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Robinson CR, Habib A, Klomjit N, Cao Q, Holtan SG. Nephrons and non-relapse mortality: simplified comorbidity index and acute kidney injury are associated with NRM in adults undergoing allogeneic hematopoietic cell transplant. FRONTIERS IN TRANSPLANTATION 2024; 3:1352413. [PMID: 38993762 PMCID: PMC11235361 DOI: 10.3389/frtra.2024.1352413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/06/2024] [Indexed: 07/13/2024]
Abstract
The Simplified Comorbidity Index (SCI) is a recently published 5-component, pre-transplant tool to predict non-relapse mortality (NRM) in allogeneic hematopoietic cell transplantation (alloHCT) patients. The SCI captures chronic kidney disease (CKD) using estimated glomerular filtration rate (eGFR) based on the CKD-EPI equation (KDIGO 2021 CKD-EPI), which may be more sensitive to predict risk of NRM than the creatinine cut-off in the 16-component, Hematopoietic Cell Transplant-Comorbidity Index (HCT-CI). We retrospectively assessed the ability of the SCI to risk-stratify patients and the impact of acute kidney injury (AKI) to NRM in adults who underwent alloHCT at the University of Minnesota. We included 373 patients who underwent their first alloHCT between 2015 and 2019. Through multivariate analysis, we found that patients with an SCI of greater than 4 had a higher risk of NRM. Additionally, we noted that AKIs stages 2-3 prior to day +100 was independently associated with a 3-fold greater NRM than patients who did not experience clinically significant AKI.
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Affiliation(s)
- Clark Raymond Robinson
- Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Alma Habib
- Department of Hematology, The Ohio State University, Columbus, OH, United States
| | - Nattawat Klomjit
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, MN, United States
| | - Qing Cao
- Biostatistics and Bioinformatics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States
| | - Shernan Grace Holtan
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, United States
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2
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León-Román J, Iacoboni G, Bermejo S, Carpio C, Bolufer M, García-Carro C, Sánchez-Salinas M, Alonso-Martínez C, Bestard O, Barba P, Soler MJ. Transient acute kidney injury after chimeric antigen receptor T-cell therapy in patients with hematological malignancies. Clin Kidney J 2024; 17:sfae027. [PMID: 38500492 PMCID: PMC10946657 DOI: 10.1093/ckj/sfae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Indexed: 03/20/2024] Open
Abstract
Background Acute kidney injury (AKI) occurs in 30% of patients infused with chimeric antigen receptor (CAR) T-cells. The purpose of this study was to identify risk factors and long-term outcomes after AKI in patients who received CAR T-cell therapy. Methods Medical records of 115 adult patients with R/R hematological malignancies treated with CD19-targeted CAR T-cells at Vall d'Hebron University Hospital between July 2018 and May 2021. Baseline demographic data including age, gender, ethnicity, body mass index (BMI), and co-morbidities, as well as the type of hematological neoplasia and prior lines of therapy were collected. Laboratory parameters including serum creatinine and whole blood hemoglobin were retrospectively reviewed and values were gathered for days +1, +7, +14, +21, and +28 post-infusion. Results A total of 24/115 (21%) patients developed AKI related to CAR T-cell therapy; 6/24 with AKI over chronic kidney disease (CKD). Two patients had AKI in the context of lymphodepleting (LD) chemotherapy and the other 22 after CAR T-cell infusion, starting at day+1 in 3 patients, day+7 in 13 patients, day +14 in 1 patient, day+21 in 2 patients, and day+28 in 3 patients. Renal function was recovered in 19/24 (79%) patients within the first month after infusion. Male gender, CKD, cytokine release syndrome (CRS), and immune effector cell-associated neurotoxicity syndrome (ICANS) were associated with AKI. Male gender, CKD, ICANS grade ≥3 and CRS grade ≥2 were identified as independent risk factors for AKI on multivariable analysis. In terms of the most frequent CAR T-cell related complications, CRS was observed in 95 (82%) patients and ICANS in 33 (29%) patients. Steroids were required in 34 (30%) patients and tocilizumab in 37 (32%) patients. Six (5%) patients were admitted to the intensive care unit (1 for septic shock, 4 for CRS grade ≥2 associated to ICANS grade ≥2, and 1 for CRS grade ≥3). A total of 5 (4.4%) patients died in the first 30 days after CAR T-cell infusion for reasons other than disease progression, including 4 cases of infectious complications and 1 of heart failure. Conclusion Our results suggest that AKI is a frequent but mild adverse event, with fast recovery in most patients.
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Affiliation(s)
- Juan León-Román
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
| | - Gloria Iacoboni
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Sheila Bermejo
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
| | - Cecilia Carpio
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - Mónica Bolufer
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
| | - Clara García-Carro
- Nephrology Department, San Carlos Clinical University Hospital, Madrid, Spain
| | - Mario Sánchez-Salinas
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - Carla Alonso-Martínez
- Pharmacy Department, Vall d´Hebron Hospital Universitari, Vall d´Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Oriol Bestard
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
| | - Pere Barba
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - María José Soler
- Nephrology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
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3
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Mamlouk O, Strati P, Feng L, Sun R, Ayers A, Steiner RE, Nair R, Flowers C, Ramdial JL, Saini N, Srour SA, Champlin RE, Kebriaei P, Nastoupil LJ, Rodriguez MA, Shpall EJ, Nieto Y, Westin J, Neelapu SS, Mandayam S, Ahmed S. Real-world analysis of safety and efficacy of CAR T-cell therapy in lymphoma patients with decreased kidney function. Br J Haematol 2024; 204:e11-e16. [PMID: 37822075 DOI: 10.1111/bjh.19152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Omar Mamlouk
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Paolo Strati
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lei Feng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ryan Sun
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amy Ayers
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Raphael E Steiner
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ranjit Nair
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christopher Flowers
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeremy L Ramdial
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Neeraj Saini
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Samer A Srour
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Richard E Champlin
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Loretta J Nastoupil
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria A Rodriguez
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yago Nieto
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jason Westin
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sattva S Neelapu
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sreedhar Mandayam
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sairah Ahmed
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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4
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Filioglou D, Husnain M, Khurana S, Simpson RJ, Katsanis E. Has the shortage of fludarabine altered the current paradigm of lymphodepletion in favor of bendamustine? Front Immunol 2023; 14:1329850. [PMID: 38077398 PMCID: PMC10702755 DOI: 10.3389/fimmu.2023.1329850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
The most common lymphodepletion regimen used prior to infusion of chimeric antigen receptor-T cells (CAR-T) is cyclophosphamide (CY) in combination with fludarabine (Flu) (CY-FLU). While cyclophosphamide (CY) possesses lymphotoxic effects, it concurrently preserves regulatory T cell activity, potentially affecting the efficacy of CAR-T cells. Moreover, the use of fludarabine (FLU) has been linked to neurotoxicity, which could complicate the early detection of immune effector cell-associated neurotoxicity syndrome (ICANS) observed in CAR-T cell therapy. Given the ongoing shortage of FLU, alternative lymphodepleting agents have become necessary. To date, only a limited number of studies have directly compared different lymphodepleting regimens, and most of these comparisons have been retrospective in nature. Herein, we review the current literature on lymphodepletion preceding CAR-T cell therapies for lymphoid hematologic malignancies, with a specific focus on the use of bendamustine (BEN). Recent evidence suggests that administering BEN before CAR-T cell infusion yields comparable efficacy, possibly with a more favorable toxicity profile when compared to CY-FLU. This warrants further investigation through randomized prospective studies.
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Affiliation(s)
| | - Muhammad Husnain
- Department of Medicine, University of Arizona, Tucson, AZ, United States
- The University of Arizona Cancer Center, Tucson, AZ, United States
| | - Sharad Khurana
- Department of Medicine, University of Arizona, Tucson, AZ, United States
- The University of Arizona Cancer Center, Tucson, AZ, United States
| | - Richard J. Simpson
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
- School of Nutritional Sciences and Wellness, University of Arizona, Tucson, AZ, United States
| | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ, United States
- Department of Medicine, University of Arizona, Tucson, AZ, United States
- The University of Arizona Cancer Center, Tucson, AZ, United States
- Department of Immunobiology, University of Arizona, Tucson, AZ, United States
- Department of Pathology, University of Arizona, Tucson, AZ, United States
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5
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Marquard F, Langebrake C, Janson D, Mahmud M, Dadkhah A, Kröger N, Ayuk F. Case Report: Lymphodepletion followed by CAR-T cell therapy with Idecabtagen vicleucel in a patient with severe renal impairment. Front Oncol 2023; 13:1288764. [PMID: 38033500 PMCID: PMC10682764 DOI: 10.3389/fonc.2023.1288764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Acute kidney injury and chronic kidney disease is common in multiple myeloma. Fludarabine which is part of lymphodepletion before CAR-T cell therapy is renally eliminated and its use is not recommended for patients with severe renal impairment defined as a glomerular filtration rate below 30ml/min/1.73m2. We administered fludarabine to a 58-year-old female patient with myeloma-associated severe renal impairment as part of lymphodepletion before Idecabtagen vicleucel infusion. Fludarabine was administered in reduced dose (15mg/m2) and cyclophosphamide with a dose of 300mg/m2 followed by hemodialysis over six hours using a larger filter (FX-100). The therapy was well tolerated with excellent CAR-T cell expansion and complete remission which is ongoing now beyond 12 months.
