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Schneider V, Cabanillas Stanchi KM, Althaus K, Schober S, Michaelis S, Seitz C, Lang P, Handgretinger R, Bakchoul T, Hammer S, Döring M. Hypofibrinolysis in pediatric patients with veno-occlusive disease in hematopoietic stem cell transplantation. J Cancer Res Clin Oncol 2023:10.1007/s00432-023-04798-9. [PMID: 37086290 PMCID: PMC10374734 DOI: 10.1007/s00432-023-04798-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/15/2023] [Indexed: 04/23/2023]
Abstract
PURPOSE Veno-occlusive disease (VOD) is a serious complication of hematopoietic stem cell transplantation (HSCT) with a high incidence in pediatric patients. This study aimed to detect signs of hypofibrinolysis using thrombelastography. METHODS In this prospective single-center study, thrombelastographic measurements (EX and TPA tests) were taken during HSCT to detect signs of impaired coagulation, clot formation, or hypofibrinolysis. RESULTS Of 51 patients undergoing allogeneic and autologous HSCT, five (9.8%) developed VOD and received defibrotide treatment. Thrombelastography measurements were also obtained from 55 healthy children as a control group. The results show that clot lysis was prolonged in VOD patients compared to other HSCT patients and control group (lysis time, TPA test: day + 14 to + 21: VOD: 330 ± 67 s vs. HSCT: 246 ± 53 s; p = 0.0106; control: 234 ± 50 s; control vs. VOD: p = 0.0299). The maximum lysis was reduced in HSCT patients compared to controls (EX test: control: 8.3 ± 3.2%; HSCT: day 0 to + 6: 5.3 ± 2.6%, p < 0.0001; day + 7 to + 13: 3.9 ± 2.1%, p < 0.0001; day + 14 to d + 21: 4.1 ± 2.3%, p < 0.0001). CONCLUSION These results suggest that HSCT patients exhibit reduced fibrinolytic capacities and patients diagnosed with VOD show signs of hypofibrinolysis. This prospective study shows that fibrinolysis can be assessed in a rapid and accessible way via thrombelastography. Thrombelastography might be a parameter to support the diagnosis of a VOD and to serve as a follow-up parameter after the diagnosis of a VOD.
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Affiliation(s)
- Veronika Schneider
- Department I-General Pediatrics, Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Karin M Cabanillas Stanchi
- Department I-General Pediatrics, Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Karina Althaus
- Center for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tübingen, Tübingen, Germany
| | - Sarah Schober
- Department I-General Pediatrics, Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Sebastian Michaelis
- Department I-General Pediatrics, Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Christian Seitz
- Department I-General Pediatrics, Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Peter Lang
- Department I-General Pediatrics, Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Rupert Handgretinger
- Department I-General Pediatrics, Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Tamam Bakchoul
- Center for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tübingen, Tübingen, Germany
| | - Stefanie Hammer
- Center for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tübingen, Tübingen, Germany
| | - Michaela Döring
- Department I-General Pediatrics, Hematology and Oncology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany.
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Tan YW, Shi YC. Early diagnostic value of liver stiffness measurement in hepatic sinusoidal obstruction syndrome induced by hematopoietic stem cell transplantation. World J Clin Cases 2022; 10:9241-9253. [PMID: 36159435 PMCID: PMC9477689 DOI: 10.12998/wjcc.v10.i26.9241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/27/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
Hematopoietic stem cell transplantation (HSCT)-sinusoidal obstruction syndrome (SOS), also known as veno-occlusive disease, is a clinical syndrome characterized by symptoms, such as right upper quadrant pain, jaundice, fluid retention, and hepatomegaly, and is caused by pre-treatment-related hepatotoxicity during the early stages after HSCT. Clinical diagnosis of HSCT-SOS is based on the revised Seattle or Baltimore standards. The revised standard by the European Society for Bone Marrow Transplantation in 2016 has good practicability and can be used in combination with these two standards. Eight studies have shown the value of liver stiffness measurement (LSM) in the early diagnosis of HSCT-SOS. Four studies investigated LSM specificity and sensitivity for the early diagnosis of HSCT-SOS. LSM can distinguish SOS from other post-HSCT complications, enabling a clear differential diagnosis. It has been shown that median LSM of patients with SOS is significantly higher than that of patients with other treatment-related liver complications (e.g., acute cholecystitis, cholangitis, antifungal drug-related liver injury, liver graft-versus-host disease, isolated liver biochemical changes, and fulminant Epstein Barr virus related hepatitis reactivation). Therefore, the above data confirmed the utility of LSM and strongly suggested that LSM improves the positive predictive value of the SOS diagnostic clinical score after allogeneic HSCT. Early diagnosis of SOS is beneficial in preventing severe HSCT complications.
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Affiliation(s)
- You-Wen Tan
- Department of Hepatology, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang 212003, Jiangsu Province, China
| | - Yi-Chun Shi
- Department of Hepatology, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang 212003, Jiangsu Province, China
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Al-Shammari HHJ, Al-Bayaa I, Al-Rubaie HA. Plasminogen Activator Inhibitor-1 in Acute Myeloid Leukemia: Is It Useful in Predicting Response to Induction Remission Therapy? Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.10370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Coagulation and fibrinolytic abnormalities are common in patients with acute myeloblastic leukemia (AML). Plasminogen activator inhibitor (PAI) activity is believed to be elevated during the initial diagnosis and relapse of AML patients.
AIM: This study aimed to evaluate the levels of plasma PAI-1 activity in AML patients before and after remission induction.
METHODS: Thirty AML patients and 20 healthy volunteers were included in this study. The patients were classified according to AML-FAB subtypes. All patients received 7+3 induction chemotherapy. They were evaluated for complete remission after induction chemotherapy and followed up for 6 months.
RESULTS: PAI-1 activity was measured by ELISA immunoassay. PAI-1 activity was significantly higher in AML patients than the control group (P=0.016), whereas there was insignificant difference among patients in various AML subgroups (P>0.05). Before and after treatment, there was a significant difference in PAI-1 activity between patients with active disease and those at remission (P= 0.023 and <0.0001, respectively).
CONCLUSION: High PAI-1 activity in AML patients is found to be associated with poor response to treatment.
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[Chinese expert consensus on the diagnosis and management of sinusoidal obstruction syndrome after hematopoietic stem cell transplantation (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:177-183. [PMID: 35405774 PMCID: PMC9072071 DOI: 10.3760/cma.j.issn.0253-2727.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Indexed: 11/11/2022]
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Yoon JH, Choi CW, Won JH. Hepatic sinusoidal obstruction syndrome/veno-occlusive disease after hematopoietic cell transplantation: historical and current considerations in Korea. Korean J Intern Med 2021; 36:1261-1280. [PMID: 34555279 PMCID: PMC8588980 DOI: 10.3904/kjim.2021.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/28/2021] [Indexed: 12/14/2022] Open
Abstract
Hepatic sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD) is a rare but severe complication of hematopoietic cell transplantation (HCT) showing high mortality. Multiple risk factors for SOS/VOD were identified, but it is often confused with other hepatic complications due to nonspecific clinical features. Therefore, diagnostic and severity criteria have been revised several times. The European Society of Blood and Marrow Transplantation suggested a new guideline that excludes the standard duration of development within 21 days, emphasizes late-onset SOS/VOD, and suggests the importance of Doppler ultrasonography. The severity criteria were further subdivided for guidance to begin active treatment using defibrotide which was approved in Korea since 2016. In a phase 3 trial, defibrotide had superior 100-day survival, compared to best available treatments (38.2% vs. 25.0%). Although several studies of SOS/VOD in Korean patients have been performed after the implementation of HCT, most involved small number of pediatric patients. Recently, the Korean Society of Blood and Marrow Transplantation investigated the incidence of SOS/VOD in the Korean population, and several influential studies of adult patients were published. Here, we summarize recent issues regarding the mechanism, diagnosis, severity criteria, prevention, and treatments of SOS/VOD in Korean patients, as well as recent analyses of nationwide incidence.
