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Sood A, Jothiswaran V, Singh A, Sharma A. Anticancer peptides as novel immunomodulatory therapeutic candidates for cancer treatment. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2024; 5:1074-1099. [PMID: 39351437 PMCID: PMC11438574 DOI: 10.37349/etat.2024.00264] [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: 05/24/2024] [Accepted: 07/27/2024] [Indexed: 10/04/2024] Open
Abstract
Cancer remains a concern after years of research in this field. Conventional therapies such as chemotherapy, radiation, and surgery are available for cancer treatment, but they are characterized by various side effects. There are several immunological challenges that make it difficult for the immune system and conventional therapies to treat cancer. Some of these challenges include heterogeneity, resistance to medicines, and cancer relapse. Even advanced treatments like immune checkpoint inhibitors (ICIs), which revolutionized cancer treatment, have associated toxicity and resistance further necessitate the exploration of alternative therapies. Anticancer peptides (ACPs) offer promising potential as cancer-fighting agents and address challenges such as treatment resistance, tumor heterogeneity, and metastasis. Although these peptides exist as components of the defense system in various plants, animals, fungi, etc., but can also be created synthetically and used as a new treatment measure. These peptides possess properties that make them appealing for cancer therapy, such as apoptosis induction, inhibition of angiogenesis, and cell membrane breakdown with low toxicity. Their capacity to specifically target cancer cells selectively holds promise for enhancing treatment environments as well as improving patients' quality of life. This review provides detailed insights into the different prospects of ACPs, including their characterization, use as immunomodulatory agents in cancer treatment, and their mechanistic details after addressing various immunological challenges in existing cancer treatment strategies. In conclusion, ACPs have promising potential as novel cancer therapeutics due to their target specificity and fewer side effects than conventional therapies.
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Affiliation(s)
- Apurva Sood
- Department of Molecular Biology and Genetic Engineering, School of Bioengineering and Biosciences, Lovely Professional University, Punjab 144411, India
| | - V.V. Jothiswaran
- Biotechnology and Medical Engineering, National Institute of Technology, Rourkela 769005, India
| | - Amrita Singh
- Biotechnology and Medical Engineering, National Institute of Technology, Rourkela 769005, India
| | - Anuradha Sharma
- Department of Molecular Biology and Genetic Engineering, School of Bioengineering and Biosciences, Lovely Professional University, Punjab 144411, India
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Nusrat S, Davis H, MacDougall K, George JN, Nakamura R, Borogovac A. Thrombotic Microangiopathy After Hematopoietic Stem Cell and Solid Organ Transplantation: A Review for Intensive Care Physicians. J Intensive Care Med 2024; 39:406-419. [PMID: 37990516 DOI: 10.1177/08850666231200193] [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] [Indexed: 11/23/2023]
Abstract
Intensive care physicians may assume the primary care of patients with transplant-associated thrombotic microangiopathy (TA-TMA), an uncommon but potentially critical complication of hematopoietic stem cell transplants (HSCTs) and solid organ transplants. TA-TMA can have a dramatic presentation with multiple organ dysfunction syndrome (MODS) associated with high morbidity and mortality. The typical presenting clinical features are hemolytic anemia, thrombocytopenia, refractory hypertension, proteinuria and worsening renal failure. Intestinal involvement, with abdominal pain, nausea and vomiting, gastrointestinal bleeding, and ascites are also common. Cardiopulmonary involvement may develop from various causes including pulmonary arteriolar hypertension, pleural and pericardial effusions, and diffuse alveolar hemorrhage. Due to other often concurrent complications after HSCT, early diagnosis and effective management of TA-TMA may be challenging. Close collaboration between ICU and transplant physicians, along with other relevant specialists, is needed to best manage these patients. There are currently no approved therapies for the treatment of TA-TMA. Plasma exchange and rituximab are not recommended unless circulating factor H (CFH) antibodies or thrombotic thrombocytopenic purpura (TTP; ADAMTS activity < 10%) are diagnosed or highly suspected. The role of the complement pathway activation in the pathophysiology of TA-TMA has led to the successful use of targeted complement inhibitors, such as eculizumab. However, the relatively larger studies using eculizumab have been mostly conducted in the pediatric population with limited data on the adult population. This review is focused on the role of intensive care physicians to emphasize the clinical approach to patients with suspected TA-TMA and to discuss diagnosis and treatment strategies.
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Affiliation(s)
- Sanober Nusrat
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Hugh Davis
- Division of Pulmonary and Critical Care Medicine, City of Hope, Duarte, CA, USA
| | - Kira MacDougall
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - James N George
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ryotaro Nakamura
- Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Azra Borogovac
- Department of Hematology and Hematopoietic Cell Transplantation, Lennar Foundation Cancer Center, City of Hope, Irvine, CA, USA
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Hurley C, McArthur J, Gossett JM, Hall EA, Barker PJ, Hijano DR, Hines MR, Kang G, Rains J, Srinivasan S, Suliman A, Qudeimat A, Ghafoor S. Intrapulmonary administration of recombinant activated factor VII in pediatric, adolescent, and young adult oncology and hematopoietic cell transplant patients with pulmonary hemorrhage. Front Oncol 2024; 14:1375697. [PMID: 38680864 PMCID: PMC11055461 DOI: 10.3389/fonc.2024.1375697] [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: 01/24/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024] Open
Abstract
Introduction Diffuse alveolar hemorrhage (DAH) is a devastating disease process with 50-100% mortality in oncology and hematopoietic cell transplant (HCT) recipients. High concentrations of tissue factors have been demonstrated in the alveolar wall in acute respiratory distress syndrome and DAH, along with elevated levels of tissue factor pathway inhibitors. Activated recombinant factor VII (rFVIIa) activates the tissue factor pathway, successfully overcoming the tissue factor pathway inhibitor (TFPI) inhibition of activation of Factor X. Intrapulmonary administration (IP) of rFVIIa in DAH is described in small case series with successful hemostasis and minimal complications. Methods We completed a single center retrospective descriptive study of treatment with rFVIIa and outcomes in pediatric oncology and HCT patients with pulmonary hemorrhage at a quaternary hematology/oncology hospital between 2011 and 2019. We aimed to assess the safety and survival of patients with pulmonary hemorrhage who received of IP rFVIIa. Results We identified 31 patients with pulmonary hemorrhage requiring ICU care. Thirteen patients received intrapulmonary rFVIIa, while eighteen patients did not. Overall, 13 of 31 patients (41.9%) survived ICU discharge. ICU survival (n=6) amongst those in the IP rFVIIa group was 46.2% compared to 38.9% (n=7) in those who did not receive IP therapy (p=0.69). Hospital survival was 46.2% in the IP group and 27.8% in the non-IP group (p=0.45). There were no adverse events noted from use of IP FVIIa. Conclusions Intrapulmonary rFVIIa can be safely administered in pediatric oncology patients with pulmonary hemorrhage and should be considered a viable treatment option for these patients.
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Affiliation(s)
- Caitlin Hurley
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Bone Marrow Transplant and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Jennifer McArthur
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Jeffrey M. Gossett
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Elizabeth A. Hall
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Patricia J. Barker
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Diego R. Hijano
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Pediatrics, University of Tennessee Health and Science Center, Memphis, TN, United States
| | - Melissa R. Hines
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Jason Rains
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Saumini Srinivasan
- Department of Pediatrics, Division of Pulmonary Medicine, University of Tennessee Health and Science Center, Memphis, TN, United States
| | - Ali Suliman
- Department of Bone Marrow Transplant and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Amr Qudeimat
- Department of Bone Marrow Transplant and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Saad Ghafoor
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
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Chopra Y, Alsabahi A, Schechter T, Mtaweh H, Sweezey N, Balit C, Ali M, Chiang KY, Gassas A, Krueger J. Pulmonary Hemorrhage in Pediatric Hematopoietic Stem Cell Transplant Recipients: A Single-Center Retrospective Study. Pediatr Crit Care Med 2024; 25:e47-e51. [PMID: 37539962 DOI: 10.1097/pcc.0000000000003350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
OBJECTIVES Pulmonary hemorrhage (PH) is a serious complication posthematopoietic stem cell transplant (HSCT). In view of limited available pediatric data, we performed a retrospective study to describe epidemiology, management, and outcomes of PH post-HSCT in children in our national center. DESIGN Retrospective study. SETTING Academic children's hospital (2000-2015). SUBJECTS Children (< 18 yr) with PH and requiring PICU care post-HSCT. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The historical prevalence of PH in our center was 2.7% (31/1,148). Twenty patients had a concomitant infection, 15 had bacterial infection, 8 had viral infection, and 3 patients had a fungal infection. With a median follow-up time of 60 months, 7 of 31 patients were alive. Early PH (< 40 d post-HSCT) was associated with improved survival (6/15 vs 1/16, p = 0.035). Patients who received high-dose pulsed corticosteroid had improved survival when compared with those who did not (7/22 vs 0/9, p = 0.0012); this also applied to the subgroup of patients with a concomitant infection (5/15 vs 0, p = 0.001). None of the patients who survived had measurable respiratory sequelae. CONCLUSIONS PH is a rare but serious complication after HSCT. Corticosteroids were associated with improved survival even in patients with a concomitant infection.
