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Och K, Turki AT, Götz KM, Selzer D, Brossette C, Theobald S, Braun Y, Graf N, Rauch J, Rohm K, Weiler G, Kiefer S, Schwarz U, Eisenberg L, Pfeifer N, Ihle M, Grandjean A, Fix S, Riede C, Rissland J, Smola S, Beelen DW, Kaddu‐Mulindwa D, Bittenbring J, Lehr T. A dynamic time-to-event model for prediction of acute graft-versus-host disease in patients after allogeneic hematopoietic stem cell transplantation. Cancer Med 2023; 13:e6833. [PMID: 38132807 PMCID: PMC10807572 DOI: 10.1002/cam4.6833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/26/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Acute graft-versus-host disease (aGvHD) is a major cause of death for patients following allogeneic hematopoietic stem cell transplantation (HSCT). Effective management of moderate to severe aGvHD remains challenging despite recent advances in HSCT, emphasizing the importance of prophylaxis and risk factor identification. METHODS In this study, we analyzed data from 1479 adults who underwent HSCT between 2005 and 2017 to investigate the effects of aGvHD prophylaxis and time-dependent risk factors on the development of grades II-IV aGvHD within 100 days post-HSCT. RESULTS Using a dynamic longitudinal time-to-event model, we observed a non-monotonic baseline hazard overtime with a low hazard during the first few days and a maximum hazard at day 17, described by Bateman function with a mean transit time of approximately 11 days. Multivariable analysis revealed significant time-dependent effects of white blood cell counts and cyclosporine A exposure as well as static effects of female donors for male recipients, patients with matched related donors, conditioning regimen consisting of fludarabine plus total body irradiation, and patient age in recipients of grafts from related donors on the risk to develop grades II-IV aGvHD. Additionally, we found that higher cumulative hazard on day 7 after allo-HSCT are associated with an increased incidence of grades II-IV aGvHD within 100 days indicating that an individual assessment of the cumulative hazard on day 7 could potentially serve as valuable predictor for later grades II-IV aGvHD development. Using the final model, stochastic simulations were performed to explore covariate effects on the cumulative incidence over time and to estimate risk ratios. CONCLUSION Overall, the presented model showed good descriptive and predictive performance and provides valuable insights into the interplay of multiple static and time-dependent risk factors for the prediction of aGvHD.
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Affiliation(s)
- Katharina Och
- Department of Clinical PharmacySaarland UniversitySaarbrückenGermany
| | - Amin T. Turki
- Department of Hematology and Stem Cell Transplantation, West‐German Cancer CenterUniversity Hospital EssenEssenGermany
| | - Katharina M. Götz
- Department of Clinical PharmacySaarland UniversitySaarbrückenGermany
| | - Dominik Selzer
- Department of Clinical PharmacySaarland UniversitySaarbrückenGermany
| | - Christian Brossette
- Department of Pediatric Oncology and HematologySaarland UniversityHomburgGermany
| | - Stefan Theobald
- Department of Pediatric Oncology and HematologySaarland UniversityHomburgGermany
| | - Yvonne Braun
- Department of Pediatric Oncology and HematologySaarland UniversityHomburgGermany
| | - Norbert Graf
- Department of Pediatric Oncology and HematologySaarland UniversityHomburgGermany
| | - Jochen Rauch
- Department of Biomedical Data & BioethicsFraunhofer Institute for Biomedical Engineering (IBMT)SulzbachGermany
| | - Kerstin Rohm
- Department of Biomedical Data & BioethicsFraunhofer Institute for Biomedical Engineering (IBMT)SulzbachGermany
| | - Gabriele Weiler
- Department of Biomedical Data & BioethicsFraunhofer Institute for Biomedical Engineering (IBMT)SulzbachGermany
| | - Stephan Kiefer
- Department of Biomedical Data & BioethicsFraunhofer Institute for Biomedical Engineering (IBMT)SulzbachGermany
| | - Ulf Schwarz
- Institute for Formal Ontology and Medical Information ScienceSaarland UniversitySaarbrückenGermany
| | - Lisa Eisenberg
- Department of Computer ScienceUniversity of TübingenTübingenGermany
| | - Nico Pfeifer
- Department of Computer ScienceUniversity of TübingenTübingenGermany
| | | | | | | | | | - Jürgen Rissland
- Institute of VirologySaarland University Medical CentreHomburgGermany
| | - Sigrun Smola
- Institute of VirologySaarland University Medical CentreHomburgGermany
- Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI)Saarland University CampusSaarbrückenGermany
| | - Dietrich W. Beelen
- Department of Hematology and Stem Cell Transplantation, West‐German Cancer CenterUniversity Hospital EssenEssenGermany
| | | | - Jörg Bittenbring