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Affiliation(s)
- Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Chul Won Choi
- Division of Hematology and Oncology, Department of Internal Medicine, Korea University Guro Hospital, Seoul,
Korea
| | - Jong-Ho Won
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul,
Korea
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Kanou S, Miyashita T, Yamamoto Y, Takada S, Nakura M, Okazaki M, Ohbatake Y, Nakanuma S, Makino I, Tajima H, Takamura H, Fushida S, Ohta T. Prophylactic Effect of Recombinant Human Soluble Thrombomodulin for Hepatic Sinusoidal Obstruction Syndrome Model Mice. In Vivo 2021; 34:1037-1045. [PMID: 32354890 DOI: 10.21873/invivo.11873] [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: 12/22/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 02/08/2023]
Abstract
AIM The present study aimed to examine the effects of prophylactic administration of recombinant human soluble thrombomodulin (rTM) for the prevention of sinusoidal obstruction syndrome (SOS). MATERIALS AND METHODS Crl:CD1 mice were allocated to the rTM, placebo, and control groups. The rTM group received an intraperitoneal administration of rTM, with intraperitoneal administration of monocrotaline (MCT) 1 h later. The placebo group received PBS instead of rTM, and the control group received PBS instead of rTM and MCT. Mice were sacrificed 48 h after MCT administration, and blood and liver tissues were evaluated. Immunostaining was performed using anti-CD42b and anti-SE-1 antibodies, and AZAN staining. Levels of plasminogen activator inhibitor (PAI-1) and endothelial nitric oxide synthase (eNOS) in whole liver tissues were estimated using RT-PCR. RESULTS Hematoxylin-eosin staining showed that SOS-related findings were markedly attenuated in the rTM group compared to the placebo group. CD42b immunostaining showed the presence of extravasated platelet activation (EPA) in the Disse space in the placebo group, but this was less noticeable in the rTM group. PAI-1 levels were significantly lower in the rTM group than in the placebo group in RT-PCR. However, eNOS levels were significantly higher in the rTM group than in the placebo group. CONCLUSION Administration of rTM may prevent SOS by protecting sinusoidal endothelial cells.
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Affiliation(s)
- Shunsuke Kanou
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Tomoharu Miyashita
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Yasuhiko Yamamoto
- Department of Biochemistry and Molecular Vascular Biology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Satoshi Takada
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Makoto Nakura
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Mitsuyoshi Okazaki
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Yoshinao Ohbatake
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Shinichi Nakanuma
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Isamu Makino
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Hidehiro Tajima
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroyuki Takamura
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Sachio Fushida
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Tetsuo Ohta
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
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Bonifazi F, Barbato F, Ravaioli F, Sessa M, Defrancesco I, Arpinati M, Cavo M, Colecchia A. Diagnosis and Treatment of VOD/SOS After Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2020; 11:489. [PMID: 32318059 PMCID: PMC7147118 DOI: 10.3389/fimmu.2020.00489] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 03/03/2020] [Indexed: 12/27/2022] Open
Abstract
Hepatic veno-occlusive disease (VOD) or sinusoidal obstruction syndrome (SOS) is a rare complication characterized by hepatomegaly, right-upper quadrant pain, jaundice, and ascites, occurring after high-dose chemotherapy, hematopoietic stem cell transplantation (HSCT) and, less commonly, other conditions. We review pathogenesis, clinical appearance and diagnostic criteria, risk factors, prophylaxis, and treatment of the VOD occurring post-HSCT. The injury of the sinusoidal endothelial cells with loss of wall integrity and sinusoidal obstruction is the basis of development of postsinusoidal portal hypertension responsible for clinical syndrome. Risk factors associated with the onset of VOD and diagnostic tools have been recently updated both in the pediatric and adult settings and here are reported. Treatment includes supportive care, intensive management, and specific drug therapy with defibrotide. Because of its severity, particularly in VOD with associated multiorgan disease, prophylaxis approaches are under investigation. During the last years, decreased mortality associated to VOD/SOS has been reported being it attributable to a better intensive and multidisciplinary approach.
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Affiliation(s)
- Francesca Bonifazi
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Francesco Barbato
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mariarosaria Sessa
- Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum-Bologna University School of Medicine S. Orsola's University Hospital, Bologna, Italy
| | - Irene Defrancesco
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Mario Arpinati
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Michele Cavo
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy.,Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum-Bologna University School of Medicine S. Orsola's University Hospital, Bologna, Italy
| | - Antonio Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Gastroenterology Unit, Borgo Trento University Hospital, Verona, Italy
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8
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Atilla E, Ataca Atilla P, Cengiz Seval G, Bektaş M, Demirer T. Current approach to early gastrointestinal and liver complications of hematopoietic stem cell transplantation. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 30:122-131. [PMID: 30459131 DOI: 10.5152/tjg.2018.18156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The gastrointestinal (GI) system is one of the most commonly affected sites during a hematopoietic stem cell transplantation (HSCT) due to toxicities of preparative regimens, the accompanying immunodeficiency, and organ damage caused by graft versus host disease. In this review, we focus on early GI and liver complications following autologous (auto-) and allogeneic (allo-) HSCT and clarify both the risk factors and therapeutic strategies. Early GI and liver complications associated with HSCT remain challenging issues. Despite the improvements in this field during the last decade, treatments for these complications still place a significant burden on both patients and the physicians treating these patients. GI and liver complications remain some of the causes of mortality associated with HSCT. For practicing hematologists, oncologists, and gastroenterologists in this field, the awareness and early diagnosis of the GI complications remain important factors to obtain optimal outcomes in this patient population.
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Affiliation(s)
- Erden Atilla
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Pınar Ataca Atilla
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Güldane Cengiz Seval
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Mehmet Bektaş
- Department of Gastroenterology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
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Corbacioglu S, Jabbour EJ, Mohty M. Risk Factors for Development of and Progression of Hepatic Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome. Biol Blood Marrow Transplant 2019; 25:1271-1280. [DOI: 10.1016/j.bbmt.2019.02.018] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/18/2019] [Indexed: 12/17/2022]
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10
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Cesaro S, Mauro M, Sattin G, Sartori MT, Saggiorato G, Paratella A, Tridello G, Bisogno G. PAI-1 and protein C as early markers of veno-occlusive disease in patients treated for Wilms tumor. Pediatr Blood Cancer 2019; 66:e27695. [PMID: 30865371 DOI: 10.1002/pbc.27695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/31/2019] [Accepted: 02/21/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hepatic veno-occlusive (VOD) disease has been described in hematopoietic stem cell transplantation (HSCT), solid tumors, and acute lymphoblastic leukemia. The incidence of VOD in Wilms tumor (WT) ranges from 1.2% to 8%. The diagnosis of VOD is clinical, and there are no validated laboratory biomarkers. PROCEDURE We prospectively evaluated the specificity and sensitivity of plasminogen-activator inhibitor-1 (PAI-1) and protein C as diagnostic markers of VOD in WT patients. Fifty patients treated from 2008 to 2016 for WT were eligible. VOD was diagnosed according to modified Seattle criteria and retrospectively reclassified according to the recently published criteria for VOD in pediatric HSCT patients. RESULTS VOD occurred in 6 of 50 patients (12%) after 20 to 97 days from starting chemotherapy. The average duration of VOD was 10 days (range, 4-13 days). PAI-1 levels were elevated in all VOD patients, while a decrease in protein C levels was observed in 33% of patients with VOD. PAI-1 antigen (Ag) values ≥ 26.4 ng/mL demonstrated high sensitivity and specificity for the clinical diagnosis of VOD with sensitivity 100%, specificity 93%; whereas protein C levels below 34.5% had sensitivity 67%, specificity 100%. Both PAI-1 and protein C had an high negative predictive value: PAI-1 Ag 100%; protein C 95%. CONCLUSIONS PAI-1 Ag and protein C have good sensitivity and specificity for the diagnosis of VOD in WT patients. Their high negative predictive value can be used in the differential diagnosis of liver toxicity, especially in VOD episodes with absent or delayed hyperbilirubinemia.
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Affiliation(s)
- Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Margherita Mauro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giulia Sattin
- Hematology Oncology Division, Department of Mother's and Child's Health, University of Padova, Padova, Italy
| | - Maria Teresa Sartori
- Clinical Medicine 1, Department of Medicine, University of Padova, Padova, Italy
| | | | - Alessandra Paratella
- Hematology Oncology Division, Department of Mother's and Child's Health, University of Padova, Padova, Italy
| | - Gloria Tridello
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Gianni Bisogno
- Hematology Oncology Division, Department of Mother's and Child's Health, University of Padova, Padova, Italy
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Abstract
Advances in the field of omics have led to a significant expansion in biomarkers identified for complications after hematopoietic stem cell transplantation (HSCT). Biomarkers can offer an effective method for early identification of a specific disease and can be used to guide therapies. Ongoing investigations to discover biomarkers for acute graft-versus-host disease as well as other post-HSCT complications may improve early diagnosis, prognosis, and the development of new therapeutic targets. The authors review the most recent and validated diagnostic, prognostic, predictive, and response to treatment biomarkers for early complications following HSCT consistent with 2014 NIH consensus on biomarker criteria.