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Affiliation(s)
- Yogi Chopra
- Department of Hematology, Oncology, Blood and Marrow Transplant and Cellular Therapy, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Amal Alsabahi
- Department of Paediatric Haemato-Oncology, Royal Hospital, Muscat, Oman
| | - Tal Schechter
- Department of Hematology, Oncology, Blood and Marrow Transplant and Cellular Therapy, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Haifa Mtaweh
- Department of Pediatric Intensive Care Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Neil Sweezey
- Department of Respiratory Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Corinne Balit
- Department of Paediatric Intensive Care Medicine, The Children's Hospital Westmead, NSW, Australia
| | - Muhammad Ali
- Department of Hematology, Oncology, Blood and Marrow Transplant and Cellular Therapy, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Kuang-Yueh Chiang
- Department of Hematology, Oncology, Blood and Marrow Transplant and Cellular Therapy, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Adam Gassas
- Department of Bone Marrow Transplantation, Royal Hospital for Children, Bristol, United Kingdom
| | - Joerg Krueger
- Department of Hematology, Oncology, Blood and Marrow Transplant and Cellular Therapy, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Franklin A, John TM, Khawaja F, Jiang Y, Yepez E, Ahuja J, Faiz SA, Bashoura L, Sheshadri A, Shannon VR, Balachandran DD, McConn K, Mulanovich VE, Bhatti M, Chemaly RF. Utility of Bronchoalveolar Lavage for the Diagnosis and Management of COVID-19 in Patients With Cancer. J Infect Dis 2023; 228:1549-1558. [PMID: 37983000 DOI: 10.1093/infdis/jiad272] [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: 02/21/2023] [Accepted: 07/14/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) on nasopharyngeal swab (NPS), remains the most reliable and practical test to diagnose coronavirus disease 2019 (COVID-19). Current literature is sparse regarding the rates of discordance between NPS and bronchoalveolar lavage (BAL) in patients with cancer. METHODS We conducted a retrospective cohort study of adult patients with cancer who had BAL samples tested for SARS-CoV-2 at a comprehensive cancer center. Patients without NPS PCR for SARS-CoV-2 before BAL were excluded. RESULTS In a cohort of 345 patients, 12% and 17% tested positive for SARS-CoV-2 on NPS and BAL, respectively. There was a 6.3% NPS-/BAL+ discordance rate and a 9.5% NPS+/BAL- discordance rate. Patients with lymphoma (adjusted odds ratio [aOR] = 4.06; P = .007) and Hispanic patients (aOR = 3.76; P = .009) were more likely to have NPS-/BAL+ discordance on multivariate analysis. Among patients with NPS- /BAL- for SARS-CoV-2, an alternate infectious (23%) and a noninfectious etiology (16%) were identified in BAL. CONCLUSIONS Our discordance rates between NPS and BAL were sufficient to recommend BAL in certain patients with cancer with a high clinical suspicion of COVID-19. BAL has value in identifying alternative etiologies of illness in patients with suspected or confirmed COVID-19.
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Affiliation(s)
- Alexander Franklin
- Department of Infectious Diseases, Infection Control and Employee Heath, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Teny M John
- Department of Infectious Diseases, Infection Control and Employee Heath, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Fareed Khawaja
- Department of Infectious Diseases, Infection Control and Employee Heath, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ying Jiang
- Department of Infectious Diseases, Infection Control and Employee Heath, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Yepez
- Department of Infectious Diseases, Infection Control and Employee Heath, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jitesh Ahuja
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Saadia A Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lara Bashoura
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ajay Sheshadri
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vickie R Shannon
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diwakar D Balachandran
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kelly McConn
- Department of Infectious Diseases, Infection Control and Employee Heath, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Victor E Mulanovich
- Department of Infectious Diseases, Infection Control and Employee Heath, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Micah Bhatti
- Department of Pathology and Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control and Employee Heath, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Lynch Y, Vande Vusse LK. Diffuse Alveolar Hemorrhage in Hematopoietic Cell Transplantation. J Intensive Care Med 2023:8850666231207331. [PMID: 37872657 DOI: 10.1177/08850666231207331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a morbid syndrome that occurs after autologous and allogeneic hematopoietic cell transplantation in children and adults. DAH manifests most often in the first few weeks following transplantation. It presents with pneumonia-like symptoms and acute respiratory failure, often requiring high levels of oxygen supplementation or mechanical ventilatory support. Hemoptysis is variably present. Chest radiographs typically feature widespread alveolar filling, sometimes with peripheral sparing and pleural effusions. The diagnosis is suspected when serial bronchoalveolar lavages return increasingly bloody fluid. DAH is differentiated from infectious causes of alveolar hemorrhage when extensive microbiological testing reveals no pulmonary pathogens. The cause is poorly understood, though preclinical and clinical studies implicate pretransplant conditioning regimens, particularly those using high doses of total-body-irradiation, acute graft-versus-host disease (GVHD), medications used to prevent GVHD, and other factors. Treatment consists of supportive care, systemic corticosteroids, platelet transfusions, and sometimes includes antifibrinolytic drugs and topical procoagulant factors. Therapeutic blockade of tumor necrosis factor-α showed promise in observational studies, but its benefit for DAH remains uncertain after small clinical trials. Even with these treatments, mortality from progression and relapse is high. Future investigational therapies could target the vascular endothelial cell biology theorized to contribute to alveolar bleeding and pathways that contribute to susceptibility, inflammation, cellular resilience, and tissue repair. This review will help clinicians navigate through the limited evidence to diagnose and treat DAH, counsel patients and families, and plan for future research.
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Affiliation(s)
- Ylinne Lynch
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lisa K Vande Vusse
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
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Sanchez-Escamilla M, Flynn J, Devlin S, Maloy M, Fatmi SA, Tomas AA, Escribano-Serrat S, Ponce D, Sauter CS, Giralt SA, Scordo M, Perales MA. EASIX score predicts inferior survival after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2023; 58:498-505. [PMID: 36721042 PMCID: PMC10513445 DOI: 10.1038/s41409-023-01922-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 01/05/2023] [Accepted: 01/13/2023] [Indexed: 02/02/2023]
Abstract
The Endothelial Activation and Stress Index (EASIX) is a prognostic tool that uses common clinical laboratory values and has been shown to predict non-relapse mortality (NRM) and overall survival (OS) at the onset of acute graft-versus-host disease (GVHD) after allogeneic hematopoietic cell transplantation (HCT). We hypothesized that EASIX calculated at different time points pre- and post- HCT may predict NRM and OS, and that EASIX calculated at onset of GVHD may predict response to steroids. We evaluated the EASIX score pre- and post-HCT in 152 patients with lymphoid malignancies undergoing unmodified reduced intensity conditioning (RIC) alloHCT with uniform GVHD prophylaxis. In multivariate analysis, EASIX calculated pre-HCT was significantly associated with higher NRM (HR = 1.64, p = 0.009) and lower OS (HR = 1.33, p = 0.046). Furthermore, EASIX calculated at day 30 and at day 100 was associated with increased NRM (HR = 1.65, p < 0.001; and HR = 1.65, p < 0.001) and decreased OS (HR = 1.27, p = 0.018; and HR = 1.49, p < 0.001), independent of HCT-CI, disease and conditioning regimen. Our study shows that high EASIX scores at various time points pre- and post-HCT are significantly associated with poorer overall outcomes. EASIX provides an independent and easily accessible tool to predict outcomes that can be complementary to other measures of risk stratification for patients undergoing HCT.
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Affiliation(s)
- Miriam Sanchez-Escamilla
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- Department of Hematological Malignancies and Stem Cell Transplantation, Research Institute of Marques de Valdecilla (IDIVAL), Santander, Spain.
| | - Jessica Flynn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Sean Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Molly Maloy
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Samira A Fatmi
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Ana Alarcon Tomas
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Silvia Escribano-Serrat
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Doris Ponce
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Craig S Sauter
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Sergio A Giralt
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Michael Scordo
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- Department of Medicine, Weill Cornell Medical College, New York, NY, 10065, USA.
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Kambhatla S, Vipparthy S, Manadan AM. Rheumatic diseases associated with alveolar hemorrhage: analysis of the national inpatient sample. Clin Rheumatol 2023; 42:1177-1183. [PMID: 36396790 PMCID: PMC9672553 DOI: 10.1007/s10067-022-06449-9] [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: 07/11/2022] [Revised: 11/06/2022] [Accepted: 11/10/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Diffuse alveolar hemorrhage (DAH) is a severe pulmonary complication of numerous diseases, including rheumatic conditions. We have conducted an observational study using inpatient data from the National Inpatient Sample to study the relationship of DAH with rheumatic conditions along with their descriptive characteristics. METHODS An observational study was conducted on hospitalizations in 2016-2018 with a principal diagnosis of DAH from the United States National Inpatient Sample database. A multivariate logistic regression analysis was performed to calculate adjusted odds ratios (ORadj) for risk factors of DAH. RESULTS A total of 5420 DAH hospitalizations were identified among 90 million hospitalizations. Mortality in this group was found to be 24.3%. Majority of patients admitted with DAH were white and male, with a mean age of 61.8 years and a mean LOS of 10.6 days. Multivariate analysis showed that multiple rheumatic diseases were associated with DAH, including anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) (ORadj 72.56) (95% C.I. 50.607-104.043), antiphospholipid antibody syndrome (APLS) (ORadj 6.51) (95% C.I. 3.734-11.366), eosinophilic granulomatosis with polyangiitis (EGPA) (ORadj 7.13) (95% C.I. 1.886-26.926), Goodpasture's (ORadj 30.58) (95% C.I. 16.360-57.176), rheumatoid arthritis (RA) (ORadj 1.60) (95% C.I. 1.158-2.212), sarcoidosis (ORadj 3.99) (95% C.I. 2.300-6.926), and systemic lupus (SLE) (ORadj 5.82) (95% C.I. 3.993-8.481). CONCLUSION Although DAH is a relatively rare entity, it carries a very high mortality. Multiple rheumatic diseases were associated with DAH hospitalizations including AAV, APLS, EGPA, Goodpasture's, RA, sarcoidosis, and SLE. Key points • It is known that DAH carries a high morbidity and mortality based on prior literature. However, large datasets on the association of rheumatic diseases with DAH are lacking • This study identifies the descriptive characteristics of patients admitted to the hospital with DAH • This study also identifies the strength of association of rheumatic diseases with DAH.
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Affiliation(s)
- Soumyasri Kambhatla
- Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA.
| | - Sharath Vipparthy
- Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA
| | - Augustine M Manadan
- Rheumatology Program Director, Cook County Hospital, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA
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Fraebel J, Engelhardt BG, Kim TK. Noninfectious Pulmonary Complications after Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2023; 29:82-93. [PMID: 36427785 DOI: 10.1016/j.jtct.2022.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/31/2022] [Accepted: 11/14/2022] [Indexed: 11/24/2022]
Abstract
Pulmonary complications after hematopoietic stem cell transplantation (HSCT) are important sources of morbidity and mortality. Improvements in infection-related complications have made noninfectious pulmonary complications an increasingly significant driver of transplantation-related mortality. Broadly, these complications can be characterized as either early or late complications, with idiopathic pneumonia syndrome and bronchiolitis obliterans syndrome the most prevalent early and late complications, respectively. Outcomes with historical treatment consisting mainly of corticosteroids are often poor, highlighting the need for a deeper understanding of these complications' underlying disease biology to guide the adoption of novel therapies that are being increasingly used in the modern era.
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Affiliation(s)
- Johnathan Fraebel
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian G Engelhardt
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt-Ingram Cancer Center, Nashville, Tennessee; Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Tae Kon Kim
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Center for Immunobiology, Nashville, Tennessee; Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt-Ingram Cancer Center, Nashville, Tennessee; Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee.
