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Melenotte C, Aimanianda V, Slavin M, Aguado JM, Armstrong-James D, Chen YC, Husain S, Van Delden C, Saliba F, Lefort A, Botterel F, Lortholary O. Invasive aspergillosis in liver transplant recipients. Transpl Infect Dis 2023:e14049. [PMID: 36929539 DOI: 10.1111/tid.14049] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Liver transplantation is increasing worldwide with underlying pathologies dominated by metabolic and alcoholic diseases in developed countries. METHODS We provide a narrative review of invasive aspergillosis (IA) in liver transplant (LT) recipients. We searched PubMed and Google Scholar for references without language and time restrictions. RESULTS The incidence of IA in LT recipients is low (1.8%), while mortality is high (∼50%). It occurs mainly early (<3 months) after LT. Some risk factors have been identified before (corticosteroid, renal, and liver failure), during (massive transfusion and duration of surgical procedure), and after transplantation (intensive care unit stay, re-transplantation, re-operation). Diagnosis can be difficult and therefore requires full radiological and clinicobiological collaboration. Accurate identification of Aspergillus species is recommended due to the cryptic species, and susceptibility testing is crucial given the increasing resistance of Aspergillus fumigatus to azoles. It is recommended to reduce the dose of tacrolimus (50%) and to closely monitor the trough level when introducing voriconazole, isavuconazole, and posaconazole. Surgery should be discussed on a case-by-case basis. Antifungal prophylaxis is recommended in high-risk patients. Environmental preventative measures should be implemented to prevent outbreaks of nosocomial aspergillosis in LT recipient units. CONCLUSION IA remains a very serious disease in LT patients and should be promptly sought and, if possible, prevented by clinicians when risk factors are identified.
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Affiliation(s)
- Cléa Melenotte
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker Enfants-Malades, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Cité, Paris, France
| | - Vishukumar Aimanianda
- Institut Pasteur, CNRS, National Reference Center for Invasive Mycoses and Antifungals, Molecular Mycology Unit, UMR2000, Paris, France
| | - Monica Slavin
- Department of Infectious Diseases, National Center for Infections in Cancer, Sir Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Center, University of Melbourne, Melbourne, Australia
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, Universidad Complutense, Madrid, Spain
| | | | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Shahid Husain
- Department of Transplant Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christian Van Delden
- Transplant Infectious Diseases Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
| | - Agnès Lefort
- Université de Paris, IAME, UMR 1137, INSERM, Paris, France.,Service de Médecine Interne, Hôpital Beaujon, AP-HP, Clichy, France
| | - Francoise Botterel
- EA Dynamyc 7380 UPEC, ENVA, Faculté de Médecine, Créteil, France.,Unité de Parasitologie-Mycologie, Département de Virologie, Bactériologie-Hygiène, Mycologie-Parasitologie, DHU VIC, CHU Henri Mondor, Créteil, France
| | - Olivier Lortholary
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker Enfants-Malades, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Cité, Paris, France.,Institut Pasteur, CNRS, National Reference Center for Invasive Mycoses and Antifungals, Molecular Mycology Unit, UMR2000, Paris, France.,Paris University, Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants Malades Hospital, AP-HP, IHU Imagine, Paris, France
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2
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Badiee P, Ghasemi F, Jafarian H. Role of biomarkers in the diagnosis of invasive aspergillosis in immunocompromised patients. Ann Clin Microbiol Antimicrob 2022; 21:44. [PMID: 36320074 PMCID: PMC9628095 DOI: 10.1186/s12941-022-00539-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 10/20/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Invasive aspergillosis is one of the important causes of infection in immunocompromised patients. This study aimed to evaluate the roles of biomarkers in the diagnosis of invasive aspergillosis and their relationship with antifungal stewardship programs. METHODS 190 sera from 52 immunocompromised patients and volunteer individuals were included in this study. 18 immunocompromised volunteers without IA and 34 patients with probable and proven aspergillosis according to the European Organization for Research and Treatment of Cancer and the Mycoses Study Group consensus definitions were entered in this study. The respective sera were evaluated for procalcitonin, soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) levels; white blood cells count (WBC) count, C reactive protein (CRP), lactate dehydrogenase (LDH), and erythrocyte sedimentation rate (ESR) values. Demographic data and clinical characteristics of patients were extracted from their files. RESULTS The male-to-female ratio and mean age of patients were 22/12 and 38.9 years, respectively. The hematologic disorder was the most predisposing factor (29/34, 85.3%). Sensitivity of biomarkers for diagnosis of invasive aspergillosis was 70.6% (cut off value > 190 pg/mL for sTREM-1, 71% (cut off value > 260 pg/mL) for PCT, 85.3% (cut off value > 193 U/L) for LDH, 94.1% (cut off value > 8 mg/l) for CRP, 64.7% (cut off value < 5200 cells/ml) for WBC, and 85.3% (cut off value > 23 mm/h) for ESR. Twelve patients died, with significantly increased sTREM-1 levels and decreased WBC count in them. CONCLUSION According to our data, evaluation of the biomarkers can help in the diagnosis, management, and prediction of the severity of Aspergillus infection, and the rational use of antifungal agents in immunocompromised patients.
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Affiliation(s)
- Parisa Badiee
- grid.412571.40000 0000 8819 4698Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Ghasemi
- grid.412571.40000 0000 8819 4698Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hadis Jafarian
- grid.412571.40000 0000 8819 4698Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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3
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Role of Iron and Iron Overload in the Pathogenesis of Invasive Fungal Infections in Patients with Hematological Malignancies. J Clin Med 2022; 11:jcm11154457. [PMID: 35956074 PMCID: PMC9369168 DOI: 10.3390/jcm11154457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 02/04/2023] Open
Abstract
Iron is an essential trace metal necessary for the reproduction and survival of fungal pathogens. The latter have developed various mechanisms to acquire iron from their mammalian hosts, with whom they participate in a continuous struggle for dominance over iron. Invasive fungal infections are an important problem in the treatment of patients with hematological malignancies, and they are associated with significant morbidity and mortality. The diagnosis of invasive clinical infections in these patients is complex, and the treatment, which must occur as early as possible, is difficult. There are several studies that have shown a possible link between iron overload and an increased susceptibility to infections. This link is also relevant for patients with hematological malignancies and for those treated with allogeneic hematopoietic stem cell transplantation. The role of iron and its metabolism in the virulence and pathogenesis of various invasive fungal infections is intriguing, and so far, there is some evidence linking invasive fungal infections to iron or iron overload. Clarifying the possible association of iron and iron overload with susceptibility to invasive fungal infections could be important for a better prevention and treatment of these infections in patients with hematological malignancies.
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4
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Chaya W, Anurathapan U, Rattanasiri S, Techasaensiri C, Pakakasama S, Apiwattanakul N. Bloodstream bacterial infections in thalassemic pediatric and adolescent patients after hematopoietic stem cell transplantation. Pediatr Transplant 2022; 26:e14168. [PMID: 34668623 DOI: 10.1111/petr.14168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/14/2021] [Accepted: 10/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Thalassemic patients usually require regular blood transfusions; however, HSCT can provide a cure. Incidence of IBI in pediatric patients post-HSCT is still scant. OBJECTIVES This study aimed to explore whether thalassemic patients had a different incidence of post-HSCT IBI compared with patients with other underlying diseases. Factors associated with IBI in the pediatric population undergoing HSCT were also investigated. METHODS In this retrospective cohort study, clinical data of pediatric patients who underwent HSCT during the period from 2011 to 2016 were reviewed and analyzed. The primary outcome was incidence of IBI within 1-year post-HSCT. RESULTS Of 123 patients, 53 were thalassemic. IBI was diagnosed in 23 patients within 1 year after HSCT (incidence: 19.5 episodes/1000 patients/month). The IBI incidence was lower in thalassemic patients than in patients with other underlying diseases (6.9 vs. 31.6 episodes/1000 patients/month). Having thalassemia as an underlying disease was the only factor associated with lower IBI in pediatric post-HSCT patients (hazard ratio: 0.245; 95% confidence interval, 0.080-0.748). In post-HSCT thalassemic patients, IBI mostly occurred within 100 days after HSCT, and most of these cases had catheter-related blood stream infection. The risk of IBI tended higher for haploidentical HSCT, but this difference was not statistically significantly different. CONCLUSION The IBI incidence after HSCT was lower in thalassemic patients than in those with other underlying diseases. Catheter-related blood stream infection was the major IBI in these patients. IBI was not a major complication in thalassemic pediatric patients undergoing HSCT.