- Department of Internal Medicine 1University Hospital of the SaarlandHomburgGermany
| | - Thorsten Lehr
- Department of Clinical PharmacySaarland UniversitySaarbrückenGermany
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Lisak M, Nicklasson M, Palmason R, Wichert S, Isaksson C, Andersson PO, Johansson JE, Lenhoff S, Brune M, Hansson M. Higher cyclosporine-A concentration increases the risk of relapse in AML following allogeneic stem cell transplantation from unrelated donors using anti-thymocyte globulin. Sci Rep 2023; 13:22777. [PMID: 38123675 PMCID: PMC10733303 DOI: 10.1038/s41598-023-50105-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
Cyclosporine-A (CsA) is used to prevent acute graft-versus-host disease (aGvHD). European Society for Blood and Marrow transplantation (EBMT) recommends a CsA target serum concentration of 200-300 µg/L during the first month after allogeneic hematopoietic stem cell transplantation (HSCT). With this study, we investigated whether a median CsA concentration > 200 µg/L (CsAhigh) the first month after HSCT, compared to ≤ 200 µg/L (CsAlow), increased the relapse risk of acute myloid leukemia (AML), using unrelated donors (URD) and antithymocyte globulin (ATG). Data was collected from 157 patients with AML, transplanted 2010-2016. The cumulative incidence of relapse (CIR) at 60 months was 50% in the CsAhigh versus 32% in the CsAlow group (p = 0.016). In univariate analysis, CsAhigh versus CsAlow (p = 0.028), 10-unit increase of CsA as a continuous variable (p = 0.017) and high risk disease (p = 0.003) were associated with higher CIR. The results remained after adjusting for disease risk. Death following relapse occurred more frequently in the CsAhigh group (p = 0.0076). There were no significant differences in rates of aGvHD, chronic GvHD (cGvHD), EBV/CMV-infections or overall survival (OS) between the two groups. In conclusion, we found that a median CsA concentration > 200 µg/L, the first month after HSCT, results in higher CIR of AML when combined with ATG.
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Affiliation(s)
- Mikael Lisak
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden.
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
| | - Malin Nicklasson
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
| | - Robert Palmason
- Department of Hematology, Skane University Hospital, Lund, Sweden
| | - Stina Wichert
- Department of Hematology, Skane University Hospital, Lund, Sweden
| | - Cecila Isaksson
- Department of Hematology, Norrland University Hospital, Umeå, Sweden
| | - Per-Ola Andersson
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jan-Erik Johansson
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Stig Lenhoff
- Department of Hematology, Skane University Hospital, Lund, Sweden
| | - Mats Brune
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Markus Hansson
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Hematology, Skane University Hospital, Lund, Sweden
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3
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Fan Q, Hui X, Li X, Li Q, Yang D, Wang Y. Reaching the cyclosporine a level target slowly in four weeks correlates with better prognosis for Chinese patients after allogeneic haematopoietic cell transplantation. Hematology 2023; 28:2275893. [PMID: 37975575 DOI: 10.1080/16078454.2023.2275893] [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: 11/23/2022] [Accepted: 10/12/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES This study investigated the impact of early cyclosporin A (CsA) initiation (day -5) on the risk of acute graft versus host disease (aGvHD) after allogeneic haematopoietic cell transplantation (allo-HSCT). METHODS Sixty-seven leukaemia patients who underwent allo-HSCT were investigated. The correlation between the CsA level in the first four weeks and the following indices was examined: GvHD, cumulative incidence (CI) of GvHD, CI of relapse at month 18, and non-relapse mortality (NRM) at month 18. RESULTS A significant association between aGvHD and CsA level in the fourth week after allo-HSCT was observed, with the incidence of aGvHD in the fourth week in the lower level group being higher than that in the higher level group (p = 0.044). The CI of aGvHD was 30.1% and 9.8% at day +90 and 42.3% and 17.1% at day +180 in the lower level and higher level groups, respectively. CONCLUSION For Chinese patients, early introduction and reaching the target CsA concentration within four weeks after allo-HSCT have a positive effect on preventing GvHD, especially in the fourth week after HSCT. Compared to the Western population, the target CsA concentration is lower and the time required to reach the target (within 4 weeks) is longer in the Chinese population (274.75 ng/mL).
