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Katlan B, Erkasar F, Topdemir M, Günaydin G, Ozen A. Veno-Occlusive Disease: A Life-saving Novel Approach With Plasma Exchange, IVIG, and Steroid, Without Defibrotide. J Pediatr Hematol Oncol 2024; 46:e348-e353. [PMID: 38810004 DOI: 10.1097/mph.0000000000002886] [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] [Received: 01/23/2024] [Accepted: 04/19/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Hepatic veno-occlusive disease (VOD) is a critical medical emergency with a high mortality rate of up to 90% if not promptly treated. Defibrotide is the only approved medication for VOD treatment, exhibiting anti-inflammatory, antithrombotic, and anti-ischemic properties. This report presents a case of severe VOD in a patient undergoing acute lymphoblastic leukemia (ALL) treatment. CASE PRESENTATION We describe the successful and rapid treatment of severe VOD in an ALL patient using therapeutic plasma exchange (TPE), intravenous immunoglobulin (IVIG), and methylprednisolone (MPZ). The patient showed significant clinical and laboratory improvement after this combined therapeutic approach. CONCLUSION This case highlights the effectiveness of TPE, IVIG, and MPZ in the treatment of severe VOD in ALL patients, providing insights into alternative therapeutic strategies in the absence of Defibrotide.
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Affiliation(s)
- Banu Katlan
- Department of Pediatrics, Division of Pediatric Intensive Care Unit
| | - Funda Erkasar
- Department of Pediatrics, Division of Pediatric Hematology
| | | | - Gulçin Günaydin
- Radiology, Mersin Training and Research Hospital, Mersin, Turkey
| | - Alptug Ozen
- Radiology, Mersin Training and Research Hospital, Mersin, Turkey
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Rashidi A, Ebadi M, Rehman TU, Elhusseini H, Kazadi D, Halaweish H, Khan MH, Hoeschen A, Cao Q, Luo X, Kabage AJ, Lopez S, Ramamoorthy S, Holtan SG, Weisdorf DJ, Khoruts A, Staley C. Multi-omics Analysis of a Fecal Microbiota Transplantation Trial Identifies Novel Aspects of Acute GVHD Pathogenesis. CANCER RESEARCH COMMUNICATIONS 2024; 4:1454-1466. [PMID: 38767452 PMCID: PMC11164016 DOI: 10.1158/2767-9764.crc-24-0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/23/2024] [Accepted: 05/15/2024] [Indexed: 05/22/2024]
Abstract
Acute GVHD (aGVHD) is a major complication of allogeneic hematopoietic cell transplantation (alloHCT) associated with gut microbiota disruptions. However, whether therapeutic microbiota modulation prevents aGVHD is unknown. We conducted a randomized, placebo-controlled trial of third-party fecal microbiota transplantation (FMT) administered at the peak of microbiota injury in 100 patients with acute myeloid leukemia receiving induction chemotherapy and alloHCT recipients. Despite improvements in microbiome diversity, expansion of commensals, and shrinkage of potential pathogens, aGVHD occurred more frequently after FMT than placebo. Although this unexpected finding could be explained by clinical differences between the two arms, we asked whether a microbiota explanation might be also present. To this end, we performed multi-omics analysis of preintervention and postintervention gut microbiome and serum metabolome. We found that postintervention expansion of Faecalibacterium, a commensal genus with gut-protective and anti-inflammatory properties under homeostatic conditions, predicted a higher risk for aGVHD. Faecalibacterium expansion occurred predominantly after FMT and was due to engraftment of unique donor taxa, suggesting that donor Faecalibacterium-derived antigens might have stimulated allogeneic immune cells. Faecalibacterium and ursodeoxycholic acid (an anti-inflammatory secondary bile acid) were negatively correlated, offering an alternative mechanistic explanation. In conclusion, we demonstrate context dependence of microbiota effects where a normally beneficial bacteria may become detrimental in disease. While FMT is a broad, community-level intervention, it may need precision engineering in ecologically complex settings where multiple perturbations (e.g., antibiotics, intestinal damage, alloimmunity) are concurrently in effect. SIGNIFICANCE Post-FMT expansion of Faecalibacterium, associated with donor microbiota engraftment, predicted a higher risk for aGVHD in alloHCT recipients. Although Faecalibacterium is a commensal genus with gut-protective and anti-inflammatory properties under homeostatic conditions, our findings suggest that it may become pathogenic in the setting of FMT after alloHCT. Our results support a future trial with precision engineering of the FMT product used as GVHD prophylaxis after alloHCT.