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Affiliation(s)
- Weerapong Chaya
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Pediatrics, Sawanpracharak Hospital, Nakhon Sawan, Thailand
| | - Usanarat Anurathapan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sasivimol Rattanasiri
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonnamet Techasaensiri
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Samart Pakakasama
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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5
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Efficacy and Safety of Iron Chelation Therapy After Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Thalassemia Patients: A Retrospective Observational Study. J Pediatr Hematol Oncol 2022; 44:e26-e34. [PMID: 34986131 DOI: 10.1097/mph.0000000000002328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 07/02/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Studies on the increased body iron load in patients with thalassemia major have thoroughly demonstrated the problems caused by iron overload. In patients who undergo hematopoietic stem cell transplantation (HSCT) as curative therapy, iron overload continues long after transplantation. There are few pediatric studies on chelation therapy in the posttransplant period. In this study, we present the outcomes of our patients who received posttransplant oral chelation therapy. PATIENTS AND METHODS This retrospective observational study evaluated the outcomes of pediatric patients with thalassemia major who used oral chelation therapy after allogeneic HSCT at the Akdeniz University Pediatric Bone Marrow Unit between January 2008 and October 2019. RESULTS Deferasirox therapy was initiated in 58 pediatric patients who underwent HSCT for thalassemia. Pretreatment mean serum ferritin was 2166±1038 ng/mL. Treatment was initiated at a mean of 12±6.7 months after transplantation and continued for a mean of 15.7±11.5 months. At treatment discontinuation, the mean serum ferritin was 693±405 ng/mL and the mean reduction was -1472.75±1121.09 ng/mL (P<0.001 vs. posttreatment). Serum ferritin was below 500 ng/mL in 52% of the patients at treatment discontinuation. Manageable side effects such as nausea, vomiting, liver enzyme elevation, and proteinuria were observed in 17% of the patients, while one patient developed ototoxicity. CONCLUSIONS Deferasirox therapy effectively reduces iron overload in the posttransplant period. Studies evaluating the effects of early treatment on the graft may help to establish guidelines for posttransplant chelation therapy. Clear guidelines are needed regarding when to initiate and discontinue treatment.
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Wiriyachai T, Chaya W, Anurathapan U, Rattanasiri S, Boonsathorn S, Chaisavaneeyakorn S, Techasaensiri C, Apiwattanakul N. Association between adenovirus infection and mortality outcome among pediatric patients after hematopoietic stem cell transplant. Transpl Infect Dis 2021; 23:e13742. [PMID: 34614296 DOI: 10.1111/tid.13742] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/18/2021] [Accepted: 09/24/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adenovirus can cause severe diseases in post-hematopoietic stem cell transplant (HSCT) patients. Because these patients also have many other factors contributing to mortality, it remains controversial whether adenovirus infection itself contributes to increased mortality in these patients. OBJECTIVE To determine if adenovirus infection contributes to mortality in pediatric post-HSCT patients. METHODS This retrospective cohort study was performed in post HSCT patients, aged 0-18 years old, admitted at Ramathibodi Hospital from 2016 to 2020. Adenovirus infection was defined as the detection of adenovirus in blood or urine by polymerase chain reaction. Multivariate cox regression was used to identify factors associated with death. RESULTS The incidence of overall adenovirus infection (viremia or viruria) in this cohort was 20.8% (26 out of 125 enrolled patients). From the multivariate cox regression analysis, overall adenovirus infection was not significantly associated with death (hazard ratio [HR]: 2.41; 95% confidence interval [CI]: 0.96-6.06; p = .060). However, presence of viremia (HR: 3.90; 95% CI: 1.40-10.86; p = .009), having maximal serum viral load > 10 000 copies/ml (HR: 3.70; 95% CI: 1.20-11.38; p = .023), presence of end-organ diseases (HR: 3.44; 95% CI: 1.18-10.01; p = .023) were associated with mortality. Underlying diseases requiring long-term immunosuppressive drugs before HSCT, invasive fungal disease, invasive bacterial infection, cytomegalovirus infection, and longer engraftment time were also associated with mortality. CONCLUSION Overall adenovirus infection does not appear to play a significant role in mortality in pediatric post-HSCT patients. However, more invasive forms of adenovirus infection were associated with mortality in these patients.
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Affiliation(s)
- Thakoon Wiriyachai
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Weerapong Chaya
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Pediatrics, Sawanpracharak Hospital, Nakhorn Swarn, Thailand
| | - Usanarat Anurathapan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sasivimol Rattanasiri
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sophida Boonsathorn
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sujittra Chaisavaneeyakorn
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonnamet Techasaensiri
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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7
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Itsaradisaikul S, Pakakasama S, Boonsathorn S, Techasaensiri C, Rattanasiri S, Apiwattanakul N. Invasive Fungal Disease Among Pediatric and Adolescent Patients Undergoing Itraconazole Prophylaxis After Hematopoietic Stem Cell Transplantation. Transplant Proc 2021; 53:2021-2028. [PMID: 33994183 DOI: 10.1016/j.transproceed.2021.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 04/05/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Invasive fungal disease (IFD) is a major cause of morbidity and mortality in patients after hematopoietic stem cell transplantation (HSCT). Itraconazole has been used for prevention of IFD, but data related to incidence and associated factors of IFD in pediatric and adolescent patients on itraconazole prophylaxis remain scarce. OBJECTIVES To identify incidence and risk factors associated with IFD among pediatric and adolescent patients receiving itraconazole prophylaxis after HSCT. METHODS Patients younger than 21 years who received itraconazole prophylaxis after HSCT from January 2007 to December 2016 were retrospectively enrolled. Incidence of IFD within 1 year and associated factors were analyzed. RESULTS All patients received itraconazole during the pre-engraftment period. Of 170 patients, 29 had IFD, with an incidence of 17.1% at 1 year. IFD at 1 year was significantly associated with increased mortality. Of 29 patients with IFD, only 9 developed IFD while on itraconazole prophylaxis (5.3%), all of whom had invasive pulmonary aspergillosis. No invasive candidiasis occurred during itraconazole prophylaxis. Prolonged neutropenia (hazard ratio [HR] = 1.08; 95% confidence interval [CI], 1.02-1.13), graft-versus-host disease within 100 days after transplantation (HR = 3.17; 95% CI, 1.17-8.57), and using etoposide in preconditioning regimens (HR = 21.60; 95% CI, 2.44-190.95) were significantly associated with IFD at 1 year. No patients had to discontinue itraconazole because of its adverse effects. CONCLUSIONS Itraconazole proffered good efficacy for prevention of candidiasis during the pre-engraftment period. Most IFD episodes occurred after the engraftment period when itraconazole had been discontinued. During this period, patients with risk factors require appropriate fungal prophylaxis.
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Affiliation(s)
- Suluk Itsaradisaikul
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Department of Pediatrics, Uttaradit Hospital, Uttaradit, Thailand
| | - Samart Pakakasama
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sophida Boonsathorn
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonnamet Techasaensiri
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sasivimol Rattanasiri
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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8
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Liu L, Gu Y, Wang Y, Shen K, Su X. The Clinical Characteristics of Patients With Nonneutropenic Invasive Pulmonary Aspergillosis. Front Med (Lausanne) 2021; 8:631461. [PMID: 33659265 PMCID: PMC7917130 DOI: 10.3389/fmed.2021.631461] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/04/2021] [Indexed: 12/04/2022] Open
Abstract
Objective: The goal of this study was to reveal the clinical manifestations of nonneutropenic invasive pulmonary aspergillosis (IPA), which are different from those of neutropenic patients. Methods: The clinical data of patients with nonneutropenic IPA were collected at the Department of Respiratory and Critical Care Medicine, Jinling Hospital, from February 2009 to November 2019. We analyzed the general conditions, clinical manifestations, imaging findings, and laboratory tests of these IPA patients. Results: A total of 116 patients with nonneutropenic IPA (31 proven and 85 probable) were included. They had an average age of 59.8 years. The most common underlying disease was chronic obstructive pulmonary disease (COPD, n = 33). The common clinical symptoms included cough (93.1%, n = 108), expectoration (59.5%, n = 69), fever (57.8%, n = 67), hemoptysis (30.2%, n = 35), and dyspnea (40.5%, n = 47). The common CT imaging manifestations included consolidation (47.4%, n = 55), cavities (47.4%, n = 55), air crescent sign (14.7%, n = 17), and nodules (8.6%, n = 10). Multiple lesions (74.1%, n = 86) were more common than single lesions (17.2%, n = 20) and diffuse lesions (8.6%, n = 10). The positive rate of laboratory tests was 88.2% (30/34) for BALF galactomannan (GM), 55.4% (56/101) for serum GM, 45.3% (48/106) for 1,3-β-D-glucan (BDG), 43.3% (46/106) for sputum culture, and 36.4% (20/55) for BALF culture. Patients who had high serum GM level [GM optical density index (ODI) >1] were more likely to have severe respiratory symptoms and higher serum ferritin. Further investigation showed that there was a positive correlation between serum GM level and serum ferritin level. Conclusion: The clinical symptoms and radiological manifestations of nonneutropenic IPA are diverse and often lead to delayed diagnosis. It is important to become more vigilant of aspergillosis in nonneutropenic patients in order to achieve early diagnosis and treatment and to reduce mortality.
