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Miller W, January S, Klaus J, Neuner E, Pande A, Krekel T. Safety and efficacy of weight-based ganciclovir dosing strategies in overweight/obese patients. Transpl Infect Dis 2023; 25:e14134. [PMID: 37615196 DOI: 10.1111/tid.14134] [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: 03/28/2023] [Revised: 07/18/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND The management of cytomegalovirus (CMV) is particularly challenging as both CMV and its usual first-line treatment, ganciclovir, are associated with neutropenia. Ganciclovir dosing is weight-based, most commonly utilizing total body weight (TBW). The subsequent high doses of ganciclovir in overweight/obese patients may increase the risk of toxicity. Utilizing adjusted body weight (AdjBW) dosing may help mitigate this risk. Therefore, the objective of this study was to evaluate the difference in toxicity and efficacy between TBW and AdjBW ganciclovir dosing strategies in overweight/obese patients. METHODS This retrospective study conducted safety and efficacy analyses of ganciclovir courses (≥72 h) used as CMV treatment. The primary safety outcome was the incidence of neutropenia (absolute neutrophil count <1000 cells/μL), and the primary efficacy outcome was a 2-log decrease in CMV polymerase chain reaction within 4 weeks following ganciclovir initiation. In both analyses, courses were excluded in which ganciclovir was dosed outside of specified renal dosing parameters for >20% of the course. RESULTS Among the 253 courses in the safety cohort, there was no difference in the incidence of neutropenia (17.4% vs. 13.5%, p = .50) in AdjBW compared to TBW dosing. In the 62 courses evaluating efficacy, there was no statistical difference between AdjBW and TBW dosing (60.0% vs. 45.2%, p = .28). No subgroups were identified in which AdjBW dosing was advantageous. CONCLUSION Utilization of AdjBW ganciclovir dosing did not result in decreased neutropenia or treatment efficacy as compared to TBW dosing. Further studies with larger patient populations would be beneficial to confirm these findings.
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Affiliation(s)
- William Miller
- Department of Pharmacy, Deaconess Hospital, Evansville, Indiana, USA
| | - Spenser January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri, USA
| | - Jeff Klaus
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri, USA
| | - Elizabeth Neuner
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri, USA
| | - Anupam Pande
- Division of Infectious Disease, Washington University in St Louis School of Medicine, Saint Louis, Missouri, USA
| | - Tamara Krekel
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri, USA
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Yu ZP, Ding JH, Sun AN, Chen BA, Ge Z, Wu DP. A New Conditioning Regimen Can Significantly Promote Post-Transplant Immune Reconstitution and Improve the Outcome of Umbilical Cord Blood Transplantation for Patients. Stem Cells Dev 2019; 28:1376-1383. [PMID: 31464164 DOI: 10.1089/scd.2019.0139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
This study included data from 81 consecutively enrolled patients with hematological diseases who had been treated with unrelated umbilical cord blood transplantation (UCBT) between September 2014 and April 2019. All patients received intense conditioning regimens with combined fludarabine and high-dose cyclophosphamide (FC) before undergoing UCBT. Sixty-seven patients received a single UCBT, and 14 patients received a double UCBT. Fifty patients were pretreated with the fludarabine, busulfan, and cyclophosphamide (FBC) protocol, while 31 patients were treated with FC before transplantation. Graft-versus-host disease (GVHD) was prevented with cyclosporine A and mycophenolate mofetil administration. According to low-resolution, human leukocyte antigen (HLA) donor-recipient matching at six sites, 53 patients had 5-6 matches, while 28 patients had 4 matches. Seventy-eight patients (96.3%) achieved complete engraftment in this study. Thirty-six patients developed acute GVHD (aGVHD). The cumulative incidence of grade I-II aGVHD at day 100 posthematopoietic stem cell transplantation was 29.6%, and the cumulative incidence of grade III-IV aGVHD was 14.8%. At the end of the follow-up, 12 patients died due to treatment-related complications, and 4 died of disease relapse after transplantation. The transplant-related deaths were due to transplant-related infection (8 of 81), GVHD (2 of 81), and organ toxicity (2 of 81). The probability of overall survival (OS) was 80.2%. A higher dose of cyclophosphamide combined with fludarabine conditioning in UCBT was an effective curative method for treatment of hematologic disorders and could enhance the engraftment of umbilical cord blood stem cells, promote post-transplant immune reconstitution, and improve OS.