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10
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Hematology Emergencies in Adults With Critical Illness. Chest 2022; 162:120-131. [DOI: 10.1016/j.chest.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/20/2022] [Accepted: 02/07/2022] [Indexed: 11/18/2022] Open
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Moreno-Castaño AB, Salas MQ, Palomo M, Martinez-Sanchez J, Rovira M, Fernández-Avilés F, Martínez C, Cid J, Castro P, Escolar G, Carreras E, Diaz-Ricart M. Early vascular endothelial complications after hematopoietic cell transplantation: Role of the endotheliopathy in biomarkers and target therapies development. Front Immunol 2022; 13:1050994. [PMID: 36479117 PMCID: PMC9720327 DOI: 10.3389/fimmu.2022.1050994] [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: 09/22/2022] [Accepted: 11/03/2022] [Indexed: 11/22/2022] Open
Abstract
This work aims to review the role of endothelial dysfunction underlying the main complications appearing early after autologous and allogeneic hematopoietic cell transplantation (HCT). The endothelial damage as the pathophysiological substrate of sinusoidal obstruction syndrome (SOS) is well established. However, there is growing evidence of the involvement of endothelial dysfunction in other complications, such as acute graft-versus-host disease (aGVHD) and transplant-associated thrombotic microangiopathy (TA-TMAs). Moreover, HCT-related endotheliopathy is not only limited to the HCT setting, as there is increasing evidence of its implication in complications derived from other cellular therapies. We also review the incidence and the risk factors of the main HCT complications and the biological evidence of the endothelial involvement and other linked pathways in their development. In addition, we cover the state of the art regarding the potential use of the biomarkers of endotheliopathy in the prediction, the early diagnosis, and the follow-up of the HCT complications and summarize current knowledge points to the endothelium and the other linked pathways described as potential targets for the prevention and treatment of HCT-complications. Lastly, the endothelium-focused therapeutic strategies that are emerging and might have a potential impact on the survival and quality of life of post-HCT-patients are additionally reviewed.
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Affiliation(s)
- Ana Belén Moreno-Castaño
- Hemostasis and Erythropathology Laboratory, Hematopathology, Pathology Department, Centre de Diagnòstic Biomèdic (CDB), Hospital Clínic, Barcelona, Spain.,Clínic, Institut Josep Carreras, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - María Queralt Salas
- Hematology Department, Bone Marrow Transplantation Unit, Institut Clínic de Malalties Hemato-Oncològiques (ICMHO), Hospital Clínic, Barcelona, Spain
| | - Marta Palomo
- Hemostasis and Erythropathology Laboratory, Hematopathology, Pathology Department, Centre de Diagnòstic Biomèdic (CDB), Hospital Clínic, Barcelona, Spain.,Clínic, Institut Josep Carreras, Barcelona, Spain.,Campus Clinic, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Julia Martinez-Sanchez
- Clínic, Institut Josep Carreras, Barcelona, Spain.,Campus Clinic, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Montserrat Rovira
- Hematology Department, Bone Marrow Transplantation Unit, Institut Clínic de Malalties Hemato-Oncològiques (ICMHO), Hospital Clínic, Barcelona, Spain
| | - Francesc Fernández-Avilés
- Hematology Department, Bone Marrow Transplantation Unit, Institut Clínic de Malalties Hemato-Oncològiques (ICMHO), Hospital Clínic, Barcelona, Spain
| | - Carmen Martínez
- Hematology Department, Bone Marrow Transplantation Unit, Institut Clínic de Malalties Hemato-Oncològiques (ICMHO), Hospital Clínic, Barcelona, Spain
| | - Joan Cid
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Apheresis & Cellular Therapy Unit, Department of Hemotherapy and Hemostasis, Institut Clínic de Malalties Hemato-Oncològiques (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Pedro Castro
- Clínic, Institut Josep Carreras, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Medical Intensive Care Unit, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Gines Escolar
- Hemostasis and Erythropathology Laboratory, Hematopathology, Pathology Department, Centre de Diagnòstic Biomèdic (CDB), Hospital Clínic, Barcelona, Spain.,Clínic, Institut Josep Carreras, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Enric Carreras
- Clínic, Institut Josep Carreras, Barcelona, Spain.,Campus Clinic, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hemostasis and Erythropathology Laboratory, Hematopathology, Pathology Department, Centre de Diagnòstic Biomèdic (CDB), Hospital Clínic, Barcelona, Spain.,Clínic, Institut Josep Carreras, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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12
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Hiskey L, Madigan T, Ristagno EH, Razonable RR, Ferdjallah A. Prevention and management of human cytomegalovirus in pediatric HSCT recipients: A review. Front Pediatr 2022; 10:1039938. [PMID: 36507142 PMCID: PMC9727199 DOI: 10.3389/fped.2022.1039938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
Cytomegalovirus (CMV), like other herpesviruses, has the unique ability to establish latent infection with subsequent reactivation during periods of stress and immunosuppression. Herpesviruses cause potentially devastating disease, particularly in hematopoietic stem cell transplant (HSCT) recipients. CMV is especially of concern in HSCT recipients given the high community seroprevalence, high risk of reactivation and high risk of transmission from HSCT donors to recipients causing primary infection after transplantation. The risk of CMV infection and severity of CMV disease varies depending on the underlying disease of the HSCT recipient, donor and recipient CMV status prior to HSCT, type of conditioning therapy in preparation for HSCT, allogeneic versus autologous HSCT, donor graft source, timing of infection in relation to HSCT, and other patient comorbidities. Different strategies exist for prevention (e.g., preemptive therapy vs. universal prophylaxis) as well as management of CMV disease (e.g., antiviral therapy, augmenting immune reconstitution, cytotoxic T-cell therapy). The purpose of this narrative review is to discuss diagnosis, prevention, and management of CMV infection and disease at different stages of HSCT, including key points illustrated through presentations of complex cases and difficult clinical scenarios. Traditional and novel strategies for CMV management will be discussed in the context of these unique clinical cases.
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Affiliation(s)
- Lisa Hiskey
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States
| | - Theresa Madigan
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States
| | - Elizabeth H Ristagno
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States
| | - Raymund R Razonable
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, United States
| | - Asmaa Ferdjallah
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States
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13
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Gavriilaki E, Ho VT, Schwaeble W, Dudler T, Daha M, Fujita T, Jodele S. Role of the lectin pathway of complement in hematopoietic stem cell transplantation-associated endothelial injury and thrombotic microangiopathy. Exp Hematol Oncol 2021; 10:57. [PMID: 34924021 PMCID: PMC8684592 DOI: 10.1186/s40164-021-00249-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 11/27/2021] [Indexed: 12/30/2022] Open
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a life-threatening syndrome that occurs in adult and pediatric patients after hematopoietic stem cell transplantation. Nonspecific symptoms, heterogeneity within study populations, and variability among current diagnostic criteria contribute to misdiagnosis and underdiagnosis of this syndrome. Hematopoietic stem cell transplantation and associated risk factors precipitate endothelial injury, leading to HSCT-TMA and other endothelial injury syndromes such as hepatic veno-occlusive disease/sinusoidal obstruction syndrome, idiopathic pneumonia syndrome, diffuse alveolar hemorrhage, capillary leak syndrome, and graft-versus-host disease. Endothelial injury can trigger activation of the complement system, promoting inflammation and the development of endothelial injury syndromes, ultimately leading to organ damage and failure. In particular, the lectin pathway of complement is activated by damage-associated molecular patterns (DAMPs) on the surface of injured endothelial cells. Pattern-recognition molecules such as mannose-binding lectin (MBL), collectins, and ficolins—collectively termed lectins—bind to DAMPs on injured host cells, forming activation complexes with MBL-associated serine proteases 1, 2, and 3 (MASP-1, MASP-2, and MASP-3). Activation of the lectin pathway may also trigger the coagulation cascade via MASP-2 cleavage of prothrombin to thrombin. Together, activation of complement and the coagulation cascade lead to a procoagulant state that may result in development of HSCT-TMA. Several complement inhibitors targeting various complement pathways are in clinical trials for the treatment of HSCT-TMA. In this article, we review the role of the complement system in HSCT-TMA pathogenesis, with a focus on the lectin pathway.
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Affiliation(s)
- Eleni Gavriilaki
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Leof. Papanikolaou, Pilea Chortiatis 570 10, Thessaloniki, Greece.
| | - Vincent T Ho
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Wilhelm Schwaeble
- Department of Veterinary Medicine, University of Cambridge, Cambridge, CB3 0ES, UK
| | - Thomas Dudler
- Discovery and Development, Omeros Corporation, 201 Elliott Ave W, Seattle, WA, 98119, USA
| | - Mohamed Daha
- Department of Nephrology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Netherlands
| | - Teizo Fujita
- Department Fukushima Prefectural General Hygiene Institute, 61-Watari-Nakakado, Fukushima, Fukushima, 960-8141, Japan
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
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14
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Eftychidis I, Sakellari I, Anagnostopoulos A, Gavriilaki E. Endothelial dysfunction and vascular complications after allogeneic hematopoietic cell transplantation: an expert analysis. Expert Rev Hematol 2021; 14:831-840. [PMID: 34388057 DOI: 10.1080/17474086.2021.1968823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Allogeneic hematopoietic cell transplantation (alloHCT) is the standard of care for many diseases. However, survivors often present with serious complications resulting from acute and chronic toxicities and it is crucial to increase consciousness from treating physicians. We performed a comprehensive review of the literature and critically examined recent available data, mostly using the PubMed and Medline search engines for original articles published over the last decade. Better understanding of many alloHCT-related disorders has shown that endothelial injury and vascular damage plays a critical role. The most widely studied endothelial injury syndromes (EIS) are veno-occlusive disease/sinusoidal obstruction syndrome (SOS/VOD), graft-versus-host-disease (GVHD), and transplant-associated thrombotic microangiopathy (TA-TMA). TA-TMA, frequently underdiagnosed, needs to be clarified using certain criteria and, as a life-threatening condition, requires immediate and intensive treatment. The first-in-class complement inhibitor eculizumab has significantly improved outcomes in both the pediatric and adult population. Cardiovascular (CV) events are the second major cause of morbidity and mortality of alloHCT survivors, after GVHD. Long-term monitoring and management of CV risk is expected to also incorporate patient stratification with CV risk prediction models, early markers of vascular dysfunction or procoagulant activity, subclinical target organ damage, arterial stiffness, and subclinical atherosclerosis.