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Affiliation(s)
- Franziska Marquard
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Langebrake
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Medicine, Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Dietlinde Janson
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maida Mahmud
- Department of Medicine (3rd), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adrin Dadkhah
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Medicine, Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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6
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Dimopoulos MA, Merlini G, Bridoux F, Leung N, Mikhael J, Harrison SJ, Kastritis E, Garderet L, Gozzetti A, van de Donk NWCJ, Weisel KC, Badros AZ, Beksac M, Hillengass J, Mohty M, Ho PJ, Ntanasis-Stathopoulos I, Mateos MV, Richardson P, Blade J, Moreau P, San-Miguel J, Munshi N, Rajkumar SV, Durie BGM, Ludwig H, Terpos E. Management of multiple myeloma-related renal impairment: recommendations from the International Myeloma Working Group. Lancet Oncol 2023; 24:e293-e311. [PMID: 37414019 DOI: 10.1016/s1470-2045(23)00223-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/02/2023] [Accepted: 05/05/2023] [Indexed: 07/08/2023]
Abstract
Here, the International Myeloma Working Group (IMWG) updates its clinical practice recommendations for the management of multiple myeloma-related renal impairment on the basis of data published until Dec 31, 2022. All patients with multiple myeloma and renal impairment should have serum creatinine, estimated glomerular filtration rate, and free light chains (FLCs) measurements together with 24-h urine total protein, electrophoresis, and immunofixation. If non-selective proteinuria (mainly albuminuria) or involved serum FLCs value less than 500 mg/L is detected, then a renal biopsy is needed. The IMWG criteria for the definition of renal response should be used. Supportive care and high-dose dexamethasone are required for all patients with myeloma-induced renal impairment. Mechanical approaches do not increase overall survival. Bortezomib-based regimens are the cornerstone of the management of patients with multiple myeloma and renal impairment at diagnosis. New quadruplet and triplet combinations, including proteasome inhibitors, immunomodulatory drugs, and anti-CD38 monoclonal antibodies, improve renal and survival outcomes in both newly diagnosed patients and those with relapsed or refractory disease. Conjugated antibodies, chimeric antigen receptor T-cells, and T-cell engagers are well tolerated and effective in patients with moderate renal impairment.
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Affiliation(s)
- Meletios A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Frank Bridoux
- Department of Nephrology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Nelson Leung
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Joseph Mikhael
- Translational Genomics Research Institute, City of Hope Cancer Center, Phoenix, AZ, USA
| | - Simon J Harrison
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | | | - Alessandro Gozzetti
- Department of Hematology, University of Siena, Policlinico S Maria alle Scotte, Siena, Italy
| | - Niels W C J van de Donk
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Katja C Weisel
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ashraf Z Badros
- Department of Medicine, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Meral Beksac
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | | | - Mohamad Mohty
- Department of Hematology, Hôpital Saint-Antoine, Sorbonne University and INSERM UMRs 938, Paris, France
| | - P Joy Ho
- Institute of Haematology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | | | - Paul Richardson
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Joan Blade
- Department of Hematology, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Philippe Moreau
- Department of Hematology, University Hospital of Nantes, Nantes, France
| | - Jesus San-Miguel
- Cancer Center Clinica Universidad de Navarra, CCUN, Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Centro de Investigación Biomédica en Red Cáncer, Pamplona, Spain
| | - Nikhil Munshi
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Brian G M Durie
- Department of Hematology/Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, First Department of Medicine, Clinic Ottakring, Vienna, Austria
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece.
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7
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Khan I, Khan N, Wolfson N, Djebabria K, Rehman MEU, Anwer F. Safety of CAR-T Cell Therapy in Patients With Renal Failure/Acute Kidney Injury: Focused Review. Clin Hematol Int 2023:10.1007/s44228-023-00037-7. [PMID: 37010812 DOI: 10.1007/s44228-023-00037-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/14/2023] [Indexed: 04/04/2023] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is novel immunotherapy targeting specifically cancerous cells, and has been shown to induce durable remissions in some refractory hematological malignancies. However, CAR T-cell therapy has adverse effects, such as cytokine release syndrome (CRS), immune effector-associated neurotoxicity syndrome (ICANS), tumor lysis syndrome (TLS), and acute kidney injury (AKI), among others. Not many studies have covered the repercussions of CAR T-cell therapy on the kidneys. In this review, we summarized the available evidence on the safety profile of CAR T-cell therapy in patients with pre-existing renal insufficiency/AKI and in those who develop AKI as a result of CAR T-cell therapy. With a 30% incidence of AKI post-CAR T-cell, various pathophysiological mechanisms, such as CRS, hemophagocytic lymphohistiocytosis (HLH), TLS, serum cytokines, and inflammatory biomarkers, have been shown to play a role. However, CRS is commonly reported as an underlying mechanism. Overall, 18% of patients in our included studies developed AKI after receiving CAR T-cell therapy, and most cases were reversible with appropriate therapy. While phase-1 clinical trials exclude patients with significant renal toxicity, two studies (Mamlouk et al. and Hunter et al.) reported successful treatment of dialysis-dependent patients with refractory diffuse large B-cell lymphoma, and demonstrated that CAR T-cell therapy and lymphodepletion (Flu/Cy) can be safely administered.
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Affiliation(s)
- Israr Khan
- Department of Internal Medicine, HMH Palisades Medical Center, 7600 River Rd, North Bergen, NJ, 07047, USA.
| | - Nida Khan
- Department of Internal Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Natalie Wolfson
- Department of Internal Medicine, Touro College of Osteopathic Medicine Harlem, OMS-III, New York, NY, USA
| | - Kawthar Djebabria
- Department of Internal Medicine, Annaba's University Hospital, Annaba, Algeria
| | | | - Faiz Anwer
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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8
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Kaur J, Valisekka SS, Hameed M, Bandi PS, Varma S, Onwughalu CJ, Ibrahim H, Mongia H. Monoclonal Gammopathy of Undetermined Significance: A Comprehensive Review. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e195-e212. [PMID: 36966041 DOI: 10.1016/j.clml.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Abstract
Monoclonal Gammopathy of Undetermined Significance (MGUS) is an asymptomatic premalignant plasma cell dyscrasia with a predominate rise of the IgG immunoglobulin fraction without end-organ damage, often diagnosed incidentally. Despite its progression into various subsequent forms of hematological malignancies, MGUS remains underdiagnosed. A literature search was conducted using the Medline, Cochrane, Embase, and Google Scholar databases, including articles published until December 2022. Keywords used encompassed "Monoclonal Gammopathy of Undetermined Significance," "Plasma Cell dyscrasia," "Monoclonal gammopathy of renal significance," and "IgM Monoclonal gammopathy of Undetermined Significance," This study aimed to conduct a critical review to update knowledge regarding the pathophysiology, risk factors, clinical features, diagnostic protocols, complications, and current and novel treatments for MGUS. We recommend a multidisciplinary approach to manage MGUS due to the complexity of the illness's etiology, diagnosis, and therapy. This comprehensive review also highlights future prospects, such as developing screening protocols for at-risk populations, prevention of disease progression by early diagnosis through genome-wide association studies, and management using Daratumumab and NSAIDs.
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Affiliation(s)
- Jasneet Kaur
- Internal Medicine, Nassau University Medical Center, East Meadow, New York, USA..
| | | | - Maha Hameed
- Internal Medicine, Florida State University/Sarasota Memorial Hospital, Sarasota, Florida, USA.
| | | | | | | | - Hany Ibrahim
- Ain Shams University, Faculty of Medicine, Cairo, Egypt.