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Affiliation(s)
- Zheng-Ping Yu
- Department of Hematology (Key Department of Jiangsu Medicine), Zhong Da Hospital, Southeast University, Nanjing, China
| | - Jia-Hua Ding
- Department of Hematology (Key Department of Jiangsu Medicine), Zhong Da Hospital, Southeast University, Nanjing, China
| | - Ai-Ning Sun
- Hematology Division, Soochow University Affiliated No 1 People's Hospital, Suzhou, China
| | - Bao-An Chen
- Department of Hematology (Key Department of Jiangsu Medicine), Zhong Da Hospital, Southeast University, Nanjing, China
| | - Zheng Ge
- Department of Hematology (Key Department of Jiangsu Medicine), Zhong Da Hospital, Southeast University, Nanjing, China
| | - De-Pei Wu
- Hematology Division, Soochow University Affiliated No 1 People's Hospital, Suzhou, China
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Devasia AJ, Mammen S, Korula A, Abraham A, Fouzia NA, Lakshmi KM, Abraham AM, Srivastava A, Mathews V, George B. A Low Incidence of Cytomegalo Virus Infection Following Allogeneic Hematopoietic Stem Cell Transplantation Despite a High Seroprevalence. Indian J Hematol Blood Transfus 2018; 34:636-642. [PMID: 30369733 DOI: 10.1007/s12288-018-0960-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 04/11/2018] [Indexed: 11/26/2022] Open
Abstract
Cytomegalovirus (CMV) infection remains an important cause of morbidity and mortality following allogeneic stem cell transplantation (SCT). We wanted to study if the high sero-prevalence seen in our population translated into a high incidence of CMV infection following SCT. This is a retrospective analysis of patients who underwent allogeneic SCT between January 2008 and December 2012 at our centre. 475 patients underwent allogeneic SCT for malignant (46.5%) and non-malignant (53.5%) haematological disorders. 463 (97.4%) SCT recipients and 403 (84.8%) SCT donors were IgG seropositive for CMV. CMV reactivation within 100 days post SCT was seen in 174 (36.6%) at a median of 41 days (range 10-100) post SCT. Ganciclovir was used in 166 patients (95.4%) for a mean duration of 16 days (range 5-32). 157 patients (90%) responded to therapy. Sixty-six patients (42.3%) had secondary reactivation of the virus. Use of a male donor (p = 0.000), donor and recipient age > 15 (p = 0.005 and 0.000), unrelated donor (p = 0.000), degree of HLA mismatch (p = 0.000), occurrence of acute GVHD (p = 0.000) and steroid refractory acute GVHD (p = 0.026) were identified as risk factors for CMV reactivation while early neutrophil recovery (< 15 days) was found to be protective (p = 0.004). On multivariate analysis, male donor (p = 0.042), degree of HLA mismatch (p = 0.006), the occurrence of acute GVHD (p = 0.000) and steroid refractory acute GVHD (p = 0.031) continued to remain significant. 5-year overall survival was significantly better in patients without CMV reactivation compared to those who developed reactivation of CMV (68.9 ± 3.7 vs 58.2 ± 4.9% p = 0.004). The incidence of CMV infection does not seem to be higher despite a high sero-prevalence of CMV. However, patients who developed CMV infection post SCT had inferior outcomes.