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Affiliation(s)
- Ioannis Eftychidis
- Hematology Department-BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Ioanna Sakellari
- Hematology Department-BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | | | - Eleni Gavriilaki
- Hematology Department-BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece
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15
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Astashchanka A, Ryan J, Lin E, Nokes B, Jamieson C, Kligerman S, Malhotra A, Mandel J, Joshua J. Pulmonary Complications in Hematopoietic Stem Cell Transplant Recipients-A Clinician Primer. J Clin Med 2021; 10:3227. [PMID: 34362012 PMCID: PMC8348211 DOI: 10.3390/jcm10153227] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/11/2021] [Accepted: 07/16/2021] [Indexed: 12/15/2022] Open
Abstract
Hematopoietic stem cell transplants (HSCT) are becoming more widespread as a result of optimization of conditioning regimens and prevention of short-term complications with prophylactic antibiotics and antifungals. However, pulmonary complications post-HSCT remain a leading cause of morbidity and mortality and are a challenge to clinicians in both diagnosis and treatment. This comprehensive review provides a primer for non-pulmonary healthcare providers, synthesizing the current evidence behind common infectious and non-infectious post-transplant pulmonary complications based on time (peri-engraftment, early post-transplantation, and late post-transplantation). Utilizing the combination of timing of presentation, clinical symptoms, histopathology, and radiographic findings should increase rates of early diagnosis, treatment, and prognostication of these severe illness states.
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Affiliation(s)
- Anna Astashchanka
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Joseph Ryan
- Division of Hematology & Oncology, Scripps Clinic, La Jolla, CA 92037, USA;
| | - Erica Lin
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Brandon Nokes
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Catriona Jamieson
- Sanford Stem Cell Clinical Center, Moores Cancer Center, Department of Medicine, Division of Regenerative Medicine, University of California San Diego, La Jolla, CA 92093, USA;
| | - Seth Kligerman
- Division of Cardiothoracic Radiology, University of California San Diego, La Jolla, CA 92121, USA;
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Jess Mandel
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Jisha Joshua
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
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16
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Shiari A, Nassar M, Soubani AO. Major pulmonary complications following Hematopoietic stem cell transplantation: What the pulmonologist needs to know. Respir Med 2021; 185:106493. [PMID: 34107323 DOI: 10.1016/j.rmed.2021.106493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/28/2021] [Accepted: 05/29/2021] [Indexed: 12/16/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is used for treatment of a myriad of both malignant and non-malignant disorders. However, despite many advances over the years which have resulted in improved patient mortality, this subset of patients remains at risk for a variety of post-transplant complications. Pulmonary complications of HSCT are categorized into infectious and non-infectious and occur in up to one-third of patients undergoing HSCT. Infectious etiologies include bacterial, viral and fungal infections, each of which can have significant mortality if not identified and treated early in the course of infection. Advances in the diagnosis and management of infectious complications highlight the importance of non-infectious pulmonary complications related to chemoradiation toxicities, immunosuppressive drugs toxicities, and graft-versus-host disease. This report aims to serve as a guide and clinical update of pulmonary complications following HSCT for the general pulmonologist who may be involved in the care of these patients.
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Affiliation(s)
- Aryan Shiari
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Mo'ath Nassar
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, 48201, USA.
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17
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Okazaki A, Takeda Y, Kiyama M, Okeie K, Shibata K. Congestive Heart Failure-associated Chronic Diffuse Alveolar Hemorrhage. Am J Respir Crit Care Med 2021; 204:723-724. [PMID: 33882263 DOI: 10.1164/rccm.202008-3149im] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Akihito Okazaki
- Koseiren Takaoka Hospital, 13869, Respiratory Medicine, Takaoka, Japan;
| | - Yoshihiro Takeda
- Koseiren Takaoka Hospital, 13869, Respiratory Medicine, Takaoka, Japan
| | - Masaru Kiyama
- Koseiren Takaoka Hospital, 13869, Cardiovascular Medicine, Takaoka, Japan
| | - Kazuyasu Okeie
- Koseiren Takaoka Hospital, 13869, Cardiovascular Medicine, Takaoka, Japan
| | - Kazuhiko Shibata
- Koseiren Takaoka Hospital, 13869, Respiratory Medicine, Takaoka, Japan
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18
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[Chinese expert consensus on the management of hemorrhagic complications after hematopoietic stem cell transplantation(2021)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:276-280. [PMID: 33979970 PMCID: PMC8120122 DOI: 10.3760/cma.j.issn.0253-2727.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Indexed: 11/09/2022]
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19
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Park JA. Treatment of Diffuse Alveolar Hemorrhage: Controlling Inflammation and Obtaining Rapid and Effective Hemostasis. Int J Mol Sci 2021; 22:E793. [PMID: 33466873 PMCID: PMC7830514 DOI: 10.3390/ijms22020793] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 02/07/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication in patients with hematologic malignancies or systemic autoimmune disorders. Pathologic findings show pulmonary capillaritis, bland hemorrhage, diffuse alveolar damage, and hemosiderin-laden macrophages, but in the majority of cases, pathogenesis remains unclear. Despite the severity and high mortality, the current treatment options for DAH remain empirical. Systemic treatment to control inflammatory activity including high-dose corticosteroids, cyclophosphamide, and rituximab and supportive care have been applied, but largely unsuccessful in critical cases. Activated recombinant factor VII (FVIIa) can achieve rapid local hemostasis and has been administered either systemically or intrapulmonary for the treatment of DAH. However, there is no randomized controlled study to evaluate the efficacy and safety, and the use of FVIIa for DAH remains open to debate. This review discusses the pathogenesis, diverse etiologies causing DAH, diagnosis, and treatments focusing on hemostasis using FVIIa. In addition, the risks and benefits of the off-label use of FVIIa in pediatric patients will be discussed in detail.
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Affiliation(s)
- Jeong A Park
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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20
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Epidemiology, Risk Factors, and Outcomes of Diffuse Alveolar Hemorrhage After Hematopoietic Stem Cell Transplantation. Chest 2021; 159:2325-2333. [PMID: 33434501 DOI: 10.1016/j.chest.2021.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/02/2020] [Accepted: 01/02/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is an uncommon complication of hematopoietic stem cell transplantation (HCT) that carries high morbidity and mortality. Limited contemporary data are available regarding the incidence, outcomes, and risk factors for DAH. RESEARCH QUESTION What are the incidence, outcomes, and risk factors for DAH developing after HCT? METHODS This was a single-center retrospective cohort study of patients who underwent HCT between January 1, 2005, and December 31, 2016. The incidence and outcomes of DAH development were evaluated. A multivariate logistic regression model was used to analyze differences between survivors and nonsurvivors. RESULTS Of 4,350 patients undergoing first-time HCT, DAH was diagnosed in 99 (2.3%). DAH was seen in 40 of 3,536 autologous HCT recipients (1.1%) and 59 of 814 allogeneic HCT recipients (7.2%). Mean age was 53 ± 13 years, and median time of DAH diagnosis was 126 days (interquartile range, 19-349 days) after HCT. In-hospital mortality and mortality 1 year after DAH diagnosis were 55.6% and 76.8%, respectively. DAH diagnosis more than 30 days after transplantation (OR, 7.06; 95% CI, 1.65-30.14), low platelet count (OR, 0.98; 95% CI, 0.96-1.0; P = .02), elevated international normalized ratio (INR; OR, 4.08; 95% CI, 0.64-25.88; P = .046) and need for invasive mechanical ventilation (OR, 8.18; 95% CI, 1.9-35.21) were associated with higher in-hospital mortality. Steroid treatment did not alter mortality (P = .80) or length of stay (P = .65). However, among those who received steroids, survival was higher in whose who received modest-dose steroids (< 250 mg methylprednisolone equivalent/d) compared with those who received high-dose steroids (≥ 250 mg methylprednisolone equivalent/d; OR, 0.21; 95% CI, 0.07-0.72). INTERPRETATION The mortality of DAH after HCT remains high, and DAH can occur long after transplantation. Later development of DAH (>30 days after HCT), need for invasive mechanical ventilation, thrombocytopenia, and elevated INR are all associated with worse outcomes.
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21
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Risk factors and outcomes of diffuse alveolar haemorrhage after allogeneic haematopoietic stem cell transplantation. Bone Marrow Transplant 2021; 56:2097-2107. [PMID: 33846561 PMCID: PMC8040008 DOI: 10.1038/s41409-021-01293-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 03/15/2021] [Accepted: 03/29/2021] [Indexed: 02/05/2023]
Abstract
Diffuse alveolar haemorrhage (DAH) is a life-threatening pulmonary complication occurring after allogeneic haematopoietic stem cell transplantation (allo-HSCT) without an explicit aetiology or a standard treatment. This study aimed to explore the occurrence and prognosis of DAH after allo-HSCT, in addition to comparing discrepancies in the incidence, clinical characteristics and outcomes of DAH between patients undergoing haploidentical HSCT (HID-HSCT) and matched related donor HSCT (MRD-HSCT). We retrospectively evaluated 92 consecutive patients among 3987 patients with a confirmed diagnosis of DAH following allo-HSCT (HID: 71 patients, MRD: 21 patients). The incidence of DAH after allo-HSCT was 2.3%, 2.4% after HID-HSCT and 2.0% after MRD-HSCT (P = 0.501). The prognosis of patients with DAH after transplantation is extremely poor. The duration of DAH was 7.5 days (range, 1-48 days). The probabilities of overall survival (OS) were significantly different between patients with and without DAH within 2 years after transplantation (P < 0.001). According to the Cox regression analysis, a significant independent risk factor for the occurrence of DAH was delayed platelet engraftment (P < 0.001), and a high D-dimer level (>500 ng/ml) was a significant risk factor for the poor prognosis of DAH. HID-HSCT is similar to MRD-HSCT in terms of the outcomes of DAH.
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22
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Fan K, McArthur J, Morrison RR, Ghafoor S. Diffuse Alveolar Hemorrhage After Pediatric Hematopoietic Stem Cell Transplantation. Front Oncol 2020; 10:1757. [PMID: 33014865 PMCID: PMC7509147 DOI: 10.3389/fonc.2020.01757] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/05/2020] [Indexed: 12/21/2022] Open
Abstract
Pulmonary complications are common following hematopoietic cell transplantation (HCT) and contribute significantly to its morbidity and mortality. Diffuse alveolar hemorrhage is a devastating non-infectious complication that occurs in up to 5% of patients post-HCT. Historically, it carries a high mortality burden of 60–100%. The etiology remains ill-defined but is thought to be due to lung injury from conditioning regimens, total body irradiation, occult infections, and other comorbidities such as graft vs. host disease, thrombotic microangiopathy, and subsequent cytokine release and inflammation. Clinically, patients present with hypoxemia, dyspnea, and diffuse opacities consistent with an alveolar disease process on chest radiography. Diagnosis is most commonly confirmed with bronchoscopy findings of progressively bloodier bronchoalveolar lavage or the presence of hemosiderin-laden macrophages on microscopy. Treatment with glucocorticoids is common though dosing and duration of therapy remains variable. Other agents, such as aminocaproic acid, tranexamic acid, and activated recombinant factor VIIa have also been tried with mixed results. We present a review of diffuse alveolar hemorrhage with a focus on its pathogenesis and treatment options.
