Clinical effectiveness of early treatment with hyperbaric oxygen therapy for severe late-onset hemorrhagic cystitis after hematopoietic stem cell transplantation in pediatric patients

An expert consensus on prevention, diagnosis, and management of hemorrhagic cystitis in pediatric hematopoietic cell transplantation, on behalf of the Infectious Disease and Hematopoietic Cell Transplant Working groups of Italian Pediatric Hematology Oncology Association (AIEOP)

The optimal management of hemorrhagic cystitis (HC) in hematopoietic stem cell transplantation (HCT) is debated, both for early onset HC (EOHC) secondary to chemotherapy toxicity and BK Polyomavirus (BKPyV)-related HC, due to the lack of controlled trials, particularly referred to pediatric setting. Actually, clinical practice is mainly based on guidelines of the European Conference on Infections in Leukemia, 6th edition, which considers both adult and pediatric populations but concludes that, despite much progress in understanding the pathogenesis, epidemiology, and risk factors, this complication still represents a disabling unmet clinical need with limited prophylactic and therapeutic options. Additionally, the Guidelines of the American Society of Clinical Oncology define the management of chemotherapeutic toxicity independently from the patients' population. A panel of experts belonging to the Hematopoietic Cell Transplant and Infectious Disease Working Group (WG) of Associazione Italiana di Emato-Oncologia Pediatrica (AIEOP) developed a consensus to define the best practices in prevention, diagnosis, and management of HC in pediatric HCT setting.

Effectiveness of hyperbaric oxygen therapy for virus-associated hemorrhagic cystitis after allogeneic hematopoietic stem cell transplantation

Although some studies have suggested the effectiveness of hyperbaric oxygen (HBO) therapy for hemorrhagic cystitis (HC) after allogeneic hematopoietic stem cell transplantation (HSCT), the role of HBO has not been established. We compared the treatment outcomes of 8 patients with viral HC (adenovirus [ADV], n = 2; BK virus [BKV], n = 6) treated with HBO (HBO[+]) and 8 patients (ADV, n = 2; BKV, n = 6) treated with conventional therapy (HBO[−]), such as urinary catheterization and intravenous cidofovir. HBO therapy was performed at 2.1 atmospheres for 90 min/day until clinical improvement was achieved. The median number of HBO treatments was 10 (range 8–12). The median duration of HBO treatment was 19.5 days (range 10–23 days). All 8 HBO(+) patients achieved complete remission (CR) at a median of 14.5 days (range 5–25 days). Of the 8 HBO(−) patients, 5 (62.5%) obtained CR and 3 remained symptomatic for 2–6 months. The cumulative incidence of transplant-related mortality at day 100 after allogeneic HSCT was significantly higher in the HBO(−) patients than in the HBO(+) patients (14.2 vs. 0%, P < 0.05). No severe HBO-related adverse effects were observed. In conclusion, HBO is a feasible option for treating viral HC after allogeneic HSCT.

Management of BK virus-associated haemorrhagic cystitis in allogeneic stem cell transplant recipients

BK virus (BKV)-related haemorrhagic cystitis (HC) is an important cause of morbidity following allogeneic haematopoietic stem cell transplantation (HSCT). The various risk factors include high-level BKV viruria and/or viremia, myeloablative conditioning, acute graft versus host disease (GVHD), cytomegalovirus viremia, and unrelated or HLA-mismatched donor. The presence of high plasma BK viral load and cytopenias have been implicated as important predictors for protracted disease course. These patients frequently require hospitalisation which may extend for several weeks. Supportive measures in the form of analgesics, intravenous hydration, bladder irrigation, and transfusion support remain the mainstay of management. Various drugs have been used with limited success in this setting. These include antiviral drugs, fluoroquinolones, leflunomide, growth factors, clotting factors, estrogens, and prostaglandins. The role of adoptive cellular immunotherapy has also been explored but lacks clinical validation. The strategies aimed at expediting urothelial repair like hyperbaric oxygen therapy (HBOT), intravesical fibrin glue and platelet-rich plasma (PRP) are emerging. Some patients with severe disease do require surgical intervention to relieve urinary obstruction. The frequent co-occurrence of acute GVHD and CMV disease further complicates the management in such patients. There is an unmet need for effective and evidence-based options for the prevention and management of this disease. Due to lack of robust data supported by randomised trials, the acceptability of the available guidelines to simplify the treatment is expected to be low. Despite the availability of various treatment options, the management of BKV-related HC in day-to-day practice continues to be a challenge. The aim of this article is to put forward an up-to-date review of the preventive and therapeutic strategies for BKV-related HC.