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Affiliation(s)
- Anup J Devasia
- 1Department of Clinical Hematology, Christian Medical College, Vellore, India
| | - Shoba Mammen
- 2Department of Clinical Virology, Christian Medical College, Vellore, India
| | - Anu Korula
- 1Department of Clinical Hematology, Christian Medical College, Vellore, India
| | - Aby Abraham
- 1Department of Clinical Hematology, Christian Medical College, Vellore, India
| | - N A Fouzia
- 1Department of Clinical Hematology, Christian Medical College, Vellore, India
| | - Kavitha M Lakshmi
- 1Department of Clinical Hematology, Christian Medical College, Vellore, India
| | - Asha Mary Abraham
- 2Department of Clinical Virology, Christian Medical College, Vellore, India
| | - Alok Srivastava
- 1Department of Clinical Hematology, Christian Medical College, Vellore, India
| | - Vikram Mathews
- 1Department of Clinical Hematology, Christian Medical College, Vellore, India
| | - Biju George
- 1Department of Clinical Hematology, Christian Medical College, Vellore, India
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Ju H, Kang H, Hong C, Lee J, Kim H, Park K, Shin H, Park J, Choi E, Lee H, Ahn H. Half-dose ganciclovir preemptive treatment of cytomegalovirus infection after pediatric allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2016; 18:396-404. [DOI: 10.1111/tid.12539] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 12/30/2015] [Accepted: 02/23/2016] [Indexed: 11/26/2022]
Affiliation(s)
- H.Y. Ju
- Center for Pediatric Oncology; National Cancer Center; Goyang-si Korea
- Cancer Research Institute; Seoul National University College of Medicine; Seoul Korea
| | - H.J. Kang
- Cancer Research Institute; Seoul National University College of Medicine; Seoul Korea
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul National University College of Medicine; Seoul Korea
| | - C.R. Hong
- Cancer Research Institute; Seoul National University College of Medicine; Seoul Korea
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul National University College of Medicine; Seoul Korea
| | - J.W. Lee
- Cancer Research Institute; Seoul National University College of Medicine; Seoul Korea
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul National University College of Medicine; Seoul Korea
| | - H. Kim
- Department of Pediatrics; Chung-ang University Hospital; Seoul Korea
| | - K.D. Park
- Cancer Research Institute; Seoul National University College of Medicine; Seoul Korea
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul National University College of Medicine; Seoul Korea
| | - H.Y. Shin
- Cancer Research Institute; Seoul National University College of Medicine; Seoul Korea
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul National University College of Medicine; Seoul Korea
| | - J.D. Park
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul National University College of Medicine; Seoul Korea
| | - E.H. Choi
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul National University College of Medicine; Seoul Korea
| | - H.J. Lee
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul National University College of Medicine; Seoul Korea
| | - H.S. Ahn
- Cancer Research Institute; Seoul National University College of Medicine; Seoul Korea
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul National University College of Medicine; Seoul Korea
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Oral Valganciclovir as Preemptive Therapy for Cytomegalovirus Reactivation in Pediatric Hematopoietic Stem Cell Transplant Patients. J Pediatr Hematol Oncol 2015. [PMID: 26207778 DOI: 10.1097/mph.0000000000000397] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cytomegalovirus (CMV) infection is one of the most common complications after allogeneic hematopoietic stem cell transplantations (HSCT). Valganciclovir (VGC) has increasingly been used as prophylaxis against CMV infection after solid organ transplantation, but data on the efficacy and safety of VGC in pediatric HSCT patients are limited. We present our experience with VGC following ganciclovir (GCV) as preemptive therapy in pediatric HSCT patients. A total of 46 patients (38% patients) were found to be positive for CMV reactivation. Patients were treated with GCV (group I, n: 22) or GCV followed by VGC (GCV+VGC, group II, n: 24). VGC was preferred in the treatment of outpatients, whereas inpatients were treated with GCV. There was no significant difference in CMV clearance (P=0.78), treatment duration (P=0.087), and second CMV infection (P=0.3) between the 2 groups. The length of hospital stay was 21 days in GCV group, 14 days in VGC following GCV group (P=0.07). There were no treatment-related side effect in both groups. In conclusion, oral administration of VGC as preemptive therapy was found to be safe and effective. It is also a more suitable application for pediatric patients instead of an intravenous route. It could reduce the duration of inpatient stay and cost of hospitalization.
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Abstract
Human adenoviruses (HAdV) are the cause of many acute infections, mostly in the respiratory and gastrointestinal (GI) tracts, as well as conjunctivitis. HAdV diseases in immunocompetent individuals are mostly self-limiting; however, in immunocompromised individuals, especially in pediatric units, HAdV infections are the cause of high morbidity and mortality. Despite the significant clinical impact, there are currently no approved antiviral therapies for HAdV infections. Here, we provide an overview of the different targets that could be considered for the design of specific drugs against HAdV, as well as the available in vitro and in vivo tools for the screening and evaluation of candidate molecules.