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9
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Wood AC, Perez AP, Arciola B, Patel K, Johnson G, DiMaggio E, Bachmeier CA, Reid K, Carallo S, Vargas MH, Faramand R, Chavez JC, Shah B, Gaballa S, Khimani F, Elmariah H, Nishihori T, Lazaryan A, Freeman C, Davila ML, Locke FL, Mhaskar R, Bassil C, Jain MD. Outcomes of CD19-Targeted Chimeric Antigen Receptor T Cell Therapy for Patients with Reduced Renal Function Including Dialysis. Transplant Cell Ther 2022; 28:829.e1-829.e8. [PMID: 36174934 PMCID: PMC9791940 DOI: 10.1016/j.jtct.2022.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/13/2022] [Accepted: 09/19/2022] [Indexed: 12/24/2022]
Abstract
Patients with renal impairment (RI) are typically excluded from trials evaluating chimeric antigen receptor (CAR) T cell therapies. We evaluated the outcomes of patients with RI receiving standard of care (SOC) CAR T cell therapy for relapsed/refractory (R/R) diffuse large B cell lymphoma (DLBCL). In this retrospective, single-center cohort study of patients with R/R DLBCL treated with SOC axicabtagene ciloleucel (axi-cel) or tisagenlecleucel (tisa-cel) after 2 or more prior lines of therapy, renal and survival outcomes were compared based on RI and fludarabine dose reduction (DR) status. RI was defined by an estimated glomerular filtration rate <60 mL/min/1.73 m2 as determined by the Modification of Diet in Renal Disease equation using day -5 creatinine (Cr) values. Acute kidney injury (AKI) was identified and graded using standard Kidney Disease: Improving Global Outcomes criteria. Renal recovery was considered to occur if Cr was within .2 mg/mL of baseline by day +30. Fludarabine was considered DR if given at <90% of the recommended Food and Drug Administration label dose. Among 166 patients treated with CAR T cell therapy were 17 patients (10.2%) with baseline RI and 149 (89.8%) without RI. After CAR T cell infusion, the incidence of any grade AKI was not significantly different between patients with baseline RI and those without RI (42% versus 21%; P = .08). Similarly, severe grade 2/3 AKI was seen in 1 of 17 patients (5.8%) with baseline RI and in 11 of 149 patients (7.3%) without RI (P = 1). Decreased renal perfusion (28 of 39; 72%) was the most common cause of AKI, with cytokine release syndrome (CRS) contributing to 17 of 39 AKIs (44%). Progression-free survival (PFS) and overall survival (OS) did not differ between patients with RI and those without RI or between those who received standard-dose fludarabine and those who received reduced-dose fludarabine. In contrast, patients with AKI had worse clinical outcomes than those without AKI (multivariable PFS: hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.2 to 3.7; OS: HR, 3.9; 95% CI, 2.1 to 7.4). Notably, peak inflammatory cytokine levels were higher in patients who experienced AKI. Finally, we describe 2 patients with end-stage renal disease (ESRD) on dialysis who received lymphodepletion and CAR T cell therapy. Baseline renal function did not affect renal or efficacy outcomes after CAR T cell therapy in DLBCL. On the other hand, patients with AKI went on to experience worse clinical outcomes. AKI was commonly related to CRS and high peak inflammatory cytokine levels. CAR T cell therapy is feasible in patients with ESRD and requires careful planning of lymphodepletion.
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Affiliation(s)
- Anthony C Wood
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ariel Perez Perez
- Blood and Marrow Transplant Program, Miami Cancer Institute, Miami, Florida
| | - Brian Arciola
- Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Kedar Patel
- Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Grace Johnson
- Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Elizabeth DiMaggio
- Department of Pharmacy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Christina A Bachmeier
- Department of Pharmacy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kayla Reid
- Department of Clinical Science, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Salvatore Carallo
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Melanie H Vargas
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rawan Faramand
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Julio C Chavez
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Bijal Shah
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Sameh Gaballa
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Farhad Khimani
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Hany Elmariah
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Taiga Nishihori
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Aleksandr Lazaryan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ciara Freeman
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Marco L Davila
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rahul Mhaskar
- Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Claude Bassil
- Department of Onconephrology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Michael D Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
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10
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Yasuda H, Yasuda M, Komatsu N. Chemotherapy for non-Hodgkin lymphoma in the hemodialysis patient: A comprehensive review. Cancer Sci 2021; 112:2607-2624. [PMID: 33938097 PMCID: PMC8253291 DOI: 10.1111/cas.14933] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/17/2021] [Accepted: 04/22/2021] [Indexed: 12/17/2022] Open
Abstract
Chemotherapy for non-Hodgkin lymphoma (NHL) in the hemodialysis (HD) patient is a challenging situation. Because many drugs are predominantly eliminated by the kidneys, chemotherapy in the HD patient requires special considerations concerning dose adjustments to avoid overdose and toxicities. Conversely, some drugs are removed by HD and may expose the patient to undertreatment, therefore the timing of drug administration in relation to HD sessions must be carefully planned. Also, the metabolites of some drugs show different toxicities and dialysability as compared with the parent drug, therefore this must also be catered for. However, the pharmacokinetics of many chemotherapeutics and their metabolites in HD patients are unknown, and the fact that NHL patients are often treated with distinct multiagent chemotherapy regimens makes the situation more complicated. In a realm where uncertainty prevails, case reports and case series reporting on actual treatment and outcomes are extremely valuable and can aid physicians in decision making from drug selection to dosing. We carried out an exhaustive review of the literature and adopted 48 manuscripts consisting of 66 HD patients undergoing 71 chemotherapy regimens for NHL, summarized the data, and provide recommendations concerning dose adjustments and timing of administration for individual chemotherapeutics where possible. The chemotherapy regimens studied in this review include, but are not limited to, rituximab, cyclophosphamide + vincristine + prednisolone (CVP) and cyclophosphamide + doxorubicin + vincristine + prednisolone (CHOP)-like regimens, chlorambucil, ibrutinib, bendamustine, methotrexate, platinum compounds, cytarabine, gemcitabine, etoposide, ifosfamide, melphalan, busulfan, fludarabine, mogamulizumab, brentuximab vedotin, and 90 Y-ibritumomab tiuxetan.
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Affiliation(s)
- Hajime Yasuda
- Department of HematologyJuntendo University School of MedicineTokyoJapan
| | - Mutsuko Yasuda
- Department of Endocrinology and MetabolismTokyo Metropolitan Bokutoh HospitalTokyoJapan
| | - Norio Komatsu
- Department of HematologyJuntendo University School of MedicineTokyoJapan
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11
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Castillo JJ, Callander NS, Baljevic M, Sborov DW, Kumar S. The evaluation and management of monoclonal gammopathy of renal significance and monoclonal gammopathy of neurological significance. Am J Hematol 2021; 96:846-853. [PMID: 33709474 PMCID: PMC8252623 DOI: 10.1002/ajh.26155] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 03/07/2021] [Indexed: 12/24/2022]
Abstract
Despite the benign nature of monoclonal gammopathy of undetermined significance (MGUS), mounting data are associating MGUS with the development of organ dysfunction, specifically monoclonal gammopathy of renal significance (MGRS) and monoclonal gammopathy of neurological significance (MGNS), which could be associated with substantial morbidity. Emerging evidence suggests that patients with MGRS and MGNS could benefit from treatments used for myeloma, Waldenström macroglobulinemia, or chronic lymphocytic leukemia, depending on the underlying pathology. However, the treatment of MGRS and MGNS is not standardized, and potentially effective therapies might not be reimbursed because these conditions do not formally meet the criteria for malignant processes. The present review aims at establishing standards for the evaluation and management of MGRS and MGNS, which can facilitate the diagnosis of and provide therapeutic options for treating practitioners and patients affected by these conditions. The careful design and execution of clinical trials for patients with MGRS and MGNS are positively encouraged.
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Affiliation(s)
- Jorge J. Castillo
- Dana‐Farber Cancer Institute Harvard Medical School Boston Massachusetts
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12
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Han X, Hao H, Li Q, Liu C, Lei J, Yu F, Chen K, Liu Y, Huang T. The interaction mechanism between fludarabine and human serum albumin researched by comprehensive spectroscopic methods and molecular docking technique. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2020; 233:118170. [PMID: 32143170 DOI: 10.1016/j.saa.2020.118170] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/03/2020] [Accepted: 02/16/2020] [Indexed: 06/10/2023]
Abstract
Fludarabine (Flu) is widely used to treat B-cell chronic lymphocytic leukemia. HSA is of the essence to human, especially in blood circulation system. The interaction mechanism between Flu and HSA was studied by comprehensive spectroscopic methods and molecular docking technique. UV-vis and FL spectrum results indicated that Flu bond with HSA, and there was a new complex produced at the binding site I in subdomain IIA. Association constants at 298 K were 1.637 × 104 M-1 and 1.552 × 104 M-1 at 310 K, respectively. The negative enthalpy (ΔH) and positive entropy (ΔS) values for the interaction revealed that the binding behavior was driven by hydrophobic forces and hydrogen bonds. The results obtained from UV, RLS spectra, 3D fluorescence and CD spectrum illustrated that Flu could change the secondary structure of HSA. According to molecule docking result, the binding energy of interaction is -11.15 kcal/mol.