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Sakurai K, Miyashita T, Okazaki M, Yamaguchi T, Ohbatake Y, Nakanuma S, Okamoto K, Sakai S, Kinoshita J, Makino I, Nakamura K, Hayashi H, Oyama K, Tajima H, Takamura H, Ninomiya I, Fushida S, Harada K, Harmon JW, Ohta T. Role for Neutrophil Extracellular Traps (NETs) and Platelet Aggregation in Early Sepsis-induced Hepatic Dysfunction. ACTA ACUST UNITED AC 2018; 31:1051-1058. [PMID: 29102925 DOI: 10.21873/invivo.11169] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/01/2017] [Accepted: 09/05/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND/AIM Severe sepsis is associated with high morbidity and mortality rates. Inflammation and coagulation play pivotal roles in the pathogenesis of sepsis leading to multiple organ failure, especially in the liver. The aim of the present study was to assess the mechanism from sepsis to liver damage in a mouse model. MATERIALS AND METHODS We created a sepsis model by injecting lipopolysaccharide (LPS) intraperitoneally in mice. At 0, 6, 12, and 24 h following intraperitoneal injection of LPS, mice were euthanised and analyzed. Primary antibodies against myeloperoxidase (MPO), hepatic sinusoidal endothelial cells (SE-1), and P-selectin (CD62p) were used. Expression and localization in neutrophil, sinusoidal endothelial, and platelet cells were assessed by immunohistochemistry. RESULTS Immunohistochemical analyses revealed a positive staining for MPO, most abundantly in neutrophil granulocytes, within the hepatic sinusoids immediately after injection. Neutrophil extracellular trap (NET)-like structures stained for MPO, indicating the presence of neutrophils undergoing NETosis, were confirmed at 6 h after LPS administration. SE-1 staining for liver sinusoidal endothelial cells was significantly reduced at 12 h post-LPS administration through sinusoidal endothelial injury or detachment. Furthermore, the presence of extravasated platelets was confirmed in the space of Disse at 24 h after LPS administration. Blood sample analyses showed that white blood cell counts and platelet counts decreased gradually, while MPO amounts increased until 12 h after LPS administration. CONCLUSION We conclude that NET formation and intravasated platelet aggregation are the first steps from sepsis to liver damage, and that extravasated platelet aggregation promoted by NET-facilitated detachment of sinusoidal endothelial cells is the origin of sepsis-induced liver dysfunction.
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Affiliation(s)
- Kentaro Sakurai
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Tomoharu Miyashita
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Mitsuyoshi Okazaki
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Takahisa Yamaguchi
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Yoshinao Ohbatake
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Shinichi Nakanuma
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Koichi Okamoto
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Seisho Sakai
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Jun Kinoshita
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Isamu Makino
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Keishi Nakamura
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Hironori Hayashi
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Katsunobu Oyama
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Hidehiro Tajima
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroyuki Takamura
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Itasu Ninomiya
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Sachio Fushida
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Kenichi Harada
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - John W Harmon
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A
| | - Tetsuo Ohta
- Department of Gastroenterological Surgery, Kanazawa University Hospital, Kanazawa, Japan
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13
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Mauro M, Saggiorato G, Sartori MT, Gallo G, De Bortoli M, Bonetti E, Zaccaron A, Vitale V, Balter R, Chinello M, Cesaro S. Venoocclusive disease due to chemotherapy for pediatric acute lymphoblastic leukemia is associated with increased levels of plasminogen-activator inhibitor-1. Pediatr Blood Cancer 2018; 65:e26963. [PMID: 29350496 DOI: 10.1002/pbc.26963] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 12/12/2017] [Accepted: 12/14/2017] [Indexed: 12/23/2022]
Abstract
We describe three cases of sinusoidal obstruction syndrome/venoocclusive disease (SOS) in pediatric patients with acute lymphoblastic leukemia (ALL). All three episodes occurred during or just after the induction or reinduction phase of treatment based on prednisone/dexamethasone, vincristine, daunorubicin, and pegylated-l-asparaginase. SOS episodes were categorized as mild/moderate and resolved in 7, 10, and 16 days using supportive measures or defibrotide therapy. In all three episodes, the clinical diagnosis of SOS was associated with a significant increase in plasminogen-activator inhibitor-1 (PAI-1) that reduced with patient clinical improvement. PAI-1 warrants study as a diagnostic marker for SOS in ALL.
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Affiliation(s)
- Margherita Mauro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | | | - Giuseppe Gallo
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Elisa Bonetti
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Ada Zaccaron
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Virginia Vitale
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Rita Balter
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Chinello
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Bajwa RPS, Mahadeo KM, Taragin BH, Dvorak CC, McArthur J, Jeyapalan A, Duncan CN, Tamburro R, Gehred A, Lehmann L, Richardson P, Auletta JJ, Woolfrey AE. Consensus Report by Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplantation Consortium Joint Working Committees: Supportive Care Guidelines for Management of Veno-Occlusive Disease in Children and Adolescents, Part 1: Focus on Investigations, Prophylaxis, and Specific Treatment. Biol Blood Marrow Transplant 2017; 23:1817-1825. [PMID: 28754544 DOI: 10.1016/j.bbmt.2017.07.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/20/2017] [Indexed: 12/13/2022]
Abstract
Veno-occlusive disease (VOD) is a common and potentially fatal complication in children undergoing hematopoietic cell transplantation (HCT). It occurs in about one-third of all patients undergoing transplantation and is fatal in 50% of patients with severe disease. Early intervention and specific treatment with defibrotide are associated with improved outcomes. However, there is a lack of supportive care guidelines for management of the multiorgan dysfunction seen in most cases. There is high variability in the management of VOD, which may contribute to the increased morbidity and mortality. Although there is ample research in the specific treatment of VOD, there is paucity of literature regarding the management of ascites, transfusions requirements, fluids and electrolyte dysfunction, delirium, and investigations in children with VOD. The joint working committees of the Pediatric Acute Lung Injury and Sepsis Investigators and the Pediatric Blood and Marrow Transplantation Consortium collaborated to develop a series of evidence-based supportive care guidelines for management of VOD. The quality of evidence was rated and recommendations were made using Grading of Recommendations, Assessment, Development and Evaluation criteria. This manuscript is part 1 of the series and focuses on the need to develop these guidelines; methodology used to establish the guidelines; and investigations needed for diagnosis, prophylaxis, and treatment of VOD in children.
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Affiliation(s)
- Rajinder P S Bajwa
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio.
| | - Kris M Mahadeo
- Division of Pediatric Blood and Marrow Transplantation, The University of Texas, MD Anderson Children's Cancer Hospital, Houston, Texas
| | - Benjamin H Taragin
- Department of Pediatric Radiology, Children's Hospital at Montefiore, Bronx, New York
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Jennifer McArthur
- Department of Pediatric Critical Care Medicine St Jude Children's Research Hospital, Memphis, Tennessee
| | - Asumthia Jeyapalan
- Division of Pediatric Critical Care Medicine, University of Miami- Miller School of Medicine, Miami, Florida
| | - Christine N Duncan
- Division of Pediatric Stem Cell Transplant, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert Tamburro
- Division of Pediatric Critical Care Medicine, Pennsylvania University, Penn State Hershey Children's Hospital, Hershey, PA
| | - Alison Gehred
- Medical Library division, Nationwide Children's Hospital, Columbus, Ohio
| | - Leslie Lehmann
- Division of Pediatric Stem Cell Transplant, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Paul Richardson
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jeffery J Auletta
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio; Division of Infectious Diseases, Nationwide Children's Hospital, Columbus
| | - Ann E Woolfrey
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, Washington
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Quercetin and baicalein suppress monocrotaline-induced hepatic sinusoidal obstruction syndrome in rats. Eur J Pharmacol 2017; 795:160-168. [DOI: 10.1016/j.ejphar.2016.12.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 12/09/2016] [Accepted: 12/12/2016] [Indexed: 12/20/2022]
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16
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Guffroy M, Falahatpisheh H, Biddle K, Kreeger J, Obert L, Walters K, Goldstein R, Boucher G, Coskran T, Reagan W, Sullivan D, Huang C, Sokolowski S, Giovanelli R, Gerber HP, Finkelstein M, Khan N. Liver Microvascular Injury and Thrombocytopenia of Antibody-Calicheamicin Conjugates in Cynomolgus Monkeys-Mechanism and Monitoring. Clin Cancer Res 2016; 23:1760-1770. [PMID: 27683177 DOI: 10.1158/1078-0432.ccr-16-0939] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 08/17/2016] [Accepted: 09/09/2016] [Indexed: 11/16/2022]
Abstract
Purpose: Adverse reactions reported in patients treated with antibody-calicheamicin conjugates such as gemtuzumab ozogamicin (Mylotarg) and inotuzumab ozogamicin include thrombocytopenia and sinusoidal obstruction syndrome (SOS). The objective of this experimental work was to investigate the mechanism for thrombocytopenia, characterize the liver injury, and identify potential safety biomarkers.Experimental Design: Cynomolgus monkeys were dosed intravenously at 6 mg/m2/dose once every 3 weeks with a nonbinding antibody-calicheamicin conjugate (PF-0259) containing the same linker-payload as gemtuzumab ozogamicin and inotuzumab ozogamicin. Monkeys were necropsied 48 hours after the first administration (day 3) or 3 weeks after the third administration (day 63).Results: PF-0259 induced acute thrombocytopenia (up to 86% platelet reduction) with nadirs on days 3 to 4. There was no indication of effects on megakaryocytes in bone marrow or activation of platelets in peripheral blood. Microscopic evaluation of liver from animals necropsied on day 3 demonstrated midzonal degeneration and loss of sinusoidal endothelial cells (SECs) associated with marked platelet accumulation in sinusoids. Liver histopathology on day 63 showed variable endothelial recovery and progression to a combination of sinusoidal capillarization and sinusoidal dilation/hepatocellular atrophy, consistent with early SOS. Among biomarkers evaluated, there were early and sustained increases in serum hyaluronic acid (HA) that correlated well with serum aspartate aminotransferase and liver microscopic changes, suggesting that HA may be a sensitive diagnostic marker of the liver microvascular injury.Conclusions: These data support the conclusion that target-independent damage to liver SECs may be responsible for acute thrombocytopenia (through platelet sequestration in liver sinusoids) and development of SOS. Clin Cancer Res; 23(7); 1760-70. ©2016 AACR.