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7
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Jain NA, Lu K, Ito S, Muranski P, Hourigan CS, Haggerty J, Chokshi PD, Ramos C, Cho E, Cook L, Childs R, Battiwalla M, Barrett AJ. The clinical and financial burden of pre-emptive management of cytomegalovirus disease after allogeneic stem cell transplantation-implications for preventative treatment approaches. Cytotherapy 2014; 16:927-33. [PMID: 24831837 DOI: 10.1016/j.jcyt.2014.02.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 02/24/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AIMS Although cytomegalovirus (CMV) infection after allogeneic stem cell transplantation (SCT) is rarely fatal, the management of CMV by pre-emptive medication for viral reactivation has toxicity and carries a financial burden. New strategies to prevent CMV reactivation with vaccines and antiviral T cells may represent an advance over pre-emptive strategies but have yet to be justified in terms of transplantation outcome and cost. METHODS We compared outcomes and post-transplantation treatment cost in 44 patients who never required pre-emptive CMV treatment with 90 treated patients undergoing SCT at our institute between 2006 and 2012. Eighty-one subjects received CD34+ selected myeloablative SCT, 12 umbilical cord blood transplants, and 41 T-replete non-myeloablative SCT. One hundred nineteen patients (89%) were at risk for CMV because either the donor or recipient was seropositive. Of these, 90 patients (75.6%) reactivated CMV at a median of 30 (range 8-105) days after transplantation and received antivirals. RESULTS There was no difference in standard transplantation risk factors between the two groups. In multivariate modeling, CMV reactivation >250 copies/mL (odds ratio = 3, P < 0.048), total duration of inpatient IV antiviral therapy (odds ratio = 1.04, P < 0.001), type of transplantation (T-deplete vs. T-replete; odds ratio = 4.65, P < 0.017) were found to be significantly associated with increased non-relapse mortality. The treated group incurred an additional cost of antiviral medication and longer hospitalization within the first 6 months after SCT of $58,000 to $74,000 per patient. CONCLUSIONS Our findings suggest that to prevent CMV reactivation, treatment should be given within 1 week of SCT. Preventative treatment may improve outcome and have significant cost savings.
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Affiliation(s)
- Natasha A Jain
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Kit Lu
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Sawa Ito
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Pawel Muranski
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Christopher S Hourigan
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Janice Haggerty
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Puja D Chokshi
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Catalina Ramos
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Elena Cho
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa Cook
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Richard Childs
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Minoo Battiwalla
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
| | - A John Barrett
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
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Yu ZP, Ding JH, Chen BA, Li YF, Ding BH, Qian J. An anti-human thymocyte globulin-based reduced-intensity conditioning regimen is associated with a higher quality of life and lower organ toxicity without affecting lymphocyte reconstitution. PLoS One 2013; 8:e73755. [PMID: 24040055 PMCID: PMC3767797 DOI: 10.1371/journal.pone.0073755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 07/22/2013] [Indexed: 11/27/2022] Open
Abstract
Reduced-intensity (RIT) conditioning regimens are gaining increased attention as a result of their advantages and efficacy. However, no data are available regarding whether these regimens improve patient quality of life (QoL). In our study, health-related QoL (HRQoL) was retrospectively assessed in 111 patients with hematological malignancies. Analysis of the Quality of Life Questionnaire indicated that 35 of the RIT patients were able to perform their normal work and returned to their baseline levels of function 2 to 3 months after transplantation. In the myeloablative (MA) group, only 24 patients were able to resume work, and these patients returned to their baseline levels of function 6 to 8 months after transplantation (68.6% vs. 40.0%, P = 0.004). Grade III–IV organ toxicity occurred in 20% of the RIT patients and in 52% of the MA patients (P = 0.001), and the cumulative incidences of grades III–IV acute graft-versus-host disease (GVHD) were 13.7% and 35.0% in RIT and MA patients, respectively (P = 0.015). In conclusion, the RIT conditioning regimens were well tolerated by the patients, with a low incidence of transplant-related mortality (TRM) and serious acute GVHD. In addition, these regimens minimized procedure-related toxicity, improved QoL and did not influence lymphocyte reconstitution; however, OS was similar for both regimens because the relapse rate was relatively increased in the RIT groups.