BK virus infection in allogeneic hematopoietic cell transplantation: An update on pathogenesis, immune responses, diagnosis and treatments

In hematopoietic cell transplantation (HCT) patients, BK polyomavirus (BKPyV) infection results in significant morbidity mainly due to hemorrhagic cystitis (HC). Despite increased knowledge acquired over recent decades, no treatment has shown effectiveness in the management of organ damage in HCT allografts. This review summarizes the current knowledge on BKPyV, from the virus constitution to the pathophysiology and immune-related mechanisms. We next focus on BKPyV-induced HC in HCT to discuss the benefit of monitoring BKPyV viruria and viremia in the management of patients. At last, we review currently used therapeutics, along with future promising therapies to propose clinical and practical guidelines and further interesting research areas.

Hyperbaric Oxygen Therapy of an Adolescent Stem Cell Transplantation Recipient with Hemorrhagic Cystitis and BK Virus

Hyperbaric oxygen therapy (HBOT) continues to show effectiveness in the treatment of several diseases and benefits such as fibroblast proliferation, capillary angiogenesis, and decreasing edema, especially in hemorrhagic cystitis (HC). We report a case of a 15-year-old male with chronic myelogenous leukemia status posthaploidentical stem cell transport with BK virus in the United States to be treated by HBOT. The patient received a total of 30 HBOT treatments for 90 minutes at 2 ATA. After HBOT treatments, patient showed signs of improvements such as cessation of hemorrhage cystitis. The findings of this case support and shows that there is growing evidence for the use of HBOT as adjunctive therapy for patients with BK virus associated with HC after stem cell transplantation.

Effects and long-term follow-up of using umbilical cord blood-derived mesenchymal stromal cells in pediatric patients with severe BK virus-associated late-onset hemorrhagic cystitis after unrelated cord blood transplantation

This is a retrospective study to evaluate the efficacy and safety of umbilical cord blood-derived mesenchymal stromal cells (MSCs) for the treatment of pediatric patients with severe BK virus-associated late-onset hemorrhagic cystitis (BKV-HC) after unrelated cord blood transplantation (UCBT). Thirteen pediatric patients with severe BKV-HC from December 2013 to December 2015 were treated with MSCs. The number of MSCs transfused in each session was 1 × 10⁶ /kg once a week until the symptoms improved. The median follow-up time was 1432 (89-2080) days. The median frequency of MSC infusion was 2 (1-3), with eight cured cases and five effective cases; the total efficacy rate was 100%. The copy number of urine BKV DNA was 4.43 (0.36-56.9) ×10⁸ /mL before MSC infusion and 2.67 (0-56.3) ×10⁸ /mL after MSC infusion; the difference was not significant (P = .219). There were no significant differences in the overall survival, disease-free survival, and the incidence of relapse and acute and chronic graft-versus-host disease between the MSC infusion group and non-MSC infusion group. There was also no significant difference in the cytomegalovirus, Epstein-Barr virus (EBV), and fungal and bacterial infection rates between the two groups. Although umbilical cord blood-derived MSCs do not reduce the number of BKV DNA copies in the urine, the cells have a high efficacy rate and minimal side effects in treating severe BKV-HC after UCBT among pediatric patients. MSCs do not affect the rates of relapse, long-term infection, or survival of patients with leukemia.

ECIL guidelines for the prevention, diagnosis and treatment of BK polyomavirus-associated haemorrhagic cystitis in haematopoietic stem cell transplant recipients

Objectives

To define guidelines for BK polyomavirus (BKPyV)-associated haemorrhagic cystitis (BKPyV-HC) after paediatric and adult HSCT.