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Affiliation(s)
- XiaoLe Han
- Key Laboratory of Catalysis and Energy Materials Chemistry of Ministry of Education & Hubei Key Laboratory of Catalysis and Materials Science, South-Central University for Nationalities, Wuhan 430074, China.
| | - Hao Hao
- Key Laboratory of Catalysis and Energy Materials Chemistry of Ministry of Education & Hubei Key Laboratory of Catalysis and Materials Science, South-Central University for Nationalities, Wuhan 430074, China
| | - QingYu Li
- Key Laboratory of Catalysis and Energy Materials Chemistry of Ministry of Education & Hubei Key Laboratory of Catalysis and Materials Science, South-Central University for Nationalities, Wuhan 430074, China
| | - ChenYin Liu
- Key Laboratory of Catalysis and Energy Materials Chemistry of Ministry of Education & Hubei Key Laboratory of Catalysis and Materials Science, South-Central University for Nationalities, Wuhan 430074, China
| | - JiaWen Lei
- Key Laboratory of Catalysis and Energy Materials Chemistry of Ministry of Education & Hubei Key Laboratory of Catalysis and Materials Science, South-Central University for Nationalities, Wuhan 430074, China
| | - Fan Yu
- Key Laboratory of Catalysis and Energy Materials Chemistry of Ministry of Education & Hubei Key Laboratory of Catalysis and Materials Science, South-Central University for Nationalities, Wuhan 430074, China
| | - Ke Chen
- Key Laboratory of Catalysis and Energy Materials Chemistry of Ministry of Education & Hubei Key Laboratory of Catalysis and Materials Science, South-Central University for Nationalities, Wuhan 430074, China
| | - Yi Liu
- State Key Laboratory of Virology & Key laboratory of Analytical Chemistry for Biology and Medicine (MOE), College of Chemistry and Molecular Sciences, Wuhan University, Wuhan 430072, China
| | - Tao Huang
- Key Laboratory of Catalysis and Energy Materials Chemistry of Ministry of Education & Hubei Key Laboratory of Catalysis and Materials Science, South-Central University for Nationalities, Wuhan 430074, China.
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13
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Cao Q, Qi H, Yao L, Liu Q. Monoclonal gammopathy of renal significance: clinical manifestation, pathogenic characteristic and treatment. Panminerva Med 2019; 62:38-53. [PMID: 30848114 DOI: 10.23736/s0031-0808.19.03609-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a group of renal disorders caused by a monoclonal immunoglobulin (MIg) secreted by a dangerous plasmatic/B-cell clone hyperplasia through MIg deposition or dysfunction of complement pathway, with increasing risk of progress to end stage renal disease (ESRD) and the underlying hematologic malignancy. The combination of renal biopsy, complete laboratory examination and bone marrow biopsy is an indispensable diagnostic tool for MGRS to identify accurately and unequivocally the pathogenic monoclonal MIg and provide guidance to treatment. Treatment of MGRS is composed of conventional therapy, chemotherapy, and stem cell transplantation to target the underlying clone and eliminate the noxious MIg on the basis of clinical data of some retrospective studies and a small amount of prospective trial. In addition, it is worthwhile point out assessment of therapeutic effect is significantly relevant for renal and overall prognosis. Thus, by comprehensively analyzing the clinical manifestations and pathogenic characteristic of MGRS, early recognition and prompt treatment can improve the prognosis and prevent post-translation recurrence with multidisciplinary cooperation.
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Affiliation(s)
- Qin Cao
- Department of Gastroenterology, The First Hospital of China Medical University, Shenyang, China
| | - Huimeng Qi
- Department of General Practice, The First Hospital of China Medical University, Shenyang, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Qiang Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China -
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14
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Chung H, Hong KT, Lee JW, Rhee SJ, Kim S, Yoon SH, Yu KS, Kang HJ. Pharmacokinetics of fludarabine and its association with clinical outcomes in paediatric haematopoietic stem cell transplantation patients. Bone Marrow Transplant 2018; 54:284-292. [DOI: 10.1038/s41409-018-0260-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 05/15/2018] [Accepted: 05/31/2018] [Indexed: 12/21/2022]
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15
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Ivaturi V, Dvorak CC, Chan D, Liu T, Cowan MJ, Wahlstrom J, Stricherz M, Jennissen C, Orchard PJ, Tolar J, Pai SY, Huang L, Aweeka F, Long-Boyle J. Pharmacokinetics and Model-Based Dosing to Optimize Fludarabine Therapy in Pediatric Hematopoietic Cell Transplant Recipients. Biol Blood Marrow Transplant 2017; 23:1701-1713. [PMID: 28684371 PMCID: PMC6108324 DOI: 10.1016/j.bbmt.2017.06.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 06/25/2017] [Indexed: 02/02/2023]
Abstract
A prospective multicenter study was conducted to characterize the pharmacokinetics (PK) and pharmacodynamics (PD) of fludarabine plasma (f-ara-a) and intracellular triphosphate (f-ara-ATP) in children undergoing hematopoietic cell transplantation (HCT) and receiving fludarabine with conditioning. Plasma and peripheral blood mononuclear cells (PBMCs) were collected over the course of therapy for quantitation of f-ara-a and f-ara-ATP. Nonlinear mixed-effects modeling was used to develop the PK model, including identification of covariates impacting drug disposition. Data from a total of 133 children (median age, 5 years; range, .2 to 17.9) undergoing HCT for a variety of malignant and nonmalignant disorders were available for PK-PD modeling. The implementation of allometric scaling of PK parameters alone was insufficient to describe drug clearance, particularly in very young children. Renal impairment was predicted to increase drug exposure across all ages. The rate of f-ara-a entry into PBMCs (expressed in pmoles per million cells) decreased over the course of therapy, resulting in 78% lower f-ara-ATP after the fourth dose (1.7 pmoles/million cells [range, .2 to 7.2]) compared with first dose (7.9 pmoles/million cells [range, .7 to 18.2]). The overall incidence of treatment-related mortality (TRM) was low at 3% and 8% at days 60 and 360, respectively, and no association with f-ara-a exposure and TRM was found. In the setting of malignancy, disease-free survival was highest at 1 year after HCT in subjects achieving a systemic f-ara-a cumulative area under the curve (cAUC) greater than 15 mg*hour/L compared to patients with a cAUC less than 15 mg*hour/L (82.6% versus 52.8% P = .04). These results suggest that individualized model-based dosing of fludarabine in infants and young children may reduce morbidity and mortality through improved rates of disease-free survival and limiting drug-related toxicity. ClinicalTrials.gov Identifier: NCT01316549.
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Affiliation(s)
- Vijay Ivaturi
- Department of Pharmacy Practice and Science, University of Maryland, Maryland, Baltimore
| | - Christopher C Dvorak
- Departments of Pediatrics, University of California San Francisco, San Francisco, California
| | - Danna Chan
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California
| | - Tao Liu
- Department of Pharmacy Practice and Science, University of Maryland, Maryland, Baltimore
| | - Morton J Cowan
- Departments of Pediatrics, University of California San Francisco, San Francisco, California
| | - Justin Wahlstrom
- Departments of Pediatrics, University of California San Francisco, San Francisco, California
| | - Melisa Stricherz
- Department of Pharmacy, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | - Cathryn Jennissen
- Department of Pharmacy, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | - Paul J Orchard
- Division of Pediatric Blood and Marrow Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Jakub Tolar
- Division of Pediatric Blood and Marrow Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Sung-Yun Pai
- Department of Pediatrics, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Liusheng Huang
- Drug Research Unit, Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California
| | - Francesca Aweeka
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California; Drug Research Unit, Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California
| | - Janel Long-Boyle
- Departments of Pediatrics, University of California San Francisco, San Francisco, California; Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California.
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16
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Personalized fludarabine dosing to reduce nonrelapse mortality in hematopoietic stem-cell transplant recipients receiving reduced intensity conditioning. Transl Res 2016; 175:103-115.e4. [PMID: 27094990 PMCID: PMC5003687 DOI: 10.1016/j.trsl.2016.03.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 03/16/2016] [Accepted: 03/22/2016] [Indexed: 11/20/2022]
Abstract
Patients undergoing hematopoietic cell transplantation (HCT) with reduced intensity conditioning (RIC) commonly receive fludarabine. Higher exposure of F-ara-A, the active component of fludarabine, has been associated with a greater risk of nonrelapse mortality (NRM). We sought to develop a model for fludarabine dosing in adult HCT recipients that would allow for precise dose targeting and predict adverse clinical outcomes. We developed a pharmacokinetic model from 87 adults undergoing allogeneic RIC HCT that predicts F-ara-A population clearance (Clpop) accounting for ideal body weight and renal function. We then applied the developed model to an independent cohort of 240 patients to identify whether model predictions were associated with NRM and acute graft versus host disease (GVHD). Renal mechanisms accounted for 35.6% of total F-ara-A Clpop. In the independent cohort, the hazard ratio of NRM at day 100 was significantly higher in patients with predicted F-ara-A clearance (Clpred) <8.50 L/h (P < 0.01) and area under the curve (AUCpred) >6.00 μg × h/mL (P = 0.01). A lower Clpred was also associated with more NRM at month 6 (P = 0.01) and trended toward significance at 12 months (P = 0.05). In multivariate analysis, low fludarabine clearance trended toward higher risk of acute GVHD (P = 0.05). We developed a model that predicts an individual's systemic F-ara-A exposure accounting for kidney function and weight. This model may provide guidance in dosing especially in overweight individuals and those with altered kidney function.