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Affiliation(s)
- Lulu Liu
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yu Gu
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Yu Wang
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Kunlu Shen
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Southern Medical University, Guangzhou, China
| | - Xin Su
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China.,Department of Respiratory and Critical Care Medicine, Jinling Hospital, Southern Medical University, Guangzhou, China
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9
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Salmi A, Holmström M, Toiviainen-Salo S, Kanerva J, Taskinen M. Iron overload after allogeneic stem cell transplantation in children with acute lymphoblastic leukemia. Pediatr Transplant 2020; 24:e13846. [PMID: 33111465 DOI: 10.1111/petr.13846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/12/2020] [Accepted: 08/04/2020] [Indexed: 01/19/2023]
Abstract
Red blood cell transfusions are an essential part of supporting care in leukemia treatment. We examined the prevalence of iron overload and its effects on organ function and childhood growth in pediatric patients after allogeneic HSCT for acute lymphoblastic leukemia. Twenty-three patients were included (median age 12.6, range 7.5-21.4 years). Body iron load was determined using laboratory tests, hepatic and cardiac MRI, and by calculating iron received from transfusions. We performed multivariate analysis to determine association of body iron load with liver enzymes, cardiac function, insulin resistance, and growth. Median plasma ferritin was 344 (range 40-3235) ng/mL and exceeded 1000 ng/mL in three patients (13%). In MRI, 11 patients (48%) had hepatic iron overload and 1 patient (4%) myocardial iron overload. In cardiac MRI, 8 patients (35%) had significant but subclinical decrease in ejection fraction (median z-score -1.7, range -3.1-0.14), but cardiac function did not associate with iron status. Alanine transaminase associated with transfused iron per time unit (P = .001) after the median follow-up of 4.5 years. No correlation was found between iron load and growth or insulin resistance. Iron overload is common in children transplanted for ALL, but iron overload associated organ dysfunction is not present at early age. We recommend evaluation of iron load for all patients at least once during follow-up after transplantation.
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Affiliation(s)
- Asta Salmi
- Division of Hematology, Oncology and Stem Cell Transplantation, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miia Holmström
- Department of Pediatric Radiology, HUS Medical Imaging Center, Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sanna Toiviainen-Salo
- Department of Pediatric Radiology, HUS Medical Imaging Center, Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jukka Kanerva
- Division of Hematology, Oncology and Stem Cell Transplantation, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mervi Taskinen
- Division of Hematology, Oncology and Stem Cell Transplantation, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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10
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Nairz M, Weiss G. Iron in infection and immunity. Mol Aspects Med 2020; 75:100864. [PMID: 32461004 DOI: 10.1016/j.mam.2020.100864] [Citation(s) in RCA: 150] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/25/2020] [Accepted: 05/05/2020] [Indexed: 12/12/2022]
Abstract
Iron is an essential micronutrient for virtually all living cells. In infectious diseases, both invading pathogens and mammalian cells including those of the immune system require iron to sustain their function, metabolism and proliferation. On the one hand, microbial iron uptake is linked to the virulence of most human pathogens. On the other hand, the sequestration of iron from bacteria and other microorganisms is an efficient strategy of host defense in line with the principles of 'nutritional immunity'. In an acute infection, host-driven iron withdrawal inhibits the growth of pathogens. Chronic immune activation due to persistent infection, autoimmune disease or malignancy however, sequesters iron not only from infectious agents, autoreactive lymphocytes and neoplastic cells but also from erythroid progenitors. This is one of the key mechanisms which collectively result in the anemia of chronic inflammation. In this review, we highlight the most important interconnections between iron metabolism and immunity, focusing on host defense against relevant infections and on the clinical consequences of anemia of inflammation.
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Affiliation(s)
- Manfred Nairz
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Austria
| | - Günter Weiss
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Austria; Christian Doppler Laboratory for Iron Metabolism and Anemia Research, Medical University of Innsbruck, Austria.
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11
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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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12
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Bauduer F, Recanzone H. Transfusional iron overload in patients receiving autologous stem cell transplantation: An underestimated problem requiring further consideration. Transfus Apher Sci 2020; 59:102837. [PMID: 32540346 DOI: 10.1016/j.transci.2020.102837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Frédéric Bauduer
- Service d'Hématologie, Centre Hospitalier De La Côte Basque, Bayonne, France; Unité d'Hémovigilance, Centre Hospitalier De La Côte Basque, Bayonne, France; Collège Des Sciences De La Santé, Université De Bordeaux, Bordeaux, France.
| | - Hervé Recanzone
- Unité d'Hémovigilance, Centre Hospitalier De La Côte Basque, Bayonne, France
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13
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Iron: an essential nutrient for Aspergillus fumigatus and a fulcrum for pathogenesis. Curr Opin Infect Dis 2019; 31:506-511. [PMID: 30379731 DOI: 10.1097/qco.0000000000000487] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW Aspergillus fumigatus is a ubiquitous saprophytic fungus that can cause life-threatening invasive aspergillosis in immunocompromised patients. Apart from the immune status of the host only a few characterized virulence factors have been identified. In this review, we describe the role of iron in the manifestation of A. fumigatus virulence. RECENT FINDINGS We gathered recent clinical evidence suggesting that tissue iron overload increases the risk of invasive aspergillosis occurrence. Furthermore, we summarize the mechanisms that A. fumigatus employs to achieve iron homeostasis and their importance in A. fumigatus proliferation in vitro. We describe two recent in-vivo models that clearly demonstrate the importance of iron in A. fumigatus growth and invasion. SUMMARY Based on these recent findings, therapy aimed at managing A. fumigatus iron homeostasis locally could make conditions more favorable to the host.
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14
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Leitch HA, Buckstein R, Zhu N, Nevill TJ, Yee KWL, Leber B, Keating MM, St Hilaire E, Kumar R, Delage R, Geddes M, Storring JM, Shamy A, Elemary M, Wells RA. Iron overload in myelodysplastic syndromes: Evidence based guidelines from the Canadian consortium on MDS. Leuk Res 2018; 74:21-41. [PMID: 30286330 DOI: 10.1016/j.leukres.2018.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/08/2018] [Accepted: 09/15/2018] [Indexed: 01/19/2023]
Abstract
In 2008 the first evidence-based Canadian consensus guideline addressing the diagnosis, monitoring and management of transfusional iron overload in patients with myelodysplastic syndromes (MDS) was published. The Canadian Consortium on MDS, comprised of hematologists from across Canada with a clinical and academic interest in MDS, reconvened to update these guidelines. A literature search was updated in 2017; topics reviewed include mechanisms of iron overload induced cellular damage, evidence for clinical endpoints impacted by iron overload including organ dysfunction, infections, marrow failure, overall survival, acute myeloid leukemia progression, and endpoints around hematopoietic stem-cell transplant. Evidence for an impact of iron reduction on the same endpoints is discussed, guidelines are updated, and areas identified where evidence is suboptimal. The guidelines address common questions around the diagnosis, workup and management of iron overload in clinical practice, and take the approach of who, when, why and how to treat iron overload in MDS. Practical recommendations for treatment and monitoring are made. Evidence levels and grading of recommendations are provided for all clinical endpoints examined.
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Affiliation(s)
- Heather A Leitch
- Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada.
| | - Rena Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nancy Zhu
- Hematology/Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Thomas J Nevill
- Leukemia/BMT Program of British Columbia, Division of Hematology, Vancouver, BC, Canada
| | - Karen W L Yee
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Brian Leber
- McMaster University, Hamilton, Ontario, Canada
| | | | - Eve St Hilaire
- Centre d'Oncologie, Dr-Leon-Richard, Moncton, New Brunswick, Canada
| | - Rajat Kumar
- Hematology/Oncology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Robert Delage
- Hematology Department, Centre Hospitalier Universitaire, Laval University, Quebec, QC, Canada
| | - Michelle Geddes
- Department of Medicine/Hematology, Foothills Medical Centre, Calgary, Alberta, Canada
| | | | - April Shamy
- Sir Mortimer B Davis Hospital, McGill University, Montreal, Quebec, Canada
| | - Mohamed Elemary
- Saskatoon Cancer Center, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Richard A Wells
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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15
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Iron overload in patients with myelodysplastic syndromes: An updated overview. Cancer 2018; 124:3979-3989. [DOI: 10.1002/cncr.31550] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/07/2018] [Accepted: 03/22/2018] [Indexed: 01/19/2023]
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16
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Ohara Y, Ito T, Ito M, Yamashita K, Toyokuni S. Acute fulminant invasive pulmonary aspergillosis in an immunocompetent host: An autopsy case report. Med Mycol Case Rep 2018; 20:39-42. [PMID: 29552460 PMCID: PMC5852298 DOI: 10.1016/j.mmcr.2018.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 02/08/2018] [Accepted: 02/08/2018] [Indexed: 11/18/2022] Open
Abstract
A 62-year-old previously healthy male who was a welder/smoker/drinker was admitted to Kani Tono Hospital for severe hypoxemia (Day 0). Initial physical and radiological examinations suggested an acute exacerbation of chronic obstructive pulmonary disease. However, respiratory failure developed rapidly, and he died on Day + 4. Aspergillus fumigatus was identified after his death, and he was diagnosed with invasive pulmonary aspergillosis. The clinical and pathological features are precisely described with pathogenetic considerations.