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Affiliation(s)
- Kimberly Fan
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Jennifer McArthur
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
| | - R Ray Morrison
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
| | - Saad Ghafoor
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
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23
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Xie J, Zhao YY, Liu J, Nong GM. Diffuse alveolar hemorrhage with histopathologic manifestations of pulmonary capillaritis: Three case reports. World J Clin Cases 2020; 8:2662-2666. [PMID: 32607347 PMCID: PMC7322415 DOI: 10.12998/wjcc.v8.i12.2662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/28/2020] [Accepted: 05/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is a multicause pulmonary capillary hemorrhage or pulmonary vascular small vessel injury (mainly capillaries, including arteries and veins), causing pulmonary microcirculation blood to accumulate in the alveolar space. DAH is classified by the histological absence or presence of pulmonary capillaritis (PC) and is rarely reported in the literature.
CASE SUMMARY This is a report of three girls aged 6-11 years with DAH and PC. Two patients had decreased hemoglobin and one had increased erythrocyte sedimentation rate. High-resolution computed tomography showed bilateral diffuse pulmonary infiltrate, and diagnosis of PC was confirmed by lung biopsy. Immunofluorescence test in one case showed granular IgG and a small amount of granular IgA deposit on the alveolar walls, and was negative in the other two cases, describing isolated pauci-immune PC. Treatment was with glucocorticoid alone or combination with immunosuppressants, and the symptoms resolved in all patients.
CONCLUSION PC is classified as isolated and immune-mediated PC associated with systemic disease. It can be controlled in most children with glucocorticoid alone or combined with immunosuppressants.
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Affiliation(s)
- Jun Xie
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Ying-Yue Zhao
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Jing Liu
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Guang-Min Nong
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
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The induction strategies administered in the treatment of multiple myeloma exhibit a deleterious effect on the endothelium. Bone Marrow Transplant 2020; 55:2270-2278. [PMID: 32404979 DOI: 10.1038/s41409-020-0947-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 02/02/2023]
Abstract
Multiple myeloma induction treatment includes proteasome inhibitors (PI) and immunomodulatory agents at present. The incidence of engraftment syndrome, a transplant complication potentially related to endothelium, has increased in the last years. Our aim was to investigate whether bortezomib (Velcade, V), thalidomide (T), and dexamethasone (D) affect the endothelium, and explore defibrotide (DF) as protective agent. Endothelial cells (ECs) in culture were exposed to the compounds separately or in combination, without (VTD) and with DF (VTD + DF). Changes in markers of: (i) inflammation (ICAM-1 expression and leukocyte adhesion), (ii) VWF production, (iii) cell permeability (VE-cadherin expression and cell monolayer integrity), and (iv) oxidative stress (ROS production and eNOS expression) were measured. ICAM-1 and VWF expression increased significantly in VTD but were similar to controls in VTD + DF. Separately, bortezomib was the main deleterious agent whereas dexamethasone showed no harmful effect. Leukocyte adhesion showed similar trends. VE-cadherin expression was lower in VTD and normalized in VTD + DF. EC permeability increased only with bortezomib. No changes were observed in oxidative stress markers. Our results demonstrate that bortezomib damages the endothelium, and DF prevents this effect. A better knowledge of the induction drugs impact will allow the design of measures to protect the endothelium.
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Lee J, Rhee CK, Kim SC, Kim YK, Kim HJ, Lee S, Cho SG, Lee JW. Use of intrapulmonary administration of thrombin in hematological malignancy patients with alveolar haemorrhage: A case series. Medicine (Baltimore) 2020; 99:e20284. [PMID: 32443373 PMCID: PMC7253869 DOI: 10.1097/md.0000000000020284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Alveolar hemorrhage (AH) is characterized by the acute onset of alveolar bleeding and hypoxemia and can be fatal. Thrombin has been widely used to achieve coagulation and hemostasis. However, the efficacy of thrombin in patients with AH is unclear. Thus, this study aimed to evaluate the efficacy of thrombin administration in patients with hematological malignancy and AH. PATIENT CONCERNS AND DIAGNOSES This retrospective study included 15 hematological malignancy patients (8 men and 7 women; mean age 47.7 ± 17.3 years) with AH who were administered intrapulmonary thrombin between March 2013 and July 2018. INTERVENTIONS AND OUTCOMES All patients received bovine-origin thrombin (1000 IU/ml, Reyon Pharmaceutical Co., Ltd., Seoul, Korea) via a fiberoptic bronchoscope. A maximum of 15 ml of thrombin was injected via the working channel to control bleeding. The ability of thrombin to control bleeding was assessed. Additionally, the change in the PaO2/FiO2 (PF) ratio after intrapulmonary thrombin administration was evaluated. Intrapulmonary thrombin was administered a minimum of 3 days after starting mechanical ventilation in all patients, and it immediately controlled the active bleeding in 13 of 15 patients (86.7%). However, AH relapse was noted in 3 of the 13 patients (23.1%). The PF ratio improved in 10 of 15 patients (66.6%), and the mean PF ratio was significantly higher after thrombin administration than before administration (P = .03). No adverse thromboembolic complications or systemic adverse events were observed. CONCLUSION Thrombin administration was effective in controlling bleeding in hematological malignancy patients with AH. Intrapulmonary thrombin administration might be a good therapeutic option for treating AH.
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Affiliation(s)
- Jongmin Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine
| | - Seok Chan Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine
| | - Young Kyoon Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine
| | - Hee Je Kim
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Lee
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok-Goo Cho
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Wook Lee
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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26
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What the Intensivists Need to Know About Critically Ill Myeloma Patients. ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7121630 DOI: 10.1007/978-3-319-74588-6_98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Multiple myeloma (MM) is a hematological malignancy characterized by an increase in aberrant plasma cells in the bone marrow leading to rising monoclonal protein in serum and urine. With the introduction of novel therapies with manageable side effects, this incurable disease has evolved into a chronic disease with an acceptable quality of life for the majority of patients. Accordingly, management of acute complications is fundamental in reducing the morbidity and mortality in MM. MM emergencies include symptoms and signs related directly to the disease and/or to the treatment; many organs may be involved including, but not limited to, renal, cardiovascular, neurologic, hematologic, and infectious complications. This review will focus on the numerous approaches that are aimed at managing these complications.
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Fan K, Hurley C, McNeil MJ, Agulnik A, Federico S, Qudeimat A, Saini A, McArthur J, Morrison RR, Sandhu H, Shah S, Ghafoor S. Case Report: Management Approach and Use of Extracorporeal Membrane Oxygenation for Diffuse Alveolar Hemorrhage After Pediatric Hematopoietic Cell Transplant. Front Pediatr 2020; 8:587601. [PMID: 33520888 PMCID: PMC7838496 DOI: 10.3389/fped.2020.587601] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Diffuse alveolar hemorrhage (DAH) is an early pulmonary complication of hematopoietic cell transplantation (HCT) associated with severe hypoxemic respiratory failure and mortality. Extracorporeal membrane oxygenation (ECMO) support is often used for respiratory failure refractory to conventional interventions; however, its use has been limited in HCT patients with DAH due to potential for worsening alveolar hemorrhage and reported high mortality. Case Presentation: We report two cases of DAH following HCT who developed refractory hypoxemic respiratory failure despite cessation of bleeding and were successfully supported with ECMO. Conclusion: DAH after HCT should not automatically preclude ECMO support; rather, these patients must be evaluated individually for ECMO within the context of their overall clinical picture.
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Affiliation(s)
- Kimberly Fan
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Caitlin Hurley
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Michael J McNeil
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Sara Federico
- Division of Solid Tumor, Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Amr Qudeimat
- Department of Bone Marrow Transplant, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Arun Saini
- Division of Pediatric Critical Care, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, United States
| | - Jennifer McArthur
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Ronald Ray Morrison
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Hitesh Sandhu
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Samir Shah
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Saad Ghafoor
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
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Abstract
Lung injury associated with cancer therapeutics is often the limiting factor that trumps otherwise successful cancer therapy. Thoracic radiation as well as cancer pharmacotherapeutics, including conventional chemotherapy, molecular targeted agents, and cancer immunotherapies, have been associated with a unique spectrum of histopathologic injury patterns that may involve the lung parenchyma, pleura, airways, and/or pulmonary vasculature. Injury patterns may be idiosyncratic, unpredictable, and highly variable from one agent class to the next. Variability in lung injury patterns within a specific therapeutic class of drugs also occurs, adding to the conundrum. Drug-induced toxicities to the thoracic cavity are infrequent, and early recognition of clinical clues portends a good outcome in most cases. Failure to recognize early clinical signs, however, may result in irreversible and potentially lethal consequences. This chapter provides an overview of our current knowledge of thoracic complications associated with cancer pharmacotherapies. The review is not intended to be a treatise of all cancer agents that adversely affect the lungs, but rather a discussion of established risk factors and histopathologic patterns of lung injury associated with broad classes of cancer agents. Optimal management strategies, based on existing clinical experience, will also be discussed. Complications associated with thoracic radiation are also reviewed. It is hoped that these discussions will facilitate early recognition and management of treatment-related thoracic complications and, ultimately, better patient outcomes.
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Affiliation(s)
- Joseph L. Nates
- Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Kristen J. Price
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX USA
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29
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Lee PY, Nelson-Maney N, Huang Y, Levescot A, Wang Q, Wei K, Cunin P, Li Y, Lederer JA, Zhuang H, Han S, Kim EY, Reeves WH, Nigrovic PA. High-dimensional analysis reveals a pathogenic role of inflammatory monocytes in experimental diffuse alveolar hemorrhage. JCI Insight 2019; 4:129703. [PMID: 31391335 DOI: 10.1172/jci.insight.129703] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/27/2019] [Indexed: 12/24/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication associated with systemic lupus erythematosus, vasculitis, and stem cell transplant. Little is known about the pathophysiology of DAH, and no targeted therapy is currently available. Pristane treatment in mice induces systemic autoimmunity and lung hemorrhage that recapitulates hallmark pathologic features of human DAH. Using this experimental model, we performed high-dimensional analysis of lung immune cells in DAH by mass cytometry and single-cell RNA sequencing. We found a large influx of myeloid cells to the lungs in DAH and defined the gene expression profile of infiltrating monocytes. Bone marrow-derived inflammatory monocytes actively migrated to the lungs and homed adjacent to blood vessels. Using 3 models of monocyte deficiency and complementary transfer studies, we established a central role of inflammatory monocytes in the development of DAH. We further found that the myeloid transcription factor interferon regulatory factor 8 is essential to the development of both DAH and type I interferon-dependent autoimmunity. These findings collectively reveal monocytes as a potential treatment target in DAH.