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Affiliation(s)
- Magali Guffroy
- Drug Safety Research and Development, Pfizer Inc., Pearl River, New York.
| | - Hadi Falahatpisheh
- Drug Safety Research and Development, Pfizer Inc., Pearl River, New York
| | - Kathleen Biddle
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - John Kreeger
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Leslie Obert
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Karen Walters
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Richard Goldstein
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Germaine Boucher
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Timothy Coskran
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - William Reagan
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Danielle Sullivan
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Chunli Huang
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | - Sharon Sokolowski
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
| | | | - Hans-Peter Gerber
- Oncology-Rinat Research & Development, Pfizer Inc., Pearl River, New York
| | - Martin Finkelstein
- Drug Safety Research and Development, Pfizer Inc., Pearl River, New York
| | - Nasir Khan
- Drug Safety Research and Development, Pfizer Inc., Groton, Connecticut
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Sinusoidal obstruction syndrome after allogeneic hematopoietic stem cell transplantation: Incidence, risk factors and outcomes. Bone Marrow Transplant 2015; 51:403-9. [DOI: 10.1038/bmt.2015.283] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 09/28/2015] [Accepted: 10/16/2015] [Indexed: 01/16/2023]
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18
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Lee JH. Biomarkers for hepatic sinusoidal obstruction syndrome after hematopoietic cell transplantation. Blood Res 2015; 50:123-5. [PMID: 26457275 PMCID: PMC4595574 DOI: 10.5045/br.2015.50.3.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Je-Hwan Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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19
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Dignan FL, Wynn RF, Hadzic N, Karani J, Quaglia A, Pagliuca A, Veys P, Potter MN. BCSH/BSBMT guideline: diagnosis and management of veno-occlusive disease (sinusoidal obstruction syndrome) following haematopoietic stem cell transplantation. Br J Haematol 2013; 163:444-57. [PMID: 24102514 DOI: 10.1111/bjh.12558] [Citation(s) in RCA: 209] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
DIAGNOSIS It is recommended that the diagnosis of veno-occlusive disease (sinusoidal obstruction syndrome) [VOD (SOS)] be based primarily on established clinical criteria (modified Seattle or Baltimore criteria) (1A). Ultrasound imaging may be helpful in the exclusion of other disorders in patients with suspected VOD (SOS) (1C). It is recommended that liver biopsy be reserved for patients in whom the diagnosis of VOD (SOS) is unclear and there is a need to exclude other diagnoses (1C). It is recommended that liver biopsies are undertaken using the transjugular approach in order to reduce the risks associated with the procedure (1C). It is suggested that the role of plasminogen activator inhibitor 1 levels remains an area for further research but that these levels should not form part of the routine diagnostic work-up for VOD (SOS) at present (2C). RISK FACTORS It is recommended that patients are assessed for risk factors for VOD (SOS) and that these risk factors are addressed prior to haematopoietic stem cell transplantation (1A). PROPHYLAXIS Defibrotide is recommended at a dose of 6.25 mg/kg intravenously four times daily for the prevention of VOD (SOS) in children undergoing allogeneic stem cell transplantation with the following risk factors: pre-existing hepatic disease, second myeloablative transplant, allogeneic transplant for leukaemia beyond second relapse, conditioning with busulfan-containing regimens, prior treatment with gemtuzumab ozogamicin, diagnosis of primary haemophagocytic lymphohistiocytosis, adrenoleucodystrophy or osteopetrosis (1A). Defibrotide is suggested at a dose of 6.25 mg/kg intravenously four times daily for the prevention of VOD (SOS) in adults undergoing allogeneic stem cell transplantation with the following risk factors: pre-existing hepatic disease, second myeloablative transplant, allogeneic transplant for leukaemia beyond second relapse, conditioning with busulfan-containing regimens, prior treatment with gemtuzumab ozogamicin, diagnosis of primary haemophagocytic lymphohistiocytosis, adrenoleucodystrophy or osteopetrosis (2B). Prostaglandin E1 is not recommended in the prophylaxis of VOD (SOS) due to lack of efficacy and toxicity (1B). Pentoxifylline is not recommended in the prophylaxis of VOD (SOS) due to lack of efficacy (1A). Ursodeoxycholic acid is suggested for use in the prophylaxis of VOD (SOS) (2C). Heparin (unfractionated and low molecular weight) is not suggested for use in the prophylaxis of VOD (SOS) due to the risk of increased toxicity (2B). Antithrombin is not suggested for the prophylaxis of VOD (SOS) due to lack of efficacy (2B). TREATMENT Defibrotide is recommended in the treatment of VOD (SOS) in adults and children (1B). Tissue plasminogen activator is not recommended for use in the treatment of VOD (SOS) due to the associated risk of haemorrhage (1B). N-acetylcysteine is not routinely recommended for use in the treatment of veno-occlusive disease due to lack of efficacy (1A). Methylprednisolone may be considered for use in the treatment of veno-occlusive disease with the appropriate caveats of caution regarding infection (2C). Judicious clinical care, particularly in the management of fluid balance, is recommended in the management of VOD (SOS) (1C). Early discussion with critical care specialists and a specialist hepatology unit is recommended in the management of VOD (SOS) and other treatment options including transjugular intrahepatic portosystemic shunt or hepatic transplantation may be considered (1C). SUMMARY A joint working group established by the Haemato-oncology subgroup of the British Committee for Standards in Haematology (BCSH) and the British Society for Blood and Marrow Transplantation (BSBMT) has reviewed the available literature and made recommendations for the diagnosis and management of veno-occlusive disease of the liver following haematopoietic stem cell transplantation (HSCT). This guideline includes recommendations for both prophylaxis and treatment of the condition and includes recommendations for children and adults undergoing HSCT.
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Affiliation(s)
- Fiona L Dignan
- Department of Haematology, Central Manchester NHS Foundation Trust, Manchester, UK
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20
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Kim H, Lee KH, Sohn SK, Jung CW, Joo YD, Kim SH, Kim BS, Choi JH, Kwak JY, Kim MK, Bae SH, Shin HJ, Won JH, Oh S, Lee WS, Park JH, Yoon SS. Hepatic sinusoidal obstruction syndrome after allogeneic hematopoietic stem cell transplantation in adult patients with idiopathic aplastic anemia. Leuk Res 2013; 37:1241-7. [PMID: 23871157 DOI: 10.1016/j.leukres.2013.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 06/04/2013] [Accepted: 06/17/2013] [Indexed: 01/20/2023]
Abstract
We retrospectively investigated the incidence, risk factors, and outcomes of SOS (sinusoidal obstruction syndrome; previously veno-occlusive disease [VOD]) after allogeneic hematopoietic stem cell transplantation (alloHSCT) in aplastic anemia. Two hundred and sixty patients were included in the analysis. SOS developed in 7.3% (n=19/260) of patients. Classical Cy (200 mg/m(2))-ATG was the most common conditioning regimen (84.2%) in the SOS group. The SOS mortality rate was 4/19 (21.1%). Univariate analyses revealed that Cy 200 mg/m(2) conditioning (p=0.035), classical Cy-ATG conditioning (p=0.007), and horse ATG conditioning (p<0.001) were significant risk factors for developing SOS. Multivariate analysis revealed that only horse ATG conditioning was a poor prognostic factor (HR=3.484; 95% CI 1.226-9.904; p=0.002). Rabbit ATG (HR 12.719; 95% CI 2.332-69.373; p=0.003) and weight gain>10% (HR 35.655; 95% CI 2.208-575.805; p=0.012) were risk factors in the overall SOS group. Both rabbit ATG conditioning and weight gain of more than 10% were associated with poor overall survival with a median of 1.2 months (5Y survival rate, any risk factor vs. none: 74.6% vs. 0.0%; p<0.001; Fig. 2) in the SOS group. In conclusion, SOS is a relatively rare (7.3%) but highly fatal (21.1%) acute complication of alloHSCT in AA, and the horse ATG conditioning regimen was a significant risk factor for developing SOS.