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Affiliation(s)
- Yuuki Ohara
- Department of Pathology and Biological Responses, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
- Corresponding author.
| | - Takahiko Ito
- Department of Hematology, JCHO Kani Tono Hospital, 1221-5 Dota, Kani 509-0206, Japan
| | - Makoto Ito
- Department of Pathology and Laboratory Medicine, Kariya Toyota General Hospital, 5-15 Sumiyoshi-cho, Kariya 448-0852, Japan
| | - Kyoko Yamashita
- Department of Pathology and Biological Responses, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Shinya Toyokuni
- Department of Pathology and Biological Responses, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
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17
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Hsu JL, Manouvakhova OV, Clemons KV, Inayathullah M, Tu AB, Sobel RA, Tian A, Nazik H, Pothineni VR, Pasupneti S, Jiang X, Dhillon GS, Bedi H, Rajadas J, Haas H, Aurelian L, Stevens DA, Nicolls MR. Microhemorrhage-associated tissue iron enhances the risk for Aspergillus fumigatus invasion in a mouse model of airway transplantation. Sci Transl Med 2018; 10:10/429/eaag2616. [PMID: 29467298 PMCID: PMC5841257 DOI: 10.1126/scitranslmed.aag2616] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 02/23/2017] [Accepted: 09/26/2017] [Indexed: 01/25/2023]
Abstract
Invasive pulmonary disease due to the mold Aspergillus fumigatus can be life-threatening in lung transplant recipients, but the risk factors remain poorly understood. To study this process, we used a tracheal allograft mouse model that recapitulates large airway changes observed in patients undergoing lung transplantation. We report that microhemorrhage-related iron content may be a major determinant of A. fumigatus invasion and, consequently, its virulence. Invasive growth was increased during progressive alloimmune-mediated graft rejection associated with high concentrations of ferric iron in the graft. The role of iron in A. fumigatus invasive growth was further confirmed by showing that this invasive phenotype was increased in tracheal transplants from donor mice lacking the hemochromatosis gene (Hfe-/- ). The invasive phenotype was also increased in mouse syngrafts treated with topical iron solution and in allograft recipients receiving deferoxamine, a chelator that increases iron bioavailability to the mold. The invasive growth of the iron-intolerant A. fumigatus double-knockout mutant (ΔsreA/ΔcccA) was lower than that of the wild-type mold. Alloimmune-mediated microvascular damage and iron overload did not appear to impair the host's immune response. In human lung transplant recipients, positive staining for iron in lung transplant tissue was more commonly seen in endobronchial biopsy sections from transplanted airways than in biopsies from the patients' own airways. Collectively, these data identify iron as a major determinant of A. fumigatus invasive growth and a potential target to treat or prevent A. fumigatus infections in lung transplant patients.
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Affiliation(s)
- Joe L. Hsu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA,Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA
| | - Olga V. Manouvakhova
- Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA
| | - Karl V. Clemons
- Infectious Diseases Research Laboratory, California Institute for Medical Research, San Jose, CA 95128, USA,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Mohammed Inayathullah
- Biomaterials and Advanced Drug Delivery Laboratory, Cardiovascular Pharmacology Division, Cardio-vascular Institute, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Allen B. Tu
- Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA
| | - Raymond A. Sobel
- Veterans Affairs Palo Alto Health Care System, Pathology and Laboratory Service, Palo Alto, CA 94304, USA,Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Amy Tian
- Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA
| | - Hasan Nazik
- Infectious Diseases Research Laboratory, California Institute for Medical Research, San Jose, CA 95128, USA,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Medical Microbiology, Istanbul University School of Medicine, Istanbul, Turkey
| | - Venkata R. Pothineni
- Biomaterials and Advanced Drug Delivery Laboratory, Cardiovascular Pharmacology Division, Cardio-vascular Institute, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Shravani Pasupneti
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA,Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA
| | - Xinguo Jiang
- Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA
| | - Gundeep S. Dhillon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Harmeet Bedi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Jayakumar Rajadas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA,Biomaterials and Advanced Drug Delivery Laboratory, Cardiovascular Pharmacology Division, Cardio-vascular Institute, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Hubertus Haas
- Division of Molecular Biology, Medical University Innsbruck, Innsbruck, Austria
| | - Laure Aurelian
- Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - David A. Stevens
- Infectious Diseases Research Laboratory, California Institute for Medical Research, San Jose, CA 95128, USA,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Mark R. Nicolls
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA,Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA,Corresponding author.
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18
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The Impact of Iron Overload in Acute Leukemia: Chronic Inflammation, But Not the Presence of Nontransferrin Bound Iron is a Determinant of Oxidative Stress. J Pediatr Hematol Oncol 2017; 39:425-439. [PMID: 28731917 DOI: 10.1097/mph.0000000000000867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the literature, studies on the oxidant effects of nontransferrin bound iron [NTBI (eLPI assay)] during chemotherapy of acute lymphoblastic leukemia and acute myeloblastic leukemia are lacking. We established NTBI and oxidative stress determinants (OSD), iron parameters, high-sensitive C-reactive protein (hs-CRP) levels, liver tests, cumulative chemotherapeutic doses, and transfused blood in 36 children with acute leukemia throughout chemotherapy. These parameters were determined at the beginning and end of chemotherapy blocks (11 time points) and in 20 healthy children using enzyme-linked immunosorbent assay, and colorimetric and fluorometric enzymatic methods. In acute lymphoblastic leukemia, NTBI, OSD, and hs-CRP were higher than controls at 4/11, 7/11, and 9/11 time points (P<0.05). At 3 time points, NTBI and OSD concurrently increased. Ferritin, soluble transferrin receptor, serum iron, and transferrin saturation were higher than in controls at 5 to 11/11 time points (P<0.05). Those with NTBI had higher iron parameters than those without NTBI (P<0.05), but showed similar OSD, hs-CRP, liver enzymes, cumulative chemotherapeutics, and transfused blood (P>0.05). OSD did not correlate with NTBI, but correlated with hs-CRP. In conclusion, NTBI is a poor predictor of OSD in acute leukemia possibly because of the heterogeneity of NTBI and chronic inflammation. Further studies are needed to delineate the pathophysiology of these diseases.
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19
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Killick SB. Iron chelation therapy in low risk myelodysplastic syndrome. Br J Haematol 2017; 177:375-387. [DOI: 10.1111/bjh.14602] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Sally B. Killick
- Department of Haematology; Royal Bournemouth Hospital NHS Foundation Trust; Bournemouth UK
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20
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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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21
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Valković T, Gačić V, Ivandić J, Petrov B, Dobrila-Dintinjana R, Dadić-Hero E, Načinović-Duletić A. Infections in Hospitalised Patients with Multiple Myeloma: Main Characteristics and Risk Factors. Turk J Haematol 2017; 32:234-42. [PMID: 26376590 PMCID: PMC4563199 DOI: 10.4274/tjh.2013.0173] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Multiple myeloma is a common haematological malignancy and immune dysfunction is the hallmark of the disease. It leads to an increased infection risk, which is still a major cause of mortality. The infection spectrum and characteristics have evolved with the introduction of novel agents. An understanding of risk factors that increase susceptibility to infections is critical in fighting them. This retrospective investigation aimed to establish the incidence and main characteristics of infections in non-transplanted hospitalised myeloma patients in our department over a 3-year period, as well as factors associated with infections. MATERIALS AND METHODS A total of 240 hospitalised patients with multiple myeloma (120 males and 120 females; average age: 69 years, range: 41-89 years) who were diagnosed or treated in our department from January 2008 to December 2010 were included in this study and their data were retrospectively analysed. RESULTS Infections were identified in 17.9% of hospitalised patients. The most common pathogen found was Pseudomonas aeruginosa. The frequency of gram-positive and gram-negative pathogens was similar. In 37.2% of cases, the agent was not isolated. The most common sites of infections were the urinary system and the blood (septicemia). The frequency of infection increased with duration of disease and the rate of reinfection was 41.9%. The patients treated with bortezomib had the highest infection occurrence. Fatal outcome occurred in 9.3% of cases. CONCLUSION The factors associated with infections in this investigation were female sex, 3B clinical stage of disease, increased serum creatinine and ferritin levels, neutropenia, poor general condition, and presence of catheters. Myeloma patients with one or more of these mentioned risk factors should be monitored with particular care in order to decrease the incidence and severity of infective complications.
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Affiliation(s)
| | | | - Jelena Ivandić
- University Hospital Centre Rijeka, Clinic of Gynaecology and Obstetrics, Rijeka, Croatia Phone: +0038551421426 E-mail:
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22
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Douglas AP, Slavin MA. Risk factors and prophylaxis against invasive fungal disease for haematology and stem cell transplant recipients: an evolving field. Expert Rev Anti Infect Ther 2016; 14:1165-1177. [PMID: 27710140 DOI: 10.1080/14787210.2016.1245613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Due to increasing intensity and complexity of therapies and longer survivorship, many patients with haematologic malignancy (HM) are at risk of invasive fungal disease (IFD). Mortality from IFD is high and treatment of an episode of IFD results in an excess length of hospital stay and costs and delays delivery of curative therapy of the underlying haematologic condition. Therefore, prevention and early recognition and treatment of IFD are crucial. Areas covered: Risk factors particular to certain HMs and haematopoietic stem cell transplantation, as well as those risk factors universal to all HM groups are examined. Expert commentary: Risk stratification identifies those patients who would benefit most from mould active versus yeast active prophylaxis and those who can be safely managed with monitoring and clinically driven interventions for IFD. This approach aids in antifungal stewardship.