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Affiliation(s)
- Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nathan Nelson-Maney
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Yuelong Huang
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anaïs Levescot
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Qiang Wang
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kevin Wei
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pierre Cunin
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Yi Li
- Division of Rheumatology, Beth Israel Deaconess Hospital, Boston, Massachusetts, USA
| | - James A Lederer
- Center for Data Sciences, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Haoyang Zhuang
- Division of Rheumatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Shuhong Han
- Division of Rheumatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Edy Y Kim
- Department of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Westley H Reeves
- Division of Rheumatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Peter A Nigrovic
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
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30
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Esiashvili N, Lu X, Ulin K, Laurie F, Kessel S, Kalapurakal JA, Merchant TE, Followill DS, Sathiaseelan V, Schmitter MK, Devidas M, Chen Y, Wall DA, Brown PA, Hunger SP, Grupp SA, Pulsipher MA. Higher Reported Lung Dose Received During Total Body Irradiation for Allogeneic Hematopoietic Stem Cell Transplantation in Children With Acute Lymphoblastic Leukemia Is Associated With Inferior Survival: A Report from the Children's Oncology Group. Int J Radiat Oncol Biol Phys 2019; 104:513-521. [PMID: 30807822 PMCID: PMC6548591 DOI: 10.1016/j.ijrobp.2019.02.034] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 01/14/2019] [Accepted: 02/14/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To examine the relationship between lung radiation dose and survival outcomes in children undergoing total body irradiation (TBI)-based hematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukemia on the Children's Oncology Group trial. METHODS AND MATERIALS TBI (1200 or 1320 cGy given twice daily in 6 or 8 fractions) was used as part of 3 HSCT preparative regimens, allowing institutional flexibility regarding TBI techniques, including lung shielding. Lung doses as reported by each participating institution were calculated for different patient setups, with and without shielding, with a variety of dose calculation techniques. The association between lung dose and transplant-related mortality, relapse-free survival, and overall survival (OS) was examined using the Cox proportional hazards regression model controlling for the following variables: TBI dose rate, TBI fields, patient position during TBI, donor type, and pre-HSCT minimal residual disease level. RESULTS Of a total of 143 eligible patients, 127 had lung doses available for this analysis. The TBI techniques were heterogeneous. The mean lung dose was reported as 904.5 cGy (standard deviation, ±232.3). Patients treated with lateral fields were more likely to receive lung doses ≥800 cGy (P < .001). The influence of lung dose ≥800 cGy on transplant-related mortality was not significant (hazard ratio [HR], 1.78; P = .21). On univariate analysis, lung dose ≥800 cGy was associated with inferior relapse-free survival (HR, 1.76; P = .04) and OS (HR, 1.85; P = .03). In the multivariate analysis, OS maintained statistical significance (HR, 1.85; P = .04). CONCLUSIONS The variability in TBI techniques resulted in uncertainty with reported lung doses. Lateral fields were associated with higher lung dose, and thus they should be avoided. Patients treated with lung dose <800 cGy in this study had better outcomes. This approach is currently being investigated in the Children's Oncology Group AALL1331 study. Additionally, the Imaging and Radiation Oncology Core Group is evaluating effects of TBI techniques on lung doses using a phantom.
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Affiliation(s)
| | - Xiaomin Lu
- Children's Oncology Group Data Center, Biostatistics, University of Florida, Gainesville, Florida
| | - Ken Ulin
- Imaging and Radiation Oncology Rhode Island QA Center, Lincoln, Rhode Island
| | - Fran Laurie
- Imaging and Radiation Oncology Rhode Island QA Center, Lincoln, Rhode Island
| | - Sandy Kessel
- Imaging and Radiation Oncology Rhode Island QA Center, Lincoln, Rhode Island
| | - John A Kalapurakal
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois
| | | | - David S Followill
- Imaging and Radiation Oncology Rhode Island QA Center, Houston, Texas
| | | | - Mary K Schmitter
- Imaging and Radiation Oncology Rhode Island QA Center, Lincoln, Rhode Island
| | - Meenakshi Devidas
- Children's Oncology Group Data Center, Biostatistics, University of Florida, Gainesville, Florida
| | - Yichen Chen
- Children's Oncology Group Data Center, Biostatistics, University of Florida, Gainesville, Florida
| | - Donna A Wall
- Manitoba Blood and Marrow Transplant Program, Winnipeg, Manitoba, Canada
| | - Patrick A Brown
- Johns Hopkins University Kimmel Cancer Center, Baltimore, Maryland
| | - Stephen P Hunger
- Children's Hospital of Philadelphia and the Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephan A Grupp
- Children's Hospital of Philadelphia and the Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Pulsipher
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
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31
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Nathan S, Ustun C. Complications of Stem Cell Transplantation that Affect Infections in Stem Cell Transplant Recipients, with Analogies to Patients with Hematologic Malignancies. Infect Dis Clin North Am 2019; 33:331-359. [PMID: 30940464 DOI: 10.1016/j.idc.2019.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article discusses the complications of hematopoietic stem cell transplantion (HSCT) that affect infections in HSCT recipients, with analogies to patients with hematologic malignancies. Mucositis, with mucosal barrier disruption, is common and increases the risk of gram-positive and anaerobic bacterial, and fungal infections, and can evolve to typhlitis. Engraftment syndrome; graft-versus-host disease, hepatic sinusoidal obstruction syndrome; and posterior reversible encephalopathy syndrome can affect the infectious potential either directly from organ dysfunction or indirectly from specific treatment. Pulmonary infections can predispose to life threatening complications including diffuse alveolar hemorrhage, idiopathic pulmonary syndrome, bronchiolitis obliterans syndrome, and bronchiolitis obliterans with organizing pneumonia.
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Affiliation(s)
- Sunita Nathan
- Section of Bone Marrow Transplant and Cellular Therapy, Division of Hematology, Oncology and Cell Therapy, Rush University Medical Center, 1725 West Harrison Street, Suite 809, Chicago, IL 60612, USA
| | - Celalettin Ustun
- Section of Bone Marrow Transplant and Cellular Therapy, Division of Hematology, Oncology and Cell Therapy, Rush University Medical Center, 1725 West Harrison Street, Suite 809, Chicago, IL 60612, USA.
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32
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Optimal dosage of methotrexate for GVHD prophylaxis in umbilical cord blood transplantation. Int J Hematol 2019; 109:440-450. [DOI: 10.1007/s12185-019-02598-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 12/28/2018] [Accepted: 01/16/2019] [Indexed: 12/30/2022]
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Mahmoud M, Evans IM, Mehta V, Pellet-Many C, Paliashvili K, Zachary I. Smooth muscle cell-specific knockout of neuropilin-1 impairs postnatal lung development and pathological vascular smooth muscle cell accumulation. Am J Physiol Cell Physiol 2019; 316:C424-C433. [PMID: 30649916 PMCID: PMC6457104 DOI: 10.1152/ajpcell.00405.2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Neuropilin 1 (NRP1) is important for neuronal and cardiovascular development due to its role in conveying class 3 semaphorin and vascular endothelial growth factor signaling, respectively. NRP1 is expressed in smooth muscle cells (SMCs) and mediates their migration and proliferation in cell culture and is implicated in pathological SMC remodeling in vivo. To address the importance of Nrp1 for SMC function during development, we generated conditional inducible Nrp1 SMC-specific knockout mice. Induction of early postnatal SMC-specific Nrp1 knockout led to pulmonary hemorrhage associated with defects in alveogenesis and revealed a specific requirement for Nrp1 in myofibroblast recruitment to the alveolar septae and PDGF-AA-induced migration in vitro. Furthermore, SMC-specific Nrp1 knockout inhibited PDGF-BB-stimulated SMC outgrowth ex vivo in aortic ring assays and reduced pathological arterial neointima formation in vivo. In contrast, we observed little significant effect of SMC-specific Nrp1 knockout on neonatal retinal vascularization. Our results point to a requirement of Nrp1 in vascular smooth muscle and myofibroblast function in vivo, which may have relevance for postnatal lung development and for pathologies characterized by excessive SMC and/or myofibroblast proliferation.
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Affiliation(s)
- Marwa Mahmoud
- Centre for Cardiovascular Biology and Medicine, BHF Laboratories, Division of Medicine, University College London , London , United Kingdom
| | - Ian M Evans
- Centre for Cardiovascular Biology and Medicine, BHF Laboratories, Division of Medicine, University College London , London , United Kingdom
| | - Vedanta Mehta
- Centre for Cardiovascular Biology and Medicine, BHF Laboratories, Division of Medicine, University College London , London , United Kingdom
| | - Caroline Pellet-Many
- Centre for Cardiovascular Biology and Medicine, BHF Laboratories, Division of Medicine, University College London , London , United Kingdom
| | - Ketevan Paliashvili
- Centre for Cardiovascular Biology and Medicine, BHF Laboratories, Division of Medicine, University College London , London , United Kingdom
| | - Ian Zachary
- Centre for Cardiovascular Biology and Medicine, BHF Laboratories, Division of Medicine, University College London , London , United Kingdom
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Respiratory Tract Diseases That May Be Mistaken for Infection. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7119916 DOI: 10.1007/978-1-4939-9034-4_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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35
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Bondeelle L, Bergeron A. Managing pulmonary complications in allogeneic hematopoietic stem cell transplantation. Expert Rev Respir Med 2018; 13:105-119. [PMID: 30523731 DOI: 10.1080/17476348.2019.1557049] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Progress in allogeneic hematopoietic stem cell transplantation (HSCT) procedures has been associated with improved survival in HSCT recipients. However, they have also brought to light organ-specific complications, especially pulmonary complications. In this setting, pulmonary complications are consistently associated with poor outcomes, and improved management of these complications is required. Areas covered: We review the multiple infectious and noninfectious lung complications that occur both early and late after allogeneic HSCT. This includes the description of these complications, risk factors, diagnostic approach and outcome. A literature search was performed using PubMed-indexed journals. Expert commentary: Multiple lung complications after allogeneic HSCT can be diagnosed concomitantly and require a multidisciplinary approach. A specific clinical evaluation including a precise analysis of a lung CT scan is necessary. Management of these lung complications, especially the noninfectious ones, is impaired by the lack of prospective, randomized control trials, suggesting preventive strategies should be developed.