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Affiliation(s)
- Hawk Kim
- Divison of Hematology and Hematological Malignancies, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
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21
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Corbacioglu S, Kernan N, Lehmann L, Brochstein J, Revta C, Grupp S, Martin P, Richardson PG. Defibrotide for the treatment of hepatic veno-occlusive disease in children after hematopoietic stem cell transplantation. Expert Rev Hematol 2012; 5:291-302. [PMID: 22780209 DOI: 10.1586/ehm.12.18] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hepatic veno-occlusive disease (VOD) is a serious complication of stem cell transplantation in children. VOD is characterized by rapid weight gain, hepatomegaly, hyperbilirubinemia and ascites. The pathogenesis of VOD is thought to involve chemotherapy and radiation-induced damage to the sinusoidal endothelium, resulting in endothelial injury, microthrombosis, subendothelial damage and cytokine activation. These processes lead to concomitant progressive hepatocellular dysfunction and subsequent fluid retention and renal impairment. Severe VOD is typically associated with multiorgan failure and high mortality. A number of possible strategies for the prevention and/or treatment of VOD in children have been investigated. The most promising agent to date is defibrotide, a novel polydeoxyribonucleotide with fibrinolytic properties but no major bleeding risk. Numerous studies, including Phase II/III trials, have shown clinical benefit in pediatric patients with the use of defibrotide treatment and prophylaxis. This review discusses VOD in children and focuses on therapeutic options, including defibrotide, in this patient population.
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22
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Reimer J, Bien S, Ameling S, Hammer E, Völker U, Hempel G, Boos J, Kroemer HK, Ritter CA. Antineoplastic agent busulfan regulates a network of genes related to coagulation and fibrinolysis. Eur J Clin Pharmacol 2012; 68:923-35. [PMID: 22286157 DOI: 10.1007/s00228-011-1209-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 12/29/2011] [Indexed: 11/28/2022]
Abstract
Purpose Hepatic veno-occlusive disease (HVOD) is one of the major complications following hematopoietic stem cell transplantation (HSCT). Although high-dose busulfan is associated with the development of HVOD, the underlying molecular mechanisms are still unknown.Methods Transcriptional gene regulation by busulfan was profiled using Affymetrix GeneChip® Human Genome U133 Plus 2.0 arrays. Messenger RNA (mRNA) expression of regulated genes was assessed by TaqMan real-time polymerase chain reaction (PCR), and protein expression and secretion was determined by enzyme-linked immunosorbent assay (ELISA)in cell supernatants, lysates, and patient plasma.Results Plasma levels of plasminogen activator inhibitor(PAI)-1 significantly increased 48 h after starting busulfan treatment IV in children preconditioned for HSCT. In vitro,busulfan significantly induced plasminogen activator inhibitor-1 (PAI-1) expression in endothelium-like ECV304 cells in a concentration- and time-dependent manner. Comparative transcriptional profiling of busulfan-treated and control ECV304 cells identified differential expression of genes related to coagulation and fibrinolysis, including tissue factor, tissue factor pathway inhibitor-1, protein S, thrombospondin-1, urokinase receptor, and PAI-1, as well as activin A and transforming growth factor beta 1 (TGF-β1). Ingenuity pathway analysis (IPA) suggested TGF-β1 as a central modulator of gene regulation by busulfan. Consequently, expression of tissue factor, urokinase receptor, and PAI-1 mRNA and PAI-1 protein secretion induced by busulfan were significantly reduced by the activin A/TGF-β1 inhibitor SB 431542 in ECV304 and primary endothelial cells.Conclusions This is the first report that directly relates busulfan exposure to antifibrinolytic activity by PAI-1 and hypercoagulation possibly mediated by members of the TGF-β1 family. This suggests further research to evaluate activin A and TGF-β1 as potential targets for HVOD treatment.
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Affiliation(s)
- Janka Reimer
- Research Center of Pharmacology and Experimental Therapeutics,Department of Pharmacology, Ernst-Moritz-Arndt-Universityof Greifswald,Greifswald, Germany
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Richardson PG, Ho VT, Giralt S, Arai S, Mineishi S, Cutler C, Antin JH, Stavitzski N, Niederwieser D, Holler E, Carreras E, Soiffer R. Safety and efficacy of defibrotide for the treatment of severe hepatic veno-occlusive disease. Ther Adv Hematol 2012; 3:253-65. [PMID: 23606935 PMCID: PMC3627330 DOI: 10.1177/2040620712441943] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome, is a potentially life-threatening complication of chemotherapeutic conditioning used in preparation for hematopoietic stem-cell transplantation (SCT). VOD may occur in up to 62% of patients undergoing SCT, with onset generally within the first month after SCT. In severe cases, 100-day mortality is in excess of 80%. Current management consists of best supportive care, with no agents to date approved for treatment in the USA or the EU. Defibrotide, a polydisperse oligonucleotide, has been shown in phase II and III trials to improve complete response and survival in patients undergoing SCT with severe VOD. This article reviews our current understanding of VOD, and examines recent clinical findings on defibrotide for the treatment and prophylaxis of VOD.
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Affiliation(s)
- Paul G Richardson
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02115, USA
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24
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Sartori MT, Cesaro S, Peruzzo M, Messina C, Saggiorato G, Calore E, Pillon M, Varotto S, Spiezia L, Cella G. Contribution of fibrinolytic tests to the differential diagnosis of veno-occlusive disease complicating pediatric hematopoietic stem cell transplantation. Pediatr Blood Cancer 2012; 58:791-7. [PMID: 21674760 DOI: 10.1002/pbc.23213] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 05/02/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Veno-occlusive disease (VOD) is a major complication following hematopoietic stem cell transplantation (HSCT). Its diagnosis is based on clinical criteria, which have a limited sensitivity. Increased plasminogen activator inhibitor-1 (PAI-1) levels have been suggested as a marker of VOD. We aimed to prospectively evaluate how the fibrinolytic parameters behaved to discriminate VOD from other liver disorders occurring after HSCT in a pediatric population. PROCEDURES A total of 195 HSCT were performed on 161 children and VOD complicated 11 cases (6.8%). Alanine aminotransferase, total bilirubin, PAI-1 antigen (PAI-1:Ag) and activity, t-PA antigen, D-dimer, prothrombin time, activated partial thromboplastin time, antithrombin, fibrinogen, and platelet counts were measured in 105 HSCT before and then weekly for 1 month after HSCT. RESULTS An early, significant increase in the fibrinolytic parameters was seen in patients who developed VOD, even before VOD was diagnosed clinically, by comparison with patients without complications or those with non-VOD liver disorders. The combined increase in bilirubin, D-dimer, and PAI-1:Ag levels beyond the normal range distinguished VOD cases from other liver complications with a high sensitivity and specificity. CONCLUSIONS Our study demonstrates that fibrinolytic tests can help diagnose VOD after HSCT in the pediatric population.
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Affiliation(s)
- Maria Teresa Sartori
- Second Chair of Internal Medicine, Department of Cardiologic, Thoracic and Vascular Sciences, University of Padova, Padova, Italy.
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Richardson P, Linden E, Revta C, Ho V. Use of defibrotide in the treatment and prevention of veno-occlusive disease. Expert Rev Hematol 2011; 2:365-76. [PMID: 21082942 DOI: 10.1586/ehm.09.30] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Hepatic veno-occlusive disease (VOD) is one of the most important complications of high-dose chemotherapy and stem cell transplantation. VOD is a clinical syndrome characterized by jaundice, hepatic enlargement and fluid retention typically seen by day +30 after transplantation. Severe VOD is complicated by multiorgan failure and a high mortality rate approaching 100%. Defibrotide (DF) is a novel agent with both antithrombotic and fibrinolytic properties that has emerged as an effective therapy for severe VOD. In Phase II studies, treatment of severe VOD has resulted in complete responses of 30-60% and survival past day 100 ranging between 32-50%. A Phase III, historically controlled study of DF for treatment of severe VOD has recently been completed and results are awaited with interest. In addition, DF may be effective prophylaxis for VOD in high-risk patients. This review will focus on a summary of the pharmacology of DF and the clinical evidence for its use in VOD.
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Affiliation(s)
- Paul Richardson
- Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115, USA.
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26
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Hepatic veno-occlusive disease following stem cell transplantation: incidence, clinical course, and outcome. Biol Blood Marrow Transplant 2009; 16:157-68. [PMID: 19766729 DOI: 10.1016/j.bbmt.2009.08.024] [Citation(s) in RCA: 397] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Accepted: 08/21/2009] [Indexed: 02/07/2023]
Abstract
The occurrence of hepatic veno-occlusive disease (VOD) has been reported in up to 60% of patients following stem cell transplantation (SCT), with incidence varying widely between studies depending on the type of transplant, conditioning regimen, and criteria used to make the diagnosis. Severe VOD is characterized by high mortality and progression to multiorgan failure (MOF); however, there is no consensus on how to evaluate severity. This review and analysis of published reports attempts to clarify these issues by calculating the overall mean incidence of VOD and mortality from severe VOD, examining the effect of changes in SCT practice on the incidence of VOD over time, and discussing the methods used to evaluate severity. Across 135 studies performed between 1979 and October 2007, the overall mean incidence of VOD was 13.7% (95% confidence interval [CI]=13.3%-14.1%). The mean incidence of VOD was significantly lower between 1979-1994 than between 1994-2007 (11.5% [95% CI, 10.9%-12.1%] vs 14.6% [95% CI, 14.0%-15.2%]; P <.05). The mortality rate from severe VOD was 84.3% (95% CI, 79.6%-88.9%); most of these patients had MOF, which also was the most frequent cause of death. Thus, VOD is less common than early reports suggested, but the current incidence appears to be relatively stable despite recent advances in SCT, including the advent of reduced-intensity conditioning. The evolution of MOF in the setting of VOD after SCT can be considered a reliable indication of severity and a predictor of poor outcome.