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17
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Shadman M, Hingorani S, Lanum SA, Pagel JM, Storb R, Maloney DG, Sandmaier BM. Allogeneic hematopoietic cell transplant for patients with end stage renal disease requiring dialysis - a single institution experience. Leuk Lymphoma 2016; 58:740-742. [PMID: 27454657 DOI: 10.1080/10428194.2016.1211280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Mazyar Shadman
- a Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,b Department of Medicine , University of Washington , Seattle , WA , USA
| | - Sangeeta Hingorani
- a Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,c Department of Pediatrics , University of Washington , Seattle , WA , USA
| | - Scott A Lanum
- d Department of Pharmacy , University of Washington , Seattle , WA , USA
| | - John M Pagel
- a Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,b Department of Medicine , University of Washington , Seattle , WA , USA
| | - Rainer Storb
- a Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,b Department of Medicine , University of Washington , Seattle , WA , USA
| | - David G Maloney
- a Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,b Department of Medicine , University of Washington , Seattle , WA , USA
| | - Brenda M Sandmaier
- a Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,b Department of Medicine , University of Washington , Seattle , WA , USA
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18
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Goede V, Hallek M. Pharmacotherapeutic Management of Chronic Lymphocytic Leukaemia in Patients with Comorbidities: New Agents, New Hope. Drugs Aging 2016; 32:877-86. [PMID: 26446155 DOI: 10.1007/s40266-015-0308-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Chronic lymphocytic leukaemia (CLL) is mostly considered a disease of the elderly. As such, many patients present with comorbidities. Several scores allow for a qualitative and quantitative assessment of comorbidity in patients with CLL. Although our knowledge about the impact of comorbidity on outcomes in patients with CLL is still incomplete, it is becoming increasingly apparent that comorbidities could negatively interfere with CLL treatment. Recently, a number of new agents have been approved for use in patients with previously untreated CLL and comorbidities (i.e. obinutuzumab, ofatumumab), as well as in patients with previously treated or high-risk CLL (i.e. idelalisib, ibrutinib). This review discusses the role of comorbidity in patients with CLL, together with the changing treatment landscape for CLL in this patient population.
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Affiliation(s)
- Valentin Goede
- German CLL Study Group, Department I of Internal Medicine, University Hospital Cologne, Centre of Integrated Oncology Cologne-Bonn, 50924, Cologne, Germany. .,Department of Geriatric Medicine, St. Marien Hospital, Cologne, Germany.
| | - Michael Hallek
- German CLL Study Group, Department I of Internal Medicine, University Hospital Cologne, Centre of Integrated Oncology Cologne-Bonn, 50924, Cologne, Germany.,Cluster of Excellence Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
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19
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Chen YB, Kawai T, Spitzer TR. Combined Bone Marrow and Kidney Transplantation for the Induction of Specific Tolerance. Adv Hematol 2016; 2016:6471901. [PMID: 27239198 PMCID: PMC4867066 DOI: 10.1155/2016/6471901] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 04/01/2016] [Accepted: 04/05/2016] [Indexed: 12/02/2022] Open
Abstract
The induction of specific tolerance, in order to avoid the detrimental effects of lifelong systemic immunosuppressive therapy after organ transplantation, has been considered the "Holy Grail" of transplantation. Experimentally, tolerance has been achieved through clonal deletion, through costimulatory blockade, through the induction or infusion of regulatory T-cells, and through the establishment of hematopoietic chimerism following donor bone marrow transplantation. The focus of this review is how tolerance has been achieved following combined bone marrow and kidney transplantation. Preclinical models of combined bone marrow and kidney transplantation have shown that tolerance can be achieved through either transient or sustained hematopoietic chimerism. Combined transplants for patients with multiple myeloma have shown that organ tolerance and prolonged disease remissions can be accomplished with such an approach. Similarly, multiple clinical strategies for achieving tolerance in patients without an underlying malignancy have been described, in the context of either transient or durable mixed chimerism or sustained full donor hematopoiesis. To expand the chimerism approach to deceased donor transplants, a delayed tolerance approach, which will involve organ transplantation with conventional immunosuppression followed months later by bone marrow transplantation, has been successful in a primate model. As combined bone marrow and organ transplantation become safer and increasingly successful, the achievement of specific tolerance may become more widely applicable.
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Affiliation(s)
- Yi-Bin Chen
- Bone Marrow Transplant Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Tatsuo Kawai
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Thomas R. Spitzer
- Bone Marrow Transplant Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
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20
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Bodge MN, Reddy S, Thompson MS, Savani BN. Preparative regimen dosing for hematopoietic stem cell transplantation in patients with chronic kidney disease: analysis of the literature and recommendations. Biol Blood Marrow Transplant 2014; 20:908-19. [PMID: 24565993 DOI: 10.1016/j.bbmt.2014.02.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is a potentially life-saving therapy that has traditionally been associated with high treatment-related mortality due to direct regimen toxicity and a high incidence of graft-versus-host disease. Historically, pre-existing renal insufficiency has been considered an exclusion criterion for transplantation. The advent of nonmyeloablative conditioning regimens as a less toxic modality for treatment has made HSCT more accessible to elderly patients and patients with comorbidities, such as renal impairment. However, there is no clear standard for how to dose preparative regimens for patients with chronic renal impairment who undergo HSCT. This article serves as a review of the current literature to provide dosing recommendations for commonly used preparative agents in the setting of chronic kidney disease, with the aim of providing optimal dosing for this patient population.
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Affiliation(s)
- Megan N Bodge
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Srividya Reddy
- Hematology and Stem Cell Transplantation Section, Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Veterans Affairs Medical Center, Nashville, Tennessee
| | - Michael Scott Thompson
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bipin N Savani
- Hematology and Stem Cell Transplantation Section, Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Veterans Affairs Medical Center, Nashville, Tennessee.
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21
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Souchet-Compain L, Nguyen S, Choquet S, Leblond V. Fludarabine in Waldenstrom’s macroglobulinemia. Expert Rev Hematol 2014; 6:229-37. [DOI: 10.1586/ehm.13.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Ding X, Herzlich AA, Bishop R, Tuo J, Chan CC. Ocular toxicity of fludarabine: a purine analog. EXPERT REVIEW OF OPHTHALMOLOGY 2014; 3:97-109. [PMID: 18461151 DOI: 10.1586/17469899.3.1.97] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The purine analogs, fludarabine and cladribine represent an important class of chemotherapy agents used to treat a broad spectrum of lymphoid malignancies. Their toxicity profiles include dose-limiting myelosuppression, immunosuppression, opportunistic infection and severe neurotoxicity. This review summarizes the neurotoxicity of high- and standard-dose fludarabine, focusing on the clinical and pathological manifestations in the eye. The mechanisms of ocular toxicity are probably multifactorial. With increasing clinical use, an awareness of the neurological and ocular vulnerability, particularly to fludarabine, is important owing to the potential for life- and sight-threatening consequences.
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Affiliation(s)
- Xiaoyan Ding
- Section of Immunopathology, Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, MD, USA; And, Zhongshan Ophthalmic Center, Sun Yet-sen University, Guangzhou, China
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23
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Abstract
Recently, the term monoclonal gammopathy of renal significance (MGRS) was introduced to distinguish monoclonal gammopathies that result in the development of kidney disease from those that are benign. By definition, patients with MGRS have B-cell clones that do not meet the definition of multiple myeloma or lymphoma. Nevertheless, these clones produce monoclonal proteins that are capable of injuring the kidney resulting in permanent damage. Except for immunoglobulin light chain amyloidosis with heart involvement in which death can be rapid, treatment of MGRS is often indicated more to preserve kidney function and prevent recurrence after kidney transplantation rather than the prolongation of life. Clinical trials are rare for MGRS-related kidney diseases, except in immunoglobulin light chain amyloidosis. Treatment recommendations are therefore based on the clinical data obtained from treatment of the clonal disorder in its malignant state. The establishment of these treatment recommendations is important until data can be obtained by clinical trials of MGRS-related kidney diseases.