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Affiliation(s)
- Zheng-Ping Yu
- Department of Hematology (Key Department of Jiangsu Medicine), ZhongDa Hospital, Southeast University, Nanjing, China
| | - Jia-Hua Ding
- Department of Hematology (Key Department of Jiangsu Medicine), ZhongDa Hospital, Southeast University, Nanjing, China
- * E-mail:
| | - Bao-An Chen
- Department of Hematology (Key Department of Jiangsu Medicine), ZhongDa Hospital, Southeast University, Nanjing, China
| | - Yu-Feng Li
- Hematology Division, Huaian Hospital, Nanjing Medical University, Huaian, China
| | - Bang-He Ding
- Hematology Division, Huaian Hospital, Nanjing Medical University, Huaian, China
| | - Jun Qian
- Hematology Division, Zhenjiang Hospital, Zhenjiang Medical University, Zhenjiang, China
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Mehta PS, Wiernikowski JT, Petrilli JAS, Barr RD. Essential medicines for pediatric oncology in developing countries. Pediatr Blood Cancer 2013; 60:889-91. [PMID: 23450774 DOI: 10.1002/pbc.24476] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 12/26/2012] [Indexed: 11/11/2022]
Abstract
The burden of cancer in children in low and middle income countries (LMICs) is substantial, comprising at least 80% of incident cases globally, and an even higher proportion of cancer-related deaths. With survival rates exceeding 80% in high income countries, it is imperative to transfer these successes to LMICs. A major challenge is the poor availability of safe, cost-effective chemotherapy. A list of 51 drugs-chemotherapeutics, infectious disease agents, and supportive care medications-is proposed as essential to improving the survival of children with cancer in LMICs with an additional 13 drugs identified as being of further value.
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Affiliation(s)
- Parth S Mehta
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas 77094, USA.
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10
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Yu ZP, Ding JH, Wu F, Liu J, Wang J, Cheng J, Zhao G. Quality of Life of Patients after Allogeneic Hematopoietic Stem Cell Transplantation with Antihuman Thymocyte Globulin. Biol Blood Marrow Transplant 2012; 18:593-9. [DOI: 10.1016/j.bbmt.2011.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Accepted: 08/11/2011] [Indexed: 10/17/2022]
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Park SY, Lee SO, Choi SH, Kim YS, Woo JH, Baek S, Sung H, Kim MN, Kim DY, Lee JH, Lee JH, Lee KH, Kim SH. Efficacy and safety of low-dose ganciclovir preemptive therapy in allogeneic haematopoietic stem cell transplant recipients compared with conventional-dose ganciclovir: a prospective observational study. J Antimicrob Chemother 2012; 67:1486-92. [PMID: 22354954 DOI: 10.1093/jac/dks043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We performed a prospective observational study comparing the efficacy and safety of low-dose ganciclovir (5 mg/kg/day) as initial preemptive therapy in allogeneic haematopoietic stem cell transplantation (HSCT) recipients with conventional-dose ganciclovir (10 mg/kg/day). METHODS All adult patients undergoing allogeneic HSCT were enrolled at a transplant centre over a 24 month period. The decision to use low-dose or conventional-dose ganciclovir was at the discretion of each attending haematologist. A logistic regression model with inverse probability of treatment weighting (IPTW) using propensity scores was performed to reduce the effect of the selection bias in assignment for ganciclovir preemptive therapy. RESULTS Of the 252 HSCT recipients, 97 (38%) received preemptive ganciclovir therapy. Of these, 53 (55%) and 44 (45%) received low-dose and conventional-dose ganciclovir, respectively. The viral clearance rate was higher in the low-dose ganciclovir group [98% (52/53)] than in the conventional-dose ganciclovir group [86% (38/44), P = 0.04], while the low-dose ganciclovir group exhibited a longer viral clearance time (median 21.0 days) than the conventional-dose ganciclovir group (median 14.0 days, P = 0.05). The rate of discontinuation of therapy due to neutropenia or nephrotoxicity was similar in the two groups, although conventional-dose ganciclovir was changed to another regimen more frequently than low-dose ganciclovir. There were three cases of cytomegalovirus (CMV) disease in each group after the initial preemptive therapy. The logistic regression models using propensity scores also revealed that there were no significant differences in viral clearance, secondary episodes of CMV infection, CMV disease and overall mortality between the two groups. CONCLUSIONS Low-dose ganciclovir appears to be safe, and to be at least as effective as conventional-dose ganciclovir for CMV viraemia in allogeneic HSCT recipients.
