopoietic cell transplantation should be screened and evaluated for liver-related complications to help improve outcomes.
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Affiliation(s)
- J P Norvell
- Department of Medicine, Division of Digestive Diseases, Emory Transplant Center, Emory University, Atlanta, GA, USA.
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21
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Wollmer E, Neubauer A. Komplikationen der allogenen Knochenmark- und Stammzelltransplantation. Internist (Berl) 2014; 55:547-60; quiz 561. [DOI: 10.1007/s00108-013-3432-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Jesudas R, Malesky A, Chu R, Fischer H, Kamat D. Reviewing the follow-up care of pediatric patients' status post-hematopoietic stem cell transplantation for the primary care pediatrician. Clin Pediatr (Phila) 2013; 52:487-95. [PMID: 23564303 DOI: 10.1177/0009922813483361] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) is a treatment modality for many oncologic as well as non-oncologic disorders. Although the side effects of different chemotherapy regimens have been well studied by several oncology consortiums, limited data is available regarding the late adverse effects of HSCT. Furthermore, pediatric-focused post-HSCT follow-up guidelines for primary care pediatricians do not exist. OBJECTIVE To provide a summary of the most common late adverse effects of HSCT and give the primary care pediatrician guidance and evidence-based information for the screening and management of this patient population. DESIGN The literature was searched using PubMed using keywords, including pediatric bone marrow transplant, hematopoietic stem cell transplant guidelines, pediatric bone marrow transplant guidelines, and pediatric bone marrow transplant immunizations. The most relevant articles out of the hundreds of results were reviewed. RESULTS Based on 9 review articles from the Pediatric Clinics of North America and 3 articles from the Biology of Blood and Marrow Transplant Journal as well as their original references, a summary of the most common late adverse effects after HSCT was constructed. Pediatric HSCT patients have a high incidence of late adverse effects, with 93% of survivors having at least 1 late adverse effect after 7 years of follow-up. CONCLUSION Late adverse effects after pediatric HSCT are common and require close screening and monitoring, which can be done by the primary care provider along with the oncologist.
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Affiliation(s)
- Rohith Jesudas
- Children's Hospital of Michigan, Detroit, MI 48201, USA.
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23
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Nakasone H, Kurosawa S, Yakushijin K, Taniguchi S, Murata M, Ikegame K, Kobayashi T, Eto T, Miyamura K, Sakamaki H, Morishima Y, Nagamura T, Suzuki R, Fukuda T. Impact of hepatitis C virus infection on clinical outcome in recipients after allogeneic hematopoietic cell transplantation. Am J Hematol 2013; 88:477-84. [PMID: 23483626 DOI: 10.1002/ajh.23436] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 03/05/2013] [Indexed: 01/12/2023]
Abstract
The impact of hepatitis C virus (HCV) infection on outcomes following allogeneic hematopoietic cell transplantation (HCT) remains a matter of debate. We have retrospectively examined the significance of HCV infection among recipients who received allogeneic HCT, using a Japan transplant outcome registry database between 2006 and 2009. Among 7,831 recipients, 136 were HCV-positive. The rate of hematopoietic recovery was lower in the HCV-positive group (neutrophil recovery of 500 × 10(6) /L or higher: 79% vs. 87% at Day 30, P = 0.087; platelet recovery of 50 × 10(9) /L or higher: 57% vs. 65% at Day 60, P = 0.012). The HCV-positive group had a significantly higher incidence of nonrelapse mortality 38% vs. 25% at 2 years, P < 0.01) and inferior overall survival (41% vs. 51% at 2 years, P < 0.01). A multivariate analysis revealed that HCV seropositivity was associated with an independent risk for higher nonrelapse mortality (hazard ratio: 1.65, P < 0.01) and inferior overall survival (hazard ratio: 1.39, P < 0.01). The incidences of death due to hepatic problems (8% vs. 2%, P < 0.01), bacterial infection (10% vs. 4%, P < 0.01), or graft failure (5% vs. 2%, P = 0.084) tended to be higher in the HCV-positive group. HCV infection had an adverse impact on the clinical outcome following HCT, especially in the setting of unrelated transplantation. Careful evaluation before embarking on HCT and intensive assessment against complications are warranted in HCV-infected recipients.