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Lukenbill J, Kalaycio M. Fludarabine: A review of the clear benefits and potential harms. Leuk Res 2013; 37:986-94. [DOI: 10.1016/j.leukres.2013.05.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 04/23/2013] [Accepted: 05/02/2013] [Indexed: 01/30/2023]
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Bouvet E, Borel C, Obéric L, Compaci G, Cazin B, Michallet AS, Laurent G, Ysebaert L. Impact of dose intensity on outcome of fludarabine, cyclophosphamide, and rituximab regimen given in the first-line therapy for chronic lymphocytic leukemia. Haematologica 2012; 98:65-70. [PMID: 23065520 DOI: 10.3324/haematol.2012.070755] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Fludarabine-cyclophosphamide-rituximab is the most efficient first-line treatment for chronic lymphocytic leukemia patients. Many dose adjustments of the original MD Anderson Cancer Center regimen have been proposed. However, whether fludarabine-cyclophosphamide-rituximab relative dose intensity may have an impact on outcome has not yet been investigated. We retrospectively assessed relative dose intensity in 106 community-based patients included in our regional healthcare network from 2004-11, all receiving fludarabine-cyclophosphamide-rituximab as first-line treatment outside clinical trials. Dose reductions were observed in 51.4% of patients, mainly decided by the individual physician and not based on recommendations (52.7%), while there were fewer reports of toxicity or dose reduction because of impaired renal function. Progression-free survival was significantly reduced in patients who had a reduction in dose intensity of more than 20% in fludarabine-cyclophosphamide and/or rituximab. Multivariate analysis showed dose of rituximab had a significant impact on minimal residual disease and progression-free survival. Although prophylactic granulocyte-colony stimulating factor significantly reduced the rate of grade 3-4 neutropenia and febrile neutropenia, it had no impact on relative dose intensity and outcome. This study shows that, in routine clinical practice, there is low adherence to the original MD Anderson Cancer Center fludarabine-cyclophosphamide-rituximab schedule, and that the decision to modify dosage was mostly taken by the individual physician and was based on anticipated toxicity. This study shows that reduction of fludarabine-cyclophosphamide and, more importantly, of rituximab doses seriously interferes with progression-free survival.
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Affiliation(s)
- Emmanuelle Bouvet
- Department of Hematology, Purpan University Hospital, Toulouse, France
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Johnson TM. Treatment and management of chronic lymphocytic leukemia in the elderly: what the pharmacist clinician should know. ACTA ACUST UNITED AC 2012; 27:274-85. [PMID: 22498987 DOI: 10.4140/tcp.n.2012.274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review the literature for current treatment options and supportive care management for elderly patients with chronic lymphocytic leukemia (CLL). DATA SOURCES PubMed searches using the terms chronic lymphocytic leukemia, elderly, practice guidelines, and controlled clinical trials were performed from 1949 through August 2011. Reference lists from relevant articles were examined for additional studies, review articles, and guidelines. STUDY SELECTION AND DATA EXTRACTION Eighty-three articles were generated and abstracted articles were chosen based on trial results that changed clinical practice, resulted in approval of new drugs for CLL by the Food and Drug Administration and/or had clinical relevance to the elderly population. DATA SYNTHESIS Fit elderly CLL patients have more treatment options than frail elderly. Most studies include patients younger than 65 years of age, and recent advances in treatment may not prove beneficial for all ages. Clinicians should use available evidence and clinical judgment when treating and monitoring elderly CLL patients. CONCLUSION Treatment armamentarium has improved over the last decade, yet clinical trials research should include more elderly cohorts as new agents are developed. Increased awareness of supportive care issues improves quality of life for a population with multiple disease complications.
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Affiliation(s)
- Tali M Johnson
- Pharmaceutical Management Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Rockville, Maryland 20852, USA.
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Successful Allogeneic Stem-Cell Transplantation in a Patient With Myelodysplastic Syndrome With Hemodialysis-Dependent End-Stage Renal Disease. Transplantation 2011; 92:e28-9. [DOI: 10.1097/tp.0b013e31822a79f1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Niscola P, Vischini G, Tendas A, Scaramucci L, Giovannini M, Bondanini F, Romani C, Brunetti GA, Cartoni C, Cupelli L, Ferrannini M, Perrotti A, Del Poeta G, Palumbo R, de Fabritiis P. Management of hematological malignancies in patients affected by renal failure. Expert Rev Anticancer Ther 2011; 11:415-32. [PMID: 21417855 DOI: 10.1586/era.11.2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The management of hematological malignancies (HM) in renally impaired patients may be a difficult task. Indeed, the kidney represents a major elimination pathway for many chemotherapeutic agents and their metabolites, whose serum levels are not usually measured in daily clinical practice. In addition, many antineoplastic drugs have a narrow therapeutic index for which they require dose adjustment when administered to patients with renal failure. Only limited data regarding the use of chemotherapy in patients with renal impairment and in those on dialysis are available. Indeed, renal patients with HM are often excluded from most clinical trials. Thus far, in order to provide recommendations, we have reviewed the pertinent literature, gathering information from published guidelines regarding chemotherapy in patients with kidney dysfunction and from articles describing the use of individual agents in renal patients with HM.
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Heher EC, Spitzer TR. Hematopoietic Stem Cell Transplantation in Patients With Chronic Kidney Disease. Semin Nephrol 2010; 30:602-14. [DOI: 10.1016/j.semnephrol.2010.09.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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High fludarabine exposure and relationship with treatment-related mortality after nonmyeloablative hematopoietic cell transplantation. Bone Marrow Transplant 2010; 46:20-6. [PMID: 20383215 PMCID: PMC2904846 DOI: 10.1038/bmt.2010.53] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Despite its common use in nonmyeloablative preparative regimens, the pharmacokinetics of fludarabine are poorly characterized in hematopoietic cell transplantation (HCT) recipients and exposure-response relationships remain undefined. Our objective of this study was to evaluate the association between plasma F-ara-A exposure, the systemically circulating moiety of fludarabine, and engraftment, acute graft vs host disease (GVHD), treatment-related mortality (TRM) and survival after HCT. The preparative regimen consisted of cyclophosphamide 50 mg/kg/day i.v. day −6; plus fludarabine 30-40 mg/m2/day i.v. on days −6 to −2 and TBI 200 cGy on day −1. F-ara-A pharmacokinetics were performed with the first dose of fludarabine in 87 adult patients. Median (range) F-ara-A AUC (0-∞) was 5.0 ug*hr/mL (2.0-11.0), clearance 15.3 L/hour (6.2-36.6), Cmin 55 ng/mL (17-166), and concentration on dayzero 16.0 ng/mL (0.1-144.1). Despite dose reductions, patients with renal insufficiency had higher F-ara-A exposures. There was strong association between high plasma concentrations of F-ara-A and increased risk of TRM and reduced overall survival. Patients with an AUC(0-∞) greater than 6.5 ug*hr/mL had 4.56 greater risk of TRM and significantly lower survival. These data suggest that clinical strategies are needed to optimize dosing of fludarabine to prevent overexposure and toxicity in HCT.
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Janssens A, Boogaerts M, Verhoef G. Development of fludarabine formulations in the treatment of chronic lymphocytic leukemia. DRUG DESIGN DEVELOPMENT AND THERAPY 2009; 3:241-52. [PMID: 20054443 PMCID: PMC2802124 DOI: 10.2147/dddt.s5603] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Fludarabine is an antineoplastic agent used in the treatment of hematological malignancies, particularly chronic lymphocytic leukemia (CLL) and indolent B-cell lymphoma. Because of its immunosuppressive effects, fludarabine has been added to reduced intensity conditioning regimens. The oral formulation of fludarabine has become widely available. Pharmacokinetic studies have shown that an oral dose of 40 mg/m2/d would provide systemic drug exposure similar to the standard intravenous (IV) dose of 25 mg/m2/d. The oral dose can be taken once daily without any dietary restrictions. Dose adjustments are mandatory in patients with renal impairment to avoid increased toxicity. Several noncomparative trials in previously untreated and treated patients with CLL have shown that treatment with the oral formulation demonstrates similar efficacy compared to historical control groups treated with the IV formulation. The tolerability profile of oral fludarabine seems similar to that of the IV formulation. Myelosuppression and infectious complications are the most frequently reported adverse events. Gastrointestinal toxicity is more frequent with the oral formulation, but is usually of mild or moderate severity. Although oral fludarabine makes treatment more convenient, health care workers must be aware of the compliance behavior of each patient.
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Affiliation(s)
- Ann Janssens
- Department of Hematology, University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium.