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Affiliation(s)
- Qingqing Fan
- Department of Pharmacy, Jiangsu Province Hospital (The First Affiliated Hospital with Nanjing Medical University), Nanjing, People's Republic of China
| | - Xiang Hui
- Department of Pharmacy, Jiangsu Province Hospital (The First Affiliated Hospital with Nanjing Medical University), Nanjing, People's Republic of China
| | - Xiang Li
- Department of Pharmacy, Jiangsu Province Hospital (The First Affiliated Hospital with Nanjing Medical University), Nanjing, People's Republic of China
| | - Qian Li
- Department of Pharmacy, Jiangsu Province Hospital (The First Affiliated Hospital with Nanjing Medical University), Nanjing, People's Republic of China
| | - Dihong Yang
- Department of Pharmacy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, People's Republic of China
| | - Yongqing Wang
- Department of Pharmacy, Jiangsu Province Hospital (The First Affiliated Hospital with Nanjing Medical University), Nanjing, People's Republic of China
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Redondo S, De Dios A, Gomis-Pastor M, Esquirol A, Aso O, Triquell M, Moreno ME, Riba M, Ruiz J, Blasco A, Tobajas E, González I, Sierra J, Martino R, García-Cadenas I. Feasibility of a new model of care for allogeneic stem cell transplantation recipients facilitated by eHealth: The MY-Medula pilot study. Transplant Cell Ther 2023:S2666-6367(23)01175-2. [PMID: 36948273 DOI: 10.1016/j.jtct.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND The use of allogeneic stem cell transplantation (allo-SCT) for the treatment of hematologic diseases is steadily increasing. However, allo-SCT has the downside of causing considerable treatment-related morbidity and mortality. Mobile technology applied to healthcare (mHealth) has proven to be a cost-effective strategy to improve care and offer new services to people with multimorbidity, but there are few data on its usefulness in allo-SCT recipients. OBJECTIVE The aim of this report was to describe a new integrated healthcare model facilitated by an mHealth platform, named EMMASalud-MY-Medula, and to report the results of a le. STUDY DESIGN The MY-Medula platform development approach consisted of 4 phases. Firstly, patient and healthcare professional needs were identified and technological development and pre-testing tests were conducted (phases 1-3, January 2016-March 2021). Then, a non-randomized, prospective, observational, single-center pilot study was conducted (October 2021-January 2022) at the adult Stem Cell Transplant Unit of a tertiary university hospital. RESULTS Twenty-eight volunteer allo-SCT recipients were included in the pilot study. Fifty percent were outpatients in the first-year post-SCT and the remaining 50% were affected by steroid-dependent graft-versus-host disease (SR-GVHD). All patients used MY-Medula application during the two-month follow-up period with a median number of visits to the application of 143 (range 6-477). A total of 2067 self-monitoring records were made, and 205 text messages were received, most of them related to symptoms description (47%) and doubts about medication (21%). In 3.4% of the cases drug dose adjustments were performed by the pharmacist because of dosing errors or interactions. At the end of the study, a 6-question Likert-type questionnaire for patients and a 22-question test for healthcare professionals showed a high degree of satisfaction (95% and 100% respectively) with the new healthcare pathway. CONCLUSIONS Re-engineering allo-SCT recipients follow-up into an integrated, multidisciplinary model of care facilitated by mHealth tools is feasible and has been associated with a high usability and degree of satisfaction by patients and healthcare professionals. A randomized trial aiming to determine the cost-effectiveness of MY-Medula-based follow-up post-SCT is currently enrolling participants.
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Affiliation(s)
- S Redondo
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universitat Autónoma de Barcelona, Spain.
| | - A De Dios
- Pharmacy Department, Hospital de la Santa Creu i Sant Pau.; Digital Health Department, Hospital de la Santa Creu i Sant Pau
| | - M Gomis-Pastor
- Pharmacy Department, Hospital de la Santa Creu i Sant Pau.; Digital Health Department, Hospital de la Santa Creu i Sant Pau
| | - A Esquirol
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universitat Autónoma de Barcelona, Spain
| | - O Aso
- Hematology Nursing Department, Hospital de la Santa Creu i Sant Pau
| | - M Triquell
- Hematology Nursing Department, Hospital de la Santa Creu i Sant Pau
| | - M E Moreno
- Pharmacy Department, Hospital de la Santa Creu i Sant Pau
| | - M Riba
- Pharmacy Department, Hospital de la Santa Creu i Sant Pau
| | - J Ruiz
- Nutrition and Dietetics Department, Hospital de la Santa Creu i Sant Pau
| | - A Blasco
- Nutrition and Dietetics Department, Hospital de la Santa Creu i Sant Pau
| | - E Tobajas
- Psycho-Oncology Department, Hospital de la Santa Creu i Sant Pau