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Affiliation(s)
- So-Youn Park
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-dong, Songpa-gu, Seoul, Republic of Korea
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12
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Chawla J, Ghobadi A, Mosley J, Verkruyse L, Trinkaus K, Abboud C, Cashen A, Stockerl-Goldstein K, Uy G, Westervelt P, DiPersio J, Vij R. Oral valganciclovir versus ganciclovir as delayed pre-emptive therapy for patients after allogeneic hematopoietic stem cell transplant: a pilot trial (04-0274) and review of the literature. Transpl Infect Dis 2011; 14:259-67. [DOI: 10.1111/j.1399-3062.2011.00689.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 07/01/2011] [Accepted: 08/28/2011] [Indexed: 11/29/2022]
Affiliation(s)
- J.S. Chawla
- Division of Oncology; Washington University School of Medicine; Saint Louis; Missouri; USA
| | - A. Ghobadi
- Division of Oncology; Washington University School of Medicine; Saint Louis; Missouri; USA
| | - J. Mosley
- Division of Oncology; Washington University School of Medicine; Saint Louis; Missouri; USA
| | - L. Verkruyse
- Division of Oncology; Washington University School of Medicine; Saint Louis; Missouri; USA
| | - K. Trinkaus
- Biostatistics; Washington University School of Medicine; Saint Louis; Missouri; USA
| | - C.N. Abboud
- Division of Oncology; Washington University School of Medicine; Saint Louis; Missouri; USA
| | - A.F. Cashen
- Division of Oncology; Washington University School of Medicine; Saint Louis; Missouri; USA
| | | | - G.L. Uy
- Division of Oncology; Washington University School of Medicine; Saint Louis; Missouri; USA
| | - P. Westervelt
- Division of Oncology; Washington University School of Medicine; Saint Louis; Missouri; USA
| | - J.F. DiPersio
- Division of Oncology; Washington University School of Medicine; Saint Louis; Missouri; USA
| | - R. Vij
- Division of Oncology; Washington University School of Medicine; Saint Louis; Missouri; USA
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13
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Kim ST, Lee MH, Kim SY, Kim SJ, Kim DH, Jang JH, Kim K, Kim WS, Jung CW. A randomized trial of preemptive therapy for prevention of cytomegalovirus disease after allogeneic hematopoietic stem cell transplantation. Int J Hematol 2010; 91:886-91. [PMID: 20454943 DOI: 10.1007/s12185-010-0580-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Revised: 02/26/2010] [Accepted: 04/19/2010] [Indexed: 11/25/2022]
Abstract
We studied the efficacy of two different doses of ganciclovir to prevent cytomegalovirus (CMV) disease in allogeneic hematopoietic stem cell transplantation (HSCT) recipients. We randomly assigned allogeneic HSCT recipients who had CMV infection to receive preemptive ganciclovir therapy with or without induction phase (5 mg/kg twice daily for 1 week). Thirty-two and thirty-six patients were randomized to the standard and the low-dose therapy group, respectively. The median time to CMV antigenemia or viremia clearance was 7 days (3-25 days) in the standard therapy group versus 11 days (3-69 days) in the low-dose therapy group (P = 0.540). The incidence of CMV disease was similar between the two groups (P = 0.366). The Kaplan-Meier estimate of event-free survival by day 180 after HSCT was 76.2% in the standard therapy group versus 66.7% in the low-dose therapy group (P = 0.590). Severe neutropenia (<0.5 x 10(9)/L) was observed in four (12.5%) patients in the standard therapy group versus two (5.6%) patients in the low-dose therapy group (P = 0.314). This study suggests that a low-dose ganciclovir preemptive therapy can be as effective as the standard-dose ganciclovir preemptive therapy for the prevention of CMV disease in allogeneic HSCT recipients.
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Affiliation(s)
- Seung Tae Kim
- Division of Hematology-Oncology, Department of Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
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Intensive care unit mortality trends in children after hematopoietic stem cell transplantation: a meta-regression analysis. Crit Care Med 2008; 36:2898-904. [PMID: 18766109 DOI: 10.1097/ccm.0b013e318186a34a] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is ongoing discussion whether intensive care unit mortality has decreased over time for children after hematopoietic stem cell transplantation. OBJECTIVE To analyze intensive care unit mortality trends in children after hematopoietic stem cell transplantation. DATA SOURCES Search of MEDLINE, EMBASE, and Cochrane databases, and a manual review of reference lists. STUDY SELECTION Prospective and retrospective cohort studies containing intensive care unit mortality data of children after hematopoietic stem cell transplantation. DATA EXTRACTION Mortality statistics and features associated with mortality were abstracted from studies of interest. To assess mortality over time, the median years of inclusion in original studies were included as risk factor. A multiple random-effects meta-regression analysis was conducted to assess the independent contribution of prognostic factors on mortality. DATA SYNTHESIS Twenty-three studies were included, reporting on 1101 intensive care unit admissions. Overall intensive care unit mortality was 60% (range, 25%-91%). Once mechanical ventilation was necessary (n = 822), mean intensive care unit mortality was 71% (range, 25%-91%). Over the years, significantly fewer intensive care unit admitted patients received mechanical ventilation (p < 0.001). Univariable analysis in all intensive care unit admitted patients showed a significant decrease in mortality associated with year of inclusion. Mechanical ventilation and pulmonary disease were associated with increased mortality. In the multiple meta-regression analysis, only pulmonary disease remained significantly associated with mortality (odds ratio = 1.21, 95% confidence interval 1.01-1.46 per 10% increase in the number of patients with pulmonary disease in studies). The association between year of inclusion and intensive care unit mortality was less pronounced (odds ratio = 0.92, 95% confidence interval 0.84-1.01). CONCLUSION There is a widely held impression that intensive care unit mortality clearly decreased in children after hematopoietic stem cell transplantation. However, characteristics of intensive care unit admitted patients significantly changed over time. After correcting for this, an improvement in intensive care unit survival was less evident. More studies are needed before a true improvement in intensive care unit survival can be confirmed.