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Tendas A, Cupelli L, Dentamaro T, Scaramucci L, Palumbo R, Niscola P, Giovannini M, Piccioni D, Perrotti AP, de Fabritiis P. Feasibility of a dose-adjusted fludarabine–melphalan conditioning prior autologous stem cell transplantation in a dialysis-dependent patient with mantle cell lymphoma. Ann Hematol 2008; 88:285-6. [DOI: 10.1007/s00277-008-0578-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 07/21/2008] [Indexed: 11/29/2022]
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Lichtman SM, Boparai MK. Anticancer drug therapy in the older cancer patient: pharmacology and polypharmacy. Curr Treat Options Oncol 2008; 9:191-203. [PMID: 18663583 DOI: 10.1007/s11864-008-0060-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Accepted: 06/06/2008] [Indexed: 12/11/2022]
Abstract
OPINION STATEMENT Older patients currently are the largest group of oncology patients and their numbers will continue to expand. There has been minimal participation of older patients in clinical trials. This has resulted in a lack of data to make high-level evidence-based decisions with regard to chemotherapy. There has now been a number of clinical trials which have given information with regard to age-related changes and the spectrum of toxicity that occurs with older patients. There is also an expanding literature on organ dysfunction. The overall data seem to indicate that there are a very few age-related changes in the pharmacokinetics of chemotherapy. The small changes that are present have not been clinically significant. It seems that the pattern of toxicity is more reflective of patient selection (functional status, performance status), comorbidity, and drug scheduling. The large number of drugs with significant renal excretion requires careful evaluation of renal function. Future clinical trial design needs to be adapted to older patients. Therefore, drugs, which will be primarily used by older patients, should be studied in older patients. These studies should involve pharmacokinetics, and oral therapies should include measurements of compliance. Phase II trials of new agents should consider prospectively dividing groups of patients by age (i.e., <75 years vs. >or=75 years). Phase I trials should consider accruing older patients. The studies can be performed in the older group by using progressive degrees of functional impairment and increasing comorbidity as a surrogate for dose limiting toxicity. Functional independence as a clinical benefit of cancer treatment in older individuals should be considered as an endpoint. Overall survival may not be an appropriate endpoint in clinical trials in the oldest group. Clinical trials should consider studying long-term functional and medical consequences of cancer treatment in long-term older cancer survivors. Journal editors should encourage the inclusion of age-related analyses in the reporting of clinical trials to provide meaningful information for clinicians caring for older patients. Ideally, the clinical trial design should prospectively incorporate age analysis to maximize clinical benefit of data generated. A careful assessment of medication used in older patients needs to be part of routine evaluation to minimize the adverse effects of polypharmacy.
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Fludarabine-based nonmyeloablative stem cell transplantation for sickle cell disease with and without renal failure: clinical outcome and pharmacokinetics. Biol Blood Marrow Transplant 2008; 13:1422-6. [PMID: 18022571 DOI: 10.1016/j.bbmt.2007.08.050] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 09/11/2007] [Indexed: 11/23/2022]
Abstract
End-organ damage is common in patients with sickle cell disease (SCD) thereby limiting the use of allogeneic stem cell transplantation (SCT). We report the outcome of 2 adult SCD patients, 1 with end-stage renal disease (ESRD), who underwent fludarabine-based nonmyeloablative SCT from HLA-identical matched siblings. To prevent fludarabine toxicity, the patient with ESRD underwent aggressive dialysis following adjusted fludarabine dosing. Pharmacokinetics of the fludarabine metabolite F-Ara-A was studied on the patient with ESRD and 2 additional patients with normal renal function. Both patients with SCD achieved full donor erythroid chimerism, have normal blood counts, and are on no immunosuppressive medications. With a 20% dose reduction followed by daily dialysis, we achieved fludarabine drug exposure that is nearly identical to that achieved in patients with normal renal function. We conclude that fludarabine-based nonmyeloablative allogeneic SCT for adult patients with SCD is feasible, even in the setting of ESRD.
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Lichtman SM, Wildiers H, Chatelut E, Steer C, Budman D, Morrison VA, Tranchand B, Shapira I, Aapro M. International Society of Geriatric Oncology Chemotherapy Taskforce: evaluation of chemotherapy in older patients--an analysis of the medical literature. J Clin Oncol 2007; 25:1832-43. [PMID: 17488981 DOI: 10.1200/jco.2007.10.6583] [Citation(s) in RCA: 180] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The elderly comprise the majority of patients with cancer and are the recipients of the greatest amount of chemotherapy. Unfortunately, there is a lack of data to make evidence-based decisions with regard to chemotherapy. This is due to the minimal participation of older patients in clinical trials and that trials have not systematically evaluated chemotherapy. This article reviews the available information with regard to chemotherapy and aging provided by a task force of the International Society of Geriatric Oncology (SIOG). Due to the lack of prospective data, the conclusions and recommendations made are a consensus of the participants. Extrapolation of data from younger to older patients is necessary, particularly to those patients older than 80 years, for which data is almost entirely lacking. The classes of drugs reviewed include alkylators, antimetabolites, anthracyclines, taxanes, camptothecins, and epipodophyllotoxins. Clinical trials need to incorporate an analysis of chemotherapy in terms of the pharmacokinetic and pharmacodynamic effects of aging. In addition, data already accumulated need to be reanalyzed by age to aid in the management of the older cancer patient.
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Affiliation(s)
- Stuart M Lichtman
- Memorial Sloan-Kettering Cancer Center, Commack, New York 11725, USA.
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Lichtman SM, Wildiers H, Launay-Vacher V, Steer C, Chatelut E, Aapro M. International Society of Geriatric Oncology (SIOG) recommendations for the adjustment of dosing in elderly cancer patients with renal insufficiency. Eur J Cancer 2007; 43:14-34. [PMID: 17222747 DOI: 10.1016/j.ejca.2006.11.004] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2006] [Accepted: 11/09/2006] [Indexed: 10/23/2022]
Abstract
A SIOG taskforce was formed to discuss best clinical practice for elderly cancer patients with renal insufficiency. This manuscript outlines recommended dosing adjustments for cancer drugs in this population according to renal function. Dosing adjustments have been made for drugs in current use which have recommendations in renal insufficiency and the elderly, focusing on drugs which are renally eliminated or are known to be nephrotoxic. Recommendations are based on pharmacokinetic and/or pharmacodynamic data where available. The taskforce recommend that before initiating therapy, some form of geriatric assessment should be conducted that includes evaluation of comorbidities and polypharmacy, hydration status and renal function (using available formulae). Within each drug class, it is sensible to use agents which are less likely to be influenced by renal clearance. Pharmacokinetic and pharmacodynamic data of anticancer agents in the elderly are needed in order to maximise efficacy whilst avoiding unacceptable toxicity.
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Abstract
Chronic lymphocytic leukaemia (CLL) is the most common leukaemia in the Western world. Historically, CLL patients have received prednisone- or chlorambucil-containing regimens, resulting in modest responses and a slim chance of long-term survival. The addition of purine nucleoside analogues, specifically fludarabine, to the armamentarium has significantly improved efficacy in treatment-naive or heavily pretreated CLL patients. Since the 1980s, fludarabine monotherapy has demonstrated an improvement in response over historical chemotherapeutic agents. Single-agent fludarabine therapy has expanded into a combination regimen containing cyclophosphamide and has further evolved to incorporate monoclonal antibodies. A review of the fludarabine literature shows that these advancements in fludarabine-containing therapy have enhanced the overall patient response with a potential increase in survival time, thus representing progress towards a superior treatment for CLL.
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MESH Headings
- Administration, Oral
- Aged
- Alemtuzumab
- Animals
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal, Humanized
- Antibodies, Monoclonal, Murine-Derived
- Antibodies, Neoplasm/administration & dosage
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/pharmacokinetics
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents, Alkylating/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cyclophosphamide/administration & dosage
- Drug Administration Schedule
- Drug Evaluation, Preclinical
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Randomized Controlled Trials as Topic
- Rituximab
- Survival Analysis
- Vidarabine/administration & dosage
- Vidarabine/analogs & derivatives
- Vidarabine/pharmacokinetics
- Vidarabine/therapeutic use
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Affiliation(s)
- Thomas Elter
- First Department of Internal Medicine, University of Cologne, Joseph-Stelzmann-Str. 9, 50924 Cologne, Germany.
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Polizzotto MN, Tam CS, Milner A, Januszewicz EH, Prince HM, Westerman D, Wolf MM, Seymour JF. The influence of increasing age on the deliverability and toxicity of fludarabine-based combination chemotherapy regimens in patients with indolent lymphoproliferative disorders. Cancer 2006; 107:773-80. [PMID: 16847886 DOI: 10.1002/cncr.22022] [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: 11/08/2022]
Abstract
BACKGROUND Fludarabine-based combination chemotherapy regimens are highly effective in the treatment of patients with indolent lymphoproliferative disorders. Despite the prevalence of such disorders in older patients, the effect of increasing age on the deliverability of these regimes has not been assessed. METHODS The authors analyzed the effect of increasing age on the deliverability and toxicity of 3 fludarabine-based regimens, all using fludarabine 25 mg/m2 per day for 3 days intravenously every 28 days, in 180 patients who were stratified into 2 age groups (age <60 years and age > or =60 years), with multivariate analysis to control for other differences between groups. The authors also explored the impact of age > or =70 years within the older cohort. RESULTS Older patients were more likely to experience an episode of nonsevere hematologic or infectious toxicity, but there was no difference in the rate of severe toxicity. Toxicity rates per cycle did not differ between age groups. The rates of neutropenia (absolute neutrophil count [ANC], < 1.0 x 10(9)/L) and severe neutropenia (ANC, 0.5 x 10(9)/L) were 22% and 13%, respectively, in older patients versus 20% and 11%, respectively, in younger patients (P > .1 for both). The rates of thrombocytopenia (platelet count, <100 x 10(9)/L) and severe thrombocytopenia (platelet count, <50 x 10(9)/L) were 21% and 5%, respectively, in older patients and 16% and 5%, respectively, in younger patients (each P value > .1). The rate of infection was 18% per cycle in older patients and 15% per cycle in younger patients (P = .2), with no difference noted in severity. Other organ toxicities were uncommon and showed no difference between age groups. The treatment-related mortality rate was <1% in both cohorts (P > .5). In multivariate analysis, increasing age and performance status influenced the incidence of hematologic toxicity, whereas only performance status influenced the rate of infection and severe infection. CONCLUSIONS Fludarabine-based combination chemotherapy regimens were well tolerated and can be delivered safely to older patients who have a good performance status with modestly increased myelosuppression but no increase in severe infectious complications or treatment-related mortality.