Methods

Review of English literature and evidence-based recommendations by expert consensus.

Results

BKPyV-HC occurs in 8%-25% of paediatric and 7%-54% of adult recipients undergoing allogeneic HSCT. Diagnosis requires the triad of cystitis, macro-haematuria and high urine BKPyV loads >7 log10 copies/mL, and exclusion of other relevant aetiologies. BKPyV viraemia is frequent and may serve as a more specific semiquantitative follow-up marker. No randomized controlled trials are available to inform antiviral prophylaxis or treatment. However, hyper-hydration and/or bladder irrigation showed limited prophylactic value. Fluoroquinolones are not effective for prophylaxis or treatment, but rather increase antibiotic resistance. Hyperbaric oxygen or fibrin glue is marginally effective based on small case series from correspondingly equipped centres. Although cidofovir has been reported to improve and/or reduce BKPyV viraemia or viruria, the current data do not support its regular use.

Conclusions

BKPyV-HC remains a disabling unmet clinical need in HSCT that requires novel approaches supported by proper clinical trials.

Hyperbaric oxygen as a treatment modality in cyclophosphamide-induced hemorrhagic cystitis

Late-onset HC is a well-recognized complication associated with cyclophosphamide/acrolein-induced toxicity. It poses a management challenge when hyperhydration and bladder irrigation do not result in clinical improvement as desired. The data regarding use of hyperbaric oxygen therapy (HBO2) as an early treatment modality in this clinical setting are limited. We present 2 cases, that were refractory to hyperhydration and bladder irrigation but responded to HBO2. They were treated with 20-30 daily sessions over weekdays with 100% oxygen for 90 minutes at 2 atmospheric pressure units (2 atm). Both patients reported improved symptoms within the first 15 sessions, and hematuria diminished by 20 sessions. Hyperbaric oxygen is a less invasive, outpatient therapy that is effective for treatment of HC and is tolerated well by young patients.

Guidelines for the diagnosis, prevention and management of chemical- and radiation-induced cystitis

Objective

Haemorrhagic cystitis (HC) is a relatively common complication of chemotherapy and radiotherapy to the pelvic area, but can be a challenging condition to treat, particularly since there is currently a lack of UK-led guidelines available on how it should optimally be defined and managed.

Materials and methods

A comprehensive literature search was undertaken to evaluate the evidence for the diagnosis, prevention and management of cancer treatment-induced HC.

Results

Recommendations and a proposed management algorithm for the diagnosis, prevention and treatment of HC, as well as the management of intractable haematuria, have been developed based on the expert opinion of the multidisciplinary consensus panel following a comprehensive review of the available clinical data.

Conclusion

These guidelines are relevant and applicable to current clinical practice and will help clinicians optimally define and manage this potentially serious condition.

Risk Factors Associated with Severity and Outcomes in Pediatric Patients with Hemorrhagic Cystitis

PURPOSE

Hemorrhagic cystitis is a complication of treatment of pediatric cancer with considerable variation in severity and morbidity. This study presents an analysis of hemorrhagic cystitis severity and treatment outcomes in a large pediatric population.

MATERIALS AND METHODS

Patients with hemorrhagic cystitis treated at St. Jude Children's Research Hospital® were identified from 1990 to 2010. Demographic data were gathered along with information pertaining to initial primary diagnosis, hemorrhagic cystitis diagnosis and treatment, and mortality. Statistical analyses were performed to evaluate associations between risk factors and severity of hemorrhagic cystitis as well as treatment outcomes.