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Affiliation(s)
- Abby P Douglas
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , Melbourne , VIC , Australia
| | - Monica A Slavin
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , Melbourne , VIC , Australia.,b Victorian Infectious Diseases Service , Royal Melbourne Hospital , Melbourne , VIC , Australia.,c Department of Medicine , University of Melbourne , Melbourne , VIC , Australia
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23
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Al-Bader N, Sheppard DC. Aspergillosis and stem cell transplantation: An overview of experimental pathogenesis studies. Virulence 2016; 7:950-966. [PMID: 27687755 DOI: 10.1080/21505594.2016.1231278] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Invasive aspergillosis is a life-threatening infection caused by the opportunistic filamentous fungus Aspergillus fumigatus. Patients undergoing haematopoietic stem cell transplant (HSCT) for the treatment of hematological malignancy are at particularly high risk of developing this fatal infection. The susceptibility of HSCT patients to infection with A. fumigatus is a consequence of a complex interplay of both fungal and host factors. Here we review our understanding of the host-pathogen interactions underlying the susceptibility of the immunocompromised host to infection with A. fumigatus with a focus on the experimental validation of fungal and host factors relevant to HSCT patients. These include fungal factors such as secondary metabolites, cell wall constituents, and metabolic adaptations that facilitate immune evasion and survival within the host microenvironment, as well as the innate and adaptive immune responses involved in host defense against A. fumigatus.
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Affiliation(s)
- Nadia Al-Bader
- a Departments of Medicine, Microbiology and Immunology , McGill University , Montréal , Québec , Canada
| | - Donald C Sheppard
- a Departments of Medicine, Microbiology and Immunology , McGill University , Montréal , Québec , Canada.,b Infectious Diseases in Global Health Program, Research Institute of the McGill University Health Center, McGill University , Montréal , Québec , Canada
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24
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Sirvent A, Auquier P, Oudin C, Bertrand Y, Bohrer S, Chastagner P, Poirée M, Kanold J, Thouvenin S, Perel Y, Plantaz D, Tabone MD, Yakouben K, Gandemer V, Lutz P, Sirvent N, Vercasson C, Berbis J, Chambost H, Leverger G, Baruchel A, Michel G. Prevalence and risk factors of iron overload after hematopoietic stem cell transplantation for childhood acute leukemia: a LEA study. Bone Marrow Transplant 2016; 52:80-87. [PMID: 27595286 DOI: 10.1038/bmt.2016.205] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/26/2016] [Accepted: 06/30/2016] [Indexed: 12/16/2022]
Abstract
Data on post-transplant iron overload (IO) are scarce in pediatrics. We conducted a prospective multicenter cohort study (Leucémie de l'Enfant et de l'Adolescent cohort) to determine the prevalence and risk factors of IO in 384 acute leukemia survivors transplanted during childhood. Prevalence of IO (ferritin level ⩾350 ng/mL) was 42.2% (95%CI 37.2-47.2%). Factors significantly associated with IO were: 1) in univariate analysis: older age at transplant (P<0.001), allogeneic versus autologous transplantation (P<0.001), radiation-based preparative regimen (P=0.035) and recent period of transplantation (P<0.001); 2) in multivariate analysis: older age at transplant in quartiles (Odds Ratio (OR)=7.64, 95% CI: 3.73-15.64 for age >12.7 years and OR=5.36, 95% CI: 2.63-10.95 for age from 8.2 to 12.7 years compared to age < 4.7 years), acute myeloid leukemia (OR=3.23, 95% CI: 1.47-7.13), allogeneic graft (OR=4.34, 95% CI: 2.07-9.12 for alternative donors and OR=2.53, 95% CI: 1.2-5.33 for siblings, compared to autologous graft) and radiation-based conditioning regimen (OR=2.45, 95% CI: 1.09-5.53). Graft-versus-host disease was an additional risk factor for allogeneic graft recipients. In conclusion, IO is a frequent complication in pediatric long-term survivors after transplantation for acute leukemia, more frequently observed in older children, those transplanted from alternative donors or with graft-versus-host disease.
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Affiliation(s)
- A Sirvent
- Department of Pediatric Hematology and Oncology, University Hospital, Montpellier, France
| | - P Auquier
- Research Unit EA 3279 and Department of Public Health, Aix-Marseille University and Timone Hospital, Marseille, France
| | - C Oudin
- Research Unit EA 3279 and Department of Public Health, Aix-Marseille University and Timone Hospital, Marseille, France.,Department of Pediatric Hematology and Oncology, Timone Enfants Hospital and Aix-Marseille University, Marseille, France
| | - Y Bertrand
- Department of Pediatric Hematology and Oncology, University Hospital, Lyon, France
| | - S Bohrer
- Department of Pediatric Hematology and Oncology, University Hospital, Montpellier, France
| | - P Chastagner
- Department of Pediatric Hematology and Oncology, Hôpital d'Enfants de Brabois, Vandoeuvre Les Nancy, France
| | - M Poirée
- Department of Pediatric Hematology and Oncology, University Hospital L'Archet, Nice, France
| | - J Kanold
- Department of Pediatric Hematology and Oncology, University Hospital, Clermont-Ferrand, France
| | - S Thouvenin
- Department of Pediatric Hematology and Oncology, University Hospital, Saint Etienne, France
| | - Y Perel
- Department of Pediatric Hematology and Oncology, University Hospital, Bordeaux, France
| | - D Plantaz
- Department of Pediatric Hematology and Oncology, University Hospital, Grenoble, France
| | - M-D Tabone
- Department of Pediatric Hematology and Oncology, Trousseau Hospital, Paris, France
| | - K Yakouben
- Department of Pediatric Hematology- Immunology, Robert Debré Hospital, and Paris Diderot University, Sorbonne Paris-Cité, Paris, France
| | - V Gandemer
- Department of Pediatric Hematology and Oncology, University Hospital, Rennes, France
| | - P Lutz
- Department of Pediatric Hematology-oncology, Hospital University, Strasbourg, France
| | - N Sirvent
- Department of Pediatric Hematology and Oncology, University Hospital, Montpellier, France
| | - C Vercasson
- Research Unit EA 3279 and Department of Public Health, Aix-Marseille University and Timone Hospital, Marseille, France
| | - J Berbis
- Research Unit EA 3279 and Department of Public Health, Aix-Marseille University and Timone Hospital, Marseille, France
| | - H Chambost
- Department of Pediatric Hematology and Oncology, Timone Enfants Hospital and Aix-Marseille University, Marseille, France
| | - G Leverger
- Department of Pediatric Hematology and Oncology, Trousseau Hospital, Paris, France
| | - A Baruchel
- Department of Pediatric Hematology- Immunology, Robert Debré Hospital, and Paris Diderot University, Sorbonne Paris-Cité, Paris, France
| | - G Michel
- Research Unit EA 3279 and Department of Public Health, Aix-Marseille University and Timone Hospital, Marseille, France.,Department of Pediatric Hematology and Oncology, Timone Enfants Hospital and Aix-Marseille University, Marseille, France
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Sivgin S, Karamustafaoglu MF, Yildizhan E, Zararsiz G, Kaynar L, Eser B, Cetin M, Unal A. The Prognostic Significance of Elevated Serum Ferritin Levels Prior to Transplantation in Patients With Lymphoma Who Underwent Autologous Hematopoietic Stem Cell Transplantation (autoHSCT): Role of Iron Overload. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2016; 16 Suppl:S152-8. [PMID: 27521313 DOI: 10.1016/j.clml.2016.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/09/2016] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Hematopoietic stem cell transplantation is a common and preferred treatment of lymphomas in many centers. Our goal was to determine the association between pretransplant iron overload and survival in patients who underwent autologous hematopoietic stem cell transplantation (autoHSCT). PATIENTS AND METHODS A total of 165 patients with lymphoma, who underwent autoHSCT between the years of 2007 and 2014, were included in this study. Ferritin levels were used to determine iron status; the cut-off value was 500 ng/mL. The relationship between iron overload and survival was assessed by statistical analysis. RESULTS The median ferritin level in the normal ferritin (ferritin < 500) group was 118 ng/mL (range, 9-494 ng/mL) and in the high-ferritin group (ferritin ≥ 500), it was 908 ng/mL (range, 503-4549 ng/mL). A total of 64 (38.8%) patients died during follow-up. Of these patients that died, 52 (81.25%) were in the high-ferritin group, and 12 (18.75%) were in the normal ferritin group (P ≤ .001). Twelve (14.1%) of 85 patients died in the normal ferritin group, and 52 (65.0%) of 80 patients died in the high-ferritin group. The overall mortality was significantly higher in the high-ferritin group (P < .001). The median overall survival was 42 months (range, 25-56 months) in the normal-ferritin group and20 months (range, 5-46) in the high-ferritin group. The difference between the groups was statistically significant (P < .001). The median disease-free survival was 39 months (range, 16-56) in the normal ferritin group and 10 months (range, 3-29) in the high-ferritin group. The difference between the groups was statistically significant (P < .001). CONCLUSION Elevated serum ferritin levels might predict poorer survival in autoHSCT recipients.