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Affiliation(s)
- Mark N Polizzotto
- Department of Hematology, The Alfred Hospital, Melbourne, Victoria, Australia
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Kielstein JT, Stadler M, Czock D, Keller F, Hertenstein B, Radermacher J. Dialysate concentration and pharmacokinetics of 2F-Ara-A in a patient with acute renal failure. Eur J Haematol 2005; 74:533-4. [PMID: 15876260 DOI: 10.1111/j.1600-0609.2005.00439.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fludarabine is frequently used for treatment of B-cell chronic lymphocytic leukemia and in conditioning regimes for hematopoietic cell transplantations. The total body clearance of the principal metabolite 2-fluoro-ara-A (2F-Ara-A) correlates with the creatinine clearance. We report data on total dialysate concentration as well as pharmacokinetics of 2F-Ara-A in a patient with anuric acute renal failure. On three consecutive days the patient received a daily dose of 80 mg (40 mg/m(2)) fludarabine and underwent three consecutive extended (daily) dialysis (ED) sessions. ED removed a considerable amount of the drug. The average dialysis clearance was 33.85 ml/min which is about 25% of the clearance in patients without renal failure. No toxic side effects of the treatment were observed. This case suggests that fludarabine treatment can be considered in patients requiring dialysis if dose reduction and adequate removal of the drug by hemodialysis is provided.
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Affiliation(s)
- Jan T Kielstein
- Department of Nephrology, Hannover Medical School, Hannover, Germany.
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Abstract
Patients with chronic kidney disease (CKD) are at high risk for adverse drug reactions and drug-drug interactions. Drug dosing in these patients often proves to be a difficult task. Renal dysfunction-induced changes in human pathophysiology regularly results may alter medication pharmacodynamics and handling. Several pharmacokinetic parameters are adversely affected by CKD, secondary to a reduced oral absorption and glomerular filtration; altered tubular secretion; and reabsorption and changes in intestinal, hepatic, and renal metabolism. In general, drug dosing can be accomplished by multiple methods; however, the most common recommendations are often to reduce the dose or expand the dosing interval, or use both methods simultaneously. Some medications need to be avoided all together in CKD either because of lack of efficacy or increased risk of toxicity. Nevertheless, specific recommendations are available for dosing of certain medications and are an important resource, because most are based on clinical or pharmacokinetic trials.
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Affiliation(s)
- Steven Gabardi
- Department of Pharmacy Services, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115-6110, USA.
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Tam CS, Wolf MM, Januszewicz EH, Grigg AP, Prince HM, Westerman D, Seymour JF. A new model for predicting infectious complications during fludarabine-based combination chemotherapy among patients with indolent lymphoid malignancies. Cancer 2004; 101:2042-9. [PMID: 15372472 DOI: 10.1002/cncr.20615] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Fludarabine-containing combination chemotherapy regimens are increasingly used in the treatment of indolent lymphoid malignancies, with the associated risk of infection being the major toxicity. Predictors of infection during fludarabine-containing combination therapy are poorly defined and optimal strategies for infection prophylaxis are not known. The authors analyzed their experience with patients treated with the fludarabine-mitoxantrone (FM) or fludarabine-cyclophosphamide (FC) regimens to develop a predictive model for infections. METHODS Ninety-two patients with indolent lymphoid malignancies were treated with FM (n = 29) or FC (n = 63). Baseline variables including age, gender, regimen, disease histology, previous therapy, time from diagnosis to current treatment, performance status, renal function, absolute neutrophil count (ANC), lymphocyte count, and immunoglobulin G levels were examined retrospectively for their association with risk of infectious complications during or within 4 weeks of therapy. RESULTS Six risk factors were associated with infectious complications: age > 60 years, > or = 3 previous therapies, previous fludarabine exposure, time from diagnosis to current treatment of > 3 years, performance status > or = 2, and baseline ANC < 2.0 x 10(9)/L. Compared with patients with 0-2 risk factors, patients with > or = 3 risk factors had higher infection rates (26% vs. 7% per cycle, P < 0.0001), more Grade 4 neutropenia (41% vs. 8% per cycle, P < 0.0001), and more neutropenic sepsis (15% vs. 1% per cycle, P < 0.0001). CONCLUSIONS Infection risk during fludarabine-containing combination chemotherapy was predicted with a model comprising six baseline risk factors. Patients predicted to be at high risk of infection were an appropriate group for consideration of prophylactic strategies.
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Affiliation(s)
- Constantine S Tam
- Leukemia/Lymphoma Service, Department of Hematology, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
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John V, Mashru S, Lichtman S. Pharmacological factors influencing anticancer drug selection in the elderly. Drugs Aging 2004; 20:737-59. [PMID: 12875610 DOI: 10.2165/00002512-200320100-00003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Persons over the age of 65 years are the fastest growing segment of the US population. In the next 30 years this segment will represent more than 20% of the population. Fifty percent of all cancers occur in this age group and therefore the total cancer burden is expected to rise. Data are becoming available that will better guide the use of chemotherapy in the older patient population. Studies are presented discussing pharmacokinetic data on a number of chemotherapeutic agents with an emphasis on those that have entered clinical practice over the past few years. Many of these agents seem to have a beneficial therapeutic index, particularly in regard to older patients. Aging can affect the pharmacokinetics of chemotherapy in a number of ways. Absorption is only modified minimally by age. The greater concern with the use of oral drugs is patient compliance. Volume of distribution is affected by changes in body composition, anaemia and decreased plasma albumin concentration. There are many drugs in which renal excretion plays an important role. Decline in glomerular filtration is a consistent phenomenon with aging. Drug metabolism is primarily affected by changes in the P450 system and coadministration of drugs which also interact with this important enzyme system. The selection of chemotherapy in the elderly is frequently determined by degree of comorbidity and the patients' functional status. These factors are critical and can often determine response and toxicity. This article discusses the changes that occur with antimetabolites, camptothecins, anthracyclines, taxanes, platinum compounds, epipodophyllotoxins and vinca alkaloids. There has also been an increasing trend toward the use of oral chemotherapy. Factors that must be considered in selecting chemotherapeutic agents include limitations of saturability of absorption, patient compliance and the pharmacokinetic and pharmacodynamic changes that occur in older patients. Interpatient variability and age-related changes in drug metabolism are discussed. Careful attention to the physiological changes with age and dose adjustments necessary for end-organ dysfunction (renal, hepatic) are needed to ensure the safe administration of chemotherapy. In this article specific diseases are discussed (breast, colon, ovarian and non-small lung cancers) with recommendations for drug selection in adjuvant chemotherapy and the treatment of metastatic disease. Future studies will need to incorporate these various factors to properly evaluate chemotherapy in older patients. Research and educational initiatives targeted to this population will need to be a priority.
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Affiliation(s)
- Veena John
- Don Monti Division of Medical Oncology, North Shore University Hospital, NYU School of Medicine, Manhasset, New York, USA
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Abstract
Chronic lymphocytic leukemia therapy has changed dramatically over the past decade, with recent studies supporting the use of fludarabine as the initial therapy for symptomatic disease. New findings relative to the use of fludarabine and complications arising from this therapy are reviewed. Exciting combination approaches using monoclonal antibodies such as rituximab or Campath-1H in combination with fludarabine offer the opportunity to improve the complete response rate further in chronic lymphocytic leukemia. Furthermore, the field of experimental therapeutics for chronic lymphocytic leukemia was advanced by the description of a new mouse model of human chronic lymphocytic leukemia and identification of several disrupted signal transduction pathways in this disease. The description of therapies that target AKT, protein kinase C, phosphodiesterase 4, mammalian target of rapamycin, histone deacetylase, and methyltransferase offer the opportunity to utilize molecularly targeted therapy for this disease. Such targeted approaches offer hope that we might be on the threshold to changing the natural history of chronic lymphocytic leukemia.
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Affiliation(s)
- Amy J Johnson
- Division of Hematology-Oncology, Department of Medicine, Ohio State University, Columbus, Ohio 43210, USA
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