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Cutler C, Stevenson K, Kim HT, Richardson P, Ho VT, Linden E, Revta C, Ebert R, Warren D, Choi S, Koreth J, Armand P, Alyea E, Carter S, Horowitz M, Antin JH, Soiffer R. Sirolimus is associated with veno-occlusive disease of the liver after myeloablative allogeneic stem cell transplantation. Blood 2008; 112:4425-31. [PMID: 18776081 PMCID: PMC2597119 DOI: 10.1182/blood-2008-07-169342] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Accepted: 08/23/2008] [Indexed: 12/19/2022] Open
Abstract
Sirolimus is an effective agent used in graft-versus-host disease (GVHD) prophylaxis after allogeneic transplantation. It also has antiproliferative effects on vascular endothelium when used to coat coronary artery stents. We noted an excess of veno-occlusive disease (VOD) in a clinical trial, and retrospectively reviewed the records of 488 patients to determine the association between sirolimus and VOD. When used with cyclophosphamide/total body irradiation (Cy/TBI) conditioning, sirolimus is associated with an increased incidence of VOD (OR 2.35, P = .005). The concomitant use of methotrexate further increased this rate (OR 3.23, P < .001), while sirolimus without methotrexate was not associated with an increased risk of VOD (OR 1.55, P = .33). Mortality after VOD diagnosis was unaffected, and overall treatment-related mortality was lowest when sirolimus was used without methotrexate. Similar findings were noted in matched, related, and unrelated as well as mismatched donor subgroups. When used with busulfan-based conditioning, sirolimus use was associated with an even higher rate of VOD (OR 8.8, P = .008). Our findings suggest that sirolimus use is associated with VOD after TBI-based transplantation when used with methotrexate after transplantation. Sirolimus-based GVHD prophylaxis without methotrexate is associated with the greatest overall survival. Myeloablative doses of busulfan should not be used with sirolimus-based immunosuppression.
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Affiliation(s)
- Corey Cutler
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA.
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Ho VT, Revta C, Richardson PG. Hepatic veno-occlusive disease after hematopoietic stem cell transplantation: update on defibrotide and other current investigational therapies. Bone Marrow Transplant 2007; 41:229-37. [PMID: 17994121 DOI: 10.1038/sj.bmt.1705899] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome (SOS), remains one of the most serious and common complications after myeloablative hematopoietic stem cell transplantation (HSCT). Clinical diagnosis of hepatic VOD is based on the clinical triad of (1) painful hepatomegaly, (2) hyperbilirubinemia and (3) unexplained fluid retention. While milder cases usually resolve spontaneously, severe VOD is associated with a grim prognosis. Defibrotide (DF), a polydisperse mixture of single-stranded oligonucleotide with antithrombotic and fibrinolytic effects on microvascular endothelium, has emerged as an effective and safe therapy for patients with severe VOD. Multiple studies, including a recent large international multicenter phase II clinical trial, have demonstrated 30-60% complete remission rates with DF, even among patients with severe VOD and multiorgan failure. This article will review our current understanding of hepatic VOD, and update the clinical trial experience with DF and other potential therapies for this feared transplant complication.
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Affiliation(s)
- V T Ho
- Department of Adult Oncology, Center for Hematologic Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Harslund J, Nielsen OL, Brünner N, Offenberg H. Gender-dependent physiological implications of combined PAI-1 and TIMP-1 gene deficiency characterized in a mouse model. Am J Physiol Regul Integr Comp Physiol 2007; 293:R1630-9. [PMID: 17652357 DOI: 10.1152/ajpregu.00380.2007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The endogenous proteinase inhibitors plasminogen activator inhibitor type 1 (PAI-1) and tissue inhibitor of metalloproteinase type 1 (TIMP-1) are two distinct proteins with separate molecular pathways. However, a close relationship between PAI-1 and TIMP-1 has been proposed indicating some degree of functional overlap due to their involvement in ECM turnover, tissue remodeling, and cellular migration and signaling. To study the housekeeping physiological implications of PAI-1 and TIMP-1, we generated a combined PAI-1 and TIMP-1 gene-deficient mouse model. We present the results on generating this specific mouse model with particular emphasis on phenotypical characteristics, blood leukocyte counts, histology, and gene expression studies of PAI-1 and TIMP-1 in various organs. We observed a significant deviation in segregation of offspring only in male mice (P < 0.01) predominantly caused by PAI-1 deficiency. In addition, the body weight in 3- and 20-wk-old male and 20-wk-old female mice was significantly different between genotypes (P <or= 0.0008). Furthermore, blood leukocyte counts were significantly different between genotypes in 20-wk-old male mice (P <or= 0.0002), whereas no significant differences were observed between genotypes in 20-wk-old female mice (P >or= 0.13). Quantifying the relative expression of PAI-1 and TIMP-1 revealed upregulation of PAI-1 (P < 0.001) in male mice only. Our data highlight the complex roles of PAI-1 and TIMP-1 on physiological parameters such as segregation of offspring (embryonic development and survival), body weight (metabolism), blood leukocyte counts (immunity), and gene expression (regulatory redundancy). We conclude that PAI-1 and TIMP-1 seem to possess gender-dependent regulatory properties on various housekeeping physiological parameters and stress the potential implications in pathological conditions.
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Affiliation(s)
- Jakob Harslund
- 1Section of Biomedicine, Dept. of Veterinary Pathobiology, Faculty of Life Sciences, Univ. of Copenhagen, Ridebanevej 9, DK-1870 Frederiksberg C, Denmark.
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Yilmaz M, Dagdas S, Aki SZ, Guler N, Akoz AG, Erdin Z, Alanoglu G, Ozet G. The relation between plasminogen activator inhibitor activity and disease activation in acute myeloblastic leukaemia patients. Int J Lab Hematol 2006; 28:313-6. [PMID: 16999721 DOI: 10.1111/j.1365-2257.2006.00820.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Coagulation and fibrinolytic abnormalities are common in patients with acute myeloblastic leukaemia (AML) like other forms of leukaemias. In this study, we investigated if total plasminogen activator inhibitor (PAI) activity, which is believed to increase in initial diagnosis and relapse in AML patients could be accepted as a relapse criterion or not. Total of 34 AML patients and 18 healthy volunteers were included in this study. The patients' diagnosis were based on clinical criteria as well as morphological, cytochemical, immunuphenotypic examinations of peripheral blood and bone marrow specimens. Total PAI activity was measured with Dade Behring Bericrom PAI reagent in BCS system. Total PAI activity was higher than 3.5 U/ml in 11 AML patients while it was normal (0.3-3.5 U/ml) in control group (P < 0.01). There was no significant difference in total PAI activity between AML subgroups (P > 0.05). We found significant difference in total PAI activity between patients who have active disease and remission. In conclusion, the total PAI activity could be accepted as a relapse and an initial diagnosis criterion of AML patients during follow up.
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Affiliation(s)
- M Yilmaz
- Ankara Numune Education and Research Hospital Clinic of Hematology, Ankara, Turkey.
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Abstract
Among the various deleterious effects of cancer chemotherapy, vascular toxicity is the least well recognized. This lack of recognition may be because the vasculotoxic phenomena are not unique to antineoplastic agents, can occur in patients without exposure to these agents, and the fact cancer itself may produce a hypercoagulable state. As a result, many vascular events either go unnoticed, are ignored, and/or are attributed to the underlying malignancy. Many antineoplastic therapies are associated with various vascular phenomena that range from simple phelibitis to lethal microangiopathy. Recognition of these events is important to minimize the morbidity and even prevent unnecessary deaths. Herein we review the vascular syndromes that have been reported in association with antineoplastic agents.
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Affiliation(s)
- Nasir Shahab
- Department of Medicine, Division of Hematology-Medical Oncology, Ellis Fischel Cancer Center, University of Missouri-Columbia, Columbia, MO 65203, USA.
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Gharib MI, Bulley SR, Doyle JJ, Wynn RF. Venous occlusive disease in children. Thromb Res 2006; 118:27-38. [PMID: 16154622 DOI: 10.1016/j.thromres.2005.02.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2005] [Revised: 02/22/2005] [Accepted: 02/28/2005] [Indexed: 12/15/2022]
Affiliation(s)
- Maged I Gharib
- Department of Haematology, Royal Manchester Children's Hospital, Hospital Road, Pendlebury, Manchester M27 4HA, United Kingdom.