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Affiliation(s)
- Serdar Sivgin
- Erciyes Stem Cell Transplantation Hospital, Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey.
| | - Mehmet Fatih Karamustafaoglu
- Erciyes Stem Cell Transplantation Hospital, Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Esra Yildizhan
- Erciyes Stem Cell Transplantation Hospital, Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Gokmen Zararsiz
- Department of Biostatistics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Leylagul Kaynar
- Erciyes Stem Cell Transplantation Hospital, Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Bulent Eser
- Erciyes Stem Cell Transplantation Hospital, Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Mustafa Cetin
- Erciyes Stem Cell Transplantation Hospital, Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Ali Unal
- Erciyes Stem Cell Transplantation Hospital, Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
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Oremland M, Michels KR, Bettina AM, Lawrence C, Mehrad B, Laubenbacher R. A computational model of invasive aspergillosis in the lung and the role of iron. BMC SYSTEMS BIOLOGY 2016; 10:34. [PMID: 27098278 PMCID: PMC4839115 DOI: 10.1186/s12918-016-0275-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 04/07/2016] [Indexed: 12/20/2022]
Abstract
Background Invasive aspergillosis is a severe infection of immunocompromised hosts, caused by the inhalation of the spores of the ubiquitous environmental molds of the Aspergillus genus. The innate immune response in this infection entails a series of complex and inter-related interactions between multiple recruited and resident cell populations with each other and with the fungal cell; in particular, iron is critical for fungal growth. Results A computational model of invasive aspergillosis is presented here; the model can be used as a rational hypothesis-generating tool to investigate host responses to this infection. Using a combination of laboratory data and published literature, an in silico model of a section of lung tissue was generated that includes an alveolar duct, adjacent capillaries, and surrounding lung parenchyma. The three-dimensional agent-based model integrates temporal events in fungal cells, epithelial cells, monocytes, and neutrophils after inhalation of spores with cellular dynamics at the tissue level, comprising part of the innate immune response. Iron levels in the blood and tissue play a key role in the fungus’ ability to grow, and the model includes iron recruitment and consumption by the different types of cells included. Parameter sensitivity analysis suggests the model is robust with respect to unvalidated parameters, and thus is a viable tool for an in silico investigation of invasive aspergillosis. Conclusions Using laboratory data from a mouse model of invasive aspergillosis in the context of transient neutropenia as validation, the model predicted qualitatively similar time course changes in fungal burden, monocyte and neutrophil populations, and tissue iron levels. This model lays the groundwork for a multi-scale dynamic mathematical model of the immune response to Aspergillus species. Electronic supplementary material The online version of this article (doi:10.1186/s12918-016-0275-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew Oremland
- Mathematical Biosciences Institute, Ohio State University, 1735 Neil Ave, Columbus OH, USA.
| | - Kathryn R Michels
- University of Virginia, Pulmonary and Critical Care Medicine, Charlottesville VA, USA
| | - Alexandra M Bettina
- University of Virginia, Pulmonary and Critical Care Medicine, Charlottesville VA, USA
| | - Chris Lawrence
- Virginia Bioinformatics Institute, Virginia Tech, 1015 Life Science Circle, Blacksburg VA, USA
| | - Borna Mehrad
- University of Virginia, Pulmonary and Critical Care Medicine, Charlottesville VA, USA
| | - Reinhard Laubenbacher
- Center for Quantitative Medicine, University of Connecticut Health Center, 236 Farmington Ave, Farmington CT, USA.,Jackson Laboratory for Genomic Medicine, 236 Farmington Ave, Farmington CT, USA
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Abstract
Iron overload is a significant cause of morbidity and mortality for patients who require frequent transfusions. We completed a prospective, cross-sectional study to evaluate the prevalence of iron overload in previously transfused childhood cancer survivors. Survivors recruited from the University of Minnesota Long-Term Follow-Up Clinic were stratified into 3 groups: oncology patients not treated with hematopoietic stem cell transplantation (HSCT) (n=27), patients treated with allogeneic HSCT (n=27), and patients treated with autologous HSCT (n=9). Serum ferritin was collected and hepatic magnetic resonance imaging (FerriScan) was obtained for those with iron overload (defined as ferritin ≥1000 ng/mL). The prevalence of iron overload in subjects with a history of allogeneic HSCT was 25.9% (95% CI, 9.4%-42.5%) compared with only 3.7% (95% CI, 0%-10.8%) in subjects treated without HSCT and 0% in subjects treated with autologous HSCT. No association was found between serum ferritin levels and the presence of cardiac, liver, or endocrine dysfunction. The prevalence of iron overload in subjects who received no HSCT or autologous HSCT is low in our study. A higher prevalence was found in patients receiving allogeneic HSCT, reiterating the importance of screening these patients for iron overload in accordance with the current Children's Oncology Group Long Term Follow-Up Guidelines.
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Clinical significance of pretransplant serum ferritin on the outcome of allogeneic hematopoietic SCT: a prospective cohort study by the Kanto Study Group for Cell Therapy. Bone Marrow Transplant 2015; 50:727-33. [DOI: 10.1038/bmt.2015.17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 12/30/2014] [Accepted: 01/05/2015] [Indexed: 11/12/2022]
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29
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Atalla A, Garnica M, Maiolino A, Nucci M. Risk factors for invasive mold diseases in allogeneic hematopoietic cell transplant recipients. Transpl Infect Dis 2015; 17:7-13. [DOI: 10.1111/tid.12328] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/15/2014] [Accepted: 09/28/2014] [Indexed: 01/23/2023]
Affiliation(s)
- A. Atalla
- Department of Internal Medicine; University Hospital; Universidade Federal de Juiz de Fora; Juiz de Fora Brazil
| | - M. Garnica
- Department of Internal Medicine; University Hospital; Universidade Federal do Rio de Janeiro; Rio de Janeiro Brazil
| | - A. Maiolino
- Department of Internal Medicine; University Hospital; Universidade Federal do Rio de Janeiro; Rio de Janeiro Brazil
| | - M. Nucci
- Department of Internal Medicine; University Hospital; Universidade Federal do Rio de Janeiro; Rio de Janeiro Brazil
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Dadwal SS, Tegtmeier B, Liu X, Frankel P, Ito J, Forman SJ, Pullarkat V. Impact of pretransplant serum ferritin level on risk of invasive mold infection after allogeneic hematopoietic stem cell transplantation. Eur J Haematol 2014; 94:235-42. [DOI: 10.1111/ejh.12421] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2014] [Indexed: 01/19/2023]
Affiliation(s)
- Sanjeet S. Dadwal
- Division of Infectious Diseases; City of Hope Medical Center; Duarte CA USA
| | - Bernard Tegtmeier
- Division of Infectious Diseases; City of Hope Medical Center; Duarte CA USA
| | - Xueli Liu
- Division of Biostatistics; City of Hope Medical Center; Duarte CA USA
| | - Paul Frankel
- Division of Biostatistics; City of Hope Medical Center; Duarte CA USA
| | - James Ito
- Division of Infectious Diseases; City of Hope Medical Center; Duarte CA USA
| | - Stephen J. Forman
- Department of Hematology and Hematopoietic Cell Transplantation; City of Hope Medical Center; Duarte CA USA
| | - Vinod Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation; City of Hope Medical Center; Duarte CA USA
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31
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Merkel DG, Nagler A. Toward resolving the unsettled role of iron chelation therapy in myelodysplastic syndromes. Expert Rev Anticancer Ther 2014; 14:817-29. [PMID: 24641787 DOI: 10.1586/14737140.2014.896208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Transfusion dependent low risk myelodysplastic syndromes (MDS) patients, eventually develop iron overload. Iron toxicity, via oxidative stress, can damage cellular components and impact organ function. In thalassemia major patients, iron chelation therapy lowered iron levels with recovery of cardiac and liver functions and significant improvement in survival. Several noncontrolled studies show inferior survival in MDS patients with iron overload, including an increase in transplant-related mortality and infection risk while iron chelation appears to improve survival in both lower risk MDS patients and in stem cell transplant settings. Collated data are presented on the pathophysiological impact of iron overload; measuring techniques and chelating agents' therapy positive impact on hematological status and overall survival are discussed. Although suggested by retrospective analyses, the lack of clear prospective data of the beneficial effects of iron chelation on morbidity and survival, the role of iron chelation therapy in MDS patients remains controversial.