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Affiliation(s)
- Louise Bondeelle
- a Université Paris Diderot, Service de Pneumologie , APHP, Hôpital Saint-Louis , Paris , France
| | - Anne Bergeron
- a Université Paris Diderot, Service de Pneumologie , APHP, Hôpital Saint-Louis , Paris , France.,b Biostatistics and Clinical Epidemiology Research Team , Univ Paris Diderot, Sorbonne Paris Cité, UMR 1153 CRESS , Paris , France
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36
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Cengiz Seval G, Topçuoğlu P, Demirer T. Current Approach to Non-Infectious Pulmonary Complications of Hematopoietic Stem Cell Transplantation. Balkan Med J 2018; 35:131-140. [PMID: 29553463 PMCID: PMC5863250 DOI: 10.4274/balkanmedj.2017.1635] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Hematopoietic stem cell transplantation is an established treatment for patients with a wide range of malignant and nonmalignant conditions. Noninfectious pulmonary complications still remain a leading cause of morbidity and mortality in these patients. Treating hematopoietic stem cell transplantation recipients with noninfectious pulmonary complications is still challenging, and the current treatment armamentarium and strategies are not adequate for patients receiving hematopoietic stem cell transplantation. Further trials are needed for a better description of the pathogenesis and the complete diagnostic criteria as well as for the development of effective therapeutic approaches for the management of noninfectious pulmonary complications of the hematopoietic stem cell transplantation. This review outlines the incidence, risk factors, pathogenesis, and clinical spectrum and discusses the current approaches to the management of noninfectious pulmonary complications of Hematopoietic stem cell transplantation.
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Affiliation(s)
- Güldane Cengiz Seval
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Pervin Topçuoğlu
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
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37
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Tomos I, Tsilika M, Aggelou E, Karageorgas T, Tsiodras S. An 80-Year-Old Man With Hemoptysis and Unilateral Patchy Opacities. Chest 2018; 154:e135-e138. [PMID: 30409367 DOI: 10.1016/j.chest.2018.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/03/2018] [Accepted: 05/14/2018] [Indexed: 10/27/2022] Open
Abstract
CASE PRESENTATION An 80-year-old man presented with a 5-day history of hemoptysis, mild shortness of breath on exertion, fatigue, and malaise. He denied chest pain or fever. He had a history of hypertension, congestive heart failure, and left nephrectomy for renal cancer 10 years earlier; he was a former cigarette smoker with a 50 pack-year history, having quit 5 years prior to presentation. The patient did not report any recent travel history or occupational or animal exposures, and he did not have gastroesophageal reflux. Medications included diltiazem hydrochloride, irbesartan, hydrochlorothiazide, and ranitidine.
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Affiliation(s)
- Ioannis Tomos
- 4th Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece.
| | - Maria Tsilika
- 4th Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Eleni Aggelou
- 4th Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Theophanis Karageorgas
- 4th Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Sotirios Tsiodras
- 4th Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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Wieruszewski PM, Herasevich S, Gajic O, Yadav H. Respiratory failure in the hematopoietic stem cell transplant recipient. World J Crit Care Med 2018; 7:62-72. [PMID: 30370228 PMCID: PMC6201323 DOI: 10.5492/wjccm.v7.i5.62] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/04/2018] [Accepted: 10/10/2018] [Indexed: 02/06/2023] Open
Abstract
The number of patients receiving hematopoietic stem cell transplantation (HSCT) is rapidly rising worldwide. Despite substantial improvements in peri-transplant care, pulmonary complications resulting in respiratory failure remain a major contributor to morbidity and mortality in the post-transplant period, and represent a major barrier to the overall success of HSCT. Infectious complications include pneumonia due to bacteria, viruses, and fungi, and most commonly occur during neutropenia in the early post-transplant period. Non-infectious complications include idiopathic pneumonia syndrome, peri-engraftment respiratory distress syndrome, diffuse alveolar hemorrhage, pulmonary veno-occlusive disease, delayed pulmonary toxicity syndrome, cryptogenic organizing pneumonia, bronchiolitis obliterans syndrome, and post-transplant lymphoproliferative disorder. These complications have distinct clinical features and risk factors, occur at differing times following transplant, and contribute to morbidity and mortality.
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Affiliation(s)
- Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, United States
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
| | - Svetlana Herasevich
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, United States
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Hemang Yadav
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
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González-Castro A, Rodriguez-Borregán JC, Chicote E, Escudero P, Ferrer D. Ácido tranexámico nebulizado como alternativa de tratamiento en la hemorragia pulmonar. Arch Bronconeumol 2018; 54:442-443. [DOI: 10.1016/j.arbres.2017.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 11/15/2017] [Accepted: 11/16/2017] [Indexed: 11/26/2022]
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40
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González-Castro A, Rodriguez-Borregán JC, Chicote E, Escudero P, Ferrer D. Nebulized Tranexamic Acid as a Therapeutic Alternative in Pulmonary Hemorrhage. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.arbr.2018.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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41
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Morishita T, Okabe M, Kawaguchi Y, Lee Y, Ohbiki M, Osaki M, Goto M, Araie H, Sato T, Goto T, Ozawa Y, Miyamura K. Higher Peak Tacrolimus Concentrations after Allogeneic Hematopoietic Stem Cell Transplantation Increase the Risk of Endothelial Cell Damage Complications. Biol Blood Marrow Transplant 2018; 24:2509-2516. [PMID: 30053646 DOI: 10.1016/j.bbmt.2018.07.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 07/17/2018] [Indexed: 02/07/2023]
Abstract
Noninfectious transplantation-related complications (TRCs) such as graft-versus-host disease (GVHD) and endothelial cell damage (TRC-EC) are critical after allogeneic hematopoietic stem cell transplantation. Tacrolimus (TAC) is used to control GVHD. Hypertension and renal failure are common adverse events after TAC treatment. Higher blood concentrations of TAC would be expected to reduce the risk of GVHD but may increase TRC-EC. TRC-EC often develops in patients with GVHD; thus, it is difficult to clinically determine the proper intensity of immunosuppression. We therefore evaluated the impact of weekly mean/peak TAC blood concentrations (PTCs) on TRC-EC occurrence and prognosis. Patients (N = 295) who received TAC as a GVHD prophylaxis at our institute from 2009 to 2016 were eligible for this retrospective study. Forty-three patients were diagnosed with TRC-EC: 8 with sinusoidal obstructive syndrome, 28 with transplant-associated microangiopathy, and 7 with idiopathic pneumonia syndrome. The cumulative incidence of TRC-EC at 12 months was 13.8% (95% confidence interval [CI] 10.1% to 18.1%). After multivariate analysis high PTCs during days 22 to 28 (hazard ratio [HR] 2.47; 95% CI, 1.37 to 4.45; P < .01) and grades II to IV acute GVHD (HR, 5.61; 95% CI, 2.99 to 10.53; P < .01) were associated with TRC-EC occurrence. The probability of overall survival (OS) at 12 months was 67.7% (95% CI, 61.7% to 73.0%). After multivariate analysis TRC-EC diagnosis (HR, 2.47, 95% CI, 1.59 to 3.83; P < .01) and high-risk disease (HR, 1.75; 95% CI, 1.17 to 2.61; P < .01) were significantly associated with poor OS. In conclusion, higher PTC during days 22 to 28 increased the risk of TRC-EC. TRC-EC development was associated with poor OS.
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Affiliation(s)
- Takanobu Morishita
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan.
| | - Motohito Okabe
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Yuuka Kawaguchi
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Yoonha Lee
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Marie Ohbiki
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Masahide Osaki
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Miyo Goto
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Hiroaki Araie
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Takahiko Sato
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Tatsunori Goto
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Koichi Miyamura
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
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42
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Vande Vusse LK, Wurfel MM, Madtes DM, Schoch HG, Harju-Baker S, Hill JA, Jerome KR, Boeckh M, Watkins TR. Alveolar levels of immuno-inflammatory mediators in diffuse alveolar hemorrhage after allogeneic transplant. Bone Marrow Transplant 2018; 53:1206-1209. [PMID: 29670209 PMCID: PMC6474338 DOI: 10.1038/s41409-018-0168-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 11/25/2017] [Accepted: 02/09/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Lisa K Vande Vusse
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA. .,Clinical Research Division, Fred Hutchinson Cancer Center Research Center, Seattle, WA, USA.
| | - Mark M Wurfel
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA
| | - David M Madtes
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Center Research Center, Seattle, WA, USA
| | - H Gary Schoch
- Clinical Research Division, Fred Hutchinson Cancer Center Research Center, Seattle, WA, USA
| | - Susanna Harju-Baker
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA
| | - Joshua A Hill
- Clinical Research Division, Fred Hutchinson Cancer Center Research Center, Seattle, WA, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Keith R Jerome
- Clinical Research Division, Fred Hutchinson Cancer Center Research Center, Seattle, WA, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Michael Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Center Research Center, Seattle, WA, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Timothy R Watkins
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA
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43
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Tang FF, Zhao XS, Xu LP, Zhang XH, Chen YH, Mo XD, Liu KY, Huang XJ. Utility of flexible bronchoscopy with polymerase chain reaction in the diagnosis and management of pulmonary infiltrates in allogeneic HSCT patients. Clin Transplant 2017; 32. [PMID: 29090481 PMCID: PMC7162290 DOI: 10.1111/ctr.13146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2017] [Indexed: 11/30/2022]
Abstract
Objectives Pulmonary infiltrates in allogeneic hematopoietic stem cell transplant (allo‐HSCT) patients are potentially life‐threatening and require early diagnosis and treatment. We aimed to retrospectively explore the clinical efficacy of polymerase chain reaction (PCR) in conjunction with flexible bronchoscopy (FB) in allo‐HSCT patients with pulmonary infiltrates. Patients and methods We retrospectively reviewed all patients undergoing FB after allo‐HSCT at the Peking University Institute of Hematology from January 2013 to December 2016. We used PCR to detect various viruses in FB specimens, particularly for 27 viruses. Results One hundred forty‐nine diagnostic FBs were performed in 130 patients. The overall diagnostic yield was 58%. Eighty‐nine percent of the patients with a positive FB result were diagnosed with a pulmonary infection. Viruses were the most common infectious diagnosis (70%), followed by fungi (48%), bacteria (38%), and Pneumocystis jirovecii (12%). Multivariate analyses showed that a chest computed tomography (CT) finding of diffuse pulmonary infiltrates (P = .012) and positive results in assisted microbiological and serological analyses (P = .000) predicted a positive FB result. FB results prompted a treatment modification in 61% of cases. Conclusions FB in conjunction with PCR is efficient in the rapid diagnosis and management of pulmonary infiltrates in allo‐HSCT patients.