| | - I González
- Hematology Nursing Department, Hospital de la Santa Creu i Sant Pau
| | - J Sierra
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universitat Autónoma de Barcelona, Spain
| | - R Martino
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universitat Autónoma de Barcelona, Spain
| | - I García-Cadenas
- Hematology Department, Hospital de la Santa Creu i Sant Pau. IIB-Sant Pau and José Carreras Leukemia Research Institutes. Departamento de Medicina, Universitat Autónoma de Barcelona, Spain
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5
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Kwan ACF, Blosser N, Ghosh S, Leyshon C, Dersch-Mills D, Puckrin RP, Duggan P, Zepeda V, Savoie L, Stewart D, Storek J, Jamani K. Toward optimization of cyclosporine concentration target to prevent acute graft-vs-host disease following myeloablative allogeneic stem cell transplant. Clin Transplant 2022; 36:e14732. [PMID: 35606904 DOI: 10.1111/ctr.14732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/09/2022] [Accepted: 05/14/2022] [Indexed: 11/28/2022]
Abstract
Despite the common use of cyclosporine (CsA) for acute graft-versus-host disease (aGVHD) prophylaxis following allogeneic stem cell transplant, the optimal CsA trough target remains unknown. Here, we report on outcomes of adult patients following myeloablative conditioning to identify an optimal CsA trough target and characterize the most relevant timeframe post-transplant for CsA trough targeting to minimize aGVHD. We retrospectively reviewed 399 consecutive patients who underwent first peripheral blood allogeneic stem cell transplant for hematological malignancies between January 2009 and December 2018. In the unadjusted and adjusted analyses, the incidence of grades 2-4 aGVHD was significantly higher among patients with an average CsA trough concentration <250 mcg/L compared to patients with an average CsA trough concentration ≥250 mcg/L during days 15-28 post-transplant (31.5% versus 18.8%, P = 0.037), with an odds ratio (OR) of 1.97 (95% confidence interval 1.04-3.71). In contrast, no correlations between CsA trough concentration and relapse, non-relapse mortality and overall survival was found. In conclusion, early post-transplant CsA trough concentrations are an important factor in the prophylaxis against aGVHD. Our findings suggest that CsA trough concentrations should be maximized between days 15-28 post-myeloablative transplant. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Nikki Blosser
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
| | - Sunita Ghosh
- Cross Cancer Institute, Edmonton, Alberta, Canada
| | | | | | | | - Peter Duggan
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
| | - Victor Zepeda
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
| | - Lynn Savoie
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
| | - Douglas Stewart
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
| | - Jan Storek
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
| | - Kareem Jamani
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
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Yao JM, Yang D, Clark MC, Otoukesh S, Cao T, Ali H, Arslan S, Aldoss I, Artz A, Amanam I, Salhotra A, Pullarkat V, Sandhu K, Stein A, Marcucci G, Forman SJ, Nakamura R, Al Malki MM. Tacrolimus initial steady state level in post-transplant cyclophosphamide-based GvHD prophylaxis regimens. Bone Marrow Transplant 2021; 57:232-242. [PMID: 34802049 PMCID: PMC8825746 DOI: 10.1038/s41409-021-01528-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 11/02/2021] [Accepted: 11/09/2021] [Indexed: 11/11/2022]
Abstract
Post-transplant cyclophosphamide (PTCy) combined with tacrolimus (TAC) as graft-versus-host disease (GvHD) prophylaxis post-hematopoietic cell transplantation (HCT) is safe and effective. Optimal serum levels of TAC in this combination remain undetermined. We hypothesized that TAC at initial steady state (TISS) of <10 ng/mL could promote optimal transplant outcomes and prevent TAC-associated toxicities. We retrospectively analyzed a consecutive case series of 210 patients who received PTCy/TAC-based prophylaxis post-HCT from 1/2013–6/2018. Patients received HCT from haploidentical (n=172) or mismatched donors (n=38), and flat dose (FD) or weight-based dose (WBD) TAC. Twenty-four-month overall survival (OS), disease free survival (DFS), and relapse rate (RR) were 61%, 56%, and 22%, respectively, in TISS <10 ng/mL cohort (n=176), and 50%, 43%, and 35%, respectively, in TISS ≥10 ng/mL cohort (n=34) (OS, P=0.71; DFS, P=0.097; RR, P=0.031). OS, DFS, RR, non-relapse mortality, acute GvHD grade II-IV, grade III-IV or chronic GvHD by TISS were similar in multivariable analysis. TISS ≥10 ng/mL conferred increased risk of viral infection (P=0.003). More patients receiving FD vs. WBD had TISS <10 ng/mL (P=0.001). Overall, TISS <10 ng/mL early post HCT conferred similar survival outcomes and lowered risk of viral infection and toxicities compared to TISS ≥10 ng/mL.