RESULTS

Of the 285 patients who met inclusion criteria 54% were male. Mean age was 11.41 years. Mean time from initial primary diagnosis to hemorrhagic cystitis onset was 29 months. Noninvasive treatment was performed in 246 patients (86%) and operative intervention was required in 14 (4.9%). Bivariate analysis demonstrated that pelvic radiation therapy (p = 0.0002), any radiation therapy (p = 0.005), acute lymphocytic leukemia (p = 0.01), bone marrow transplantation (p = 0.0225), cyclophosphamide exposure (p = 0.0419) and BK virus positivity (p = 0.0472) were predictors of higher grade hemorrhagic cystitis. Factors correlating with the need for invasive management on bivariate analysis included pelvic radiation therapy (p = 0.0266), bone marrow transplantation (p = 0.0007), hematological malignancy (p = 0.0066), ifosfamide exposure (p = 0.0441) and male gender (p = 0.0383). Multivariate analysis showed independent effects of pelvic radiation therapy (p = 0.001) and delayed onset of hemorrhagic cystitis (p = 0.0444).

CONCLUSIONS

Severity of hemorrhagic cystitis and failure of noninvasive management correlate with several identifiable risk factors. Prospective identification of patients with these risk factors may allow for targeted early intervention in those at highest risk.

Incidence and risk factors for hemorrhagic cystitis in unmanipulated haploidentical transplant recipients

BACKGROUND

Hemorrhagic cystitis (HC) is a common complication after hematopoietic allogeneic stem cell transplantation (HSCT) associated with intensity of the conditioning regimen, cyclophosphamide (Cy) therapy, and BK polyomavirus (BKPyV) infection.

METHODS

We analyzed 33 consecutive haploidentical (haplo) HSCT recipients transplanted for hematologic diseases. Eleven patients had a previous transplant. Median follow-up was 11 months. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine + mycophenolate mofetil and post-HSCT Cy.

RESULTS

Thirty-two of 33 patients achieved neutrophil recovery. Cumulative incidence (CI) of platelet recovery was 65%. CI grade II-IV acute GVHD was 44%. Twenty patients developed HC in a median time of 38 days. CI of HC at day 180 was 62%. BKPyV was positive in blood and urine of 91% of patients at HC onset. HC resolved in 18/20 patients. Factors associated with HC were previous transplant (P = 0.01) and occurrence of cytomegalovirus reactivation before HC (P = 0.05). Grade II-IV acute GVHD was not associated with HC (P = 0.62). CI of day 180 viral infections was 73%. Two-year overall survival (OS) was 50%; HC did not impact OS (P = 0.29).

CONCLUSION

The incidence of HC after haplo with post-HSCT Cy is high and is associated with morbidity, especially in high-risk patients such as those with a previous transplant history and with impaired immune reconstitution.

BK virus-associated hemorrhagic cystitis after pediatric stem cell transplantation

Hemorrhagic cystitis is a common stem cell transplantation-related complication. The incidence of early-onset hemorrhagic cystitis, which is related to the pretransplant conditioning regimen, has decreased with the concomitant use of mesna and hyperhydration. However, late-onset hemorrhagic cystitis, which is usually caused by the BK virus, continues to develop. Although the BK virus is the most common pathogenic microorganism of poststem cell transplantation late-onset hemorrhagic cystitis, pediatricians outside the hemato-oncology and nephrology specialties tend to be unfamiliar with hemorrhagic cystitis and the BK virus. Moreover, no standard guidelines for the early diagnosis and treatment of BK virus-associated hemorrhagic cystitis after stem cell transplantation have been established. Here, we briefly introduce poststem cell transplantation BK virus-associated hemorrhagic cystitis.

Successful hyperbaric oxygen therapy for refractory BK virus-associated hemorrhagic cystitis after cord blood transplantation

BK virus-associated hemorrhagic cystitis (BKV-HC) is a common and major cause of morbidity in recipients of allogeneic hematopoietic stem cell transplantation. A 32-year-old woman developed severe BKV-HC on day 24 after cord blood transplantation (CBT). Despite supportive therapies - such as hyperhydration, forced diuresis, and urinary catheterization - macroscopic hematuria and bladder irritation persisted for over a month. Hyperbaric oxygen (HBO) therapy at 2.1 atmospheres for 90 min per day was started on day 64 after CBT. Macroscopic hematuria resolved within a week, and microscopic hematuria was no longer detectable within 2 weeks. Hematuria did not recur after 11 sessions of HBO therapy, and no significant side effects were observed during or after treatment. HBO therapy could thus be useful in controlling refractory BKV-HC after CBT.