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Affiliation(s)
- Drorit G Merkel
- Division of Hematology, Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Israel
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33
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Akı ŞZ, Paşaoğlu H, Yeğin ZA, Suyanı E, Demirtaş CY, Özkurt ZN, Yağcı M, Sucak GT. Impact of prohepcidin levels and iron parameters on early post-transplantation toxicities. Hematology 2013; 16:284-90. [DOI: 10.1179/102453311x13085644680023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
| | - Hatice Paşaoğlu
- Department of BiochemistryFaculty of Medicine, Gazi University, Ankara, Turkey
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34
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Sivgin S, Baldane S, Ozenmis T, Keklik M, Kaynar L, Kurnaz F, Sivgin H, Zararsız G, Cetin M, Unal A, Eser B. The impact of pretransplant hypoalbuminemia on survival in patients with leukemia who underwent allogeneic hematopoietic stem cell transplantation (alloHSCT): a nutritional problem? Transplant Proc 2013; 45:3371-4. [PMID: 24182818 DOI: 10.1016/j.transproceed.2013.02.144] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 12/21/2012] [Accepted: 02/27/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Serum albumin level is considered to be a marker reflecting the nutritional status in both healthy subjects and patients with malignancies. In this study we sought to investigate the association between pretransplantation serum albumin levels and prognosis among patients with leukemia who underwent allogeneic hematopoietic stem cell transplantation (alloHSCT). METHODS We retrospectively analyzed the data of 102 patients who underwent alloHSCT from 2004 to 2010. Pretransplant serum albumin, D-dimer, creatinine, and fibrinogen levels drawn within 10 days before transplantation were obtained from patient files. All parameters were divided into 2 groups: normal levels (group 1) versus abnormal levels (group 2). Our normal range of serum albumin is 3.2-5.2 g/dL; patients with pretransplantation albumin level ≥3.2 g/dL were included in group 1 versus group 2 with <3.2 g/dL. RESULTS The patients included 42 (41.1%) female and 60 (58.9%) male patients. The diagnoses were acute myeloblastic leukemia in 65 (63.7%) and acute lymphoblastic leukemia in 37 (36.3%). The median age was 26.0 years (range, 13-57). Univariate and multivariate analysis showed that patients with serum albumin levels <3.2 g/dL experienced significantly lower overall survival (OS) compared with ≥3.2 g/dL (hazard ratio [HR] 2.32 [range, 1.23-4.54] and HR 2.70 [range 1.38-5.26], respectively; P = .009). The median (range) OS in group 2 was 230.0 (184.0-544.0) days versus 570.5 (249.5-1,101.0) days in group 1 (P = .007). For disease free survival (DFS) evaluation, univariate and multivariate analysis showed that patients with serum albumin levels <3.2 g/dL had significantly lower values compared with patients with serum albumin ≥3.2 g/dL. (HR 2.17 [range 0.98-4.76] and HR 2.85 [range, 1.25-6.66], respectively; P = .046). The median (range) DFS in group 2 was 184.0 (61.0-524.0) days versus 445.0 (199.0-917.5) days in group 1 (P = .045). Among the patient characteristics the presence of infection was a significant independent variable for worse OS (HR 2.12 [range, 0.98-4.36], P = .036). The other parameters-age, sex, donor status, time to transplant interval, conditioning regimens, HLA status, and number of total infused CD34(+) cells-showed no significant effect on OS and DFS (P = .05). CONCLUSIONS Pretransplantation decreased serum albumin levels were associated with poor survival in patients with leukemia who underwent alloHSCT.
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Affiliation(s)
- S Sivgin
- Department of Hematology, Dedeman Stem Cell Transplantation Hospital, Kayseri, Turkey.
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Targeting iron acquisition blocks infection with the fungal pathogens Aspergillus fumigatus and Fusarium oxysporum. PLoS Pathog 2013; 9:e1003436. [PMID: 23853581 PMCID: PMC3708856 DOI: 10.1371/journal.ppat.1003436] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 05/02/2013] [Indexed: 12/21/2022] Open
Abstract
Filamentous fungi are an important cause of pulmonary and systemic morbidity and mortality, and also cause corneal blindness and visual impairment worldwide. Utilizing in vitro neutrophil killing assays and a model of fungal infection of the cornea, we demonstrated that Dectin-1 dependent IL-6 production regulates expression of iron chelators, heme and siderophore binding proteins and hepcidin in infected mice. In addition, we show that human neutrophils synthesize lipocalin-1, which sequesters fungal siderophores, and that topical lipocalin-1 or lactoferrin restricts fungal growth in vivo. Conversely, we show that exogenous iron or the xenosiderophore deferroxamine enhances fungal growth in infected mice. By examining mutant Aspergillus and Fusarium strains, we found that fungal transcriptional responses to low iron levels and extracellular siderophores are essential for fungal growth during infection. Further, we showed that targeting fungal iron acquisition or siderophore biosynthesis by topical application of iron chelators or statins reduces fungal growth in the cornea by 60% and that dual therapy with the iron chelator deferiprone and statins further restricts fungal growth by 75%. Together, these studies identify specific host iron-chelating and fungal iron-acquisition mediators that regulate fungal growth, and demonstrate that therapeutic inhibition of fungal iron acquisition can be utilized to treat topical fungal infections.
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36
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Association of iron overload with allogeneic hematopoietic cell transplantation outcomes: a prospective cohort study using R2-MRI-measured liver iron content. Blood 2013; 122:1678-84. [PMID: 23777771 DOI: 10.1182/blood-2013-04-499772] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Using liver magnetic resonance imaging (R2-MRI) to quantify liver iron content (LIC), we conducted a prospective cohort study to determine the association between iron overload and adult allogeneic hematopoietic cell transplantation (HCT) outcomes. Patients received pretransplant ferritin measurements; patients with ferritin >500 ng/mL underwent R2-MRI. Patients were defined as no iron overload (N = 28) and iron overload (LIC >1.8 mg/g; N = 60). Median LIC in the iron-overload group was 4.3 mg/g (range, 1.9-25.4). There was no difference in the 1-year probability of overall survival, nonrelapse mortality, relapse, acute or chronic graft-versus-host disease, organ failure, infections, or hepatic veno-occlusive disease between groups. We also found no difference in the cumulative incidence of a composite end point of nonrelapse mortality, any infection, organ failure, or hepatic veno-occlusive disease (1-year cumulative incidence, 71% vs 80%; P = .44). In multivariate analyses, iron-overload status did not impact risks of overall mortality (relative risk = 2.3; 95% confidence interval, 0.9-5.9; P = .08). In conclusion, we found no association between pretransplant iron overload and allogeneic HCT outcomes. Future studies in this population should use LIC to define iron overload instead of ferritin.
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Zabalza A, Gorosquieta A, Equiza EP, Olavarria E. Voriconazole and its clinical potential in the prophylaxis of systemic fungal infection in patients with hematologic malignancies: a perspective review. Ther Adv Hematol 2013; 4:217-30. [PMID: 23730499 PMCID: PMC3666449 DOI: 10.1177/2040620713481796] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Invasive fungal infections (IFIs) have become high prevalence in patients with hematologic malignancies. Drug-based strategies for IFIs include various approaches such as prophylactic, empiric, preemptive, and directed treatment. Prophylaxis is an attractive strategy in high-risk patients, given the lack of reliable diagnostics and the high mortality rate associated with IFIs. Prophylaxis includes the use of antifungal drugs in all patients at risk. An ideal antifungal compound for prophylaxis should have a potent and broad activity, be available both orally and intravenously, and have a low toxicity profile. Voriconazole fulfills all these criteria. The clinical efficacy of voriconazole against the majority of fungal pathogens makes it potentially very useful for the prevention of IFIs in patients with hematologic malignancies. Voriconazole appears to be very effective for the primary and secondary prevention of IFIs in these patients and recipients of allogeneic hematopoietic stem-cell transplantation. Randomized controlled trials evaluating voriconazole as primary antifungal prophylaxis in patients with neutropenia treated for a variety of hematologic malignancies have been performed, confirming its value as a prophylactic agent. Voriconazole is generally safe and well tolerated; however, its use is also associated with a number of concerns. In most patients with hematologic malignancies there is the potential for pharmacokinetic drug-drug interactions given that voriconazole is metabolized through the P450 cytochrome system.