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Affiliation(s)
- Janny M Yao
- Department of Pharmacy, City of Hope National Medical Center, Duarte, CA, USA
| | - Dongyun Yang
- Department of Computational and Quantitative Medicine, Division of Biostatistics, City of Hope National Medical Center, Duarte, CA, USA
| | - Mary C Clark
- Department of Clinical and Translational Project Development, City of Hope National Medical Center, Duarte, CA, USA
| | - Salman Otoukesh
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Thai Cao
- Bone Marrow Transplant Department, Kaiser Permanente, Los Angeles, CA, USA
| | - Haris Ali
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Shukaib Arslan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Andrew Artz
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Idoroenyi Amanam
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Amandeep Salhotra
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Vinod Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Karamjeet Sandhu
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Anthony Stein
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Guido Marcucci
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA.
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7
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Deml L, Hüber CM, Barabas S, Spindler T, Cozzi E, Grossi P. Stimulatory Effect of CMV Immunoglobulin on Innate Immunity and on the Immunogenicity of CMV Antigens. Transplant Direct 2021; 7:e781. [PMID: 34712781 PMCID: PMC8547921 DOI: 10.1097/txd.0000000000001236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/29/2021] [Indexed: 12/25/2022] Open
Abstract
Background. Cytomegalovirus (CMV) immunoglobulin (CMVIG) is used for the prophylaxis of CMV infection after transplantation. Beyond providing passive CMV-specific immunity, CMVIG exerts enhancing and suppressive immunomodulatory functions. Although the anti-inflammatory activities of CMVIG have been extensively documented, its immunostimulatory activities remain poorly characterized. Methods. This exploratory study analyzed the capacity of CMVIG to modulate cell-mediated innate and adaptive immunities in vitro on freshly isolated peripheral blood mononuclear cells (PBMCs) of CMV-seropositive and -seronegative healthy individuals, using interferon-γ (IFN-γ) enzyme-linked immunospot and intracellular cytokine staining assays. Results. We showed that CMVIG treatment increases the number of IFN-γ–secreting PBMCs of both CMV-seronegative and -seropositive individuals, indicating a global stimulatory effect on innate immune cells. Indeed, CMVIG significantly increased the frequency of natural killer cells producing the T helper cell 1–type cytokines tumor necrosis factor and IFN-γ. This was associated with the induction of interleukin-12–expressing monocytes and the activation of cluster of differentiation (CD) 4+ and CD8+ T cells, as measured by the expression of tumor necrosis factor and IFN-γ. Interestingly, stimulation of PBMCs from CMV-seropositive subjects with CMVIG-opsonized CMV antigens (phosphoprotein 65, CMV lysate) enhanced CD4+ and CD8+ T-cell activation, suggesting that CMVIG promotes the immunogenicity of CMV antigens. Conclusions. Our data demonstrate that CMVIG can stimulate effector cells of both innate and adaptive immunities and promote the immunogenicity of CMV antigens. These immunostimulatory properties might contribute to the protective effect against CMV infection mediated by CMVIG.
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Affiliation(s)
- Ludwig Deml
- Lophius Biosciences GmbH, Regensburg, Germany
| | | | | | | | - Emanuele Cozzi
- Transplant Immunology Unit, University of Padua, Padova, Italy
| | - Paolo Grossi
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, Varese, Italy
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8
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Chung EK, Yee J, Kim JY, Gwak HS. Low cyclosporine concentrations in children and time to acute graft versus host disease. BMC Pediatr 2020; 20:206. [PMID: 32393210 PMCID: PMC7212619 DOI: 10.1186/s12887-020-02125-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 05/05/2020] [Indexed: 11/19/2022] Open
Abstract
Background Achievement of target blood concentrations of cyclosporine (CsA) early after transplantation is known to be highly effective for reducing the incidence of acute graft versus host disease (aGVHD). However, no research has been conducted for predicting aGVHD occurrence with low CsA concentrations at different time periods. The objective of this study was to investigate the risk of aGVHD according to low CsA concentrations at lag days in children with allogenic hematopoietic stem cell transplantation (HSCT). Methods The records of 61 consecutive children who underwent allogeneic HSCT and received CsA as prophylaxis against aGVHD between May 2012 and March 2015 were retrospectively evaluated. The main outcome was any association between low CsA concentrations at lag days and aGVHD occurrence, which was examined for the first month after transplantation. Mean CsA concentrations at three lag periods were calculated: lag days 0–6, 7–13, and 14–20 before aGVHD occurrence. Results Patients whose mean CsA concentrations at lag days 0–6 did not reach the initial target concentration had 11.0-fold (95% confidence interval [CI]: 2.3–51.9) greater incidence of aGVHD. In addition, the AORs of low CsA concentrations at lag days 7–13 and 14–20 for developing aGVHD were 108.2 (95% CI: 7.7–1515.5) and 12.1 (95% CI: 1.1–138.1), respectively. Conclusions After low CsA concentrations are detected, careful attention needs to be paid to prevent aGVHD.