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Smith LH, Dixon JD, Stringham JR, Eren M, Elokdah H, Crandall DL, Washington K, Vaughan DE. Pivotal role of PAI-1 in a murine model of hepatic vein thrombosis. Blood 2005; 107:132-4. [PMID: 16160004 PMCID: PMC1895352 DOI: 10.1182/blood-2005-07-2681] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Hepatic veno-occlusive disease (VOD) is a common complication of high-dose chemotherapy associated with bone marrow transplantation. While the pathogenesis of VOD is uncertain, plasminogen activator inhibitor-1 (PAI-1) has emerged as a diagnostic marker and predictor of VOD in humans. In this study, we investigated the role of PAI-1 in a murine model of VOD produced by long-term nitric oxide synthase inhibition using L-NAME. After 6 weeks, wild-type (WT) mice developed extensive fibrinoid hepatic venous thrombi and biochemical evidence of hepatic injury and dysfunction. In contrast, PAI-1-deficient mice were largely protected from the development of hepatic vein thrombosis. Furthermore, WT mice that received tiplaxtinin, an antagonist of PAI-1, were effectively protected from L-NAME-induced thrombosis. Taken together, these data indicate that NO and PAI-1 play pivotal and antagonistic roles in hepatic vein thrombosis and that PAI-1 is a potential target in the prevention and treatment of VOD in humans.
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Affiliation(s)
- Layton H Smith
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, 2220 Pierce Ave, Nashville, TN 37232, USA
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Imoto S, Murayama T, Nagai K, Hirabayashi N, Tanaka C, Misawa M, Kawasaki K, Mizuno I, Koizumi T, Kajimoto K, Takahashi T, Hara H, Kumagai S, Saigo K. Usefulness of Sequential Automated Analysis of Fragmented Red Blood Cells for the Differential Diagnosis of Thrombotic Thrombocytopenic Purpura-Hemolytic Uremic Syndrome following Allogeneic Hematopoietic Cell Transplantation. ACTA ACUST UNITED AC 2005; 11:131-6. [PMID: 16024337 DOI: 10.1532/lh96.04065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Differentiating thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) from other complications following allogeneic hematopoietic cell transplantation (HPCT) requires objective, reliable markers. To this purpose, we assessed the clinical usefulness of sequential quantified analysis of fragmented red blood cells (FRC) with the Sysmex XE-2100 automated hematology analyzer. The correlation between manual and automated counting was significant (r = 0.917; P < .0001). Of 25 cases, the peak FRC percentage (FRC%) exceeded 1.3% after allogeneic HPCT in 11 cases, and lactate dehydrogenase levels were elevated in 5 of these 11 cases. Two patients received diagnoses of TTP-HUS following allogeneic HPCT, and both had initial diagnoses of acute graft-versus-host disease. In both cases, the sharp increase in the FRC% to >3% simultaneously with clinical exacerbation was helpful for differentiating TTP-HUS following allogeneic HPCT from other complications. We conclude that FRC% data sequentially obtained by an automated count seem to be useful as an objective marker of TTP-HUS following allogeneic HPCT.
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Affiliation(s)
- Shion Imoto
- Hyogo Red Cross Blood Center, 1-4-5 Wakinohamakaigan-dori, Chuo-ku, Kobe, Hyogo, Japan.
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Pihusch V, Pihusch M, Penovici M, Kolb HJ, Hiller E, Pihusch R. Transforming growth factor beta-1 released from platelets contributes to hypercoagulability in veno-occlusive disease following hematopoetic stem cell transplantation. Thromb Res 2005; 116:233-40. [PMID: 15935832 DOI: 10.1016/j.thromres.2004.12.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2004] [Revised: 12/02/2004] [Accepted: 12/14/2004] [Indexed: 01/04/2023]
Abstract
BACKGROUND Hepatic veno-occlusive disease (VOD) is one of the most disastrous complications after allogeneic hematopoetic stem cell transplantation (HSCT). Thrombocytopenia with refractoriness to platelet transfusions suggests an increased platelet consumption in these patients. Interactions between platelets and endothelial cells might contribute to the hypercoagulable state at the sinusoidal endothelium as a central mechanism in the pathogenesis of VOD. STUDY DESIGN The influence of activated platelets on cultured human endothelial cells was investigated in vitro. We focused on the release of plasminogen activator inhibitor-1 (PAI-1) from endothelial cells which has earlier been found to be significantly elevated in plasma of VOD patients. Endothelial cells isolated from human umbilical cords (HUVEC) were incubated with activated platelets. The release of PAI-1 in the presence or absence of specific antibodies was determined by ELISA technique. Tissue factor (TF) expression on endothelial cells was observed by flowcytometric analysis. RESULTS HUVEC incubated with activated platelets were found to release significantly more PAI-1 compared to untreated cultures. The endothelial PAI-1-secretion after incubation of HUVEC with activated platelets was completely inhibited by an IgG monoclonal antibody against human transforming growth factor beta-1 (TGF beta-1). In contrast, PAI-1 production was not suppressed after inhibition of HUVEC-platelet-interaction by an IgG monoclonal antibody against CD154 (CD40L) expressed on the surface of activated platelets. An increased release of PAI-1 and an increased expression of tissue factor (TF) on the endothelial cell surface were observed after stimulation with TGF beta-1. CONCLUSION TGF beta-1 released from activated platelets contributes to the hemostatic imbalance at the sinusoidal endothelium in patients with hepatic VOD by increase of endothelial cell PAI-1 production and TF expression. As a potent profibrotic cytokine, TGF beta-1 might further be involved in phlebosclerosis and sinusoidal fibrosis occurring in VOD.
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Affiliation(s)
- Verena Pihusch
- Klinikum Grosshadern der LMU München, Medizinische Klinik III, Marchioninistrasse 15, 81377 Münich, Germany.
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Lee JH, Choi SJ, Lee JH, Kim SE, Park CJ, Chi HS, Lee MS, Lee JS, Kim WK, Lee KH. Decreased incidence of hepatic veno-occlusive disease and fewer hemostatic derangements associated with intravenous busulfan vs oral busulfan in adults conditioned with busulfan + cyclophosphamide for allogeneic bone marrow transplantation. Ann Hematol 2004; 84:321-30. [PMID: 15580502 DOI: 10.1007/s00277-004-0982-4] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2004] [Accepted: 11/02/2004] [Indexed: 12/17/2022]
Abstract
We investigated the occurrence of hepatic veno-occlusive disease (VOD) after allogeneic bone marrow transplantation (BMT) in 241 adults conditioned with busulfan + cyclophosphamide at a single institute and retrospectively compared 186 patients who received oral busulfan (O-Bu group) with 55 patients who received intravenous busulfan (I-Bu group). Various hemostatic parameters were determined at baseline and on days 0, 7, 14, and 21. Hepatic VOD occurred in 41.7% of the O-Bu group and in 18.5% of the I-Bu group. Multivariate analysis revealed that the I-Bu group had significantly decreased risk of VOD compared to the O-Bu group [p=0.006, odds ratio: (OR) 0.345]. Eleven patients in the O-Bu group and none of the I-Bu group developed severe VOD. A repeated measures analysis of variance (ANOVA) with a between-subjects factor revealed significant differences in post-transplant levels of antithrombin III, tissue plasminogen activator (tPA), plasminogen activator inhibitor 1 (PAI-1), and D-dimer according to the occurrence of VOD. The level of antithrombin III was significantly lower, whereas the level of D-dimer was significantly higher, in the O-Bu group than in the I-Bu group. These findings show that, in adults conditioned with busulfan + cyclophosphamide, intravenous busulfan was associated with significantly decreased incidence of VOD and fewer hemostatic derangements after allogeneic BMT compared to oral busulfan.
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Affiliation(s)
- Je-Hwan Lee
- Department of Internal Medicine, Asan Medical Center, 388-1 Poongnap-2-dong, Songpa-gu, Seoul 138-736, South Korea.
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Lee KH, Choi SJ, Lee JH, Kim S, Seol M, Lee YS, Kim WK, Lee JS, Lee JH. Cyclosporine alone vs cyclosporine plus methotrexate for post-transplant immunosuppression after HLA-identical sibling bone marrow transplantation: a randomized prospective study. Bone Marrow Transplant 2004; 34:627-36. [PMID: 15300231 DOI: 10.1038/sj.bmt.1704624] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The role of methotrexate (MTX), given with cyclosporine (CS), after HLA-identical sibling bone marrow transplantation needs to be defined. In all, 80 patients with hematologic malignancies were enrolled in a prospective randomized trial. All were given BuCy conditioning. The 40 patients in the CS arm received CS 3 mg/kg/day intravenously, with subsequent oral dosing. Patients in the CS + MTX arm received, in addition to CS, MTX intravenously, 15 mg/m2 on day 1, and 10 mg/m2 on days 3, 6, and 11. Transplantation-related mortality was low in both groups of patients (13 vs 11% for CS vs CS + MTX groups, P = 0.94). The CS group had a significantly higher frequency of chronic graft-versus-host disease (56 vs 32%, P = 0.05). After a median follow-up of 22.1 months (5.1-47.8 months), three of 30 vs 10 of 28 patients with acute leukemia/myelodysplastic syndrome (MDS) in CS group vs CS + MTX group relapsed (P = 0.01) yielding better overall survival for patients with acute leukemia/MDS treated with CS (P = 0.02). After HLA-identical sibling bone marrow transplantation, immunosuppression with CS, with or without MTX, resulted in similarly low transplantation-related mortality. In acute leukemia/MDS, decreased relapse with patient survival prolongation was observed in the CS group.