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Preemptive therapy with ganciclovir 5 mg/kg once daily for cytomegalovirus infection after unrelated cord blood transplantation. Bone Marrow Transplant 2007; 41:371-6. [PMID: 17982495 DOI: 10.1038/sj.bmt.1705910] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The efficacy and safety of preemptive therapy using ganciclovir (GCV) 5 mg/kg once daily for CMV infection after unrelated cord blood transplantation (CBT) were studied. The initial preemptive therapy with GCV 5 mg/kg once daily led to resolution of CMV antigenemia in 25 of 34 patients (74%). In the remaining 9 patients (26%), antigenemia resolved after dose-escalation of GCV or change to foscarnet therapy. Recurrence of antigenemia was seen in 18 patients (53%). A total of 12 patients received the second preemptive therapy with GCV 5 mg/kg once daily, which led to resolution of antigenemia in 11 of 12 patients (92%). The remaining 1 patient (8%) required change to foscarnet therapy. None of 34 patients developed CMV disease. Neutropenia with an absolute neutrophil number of less than 1 and 0.5 x 10(9) per liter after GCV therapy occurred in 12 (35%) and 1 (3%) patients, respectively, after the initial therapy, and in 2 (17%) and 0 (0%) patients, respectively, after the second therapy. No patients developed neutropenic fever or secondary graft failure after GCV therapy. There were no deaths directly attributable to GCV therapy. The present study suggests that antigenemia-based preemptive strategy using GCV 5 mg/kg once daily is feasible and effective for CBT recipients.
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Abstract
OBJECTIVE To review the available clinical data on the critical care complications of hematopoietic stem cell transplantation (HSCT). DATA SOURCE The MEDLINE database and references from the identified articles related to the critical care in HSCT. CONCLUSION HSCT is an important treatment for a variety of malignant and nonmalignant conditions. The procedure is, however, limited by significant complications that may involve every organ of the body. Up to 40% of HSCT recipients are admitted to the intensive care unit as a result of severe complications related to the transplantation. The outcome of those critically ill patients has been traditionally poor. However, recent advances in the transplantation procedure, diagnostic studies, antimicrobial prophylaxis and therapy, and intensive care unit care have improved the outcome of these patients. The increasing number of HSCTs performed annually, the unique complications that develop in these patients, and the improvement in the intensive care unit outcome make knowledge about the critical care aspect of HSCT an essential part of the current practice of critical care medicine.
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Affiliation(s)
- Ayman O Soubani
- Division of Pulmonary, Critical Care, and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
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Verkruyse LA, Storch GA, Devine SM, Dipersio JF, Vij R. Once daily ganciclovir as initial pre-emptive therapy delayed until threshold CMV load ⩾10000 copies/ml: a safe and effective strategy for allogeneic stem cell transplant patients. Bone Marrow Transplant 2005; 37:51-6. [PMID: 16284613 DOI: 10.1038/sj.bmt.1705213] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Quantitative polymerase chain reaction (QPCR) for cytomegalovirus (CMV) is emerging as the preferred screening method for detection of CMV viremia in patients following allogeneic bone marrow and peripheral blood stem cell transplant. However, there are currently no universally accepted QPCR treatment thresholds at which to start pre-emptive therapy. We report here results of a pre-emptive therapy strategy using ganciclovir (GCV) 5 mg/kg initiated once daily (ODG) delayed till a threshold CMV load of > or =10 000 copies/ml whole blood in clinically stable patients. Sixty-nine at risk patients underwent allogeneic stem cell transplant. 48/69 (70%) patients had an initial episode of CMV viremia. 5/48 (10%) cleared viremia without requiring treatment. 28/43 (65%) patients requiring treatment initiated treatment with ODG. 17/28 (61%) patients successfully cleared CMV viremia on ODG, 10/28 (36%) patients required dose escalation to twice daily GCV for increasing viral loads. There were two cases of CMV disease (colitis) and no deaths due to CMV disease in patients initiating treatment with ODG. We conclude delaying pre-emptive therapy with ODG until whole blood QPCR> or =10 000 copies/ml is a safe and effective strategy for CMV viremia after allogeneic stem cell transplant in clinically stable patients.