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Affiliation(s)
- Eun Kyung Chung
- Graduate School of Converging Clinical & Public Health, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, Korea.,Department of Pharmacy, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul, 05535, Korea
| | - Jeong Yee
- College of Pharmacy & Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, Korea
| | - Jae Youn Kim
- Department of Pharmacy, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul, 05535, Korea
| | - Hye Sun Gwak
- Graduate School of Converging Clinical & Public Health, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, Korea. .,College of Pharmacy & Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, Korea.
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9
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Yang X, Yang S, Sun A, Qiu H, Tang X, Han Y, Wu D. Impact of cyclosporine-A concentration in T-cell replete haploidentical allogeneic stem cell transplantation. Clin Transplant 2018; 32:e13220. [PMID: 29493007 DOI: 10.1111/ctr.13220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2018] [Indexed: 01/22/2023]
Abstract
This paper aims to study whether cyclosporine-A (CSA) levels have an impact on the clinical outcome of patients with T-cell replete haploidentical allogeneic hematopoietic stem cell transplantation (allo-HSCT). We analyzed 140 consecutive patients who had been given T-cell replete haploidentical allo-HSCT in our institute to assess the effect of CSA concentration in the early stages of allo-HSCT on clinical outcomes, such as hematopoietic recovery, acute graft vs host disease (aGVHD), infection, disease-free survival (DFS), and overall survival (OS). The median concentrations of CSA in the blood in the 1st, 2nd, 3rd, and 4th week after allo-HSCT were 218, 235, 263, and 270 ng/mL, respectively. Additionally, 46%, 40%, 27%, and 18% of the patients had CSA blood levels below 200 ng/mL during those weeks. In total, 39 patients developed aGVHD (grade II-IV), for a cumulative incidence of 27.8%, at a median of 32 days. Patients having a low CSA concentration (below 200 ng/mL) in the 3rd week had a higher cumulative incidence of grade II-IV aGVHD (P = .02). In addition, multivariate logistic regression analysis showed that low CSA concentration (below 200 ng/mL) in the 3rd week was an independent risk factor of grade II-IV aGVHD (P = .02; odds ratio = 2.66; 95% CI, 1.15-6.17). However, CSA levels during the first 4 weeks did not have a significant impact on the patients' hematopoietic recovery, infection, DFS, and OS. Our data indicated that adequate management of CSA levels during the peri-engraftment period might improve clinical outcomes for those with T-cell replete haploidentical allo-HSCT.
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Affiliation(s)
- Xiaofei Yang
- Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Shuo Yang
- Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Aining Sun
- Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Huiying Qiu
- Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiaowen Tang
- Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yue Han
- Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Depei Wu
- Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
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10
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Park S, Kim K, Jang JH, Kim SJ, Kim WS, Jung CW. Blood concentration of cyclosporine during early post-transplant period may have influence on the occurrence of chronic graft versus host disease in patients who received allogeneic hematopoietic stem cell transplantation. Oncotarget 2018; 7:59892-59901. [PMID: 27494893 PMCID: PMC5312356 DOI: 10.18632/oncotarget.10988] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 06/30/2016] [Indexed: 11/25/2022] Open
Abstract
Introduction It has rarely been studied that how the blood level of CsA affect the incidence of chronic GVHD after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Methods A total of 183 patients who underwent allo-HSCT from an HLA-matched or haplo matched family donors between 2006 and 2014 were reviewed. Results The average monthly CsA blood concentration (CsAavr, ng/ml) was calculated in each patient: 0-1, 1-2, and 2-3 months after allo-HSCT. CsAavr at the first month showed significant association with the occurrence of moderate to severe cGVHD in multivariate analysis adjusted for gender, age, total body irradiation, anti-thymocyte globulin, acute GVHD ≥ grade 2 and CsAavr levels of other periods. The risk of cGVHD development was lowest in patients with CsAavr of 200-250 ng/ml when compared to those with CsAavr of ≥ 250 or < 200 ng/ml (p=0.003). Conclusions CsA level between 200 and 250 mg/ml during the first month after transplantation was significantly associated with the decreased risk of moderate to severe cGVHD.