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Affiliation(s)
| | | | | | | | - Makoto Murata
- Department of Hematology and Oncology; Nagoya University Graduate School of Medicine; Nagoya; Japan
| | - Kazuhiro Ikegame
- Division of Hematology; Department of Internal Medicine; Hyogo College of Medicine; Nishinomiya; Japan
| | - Takeshi Kobayashi
- Hematology Division; Tokyo Metropolitan Cancer & Infectious Disease Center, Komagome Hospital; Tokyo; Japan
| | - Tetsuya Eto
- Department of Hematology; Hamanomachi Hospital; Fukuoka; Japan
| | - Koichi Miyamura
- Department of Hematology; Japanese Red Cross Nagoya First Hospital; Nagoya; Japan
| | - Hisashi Sakamaki
- Hematology Division; Tokyo Metropolitan Cancer & Infectious Disease Center, Komagome Hospital; Tokyo; Japan
| | - Yasuo Morishima
- Division of Epidemiology and Prevention; Aichi Cancer Center Research Institute; Nagoya; Japan
| | - Tokiko Nagamura
- Department of Cell Processing and Transfusion; Institute of Medical Science; University of Tokyo; Tokyo; Japan
| | - Ritsuro Suzuki
- Department of HSCT Data Management and Biostatistics; Nagoya University; Nagoya; Japan
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Sivgin S, Eser B. The management of iron overload in allogeneic hematopoietic stem cell transplant (alloHSCT) recipients: where do we stand? Ann Hematol 2013; 92:577-86. [PMID: 23430087 DOI: 10.1007/s00277-013-1682-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 01/15/2013] [Indexed: 01/19/2023]
Abstract
Iron overload (IO), primarily related to multiple red blood cell transfusions, is a relatively common complication in hematopoietic stem cell transplant (HSCT) recipients. Elevated pretransplant ferritin levels have been reported to increase the risk of non-relapse mortality following HSCT and might influence the risk of acute and chronic graft versus host disease. IO has been shown to be an important cause of mortality and morbidity in patients who have undergone alloHSCT (Armand et al., Blood 109:4586-4588, 2007; Kim et al., Acta Haematol 120:182-189, 2008; Kataoka et al., Biol Blood Marrow Transplant 15:195-204, 2009). We know that excessive iron accumulation results in tissue damage and organ failure, mainly as a result of the generation of free radicals that cause oxidative damage and organ dysfunction (e.g., hepatotoxicity, cardiotoxicity, and endocrine dysfunction) (Altes et al., Bone Marrow Transplantation 29: 987-989, 2002; Papanikolaou et al., Toxicol Appl Pharmac 202:199-211, 2005). In the last decade, efforts have been directed toward identifying alternative treatment for IO in alloHSCT recipients to maintain improved transplant outcomes.
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Affiliation(s)
- Serdar Sivgin
- Department of Hematology, Faculty of Medicine, Dedeman Stem Cell Transplantation Hospital, Erciyes University, Kayseri, Turkey.
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25
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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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26
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Ali S, Pimentel JD, Munoz J, Shah V, McKinnon R, Divine G, Janakiraman N. Iron Overload in Allogeneic Hematopoietic Stem Cell Transplant Recipients. Arch Pathol Lab Med 2012; 136:532-8. [DOI: 10.5858/arpa.2011-0190-oa] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Patients who undergo hematopoietic stem cell transplant are at an increased risk of developing iron overload.
Objectives.—To describe the effect of hepatic iron overload on hematopoietic stem cell transplant recipients and to validate the utility of histologic scoring system of iron granules in the liver.
Design.—Records of 154 post allogeneic hematopoietic stem cell transplant patients were reviewed. Forty-nine patients underwent liver biopsy. Histologic hepatic iron overload was defined as a score of 2 or greater (scale, 0–4).
Results.—Twenty-eight of 49 patients (57%) evaluated by liver biopsy had hepatic iron overload; 17 had moderate to severe hepatic iron overload (score, 3 or 4). In multivariate analysis, a significant correlation was discovered between hepatic iron overload and the number of transfusions (P < .001), posttransplant serum ferritin levels (P = .004), lactate dehydrogenase levels (P = .03), and the development of blood stream infections (P = .02). There was no correlation between hepatic iron overload and abnormal liver function test results. While 37 patients (76%) died after receiving a transplant, mortality was not influenced by hepatic iron overload but was significantly higher in older patients, in patients with lower serum albumin levels, higher serum bilirubin levels, and higher clinical grade of acute graft-versus-host disease (P = .04, P = .001, P = <.001, and P = .004, respectively).
Conclusions.—Hepatic iron overload is commonly identified in hematopoietic stem cell transplant patients and can be accurately diagnosed by liver biopsy. In addition, hepatic iron overload has been identified in patients receiving as few as 25 units of packed red blood cells, with elevated posttransplant serum ferritin levels, and with blood stream infections.
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27
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Brissot E, Savani BN, Mohty M. Management of High Ferritin in Long-Term Survivors After Hematopoietic Stem Cell Transplantation. Semin Hematol 2012; 49:35-42. [DOI: 10.1053/j.seminhematol.2011.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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Kida A, McDonald GB. Gastrointestinal, Hepatobiliary, Pancreatic, and Iron-Related Diseases in Long-Term Survivors of Allogeneic Hematopoietic Cell Transplantation. Semin Hematol 2012; 49:43-58. [DOI: 10.1053/j.seminhematol.2011.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Nieder ML, McDonald GB, Kida A, Hingorani S, Armenian SH, Cooke KR, Pulsipher MA, Baker KS. National Cancer Institute-National Heart, Lung and Blood Institute/pediatric Blood and Marrow Transplant Consortium First International Consensus Conference on late effects after pediatric hematopoietic cell transplantation: long-term organ damage and dysfunction. Biol Blood Marrow Transplant 2011; 17:1573-84. [PMID: 21963877 PMCID: PMC3215762 DOI: 10.1016/j.bbmt.2011.09.013] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 09/27/2011] [Indexed: 01/19/2023]
Abstract
Long-term complications after hematopoietic cell transplantation (HCT) have been studied in detail. Although virtually every organ system can be adversely affected after HCT, the underlying pathophysiology of these late effects remain incompletely understood. This article describes our current understanding of the pathophysiology of late effects involving the gastrointestinal, renal, cardiac, and pulmonary systems, and discusses post-HCT metabolic syndrome studies. Underlying diseases, pretransplantation exposures, transplantation conditioning regimens, graft-versus-host disease, and other treatments contribute to these problems. Because organ systems are interdependent, long-term complications with similar pathophysiologic mechanisms often involve multiple organ systems. Current data suggest that post-HCT organ complications result from cellular damage that leads to a cascade of complex events. The interplay between inflammatory processes and dysregulated cellular repair likely contributes to end-organ fibrosis and dysfunction. Although many long-term problems cannot be prevented, appropriate monitoring can enable detection and organ-preserving medical management at earlier stages. Current management strategies are aimed at minimizing symptoms and optimizing function. There remain significant gaps in our knowledge of the pathophysiology of therapy-related organ toxicities disease after HCT. These gaps can be addressed by closely examining disease biology and identifying those patients at greatest risk for adverse outcomes. In addition, strategies are needed for targeted disease prevention and health promotion efforts for individuals deemed at high risk because of their genetic makeup or specific exposure profile.