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Affiliation(s)
- L A Verkruyse
- Section of Bone Marrow Transplantation and Leukemia, Washington University School of Medicine, St Louis, MO 63110, USA
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Ji SQ, Chen HR, Yan HM, Wang HX, Liu J, Zhu PY, Xiao MH, Xun CQ. Anti-CD25 monoclonal antibody (basiliximab) for prevention of graft-versus-host disease after haploidentical bone marrow transplantation for hematological malignancies. Bone Marrow Transplant 2005; 36:349-54. [PMID: 15968293 DOI: 10.1038/sj.bmt.1705046] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Haploidentical donors are available for most patients who need allografts but do not have matched donors. However, GVHD, rejection, delayed immune reconstitution, and infections have been significant barriers. We designed a haploidentical BMT protocol focusing on prevention of GVHD and rejection. A total of 53 leukemic patients underwent haploidentical G-CSF-primed BMT without ex vivo T-cell depletion. GVHD prophylaxis consisted of antithymocyte globulin, cyclosporine, methotrexate, and mycophenolate mofetil. In all, 38 patients (the CD25 group) received additional anti-CD25 monoclonal antibody basiliximab. The results were compared to 15 patients who did not receive basiliximab. All patients achieved trilineage engraftment with full-donor chimerism. The incidence of acute II-IV GVHD was 11% in the CD25 group vs 33% in the control group (P=0.046). The overall incidence of extensive chronic GVHD was 15%. T, B, and NK cells recovered within 12 months post transplant. The disease-free survival at 2 years was 53% with a median follow-up of 31 months. In conclusion, G-CSF primed haploidentical BMT along with sequential immunosuppressive agents as described here deserves further study.
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Affiliation(s)
- S-Q Ji
- Research Institution of Hematology, and Air Force General Hospital, Air Force of China, PLA, Beijing, PR China
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Antiviral drugs. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s0378-6080(05)80451-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Kotloff RM, Ahya VN, Crawford SW. Pulmonary complications of solid organ and hematopoietic stem cell transplantation. Am J Respir Crit Care Med 2004; 170:22-48. [PMID: 15070821 DOI: 10.1164/rccm.200309-1322so] [Citation(s) in RCA: 231] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The ability to successfully transplant solid organs and hematopoietic stem cells represents one of the landmark medical achievements of the twentieth century. Solid organ transplantation has emerged as the standard of care for select patients with severe vital organ dysfunction and hematopoietic stem cell transplantation has become an important treatment option for patients with a wide spectrum of nonmalignant and malignant hematologic disorders, genetic disorders, and solid tumors. Although advances in surgical techniques, immunosuppressive management, and prophylaxis and treatment of infectious diseases have made long-term survival an achievable goal, transplant recipients remain at high risk for developing a myriad of serious and often life-threatening complications. Paramount among these are pulmonary complications, which arise as a consequence of the immunosuppressed status of the recipient as well as from such factors as the initial surgical insult of organ transplantation, the chemotherapy and radiation conditioning regimens that precede hematopoietic stem cell transplantation, and alloimmune mechanisms mediating host-versus-graft and graft-versus-host responses. As the population of transplant recipients continues to grow and as their care progressively shifts from the university hospital to the community setting, knowledge of the pulmonary complications of transplantation is increasingly germane to the contemporary practice of pulmonary medicine.
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Affiliation(s)
- Robert M Kotloff
- Section of Advanced Lung Disease and Lung Transplantation, Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Medical Center, 838 West Gates, 3400 Spruce Street, Philadelphia, PA 19027, USA.
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