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Affiliation(s)
- K-H Lee
- Sections of Hematology and Oncology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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Lee KH, Lee JH, Choi SJ, Lee JH, Kim S, Seol M, Lee YS, Kim WK, Seo EJ, Park CJ, Chi HS, Lee JS. Bone marrow vs extramedullary relapse of acute leukemia after allogeneic hematopoietic cell transplantation: risk factors and clinical course. Bone Marrow Transplant 2004; 32:835-42. [PMID: 14520431 DOI: 10.1038/sj.bmt.1704223] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A total of 118 consecutive adult patients with acute leukemia (78 AML, 36 ALL, and four acute mixed lineage leukemia) underwent allogeneic hematopoietic cell transplantation (HCT) after conditioning with BuCy (n=113) or a nonmyeloablative regimen of busulfan-fludarabine (n=5). After a median follow-up of 35.8 months (range, 6.4-91.0), 34 patients experienced at least one episode of leukemia relapse. Of 34 initial episodes, 14 (41%) occurred in extramedullary sites, with (n=8) or without (n=6) concomitant bone marrow involvement. The median time to relapse in the extramedullary sites was longer than that of relapse in bone marrow only (13.5 vs 6.1 months, P=0.046). Acute leukemia subtype and disease status at HCT showed an independent predictive value for overall relapse, as well as for extramedullary relapse with or without bone marrow involvement (Philadelphia chromosome positive acute leukemia vs low-risk AML, relative risk 22.68 (95% CI, 2.18-235.64); other than first CR vs first CR, relative risk 5.61 (95% CI, 1.80-17.51)), but not for bone marrow relapse. Our study suggests that there may be different pathogenetic mechanisms for bone marrow vs extramedullary relapse of acute leukemia after allogeneic HCT. The mode of relapse needs to be investigated in future reports of acute leukemia treated with allogeneic HCT.
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Affiliation(s)
- K-H Lee
- Division of Oncology-Hematology, Department of Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea.
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Lee KH, Lee JH, Choi SJ, Lee JH, Kim S, Seol M, Lee YS, Kim WK, Lee JS. Failure of trilineage blood cell reconstitution after initial neutrophil engraftment in patients undergoing allogeneic hematopoietic cell transplantation – frequency and outcomes. Bone Marrow Transplant 2004; 33:729-34. [PMID: 14755315 DOI: 10.1038/sj.bmt.1704428] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The outcomes of patients who experience the failure to reconstitute a trilineage of blood cells after initial neutrophil engraftment were evaluated in 178 patients with hematologic disorders, who underwent allogeneic HCT. Of 165 qualified patients (five with primary engraftment failure; eight deaths before day 60 of HCT), 43 (26%) satisfied the criteria for the initial (n=22; failure of platelet >20 000/microl or red blood cell transfusion independence/reticulocyte count >/=1.0% by day 60) or subsequent (n=21, ANC <500/microl for >/=3 days, platelet <20 000/microl for >/=7 days, or red blood cells transfusion/reticulocyte <1.0% after initial trilineage reconstitution) failure. GVHD was the most common clinical condition associated with cytopenia (n=24). In all, 20 patients (47%) recovered at least partially with a median of 52 days (range 8-323) later, with 12 of those 20 patients recovering completely. The eventual reconstitution failure rate was 14% (23/163 patients). The number of cell lineages involved in the cytopenia was the only independent variable that predicted partial recovery (1 lineage vs 2-3 lineages with odds ratio of 8.69 (95% CI 1.96-38.60), P=0.004). Five/20 patients with vs 20/23 patients without partial recovery died. Trilineage reconstitution failures after allogeneic HCT need systematic analysis in the future studies.
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Affiliation(s)
- K-H Lee
- Section of Hematology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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40
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Lee KH, Lee JH, Choi SJ, Lee JH, Kim S, Seol M, Lee YS, Kim WK, Kwon MR, Choi SJ, Park CJ, Chi HS, Lee JS. Monthly prospective analysis of hematopoietic chimerism after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2003; 32:423-31. [PMID: 12900780 DOI: 10.1038/sj.bmt.1704147] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
SUMMARY Hematopoietic chimerism (HpC) was assayed monthly using a sensitive, polymerase chain reaction (PCR) -based method in consecutive patients. Between January 1998 and April 2002, 181 patients underwent non-T cell depleted allogeneic hematopoietic cell transplantation (HCT). A total of 163 patients were evaluable for HpC at 1 month (11 early deaths; no informative band for HpC analysis/no genomic DNA in seven). In all, 53 of 163 patients (33%, median recipient DNA of 15% (range 5-95)), 39 of 151 patients (26%), and 27 of 142 patients (19%) showed mixed chimerism (MC) at 1, 2, and 3 months after HCT, respectively. Conditioning regimen (busulfan-fludarabine-ATG vs BuCy, relative risk 3.99 (95% CI 1.16-10.92)), neutrophil engraftment (>/=day 17 vs </=day 16, relative risk 2.49 (95% CI 1.14-5.41)), and acute graft-versus-host disease within 30 days (none vs yes, relative risk 4.78 (95% CI 1.50-15.17)) were independent variables that showed significant correlation with having >/=5% recipient DNA at 1 month. Five patients experienced secondary graft failure. All five patients showed MC at 1 month with median recipient DNA of 40%. None of the 109 patients with complete chimerism experienced graft failure (P=0.002). Our study showed that MC shown on monthly analysis of HpC after allogeneic HCT is a significant predictor of secondary graft failure. Bone Marrow Transplantation (2003) 32, 423-431. doi:10.1038/sj.bmt.1704147
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Affiliation(s)
- K-H Lee
- Department of Medicine, Division of Oncology-Hematology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
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Falanga A, Vignoli A, Marchetti M, Barbui T. Defibrotide reduces procoagulant activity and increases fibrinolytic properties of endothelial cells. Leukemia 2003; 17:1636-42. [PMID: 12886253 DOI: 10.1038/sj.leu.2403004] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Defibrotide (DF), a polydeoxyribonucleotide with antithrombotic properties, has recently proven effective in patients with severe hepatic veno-occlusive disease (VOD), a life-threatening complication of high-dose chemo/radiotherapy regimens for stem cell transplantation. To understand the mechanism of its beneficial effect, we studied the impact of DF on the expression of tissue factor (TF) and fibrinolytic proteins (PAI-1 and t-PA) on endothelial cells. The in vitro response to DF of two types of human endothelial cells (ECs) of different origins, that is from macrovascular (HUVEC) and microvascular (HMEC-1 cell line) beds, was evaluated in the presence or absence of a proinflammatory stimulus (ie bacterial endotoxin, LPS). The results show that DF was able to significantly reduce the LPS-induced TF expression by HMEC-1, and less prominently by HUVEC. In addition, DF importantly influenced the fibrinolytic properties of both HMEC-1 and HUVEC. Specifically, it dose-dependently counteracted the LPS-induced increase in PAI-1 levels and decrease in t-PA activity expression. It also significantly incremented t-PA antigen in resting EC. Decreasing the procoagulant activity and increasing the fibrinolytic potential of EC favors an anticoagulant phenotype of the endothelium, which may protect from fibrin deposition and vascular occlusion.
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Affiliation(s)
- A Falanga
- Department of Hematology, Ospedali Riuniti, Bergamo, Italy
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Abstract
Hepatic veno-occlusive disease (VOD) is a major cause of morbidity and mortality following high dose cytotoxic therapy for stem cell transplantation (SCT). Pre-existing liver damage, SCT-related therapy, and genetic polymorphisms all appear to increase the risk of developing VOD. Studies of biological markers during SCT suggest that cytokines, haemostasis, and hepatic drug metabolism via the glutathione pathway are all involved in the pathogenesis of VOD. Until recently, treatment options were limited and experimental therapies directed at the pathogenesis of the disease were mostly unsuccessful. However, Defibrotide, a relatively new agent that has modulatory effects on vascular endothelium, cytokine release, and haemostasis, has been used with some success in the management and prophylaxis of VOD. In the future, a better understanding of genetic polymorphisms and biological markers which may be important in the pathogenesis of VOD, may enable us to predict which patients are most likely to be affected.
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Affiliation(s)
- Jason A Coppell
- Haemophilia Centre and Haemostasis Unit, Royal Free Campus, Royal Free and University College Medical School, Pond Street, London NW3 2QG, UK.
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