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Affiliation(s)
| | - George B. McDonald
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Aiko Kida
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Sangeeta Hingorani
- University of Washington, Seattle Children’s Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Kenneth R. Cooke
- Case Western Reserve University, Rainbow Babies & Children’s Hospital, Cleveland, OH
| | - Michael A. Pulsipher
- Primary Children’s Medical Center, Division of Hematology/BMT, University of Utah School of Medicine/Huntsman Cancer Institute, Salt Lake City, UT
| | - K. Scott Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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Wolff D, Bertz H, Greinix H, Lawitschka A, Halter J, Holler E. The treatment of chronic graft-versus-host disease: consensus recommendations of experts from Germany, Austria, and Switzerland. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:732-40. [PMID: 22114649 PMCID: PMC3221419 DOI: 10.3238/arztebl.2011.0732] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 03/08/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic graft-versus-host disease (cGVHD) is the commonest complication of allogeneic bone marrow and blood stem-cell transplantation, occurring in 50% of all cases and causing late mortality in as many as 25%. There are now about 10 000 patients with cGVHD in Germany, and their number is growing by about 500 each year. cGVHD is a chronic multisystem disease due to impaired tolerance mechanisms. It affects many organs in variable ways, impairing organ function and lowering quality of life. METHODS We present consensus recommendations on the treatment of cGVHD that were developed jointly by the German Working Group on Bone Marrow and Blood Stem-Cell Transplantation, the German and Austrian Societies of Hematology and Oncology, the Swiss Blood Stem-Cell Transplantation Group, and the German-Austrian Working Group on Pediatric Stem-Cell Transplantation. All of the recommendations are based on an evaluation of selected publications. RESULTS Recommendations are given regarding the diagnostic evaluation of cGVHD, first-line treatment (which has a response rate of 30% to 50%), second-line treatment, and topical immunosuppression. Patients with cGVHD should also receive supportive care including anti-infective prophylaxis, vaccinations, hormone replacement, prevention and treatment of osteoporosis, physiotherapy, rehabilitation, and psychosocial assistance. CONCLUSION Patients with cGVHD need multidisciplinary care under the guidance of the transplantation center. The aim of these recommendations is to standardize the treatment of cGVHD and thereby improve patient care.
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Affiliation(s)
- Daniel Wolff
- Abteilung für Hämatologie und Internistische Onkologie, Universität Regensburg, Franz-Josef Strauss Allee 11, 93053 Regensburg, Germany.
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Kagoya Y, Takahashi T, Nannya Y, Shinozaki A, Ota S, Fukayama M, Kurokawa M. Hyperbilirubinemia after hematopoietic stem cell transplantation: comparison of clinical and pathologic findings in 41 autopsied cases. Clin Transplant 2011; 25:E552-7. [PMID: 21919962 DOI: 10.1111/j.1399-0012.2011.01498.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Hyperbilirubinemia is often associated with morbidity and mortality after hematopoietic stem cell transplantation (HSCT). Diagnosis of its etiology is usually made clinically among various possible causes, and analysis of histological findings as compared with the clinical diagnosis has not been performed sufficiently. We retrospectively analyzed clinical and pathological findings in 41 autopsied patients who died with hyperbilirubinemia (>2 mg/dL). Overall, liver graft-versus-host disease (GVHD) showed the most prominent discordance between clinical and pathological diagnoses. Only 11 of the 22 patients, considered to have liver GVHD clinically, had GVHD findings at autopsy. Serum gamma-glutamyl transpeptidase (GGT), GGT/aspartate aminotransferase (AST) ratio, and alkaline phosphatase (ALP)/AST ratio in GVHD patients were significantly higher compared with those without GVHD (p = 0.02, <0.01, and 0.03, respectively), which was useful in clinical diagnosis of liver GVHD. Other major findings include liver invasion of the primary malignancies in 8 patients, post-transplant lymphoproliferative disorder of the liver in two patients, and disseminated liver invasion by fungus or varicella-zoster virus in one patient, respectively. Although analysis of clinical data is useful for narrowing diagnosis, histological analysis by liver biopsy is crucially important, especially in cases suspected of having GVHD.