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Affiliation(s)
- Fei-Fei Tang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Xiao-Su Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing, China
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44
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Vande Vusse LK, Madtes DK. Early Onset Noninfectious Pulmonary Syndromes after Hematopoietic Cell Transplantation. Clin Chest Med 2017; 38:233-248. [PMID: 28477636 PMCID: PMC7126669 DOI: 10.1016/j.ccm.2016.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Lisa K Vande Vusse
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Mailstop D5-360, Seattle, WA 98109, USA; Division of Pulmonary and Critical Care Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA.
| | - David K Madtes
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Mailstop D5-360, Seattle, WA 98109, USA
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45
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46
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Mishra R, Cano E, Venkatram S, Diaz-Fuentes G. An interesting case of mycoplasma pneumonia associated multisystem involvement and diffuse alveolar hemorrhage. Respir Med Case Rep 2017; 21:78-81. [PMID: 28413775 PMCID: PMC5384885 DOI: 10.1016/j.rmcr.2017.03.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 12/18/2022] Open
Abstract
Severe mycoplasma pneumonia is a rare entity with only 0.5–2% of cases having a fulminant course. We present a 74-year-old woman with hypertension, diabetes mellitus and remote history of marginal zone B-cell lymphoma admitted with abdominal pain and diarrhea of 1–2 days associated with body-aches, dyspnea, dry cough and weight loss for 2–3 weeks. On physical exam, she was febrile, tachypneic, tachycardic and hypoxic on room air. Chest examination revealed diffuse crackles and end-expiratory wheezes. Laboratory tests showed anemia, acute-on-chronic kidney injury and hyaline casts and epithelial cells in the urine analysis. Chest roentgenogram and computed tomograhphy scan showed pulmonary infiltrates. Intravenous ceftriaxone and azithromycin with bronchodilators were initiated. Her clinical course was complicated by hypoxic respiratory failure, hemoptysis, and worsening of infiltrates, requiring intubation and mechanical ventilation. Bronchoscopic bronchoalveolar lavage was consistent with diffuse alveolar hemorrhage (DAH). The patient's serum was positive for IgM antibody to Mycoplasma pneumoniae [1134 U/mL] and Anti-I-specific IgM-cold-agglutining [1:40]. A diagnosis of severe mycoplasma infection with DAH was made. The patient was treated with an additional course of doxycycline, pulse dose steroids and plasmapharesis with good clinical response. Surgical lung biopsy showed focal acute lung injury. Bone marrow biopsy and fat pad biopsy were normal. She was liberated from mechanical ventilation and discharged. She returned within 24 hours of discharge with cardiac arrest and new onset right-bundle-branch-block. We hypothesize our patient had severe mycoplasma pneumonia with DAH and multisystem complications of the same including a possible venous thrombo-embolic episode leading to her demise.
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Affiliation(s)
- Rashmi Mishra
- Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, 1650 Grand Concourse, Bronx, NY 10457, United States
| | - Edison Cano
- Department of Medicine, Bronx Lebanon Hospital Center, 1650 Grand Concourse, Bronx, NY 10457, United States
| | - Sindhaghatta Venkatram
- Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, 1650 Grand Concourse, Bronx, NY 10457, United States
| | - Gilda Diaz-Fuentes
- Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, 1650 Grand Concourse, Bronx, NY 10457, United States
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47
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Tanaka N, Kunihiro Y, Kobayashi T, Yujiri T, Kido S, Ueda K, Matsunaga N. High-resolution CT findings of idiopathic pneumonia syndrome after haematopoietic stem cell transplantation: based on the updated concept of idiopathic pneumonia syndrome by the American Thoracic Society in 2011. Clin Radiol 2016; 71:953-959. [PMID: 27421574 DOI: 10.1016/j.crad.2016.06.109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 06/07/2016] [Accepted: 06/10/2016] [Indexed: 10/21/2022]
Abstract
Idiopathic pneumonia syndrome (IPS) is an acute lung dysfunction of non-infectious aetiology and a severe complication following haematopoietic stem cell transplantation (HSCT). Recently, the American Thoracic Society (ATS) updated the concept of IPS and extended the concept to a wider range; it defined IPS as "an idiopathic syndrome of pneumopathy after HSCT, with evidence of widespread alveolar injury and in which infectious aetiologies and cardiac dysfunction, acute renal failure, or iatrogenic fluid overload have been excluded." The ATS also categorised the presumed site of primary tissue injury into three patterns (pulmonary parenchyma, vascular endothelium, and airway epithelium), each of which has several entities. Since the therapeutic strategies for IPS are clearly different from those of infectious diseases, and therapeutic delay causes a poor prognosis, radiologists should be aware of some characteristic HRCT findings of IPS, which includes a wide spectrum of entities. In this article, the characteristic HRCT findings of these entities, including acute interstitial pneumonia/acute respiratory distress syndrome, eosinophilic pneumonia, non-cardiogenic capillary leak syndrome, diffuse alveolar haemorrhage, transfusion-related acute lung injury, organising pneumonia, and bronchiolitis obliterans syndrome, are shown.
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Affiliation(s)
- N Tanaka
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan; Department of Radiology, Saiseikai Yamaguchi General Hospital, 2-11 Midoricho, Yamaguchi, Yamaguchi 753-8517, Japan.
| | - Y Kunihiro
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan
| | - T Kobayashi
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan
| | - T Yujiri
- Division of Endocrinology, Metabolism, Hematological Science and Therapeutics, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan
| | - S Kido
- Medical Engineering Science, Yamaguchi University Graduate School of Medicine, 2-16-1, Tokiwadai, Ube 755-8611, Japan
| | - K Ueda
- Department of Surgery and Clinical Science, Yamaguchi University Graduate, School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
| | - N Matsunaga
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan
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48
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Tatekawa S, Kohno A, Ozeki K, Watamoto K, Ueda N, Yamaguchi Y, Kobayashi T, Yokota I, Teramukai S, Taniwaki M, Kuroda J, Morishita Y. A Novel Diagnostic and Prognostic Biomarker Panel for Endothelial Cell Damage-Related Complications in Allogeneic Transplantation. Biol Blood Marrow Transplant 2016; 22:1573-1581. [PMID: 27246373 DOI: 10.1016/j.bbmt.2016.05.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/20/2016] [Indexed: 12/28/2022]
Abstract
Noninfectious transplantation-related complications (TRCs), such as graft-versus-host disease or TRC with endothelial cell damage (TRC-EC), remain as the major obstacle for successful allogeneic hematopoietic cell transplantation (allo-HCT). However, the diagnosis and prognosis for the emergence of these complications are difficult to define during the early post allo-HCT period. Here, we tried to generate a novel diagnostic system for TRC-EC by analyzing 188 adult patients who received allo-HCT. Our study found that the peripheral blood levels of angiopoietin 2 (ANG2), C-reactive protein (CRP), D-dimer, and thrombomodulin (TM) at the onset of TRCs were significantly associated with the development of TRC-EC. We next developed a composite biomarker panel incorporating the risk values of ANG2, CRP, D-dimer, and TM at the onset of TRCs, which classified these patients into 3 risk groups: low, intermediate, and high risk. As a result, the panel was useful not only for the diagnosis of TRC-EC with high specificity and sensitivity, but also for the prediction of the patients' long-term outcome. The 5-year overall survival (OS) rates of patients in the low-, intermediate-, and high-risk groups since the occurrence from TRCs were 76.2%, 54.9%, and 26.9%, respectively, and the high-risk score was significantly associated with both poor OS (hazard ratio [HR], 5.60; 95% confidence interval [CI], 2.81 to 11.20; P < .01) and frequent nonrelapse mortality (HR, 19.75; 95% CI, 5.59 to 69.77; P < .01). Thus, the composite panel proposed in this study provides a powerful tool for the diagnosis of TRC-EC and for the prediction of survival for patients with TRC-EC after allo-HCT.
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Affiliation(s)
- Shotaro Tatekawa
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan; Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan
| | - Akio Kohno
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan
| | - Kazutaka Ozeki
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan
| | - Koichi Watamoto
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan; Department of Hematology, Komaki City Hospital, Aichi, Japan
| | - Norihiro Ueda
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan; Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yohei Yamaguchi
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan; Department of Hematology and Oncology, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Tsutomu Kobayashi
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masafumi Taniwaki
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Junya Kuroda
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Yoshihisa Morishita
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan; Department of Internal Medicine, Seirei Hospital, Nagoya, Aichi, Japan
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49
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Diab M, ZazaDitYafawi J, Soubani AO. Major Pulmonary Complications After Hematopoietic Stem Cell Transplant. EXP CLIN TRANSPLANT 2016; 14:259-70. [PMID: 27040986 DOI: 10.6002/ect.2015.0275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Both autologous and allogeneic hematopoietic stem cell transplants are important therapeutic options for several benign and malignant disorders. Pulmonary complications, although they have become less frequent, remain a significant cause of morbidity and mortality after hematopoietic stem cell transplant. These complications range from bacterial, fungal, and viral pulmonary infections to noninfectious conditions such as diffuse alveolar hemorrhage and idiopathic pneumonia syndrome. Bronchiolitis obliterans syndrome is the primary chronic pulmonary complication, and treatment of this condition remains challenging. This report highlights the advances in the diagnosis and management of the major pulmonary complications after hematopoietic stem cell transplant. It also underscores the need for prospective and multicenter research to have a better understanding of the mechanisms behind these complications and to obtain more effective diagnostic tool and therapeutic options.
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Affiliation(s)
- Maria Diab
- From the Wayne State University School of Medicine, Detroit, Michigan, USA
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50
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Park JA. Diffuse alveolar hemorrhage and recombinant factor VIIa treatment in pediatric patients. KOREAN JOURNAL OF PEDIATRICS 2016; 59:105-13. [PMID: 27186216 PMCID: PMC4865620 DOI: 10.3345/kjp.2016.59.3.105] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/12/2015] [Accepted: 07/07/2015] [Indexed: 01/13/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication in patients with hematologic malignancies or autoimmune disorders. The current treatment options, which include corticosteroids, transfusions, extracorporeal membrane oxygenation (ECMO), and immunosuppressants, have been limited and largely unsuccessful. Recombinant activated factor VII (rFVIIa) has been successfully administered, either systemically or bronchoscopically, to adults for the treatment of DAH, but there are few data on its use in pediatric patients. The current literature in the PubMed database was reviewed to evaluate the efficacy and risk of rFVIIa treatment for DAH in pediatric patients. This review discusses the diagnosis and treatment of DAH, as well as a new treatment paradigm that includes rFVIIa. Additionally, the risks and benefits of off-label use of rFVIIa in pediatric patients are discussed.
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Affiliation(s)
- Jeong A Park
- Department of Pediatrics, Inje University Haeundae-Paik Hospital, Inje University College of Medicine, Busan, Korea
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