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Affiliation(s)
- Silvia Park
- Division of Hematology-Oncology, Department of Medicine, Sungkyunkwan University of School of Medicine, Seoul, Korea
| | - Kihyun Kim
- Division of Hematology-Oncology, Department of Medicine, Sungkyunkwan University of School of Medicine, Seoul, Korea
| | - Jun Ho Jang
- Division of Hematology-Oncology, Department of Medicine, Sungkyunkwan University of School of Medicine, Seoul, Korea
| | - Seok Jin Kim
- Division of Hematology-Oncology, Department of Medicine, Sungkyunkwan University of School of Medicine, Seoul, Korea
| | - Won Seog Kim
- Division of Hematology-Oncology, Department of Medicine, Sungkyunkwan University of School of Medicine, Seoul, Korea
| | - Chul Won Jung
- Division of Hematology-Oncology, Department of Medicine, Sungkyunkwan University of School of Medicine, Seoul, Korea
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11
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Clemmons AB, Alexander M, DeGregory K, Kennedy L. The Hematopoietic Cell Transplant Pharmacist: Roles, Responsibilities, and Recommendations from the ASBMT Pharmacy Special Interest Group. Biol Blood Marrow Transplant 2017; 24:914-922. [PMID: 29292057 DOI: 10.1016/j.bbmt.2017.12.803] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 12/26/2017] [Indexed: 12/14/2022]
Abstract
Pharmacists are increasingly recognized as an essential member of the multidisciplinary team for hematopoietic cell transplant (HCT) patients. However, until recently, their educational background, required training, and potential roles have not been well described. Therefore, the purpose of this manuscript is to provide supporting evidence for the HCT Clinical Pharmacist Role Description, which has been endorsed by several organizations including the American Society for Blood and Marrow Transplantation. This document provides justification for the various roles pharmacists fulfill with respect to medication management, transitions of care, patient and provider education, policy development, quality improvement, and research. Furthermore, evidence supporting the value, financially and otherwise, HCT pharmacists provide is reviewed. Pharmacists in the HCT setting are encouraged to report on novel practice models and potential impact of their services to increase awareness and utilization of HCT pharmacists.
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Affiliation(s)
- Amber B Clemmons
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, Georgia; Department of Pharmacy, Augusta University (AU) Medical Center, Augusta, Georgia.
| | - Maurice Alexander
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Kathlene DeGregory
- Department of Pharmacy, University of Virginia Health System, Charlottesville, Virginia
| | - LeAnne Kennedy
- Department of Pharmacy, Wake Forest Baptist Health, Winston Salem, North Carolina
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12
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Gupta A, Punatar S, Mathew L, Kannan S, Khattry N. Cyclosporine Plus Methotrexate or Cyclosporine Plus Mycophenolate Mofetil as Graft Versus Host Disease Prophylaxis in Acute Leukemia Transplant: Comparison of Toxicity, Engraftment Kinetics and Transplant Outcome. Indian J Hematol Blood Transfus 2016; 32:248-56. [PMID: 27429515 PMCID: PMC4930757 DOI: 10.1007/s12288-015-0577-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 07/25/2015] [Indexed: 11/25/2022] Open
Abstract
We sought to compare two graft-versus-host disease (GVHD) prophylaxis regimen, cyclosporine and methotrexate (CsA+MTX) with CsA+mycophenolate mofetil (MMF) in 77 acute leukemia patients who underwent hematopoietic stem cell transplant (HSCT) between January 2008 and March 2013. Fifty-three patients received CsA+MTX while 24 received CsA+MMF. The incidence of grade 3-4 mucositis and grade 3-4 diarrhea was 74 and 6 % with CsA+MTX compared to 33 % and 21 % with CsA+MMF (P = 0.001 and 0.09 respectively). Forty-two (79 %) patients in CsA+MTX group required total parenteral nutrition compared to 14 (58 %) in CsA+MMF group (P = 0.09). The incidence of engraftment fever was 17 % with CsA+MTX and 41 % with CsA+MMF (P = 0.02). The median time to neutrophil and platelet engraftment was 14 days and 13 days with CsA+MTX compared to 12 days and 10 days with CsA+MMF (P = 0.003 and 0.08 respectively). The incidence of any grade and grade II-IV acute GVHD was 45 and 13 % with CsA+MTX compared to 42 and 29 % with CsA+MMF (P = NS). Incidence of overall and extensive chronic GVHD was 57 and 38 % with CsA+MTX compared to 42 and 17 % with CsA+MMF (P = NS). Incidence of relapse was 38 % with CsA+MTX compared to 33 % with CsA+MMF (P = NS). TRM was 6 % with CsA+MTX and 21 % with CsA+MMF (P = NS). At 2 years, overall survival (OS) was 64 % in CsA+MTX group compared to 46 % in CsA+MMF group (P = NS). We conclude that CsA+MMF is associated with lesser toxicity, faster myeloid engraftment and similar rates of acute and chronic GVHD, TRM, relapse and OS compared to CsA+MTX in acute leukemia transplant.