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Affiliation(s)
- Yuki Kagoya
- Department of Hematology and Oncology, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Lee JW, Lee DH, Jang PS, Yi MS, Chung NG, Cho B, Jeong DC, Kim HK. Prognostic implications of the NIH consensus criteria in children with chronic graft-versus-host disease. Yonsei Med J 2011; 52:779-86. [PMID: 21786443 PMCID: PMC3159944 DOI: 10.3349/ymj.2011.52.5.779] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE In this study, we analyzed a cohort of children with chronic graft-versus-host disease (GvHD) according to the NIH consensus classification (NCC) in order to observe whether global assessment at diagnosis correlates with GvHD-specific endpoints. We then studied the clinical course of these patients, specifically with regards to episodes of GvHD exacerbation requiring treatment escalation. MATERIALS AND METHODS Recipients of either allogeneic bone marrow transplantation (BMT) or peripheral blood stem cell transplantation (PBSCT) from January 2006 to August 2008 at the Department of Pediatrics, The Catholic University of Korea were evaluated for chronic GvHD, which was diagnosed according to the NCC. The course of chronic GvHD in these patients was then followed. RESULTS Of 59 evaluable patients, 23 developed chronic GvHD for a cumulative incidence of 39.3%. Upon multivariate analysis, previous acute GvHD (≥grade II) had a significant impact on chronic GvHD incidence. With a median duration of systemic treatment for chronic GvHD of 501 days, no significant relationship was found between initial global severity of chronic GvHD and either duration of immunosuppressive treatment or final clinical response to treatment. Fifteen patients (65%) experienced at least one episode of chronic GvHD exacerbation during the period of follow-up, with a median of four exacerbations in the subgroup of patients who experienced such events. Lung GvHD resulted in the highest number of exacerbations per diagnosed patient, followed by oral GvHD. CONCLUSION Analysis of this small cohort indicates that global assessment as proposed by the NCC may have limited correlations with GvHD-specific endpoints, possibly due to the favorable response of children to treatment.
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Affiliation(s)
- Jae Wook Lee
- Department of Pediatrics, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Dae-Hyoung Lee
- Department of Pediatrics, Hallym University, College of Medicine, Seoul, Korea
| | - Pil-Sang Jang
- Department of Pediatrics, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Mi-Sung Yi
- Department of Biostatistics, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Nack-Gyun Chung
- Department of Pediatrics, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Bin Cho
- Department of Pediatrics, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Dae-Chul Jeong
- Department of Pediatrics, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Hack-Ki Kim
- Department of Pediatrics, The Catholic University of Korea, College of Medicine, Seoul, Korea
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Mulder RL, van Dalen EC, Van den Hof M, Leclercq E, Bresters D, Koot BGP, Castellino SM, Loke Y, Post PN, Caron HN, Postma A, Kremer LCM. Hepatic late adverse effects after antineoplastic treatment for childhood cancer. Cochrane Database Syst Rev 2011; 2011:CD008205. [PMID: 21735424 PMCID: PMC6464972 DOI: 10.1002/14651858.cd008205.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Survival rates have greatly improved as a result of more effective treatments for childhood cancer. Unfortunately the improved prognosis has resulted in the occurrence of late, treatment-related complications. Liver complications are common during and soon after treatment for childhood cancer. However, among long-term childhood cancer survivors the risk of hepatic late adverse effects is largely unknown. To make informed decisions about future cancer treatment and follow-up policies it is important to know the risk of, and associated risk factors for, hepatic late adverse effects. OBJECTIVES To evaluate the existing evidence on the association between antineoplastic treatment for childhood cancer and hepatic late adverse effects. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 2), MEDLINE (1966 to June 2009) and EMBASE (1980 to June 2009). In addition, we searched reference lists of relevant articles and conference proceedings. SELECTION CRITERIA All studies except case reports, case series and studies including less than 10 patients that examined the association between antineoplastic treatment for childhood cancer (aged 18 years or less at diagnosis) and hepatic late adverse effects (one year or more after the end of treatment). DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection, risk of bias assessment and data extraction. MAIN RESULTS We identified 20 cohort studies investigating hepatic late adverse effects after antineoplastic treatment for childhood cancer. All studies had methodological limitations. The prevalence of hepatic late adverse effects varied widely, between 0% and 84.2%. Selecting studies where the outcome of hepatic late adverse effects was well defined as alanine aminotransferase (ALT) above the upper limit of normal resulted in five studies. In this subgroup the prevalence of hepatic late adverse effects ranged from 8.0% to 52.8%, with follow-up durations varying from one to 27 years after the end of treatment. A more stringent selection process using the outcome definition of ALT as above twice the upper limit of normal resulted in three studies, with a prevalence ranging from 7.9% to 44.8%. Chronic viral hepatitis was identified as a risk factor for hepatic late adverse effects in univariate analyses. It is unclear which specific antineoplastic treatments increase the risk of hepatic late adverse effects AUTHORS' CONCLUSIONS The prevalence of hepatic late adverse effects ranged from 7.9% to 52.8% when selecting studies with an adequate outcome definition. It has not been established which childhood cancer treatments result in hepatic late adverse effects. There is a suggestion that chronic viral hepatitis increases the risk of hepatic late adverse effects. More well-designed studies are needed to reliably evaluate the prevalence of, and risk factors for, hepatic late adverse effects after antineoplastic treatment for childhood cancer.