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Affiliation(s)
- Amaya Zabalza
- Hematology Department, Complejo Hospitalario de Navarra, Pamplona, Spain, and Biomedical Research Center (NavarraBiomed), Navarra, Spain
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38
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Virtanen JM, Itälä-Remes MA, Remes KJ, Vahlberg T, Saunavaara JP, Sinisalo M, Parkkola RK. Prognostic impact of pretransplant iron overload measured with magnetic resonance imaging on severe infections in allogeneic stem cell transplantation. Eur J Haematol 2013; 91:85-93. [DOI: 10.1111/ejh.12123] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2013] [Indexed: 01/19/2023]
Affiliation(s)
- Johanna M. Virtanen
- Department of Radiology; Medical Imaging Centre of Southwest Finland; University of Turku and Turku University Hospital; Turku; Finland
| | - Maija A. Itälä-Remes
- Department of Medicine; University of Turku and Turku University Hospital; Turku; Finland
| | - Kari J. Remes
- Department of Medicine; University of Turku and Turku University Hospital; Turku; Finland
| | - Tero Vahlberg
- Department of Biostatistics; University of Turku; Turku; Finland
| | - Jani P. Saunavaara
- Department of Radiology; Medical Imaging Centre of Southwest Finland; University of Turku and Turku University Hospital; Turku; Finland
| | - Marjatta Sinisalo
- Department of Medicine; Tampere University Hospital; Tampere; Finland
| | - Riitta K. Parkkola
- Department of Radiology; Medical Imaging Centre of Southwest Finland; University of Turku and Turku University Hospital; Turku; Finland
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Álvarez F, Fernández-Ruiz M, Aguado JM. [Iron and invasive fungal infection]. Rev Iberoam Micol 2013; 30:217-25. [PMID: 23684655 DOI: 10.1016/j.riam.2013.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 04/08/2013] [Accepted: 04/30/2013] [Indexed: 01/19/2023] Open
Abstract
Iron is an essential factor for both the growth and virulence of most of microorganisms. As a part of the innate (or nutritional) immune system, mammals have developed different mechanisms to store and transport this element in order to limit free iron bioavailability. To survive in this hostile environment, pathogenic fungi have specific uptake systems for host iron sources, one of the most important of which is based on the synthesis of siderophores-soluble, low-molecular-mass, high-affinity iron chelators. The increase in free iron that results from iron-overload conditions is a well-established risk factor for invasive fungal infection (IFI) such as mucormycosis or aspergillosis. Therefore, iron chelation may be an appealing therapeutic option for these infections. Nevertheless, deferoxamine -the first approved iron chelator- paradoxically increases the incidence of IFI, as it serves as a xeno-siderophore to Mucorales. On the contrary, the new oral iron chelators (deferiprone and deferasirox) have shown to exert a deleterious effect on fungal growth both in vitro and in animal models. The present review focuses on the role of iron metabolism in the pathogenesis of IFI and summarises the preclinical data, as well as the limited clinical experience so far, in the use of new iron chelators as treatment for mucormycosis and invasive aspergillosis.
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Affiliation(s)
- Florencio Álvarez
- Servicio de Medicina Interna, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (i+12), Universidad Complutense, Madrid, España
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40
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Barba P, Valcárcel D, Pérez-Simón JA, Fernández-Avilés F, Piñana JL, Martino R, López-Anglada L, Rovira M, Garcia-Cadenas I, Novelli S, Carreras E, López Corral L, Sierra J. Impact of Hyperferritinemia on the Outcome of Reduced-Intensity Conditioning Allogeneic Hematopoietic Cell Transplantation for Lymphoid Malignancies. Biol Blood Marrow Transplant 2013; 19:597-601. [DOI: 10.1016/j.bbmt.2012.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 12/26/2012] [Indexed: 01/19/2023]
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Sivgin S, Baldane S, Kaynar L, Kurnaz F, Pala C, Sivgin H, Keklik M, Demiraslan H, Cetin M, Eser B, Unal A. Pretransplant iron overload may be associated with increased risk of invasive fungal pneumonia (IFP) in patients that underwent allogeneic hematopoietic stem cell transplantation (alloHSCT). Transfus Apher Sci 2013; 48:103-8. [PMID: 22985533 DOI: 10.1016/j.transci.2012.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 08/16/2012] [Indexed: 02/08/2023]
Abstract
Invasive fungal pneumonia (IFP) has become increasingly common in patients that previously underwent alloHSCT. The aim of this study was to determine the role of hyperferritinemia, via iron overload in invasive fungal pneumonia in patients that underwent alloHSCT. Medical records of 73 patients with pneumonia that underwent alloHSCT were studied retrospectively, whereby a pre-transplantation serum ferritin level measured up to 100 days prior to transplantation of patients with invasive fungal pneumonia (IFP) and non-fungal pneumonia (non-IFP) was compared. Patient records revealed 35 and 38 cases of IFP and non-IFP, respectively. In risk evaluation for IFP, age, gender, HLA status, conditioning regimen, smoking history, and underlying disease were not significantly different among groups (p>0.05). However, performance status (Karnofsky) was significantly lower in patients with IFP (p<0.05). The median ferritin levels were 1,705 ng/ml (41-7198) in the IFP group and 845 ng/ml (18-7099) in non-IFP group and the difference was found statistically significant (p=0.001). Elevated pretransplant serum ferritin level is associated with IFP in patients that underwent alloHSCT, in particular when values exceed 1550 ng/ml.
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Affiliation(s)
- Serdar Sivgin
- Dedeman Stem Cell Transplantation Hospital, Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey.
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Toma A, Fenaux P, Dreyfus F, Cordonnier C. Infections in myelodysplastic syndromes. Haematologica 2012; 97:1459-70. [PMID: 22733024 PMCID: PMC3487546 DOI: 10.3324/haematol.2012.063420] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 05/17/2012] [Accepted: 06/13/2012] [Indexed: 12/19/2022] Open
Abstract
Myelodysplastic syndromes are associated with a risk of severe infections. While neutropenia is likely to be the main predisposing factor, several other immune defects have been reported, including impaired neutrophil function, B-, T- and NK-cell defects and the possible consequences of iron overload due to red blood cell transfusions. The advanced age of most patients, their frequent comorbidities, and the fact that drugs such as hypomethylating agents and lenalidomide, which are effective in myelodysplastic syndromes but can transiently worsen neutropenia, may increase the risk of infection and their severity in this context. The majority of infections in myelodysplastic syndromes are bacterial, while the incidence of fungal infections is not well known and viral infections seem to be rare. No prophylactic measures against infections have demonstrated efficacy in myelodysplastic syndromes. However, pending more data, we propose here some recommendations for the management of patients with myelodysplastic syndromes. In the future, an important contribution can be made by prospective trials testing the efficacy of prophylactic and therapeutic approaches to infection in these patients, especially in the context of the new drugs available for myelodysplastic syndromes.
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Affiliation(s)
- Andréa Toma
- Department of Hematology Henri Mondor University Hospital, 94000 Créteil, France.
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The clinical, quality of life, and economic consequences of chronic anemia and transfusion support in patients with myelodysplastic syndromes. Leuk Res 2012; 36:525-36. [DOI: 10.1016/j.leukres.2012.01.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 12/28/2011] [Accepted: 01/09/2012] [Indexed: 12/17/2022]
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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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Fuji S, Kapp M, Einsele H. Challenges to Preventing Infectious Complications, Decreasing Re-hospitalizations, and Reducing Cost Burden in Long-Term Survivors After Allogeneic Hematopoietic Stem Cell Transplantation. Semin Hematol 2012; 49:10-4. [DOI: 10.1053/j.seminhematol.2011.10.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Parmar S, de Lima M, Deeg HJ, Champlin R. Hematopoietic stem cell transplantation for myelodysplastic syndrome: a review. Semin Oncol 2011; 38:693-704. [PMID: 21943676 DOI: 10.1053/j.seminoncol.2011.04.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) continues to be the only curative option for myelodysplastic syndrome (MDS). Since the majority of the patients with this disease are often older and frail, treatment-related mortality and morbidity remain major obstacles to be overcome. Reduced-intensity conditioning and continued lines of investigation in the field of allogeneic transplantation are expected to ultimately improve the overall therapeutic approach to MDS. In this review we summarize current recommendations and controversies surrounding HSCT for MDS, as well as the use of novel therapeutics in the peri-transplant period.
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Affiliation(s)
- Simrit Parmar
- Department of Stem Cell Transplantation and Cellular Therapy, M.D. Anderson Cancer Center, Houston, USA
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Cornely OA, Aversa F, Cook P, Jones B, Michallet M, Shea T, Vallejo C. Evaluating the role of prophylaxis in the management of invasive fungal infections in patients with hematologic malignancy. Eur J Haematol 2011; 87:289-301. [DOI: 10.1111/j.1600-0609.2011.01682.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Kanda J, Kawabata H, Chao NJ. Iron overload and allogeneic hematopoietic stem-cell transplantation. Expert Rev Hematol 2011; 4:71-80. [PMID: 21322780 DOI: 10.1586/ehm.10.81] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Iron overload is frequently observed in patients with hematologic diseases before and after allogeneic stem-cell transplantation because they usually receive multiple red blood cell transfusions. Elevated pretransplant serum ferritin levels, which are widely used as indicators of body iron status, are significantly associated with a lower overall survival rate and a higher incidence of treatment-related complications; for example, infections and hepatic veno-occlusive disease. As serum ferritin levels are affected, not only by iron loading but also by inflammation, imaging techniques to quantify tissue iron levels have been developed, for example, quantitative MRI using the transverse magnetic relaxation rate, and superconducting quantum interference devices. Iron chelators, such as deferasirox, a new oral iron-chelating agent, reduce iron load in transfusion-dependent patients. Iron-chelating therapy before and/or after transplantation is a promising strategy to improve the clinical outcomes of transplant patients with iron overload. However, further research is needed to prove the direct relationship between iron overload and adverse outcomes, as well as to determine the effects of treatment for iron overload on outcomes of allogeneic stem-cell transplantation.
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Affiliation(s)
- Junya Kanda
- Division of Cellular Therapy, Department of Medicine, Duke University Medical Center, 2400 Pratt Street, Suite 1100, Durham, NC 27705, USA.
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Caira M, Mancinelli M, Leone G, Pagano L. Invasive aspergillosis in acute leukemias: old and new risk factors and epidemiological trends. Med Mycol 2011; 49 Suppl 1:S13-6. [DOI: 10.3109/13693786.2010.509138] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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