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Affiliation(s)
- Alok Gupta
- />Bone Marrow Transplant Unit, Department of Medical Oncology, ACTREC, Tata Memorial Centre, Sector 22, Room No. 247, Paymaster Shodhika, Kharghar, Navi-Mumbai, 410210 India
| | - Sachin Punatar
- />Bone Marrow Transplant Unit, Department of Medical Oncology, ACTREC, Tata Memorial Centre, Sector 22, Room No. 247, Paymaster Shodhika, Kharghar, Navi-Mumbai, 410210 India
| | - Libin Mathew
- />Bone Marrow Transplant Unit, Department of Medical Oncology, ACTREC, Tata Memorial Centre, Sector 22, Room No. 247, Paymaster Shodhika, Kharghar, Navi-Mumbai, 410210 India
| | - Sadhana Kannan
- />Department of Biostatistics, ACTREC, Tata Memorial Centre, Sector 22, Kharghar, Navi-Mumbai, India
| | - Navin Khattry
- />Bone Marrow Transplant Unit, Department of Medical Oncology, ACTREC, Tata Memorial Centre, Sector 22, Room No. 247, Paymaster Shodhika, Kharghar, Navi-Mumbai, 410210 India
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13
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Tafazoli A. Cyclosporine use in hematopoietic stem cell transplantation: pharmacokinetic approach. Immunotherapy 2015; 7:811-36. [DOI: 10.2217/imt.15.47] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Cyclosporine is one of the most vital agents in the process of successful allogeneic hematopoietic stem cell transplantation. Despite a long history and worldwide extent of cyclosporine use for prevention of graft versus host disease, currently there are lots of uncertainties about its optimal method of application to reach the best clinical outcome. A major portion of this problem stems from complicated cyclosporine pharmacokinetics. Study of cyclosporine pharmacokinetic behavior can significantly help recognition of its effectiveness and consequently, optimization of dosing, administration, monitoring and management of adverse effects. In this review, highly accredited but sparse scientific data are gathered in order to provide a better insight for preparation of practice guidelines and directing future studies for allogeneic hematopoietic cell recipients.
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Affiliation(s)
- Ali Tafazoli
- Clinical Pharmacy Department, School of Pharmacy, Shahid Beheshti University of Medical Sciences (SBMU), Vali-e-Asr Avenue, Niayesh Junction, PO Box: 14155/6153 Tehran, Iran
- Taleghani Bone Marrow Transplantation Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences (SBMU), Vali-e-Asr Avenue, Niayesh Junction, PO Box 14155/6153 Tehran, Iran
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14
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Risk Factors, Pattern and Clinical Outcome of Acute Graft Versus Host Disease in Acute Leukemia Patients Undergoing Allogeneic Stem Cell Transplant. Indian J Hematol Blood Transfus 2015; 31:404-12. [PMID: 26306063 DOI: 10.1007/s12288-014-0499-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 12/30/2014] [Indexed: 10/24/2022] Open
Abstract
We sought to determine risk factors, pattern and outcome of acute graft versus host disease (aGVHD) in seventy-seven acute leukemia patients who underwent allogeneic stem cell transplant at our centre from January 2008 to March 2013. GVHD prophylaxis with cyclosporine-methotrexate or cyclosporine-mycophenolate mofetil was used. Patients were divided in 2 groups, grade II-IV aGVHD (group A) and grade 0-I aGVHD (group B). Incidence of any grade and grade II-IV aGVHD was 44 and 18 %, respectively. The most common site of aGVHD was gastro-intestinal tract (65 %) followed by skin (35 %). Higher total nucleated cell (TNC) dose infused was associated with increased incidence of grade II-IV aGVHD. Incidence of relapse and incidence of slippage of chimerism was 21 and 36 % in group A while 37 and 27 % in group B respectively. Transplant related mortality (TRM) was 21 % in group A and 13 % in group B. Probability of OS and RFS at 4 years was 63 and 34 % in group A compared with 40 and 38 % in group B, respectively. We conclude that higher TNC dose infused is a risk factor for grade II-IV aGVHD with gut being the commonest site. Grade II-IV aGVHD did not have a significant impact on incidence of relapse, TRM and OS.
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15
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Role in calcineurin inhibitors for inflammatory bowel disease in the biologics era: when and how to use. Inflamm Bowel Dis 2014; 20:2151-6. [PMID: 25029618 DOI: 10.1097/mib.0000000000000130] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ulcerative colitis and Crohn's disease, which is the 2 major forms of inflammatory bowel disease, are chronic relapsing and remitting inflammatory disorder of the gastrointestinal tract. During the last 30 years, the therapy for patients with refractory inflammatory bowel diseases is still challenging despite the fact that morbidity and mortality rates have been obviously reduced. The conventional management with corticosteroids has been modified by the introduction of calcineurin inhibitors and biologics. In this review, we focus on role in calcineurin inhibitors for patients with inflammatory bowel disease in the currently clinical practice.
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