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Affiliation(s)
- Renée L Mulder
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Elvira C van Dalen
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Malon Van den Hof
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Edith Leclercq
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Dorine Bresters
- Leiden University Medical CenterDepartment of Paediatric Immunology, Haemato‐Oncology, Bone Marrow Transplantation and Auto‐immune Diseases, Willem‐Alexander Kinder‐ en JeugdcentrumPO Box 9600LeidenNetherlands2300 RC
| | - Bart GP Koot
- Emma Children's Hospital / Academic Medical CenterDepartment of Paediatric Gastroenterology and NutritionP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Sharon M Castellino
- Wake Forest University School of MedicinePediatrics section Hematology/OncologyMedical Center blvd.Winston‐Salem, NCUSA27157
| | - Yoon Loke
- University of East AngliaSchool of MedicineNorwichUKNR4 7TJ
| | - Piet N Post
- Dutch Institute for Healthcare Improvement CBOPO Box 20064UtrechtNetherlands3502 LB
| | - Huib N Caron
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
| | - Aleida Postma
- University Medical Center Groningen and University of Groningen, Beatrix Children's HospitalDepartment of Paediatric OncologyPostbus 30.000GroningenNetherlands9700 RB
| | - Leontien CM Kremer
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyP.O. Box 22660AmsterdamNetherlands1100 DD
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Leitch HA. Optimizing therapy for iron overload in the myelodysplastic syndromes: recent developments. Drugs 2011; 71:155-77. [PMID: 21275444 DOI: 10.2165/11585280-000000000-00000] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The myelodysplastic syndromes (MDS) are characterized by cytopenias and risk of progression to acute myeloid leukaemia (AML). Most MDS patients eventually require transfusion of red blood cells for anaemia, placing them at risk of transfusional iron overload. In β-thalassaemia major, transfusional iron overload leads to organ dysfunction and death; however, with iron chelation therapy, organ function is improved, and survival improved to near normal and correlated with the degree of compliance with chelation. In lower-risk MDS, several nonrandomized studies suggest an adverse effect of iron overload on survival and that lowering iron with chelation may minimize this impact. Emerging data indicate that chelation may improve organ function, particularly hepatic function, and a minority of patients may have improvement in cell counts and decreased transfusion requirements. While guidelines for MDS generally recommend chelation in selected lower-risk patients, data from nonrandomized trials suggest iron overload may impact adversely on the outcome of higher-risk MDS and stem cell transplantation (SCT). This effect may be due to increased transplant-related mortality, infection and AML progression, and preliminary data suggest that lowering iron may be beneficial in this patient group. Other areas of active and future investigation include optimizing the monitoring of iron overload using imaging such as T2* MRI and measures of labile iron and oxidative stress; correlating new methods of measuring iron to clinical outcomes; clarifying the contribution of different cellular and extracellular iron pools to iron toxicity; optimizing chelation by using agents that access the appropriate iron pools to minimize the relevant clinical consequences in individual patients; and incorporating measures of quality of life and co-morbidities into clinical trials of chelation in MDS. It should be noted that chelation is costly and potentially toxic, and in MDS should be initiated after weighing potential risks and benefits for each patient until more definitive data are available. In this review, data on the impact of iron overload in MDS and SCT are discussed; for example, several noncontrolled studies show inferior survival in patients with iron overload in these clinical settings, including an increase in transplant-related mortality and infection risk. Possible mechanisms of iron toxicity include oxidative stress, which can damage cellular components, and the documented impact of lowering iron on organ function with measures such as iron chelation therapy includes an improvement in elevated liver transaminases. Lowering iron also appears to improve survival in both lower-risk MDS and SCT in nonrandomized studies. Selected aspects of iron metabolism, transport, storage and distribution that may be amenable to future intervention and improved removal of iron from important cellular sites are discussed, as are attempts to quantify quality of life and the importance of co-morbidities in measures to treat MDS, including chelation therapy.
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Affiliation(s)
- Heather A Leitch
- Division of Hematology, St Paul's Hospital and the University of British Columbia, 440–1144 Burrard Street, Vancouver, BC, Canada.
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Ramos CA, Saliba RM, de Pádua Silva L, Khorshid O, Shpall EJ, Giralt S, Patah PA, Hosing CM, Popat UR, Rondon G, Nieto Y, Champlin RE, de Lima M. Resolved hepatitis B virus infection is not associated with worse outcome after allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2010; 16:686-94. [PMID: 20056165 DOI: 10.1016/j.bbmt.2009.12.532] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Accepted: 12/24/2009] [Indexed: 02/03/2023]
Abstract
Serologic evidence of resolved hepatitis B virus (HBV) infection has been associated with reactivation of hepatitis after allogeneic hematopoietic stem cell transplantation (allo-HSCT), but the true impact of this finding is unknown. We conducted a retrospective matched-control analysis of the outcomes of 76 patients with positive HBV core antibody (HBcAb) and negative HBV surface antigen (HBsAg) at the time of allo-HSCT for hematologic or solid malignancies. Control patients (matched controls), with negative serology for HBV and other viral hepatitides, were matched by age, diagnosis, disease risk, intensity of conditioning regimen, and donor type. In addition, the HBcAb-positive patients and all seronegative patients (all controls, n = 1858) undergoing transplantation during the same period were compared to adjust for other confounding effects. Patient characteristics and baseline hepatic function studies were similar in the HBcAb-positive and matched control groups. The cumulative incidence of hepatitis B reactivation (defined as the emergence of HBsAg in serum) was 11.6% at 3 years. There were no significant differences in overall survival, relapse, nonrelapse mortality, and incidence of acute graft-versus-host disease between the HBcAb-positive and control groups. Our data suggest that seropositivity for HBcAb and seronegativity for HBsAg at the time of transplantation does not seem to adversely affect outcome after allo-HSCT.
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Affiliation(s)
- Carlos A Ramos
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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Ozkurt ZN, Yegin ZA, Yenicesu I, Aki SZ, Yagci M, Sucak GT. Impact of ABO-incompatible donor on early and late outcome of hematopoietic stem cell transplantation. Transplant Proc 2010; 41:3851-8. [PMID: 19917400 DOI: 10.1016/j.transproceed.2009.06.189] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 06/19/2009] [Indexed: 10/20/2022]
Abstract
ABO incompatibility is not a barrier to allogeneic hematopoietic stem cell transplantation (HSCT). However, the impact of an ABO mismatch on the outcome of the HSCT remains controversial. We analyzed whether ABO incompatibility leads to an increased risk of early/late complications, mortality, or increased transfusion requirements. The 147 consecutive allogeneic HSCTs includes 80 ABO-identical and 25 major, 30 minor, and 12 bidirectional ABO-mismatched grafts. The four groups were balanced with respect to disease status at transplantation. Transplantation-related mortality was significantly greater (P < .01) and overall survival significantly shorter (P = 0.2) among HSCT recipients with minor ABO-mismatched grafts. The relapse rate, progression-free survival, and transfusion requirements until discharge were not different between ABO-identical and ABO-mismatched groups. Pure red cell aplasia (PRCA); (P < .0001) and delayed red blood cell (RBC) engraftment (P < .001) were more frequent in HSCT recipients with major mismatched donors. Delayed RBC engraftment was associated with posttransplantation hyperferritininemia and increased mortality risk (P = .05). The greater frequency of sinusoidal obstruction syndrome and graft-versus-host disease (GVHD) in patients with minor mismatched transplants, did not show statistical significance. In contrast severe GVHD was significantly more frequent among minor mismatched patients (P = .04). ABO-mismatched HSCT might have an unfavorable impact on transplant outcomes. Selection of ABO-compatible donors when possible, strategies to prevent and treat PRCA, modifications in transfusion practice, and effective iron chelation are among the measures that can improve transplant outcomes.
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Affiliation(s)
- Z N Ozkurt
- Gazi University Faculty of Medicine, Besevler, Ankara, Turkey
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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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Busca A, Falda M, Manzini P, D'Antico S, Valfrè A, Locatelli F, Calabrese R, Chiappella A, D'Ardia S, Longo F, Piga A. Iron Overload in Patients Receiving Allogeneic Hematopoietic Stem Cell Transplantation: Quantification of Iron Burden by a Superconducting Quantum Interference Device (SQUID) and Therapeutic Effectiveness of Phlebotomy. Biol Blood Marrow Transplant 2010; 16:115-22. [DOI: 10.1016/j.bbmt.2009.09.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 09/16/2009] [Indexed: 10/20/2022]
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Socié G, de Latour RP, McDonald GB. Hepatitis C virus and allogeneic stem cell transplantation still matters! Haematologica 2009; 94:170-2. [PMID: 19181791 DOI: 10.3324/haematol.2008.002048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Chotsampancharoen T, Gan K, Kasow KA, Barfield RC, Hale GA, Leung W. Iron overload in survivors of childhood leukemia after allogeneic hematopoietic stem cell transplantation. Pediatr Transplant 2009; 13:348-52. [PMID: 18518909 DOI: 10.1111/j.1399-3046.2008.00983.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Iron overload has not been studied extensively and prospectively in pediatric survivors of allogeneic hematopoietic stem cell transplantation (HSCT); therefore, we conducted a prospective long-term study of 133 survivors of childhood leukemia to assess the incidence of and risk factors for iron overload and to investigate its association with organ dysfunction. One yr after HSCT, the mean serum ferritin level was 1158 ng/mL (range, 22-3264 ng/mL), with 124 patients (93.2%) having a serum ferritin level that exceeded the upper limit of the normal range (110 ng/mL). Thereafter, the serum ferritin level declined over time. There was a positive correlation between the level of serum ferritin and that of total bilirubin (r = 0.21, p < 0.001) and glutamate pyruvate transaminase (r = 0.17, p < 0.001). A high concentration of serum ferritin was associated with low cardiac fractional shortening (r = -0.15, p = 0.047). In addition, patients with hypothyroidism and GH deficiency had a higher level of serum ferritin than those without (p < 0.02). We conclude that iron overload is common after HSCT and is associated with hepatic, cardiac, and endocrine dysfunction.
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Affiliation(s)
- Thirachit Chotsampancharoen
- Division of Bone Marrow Transplantation and Cellular Therapy, Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
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Ramos CA, Saliba RM, de Pádua L, Khorshid O, Shpall EJ, Giralt S, Patah PA, Hosing CM, Popat UR, Rondon G, Khouri IF, Nieto YL, Champlin RE, de Lima M. Impact of hepatitis C virus seropositivity on survival after allogeneic hematopoietic stem cell transplantation for hematologic malignancies. Haematologica 2009; 94:249-57. [PMID: 19144658 PMCID: PMC2635398 DOI: 10.3324/haematol.13756] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Because hepatitis C virus infection causes hepatic and immunological dysfunction, we hypothesized that seropositivity for this virus could be associated with increased non-relapse mortality after allogeneic hematopoietic stem cell transplantation. DESIGN AND METHODS We performed a case-control study of the outcomes of patients who were hepatitis C virus seropositive at the time of allogeneic hematopoietic stem cell transplantation (N=31). Patients positive for hepatitis C virus were considered candidates for stem cell transplantation only if they had no significant evidence of hepatic dysfunction. Matched controls (N=31) were seronegative for viral hepatitides and were paired according to age, diagnosis, disease stage, conditioning regimen and donor type. We also compared the hepatitis C virus seropositive patients to all seronegative patients (all controls, N=1800) transplanted during the same period, to adjust for other confounding effects. RESULTS The median age of the seropositive patients was 49 (range 26-72); 15 had acute myeloid leukemia/myelodysplastic syndrome, 6 had chronic myeloid leukemia/myeloproliferative disease, 6 non-Hodgkin's lymphoma, 2 myeloma, 1 acute lymphocytic leukemia and 1 Hodgkin's lymphoma; 61% had poor risk disease; 68% had related donors; 68% received reduced intensity conditioning; 7 patients had mildly abnormal alanine transaminase levels (all less than three times the upper limit of normal) and 1 patient had minimally elevated bilirubin. These characteristics were similar to those of the matched control group. Median overall survival was 3, 18 and 20 months, and 1-year survival was 29%, 56% and 56%, in the hepatitis C virus, matched and all controls groups, respectively (hazard ratio for death 3.1, 95% confidence interval 1.9-5.6, p<0.001 in multivariate analysis). Non-relapse mortality at 1 year was 43%, 24% and 23%, respectively (hazard ratio 3.3, 95% confidence interval 1.8-7.1, p<0.01). Disease progression and graft-versus-host disease rates were comparable. CONCLUSIONS Hepatitis C virus seropositivity is a significant risk factor for non-relapse mortality after allogeneic hematopoietic stem cell transplantation even in patients with normal or minimally abnormal liver function tests.
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Affiliation(s)
- Carlos A. Ramos
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Rima M. Saliba
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Leandro de Pádua
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Ola Khorshid
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth J. Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Sergio Giralt
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Poliana A. Patah
- Departamento de Oncologia, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Chitra M. Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Uday R. Popat
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Issa F. Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Yago L. Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Richard E. Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Marcos de Lima
- Department of Stem Cell Transplantation and Cellular Therapy, the University of Texas M. D. Anderson Cancer Center, Houston, TX, USA,Correspondence: Marcos de Lima, MD, Associate Professor of Medicine, Department of Stem Cell, Transplantation and Cellular Therapy, The University of Texas M.D., Anderson Cancer Center 1515 Holcombe Blvd., Unit 423, Houston, TX 77030, Phone: 713-792-8750, E-mail:
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Kataoka K, Nannya Y, Hangaishi A, Imai Y, Chiba S, Takahashi T, Kurokawa M. Influence of Pretransplantation Serum Ferritin on Nonrelapse Mortality after Myeloablative and Nonmyeloablative Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2009; 15:195-204. [DOI: 10.1016/j.bbmt.2008.11.012] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2008] [Accepted: 11/09/2008] [Indexed: 11/16/2022]
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Faraci M, Dini G. Assessing the risk of transplant-related complications and individually tailoring the HSCT procedure in children and adolescents—is it possible? Bone Marrow Transplant 2008; 42 Suppl 2:S90-6. [DOI: 10.1038/bmt.2008.292] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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The role of liver biopsy in the workup of liver dysfunction late after SCT: is the role of iron overload underestimated? Bone Marrow Transplant 2008; 42:461-7. [PMID: 18604240 DOI: 10.1038/bmt.2008.193] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Abnormalities in liver function tests are common in hematopoietic SCT (HSCT) recipients. We retrospectively investigated the role of liver biopsy in determining the cause of elevated liver enzymes and its impact on the management of patients in the post-HSCT setting. A total of 24 consecutive liver biopsies were obtained from 20 patients from September 2003 to December 2007. A definite histopathologic diagnosis was obtained in 91.7% of the biopsies. Iron overload (IO) was found in 75% and GVHD in 54.2% of the patients. The initial clinical diagnosis of GVHD was confirmed in 56.5% and refuted in 43.5% of the allogeneic HSCT recipients. The median number of post transplant transfusions, percent transferrin saturation and ferritin levels were found to be higher in patients who had histologically proven hepatic IO (p1=0.007, p2=0.003 and p3=0.009, respectively). Regression analysis showed a significant correlation between serum ferritin levels and histological grade of iron in the hepatocytes. Our data suggest that hepatic IO is a frequent finding in the post-HSCT setting, which contributes to hepatic dysfunction and it should be considered in the differential diagnosis, particularly in patients with high serum ferritin levels.
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Peffault de Latour R, Ribaud P, Robin M, Valla D, Marcellin P, Socié G, Asselah T. Allogeneic hematopoietic cell transplant in HCV-infected patients. J Hepatol 2008; 48:1008-17. [PMID: 18433917 DOI: 10.1016/j.jhep.2008.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatitis C virus (HCV) is a major cause of liver disease worldwide. After allogeneic Hematopoietic Cell Transplant (HCT), HCV is known to be associated with transient hepatitis in the immediate post-transplant period, and a potential risk factor of veno-occlusive disease (SOS). Very recently, HCV-infected HCT recipients have been shown to be at higher risk of earlier cirrhosis, leading to greater morbidity and mortality. Long-term survivors after HCT are thus at a high risk for HCV-related complications and, as a consequence, the treatment of HCV infection becomes critical. We describe here the potential clinical complications in HCV-infected recipients, in the short, but also the long-term follow-up after HCT. The pathophysiology of liver fibrosis is discussed as well as the present recommended therapy in this particular population.
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Bresters D, Van Gils ICM, Dekker FW, Lankester AC, Bredius RGM, Schweizer JJ. Abnormal liver enzymes two years after haematopoietic stem cell transplantation in children: prevalence and risk factors. Bone Marrow Transplant 2007; 41:27-31. [PMID: 17994124 DOI: 10.1038/sj.bmt.1705887] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
To establish the prevalence of elevated liver enzymes in children transplanted in a Dutch haematopoietic stem cell transplantation (HSCT) centre, we retrospectively assessed AST and ALT values at 2 years after HSCT. Age, sex, diagnosis, type of transplant, conditioning regimen and early post-transplant complications involving the liver (veno-occlusive disease, acute GVHD, viral reactivation) were analysed as risk factors. AST and ALT values were available at 2 years after HSCT in 216 of 290 patients (75%) alive at that time and were above normal in 53 (25%) and at least twice normal in 17 (8%) patients. Older age at HSCT and a diagnosis of benign haematological disease are risk factors for abnormal liver enzymes late after HSCT. In half of the patients with benign haematological disease, iron overload is the most likely aetiological factor. Chronic hepatitis B or C is uncommon in our centre. In conclusion, the prevalence of abnormal liver enzymes late after HSCT in our centre is lower than reported in previous studies. Abnormal liver enzymes occur more often in children who are older at HSCT and transplanted for benign haematological disease. Long-term follow-up is crucial to establish if elevated liver enzymes precede clinical liver disease.
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Affiliation(s)
- D Bresters
- Department of Paediatric Immunology, Haemato-Oncology, Bone Marrow Transplantation and Auto-immune Diseases, Leiden University Medical Centre, Leiden, The Netherlands.
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Melín-Aldana H, Thormann K, Duerst R, Kletzel M, Jacobsohn DA. Hepatitic pattern of graft versus host disease in children. Pediatr Blood Cancer 2007; 49:727-30. [PMID: 17066458 DOI: 10.1002/pbc.21069] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Liver involvement by graft-versus-host disease (GVHD) is characterized histologically by bile duct damage, which may be severe. A different pattern, "hepatitic GVHD," has been described in adult patients. This pattern also shows marked lobular hepatitis and hepatocellular damage. We report the development of hepatitic GVHD in six pediatric patients. PROCEDURE Clinical information and histologic features of liver biopsy samples were retrospectively reviewed. RESULTS Patients' ages ranged from 3 to 11 years. Underlying diagnosis, pre-transplant conditioning and GVHD prophylaxis varied. Peripheral blood stem cells were the source of the allograft in four patients, matched sibling in one, and matched-unrelated donor in one. Hepatic GVHD was detected between 149 and 310 days post-transplant. Prior acute GVHD had developed in two patients, and involved the skin and/or gastrointestinal tract. No patients had significant ductopenia. Only one patient had significant lymphocytic infiltration of bile ducts (ductitis). Bile duct epithelial damage and significant portal/periportal inflammation were present in all patients. Lobular necro-inflammation was present in five patients. Five patients improved with immunosuppression and one died with progressive GVHD. CONCLUSIONS This series focuses on hepatitic GVHD in pediatric patients. Clinical and histologic patterns are similar to what has been described in adults. Specific etiology and pathogenesis of this entity remain unclear.
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Affiliation(s)
- Héctor Melín-Aldana
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Juvonen E, Sahlstedt L, Parkkinen J, Ruutu T. Inhibition of erythroid and granulocyte-macrophage colony formation by non-transferrin-bound iron in vitro: protective effect of apotransferrin. Eur J Haematol 2007; 79:126-31. [PMID: 17596197 DOI: 10.1111/j.1600-0609.2007.00887.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The aim of the study was to investigate in vitro the effect of free iron on erythroid and granulocyte-macrophage colony formation and the effect of binding free iron with apotransferrin. METHODS Normal haematopoietic progenitors were cultured in vitro with different concentrations of free iron in the form of ferric nitrilotriacetic acid (FeNTA). Parallel cultures were performed after the preincubation of FeNTA with apotransferrin. RESULTS Free iron inhibited colony formation by erythroid and granulocyte-macrophage progenitors and reduced the size of the colonies in a dose-dependent manner. Preincubation of FeNTA with apotransferrin diminished the inhibitory effect of FeNTA on colony formation increasing both the number and the size of colonies. CONCLUSIONS Free iron was toxic to haematopoietic progenitors in in vitro cultures; the toxic effect could be reduced with apotransferrin.
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Affiliation(s)
- Eeva Juvonen
- Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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