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Affiliation(s)
- Armin Rashidi
- Clinical Research Division, Fred Hutchinson Cancer Center; and Division of Oncology, University of Washington, Seattle, Washington
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Maryam Ebadi
- Department of Radiation Oncology, University of Washington and Fred Hutchinson Cancer Center, Seattle, Washington
| | - Tauseef U. Rehman
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Heba Elhusseini
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David Kazadi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Hossam Halaweish
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Mohammad H. Khan
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Andrea Hoeschen
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Xianghua Luo
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Amanda J. Kabage
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Sharon Lopez
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | | | - Shernan G. Holtan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J. Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Alexander Khoruts
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Biotechnology Institute, University of Minnesota, St. Paul, Minnesota
- Center for Immunology, University of Minnesota, Minneapolis, Minnesota
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Hall MD, Howell RM, Jackson A, Owens CA, Hernandez S, Castellino SM, Ronckers CM, Constine LS, Bradley JA. Liver Late Effects in Childhood Cancer Survivors Treated With Radiation Therapy: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:575-587. [PMID: 37480885 DOI: 10.1016/j.ijrobp.2023.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/10/2023] [Accepted: 06/11/2023] [Indexed: 07/24/2023]
Abstract
PURPOSE A pediatric normal tissue effects in the clinic (PENTEC) comprehensive review of patients with childhood cancer who received radiation therapy (RT) to the liver was performed to develop models that may inform RT dose constraints for the liver and improve risk forecasting of toxicities. METHODS AND MATERIALS A systematic literature search was performed to identify published data on hepatic toxicities in children. Treatment and outcome data were extracted and used to generate normal tissue complication probability (NTCP) models. Complications from both whole and partial liver irradiation were considered. For whole liver irradiation, total body irradiation and non-total body irradiation treatments were considered, but it was assumed that the entire liver received the prescribed dose. For partial liver irradiation, only Wilms tumor flank field RT could be analyzed. However, a prescribed dose assumption could not be applied, and there was a paucity of analyzable liver dosimetry data. To associate the dose-volume exposures with the partial volume complication data from flank irradiation, liver dose-volume metrics were reconstructed for Wilms tumor flank RT using age-specific computational phantoms as a function of field laterality and superior extent of the field. RESULTS The literature search identified 2103 investigations pertaining to hepatic sinusoidal obstructive syndrome (SOS) and liver failure in pediatric patients. All abstracts were screened, and 241 articles were reviewed in full by the study team. A model was developed to calculate the risk of developing SOS after whole liver RT. RT dose (P = .006) and receipt of nonalkylating chemotherapy (P = .01) were significant. Age <20 years at time of RT was borderline significant (P = .058). The model predicted a 2% risk of SOS with zero RT dose, 6.1% following 10 Gy, and 14.5% following 20 Gy to the whole liver (modeled as the linear-quadratic equivalent dose in 2-Gy fractions [α/β = 3 Gy]). Patients with Wilms tumor treated with right flank RT had a higher observed rate of SOS than patients receiving left flank RT, but data were insufficient to generate an NTCP model for partial liver irradiation. From the phantom-based dose reconstructions, mean liver dose was estimated to be 2.16 ± 1.15 Gy and 6.54 ± 2.50 Gy for left and right flank RT, respectively, using T10-T11 as the superior field border and a prescription dose of 10.8 Gy (based on dose reconstruction). Data were sparse regarding rates of late liver injury after RT, which suggests low rates of severe toxicity after treatment for common pediatric malignancies. CONCLUSIONS This pediatric normal tissue effects in the clinic (PENTEC) review provides an NTCP model to estimate the risk of hepatic SOS as a function of RT dose following whole liver RT and quantifies the range of mean liver doses from typical Wilms tumor flank irradiation fields. Patients treated with right flank RT had higher rates of SOS than patients treated with left flank RT, but data were insufficient to develop a model for partial liver irradiation. Risk of SOS was estimated to be approximately ≤6% in pediatric patients receiving whole liver doses of <10 Gy.
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Affiliation(s)
- Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida.
| | - Rebecca M Howell
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Constance A Owens
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Soleil Hernandez
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon M Castellino
- Department of Pediatric Oncology, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia; Department of Pediatrics, Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia
| | - Cecile M Ronckers
- Department of Pediatrics, UMC Amsterdam, Location AMC, Amsterdam, The Netherlands; Department of Pediatric Oncology, Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands; Institute of Biostatistics and Registry Research, Medical University Brandenburg-Theodor Fontane, Neuruppin, Germany
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
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Lindner S, Miltiadous O, Ramos RJF, Paredes J, Kousa AI, Dai A, Fei T, Lauder E, Frame J, Waters NR, Sadeghi K, Armijo GK, Ghale R, Victor K, Gipson B, Monette S, Russo MV, Nguyen CL, Slingerland J, Taur Y, Markey KA, Andrlova H, Giralt S, Perales MA, Reddy P, Peled JU, Smith M, Cross JR, Burgos da Silva M, Campbell C, van den Brink MRM. Altered microbial bile acid metabolism exacerbates T cell-driven inflammation during graft-versus-host disease. Nat Microbiol 2024; 9:614-630. [PMID: 38429422 PMCID: PMC11196888 DOI: 10.1038/s41564-024-01617-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 01/22/2024] [Indexed: 03/03/2024]
Abstract
Microbial transformation of bile acids affects intestinal immune homoeostasis but its impact on inflammatory pathologies remains largely unknown. Using a mouse model of graft-versus-host disease (GVHD), we found that T cell-driven inflammation decreased the abundance of microbiome-encoded bile salt hydrolase (BSH) genes and reduced the levels of unconjugated and microbe-derived bile acids. Several microbe-derived bile acids attenuated farnesoid X receptor (FXR) activation, suggesting that loss of these metabolites during inflammation may increase FXR activity and exacerbate the course of disease. Indeed, mortality increased with pharmacological activation of FXR and decreased with its genetic ablation in donor T cells during mouse GVHD. Furthermore, patients with GVHD after allogeneic hematopoietic cell transplantation showed similar loss of BSH and the associated reduction in unconjugated and microbe-derived bile acids. In addition, the FXR antagonist ursodeoxycholic acid reduced the proliferation of human T cells and was associated with a lower risk of GVHD-related mortality in patients. We propose that dysbiosis and loss of microbe-derived bile acids during inflammation may be an important mechanism to amplify T cell-mediated diseases.
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Affiliation(s)
- Sarah Lindner
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oriana Miltiadous
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ruben J F Ramos
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jenny Paredes
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anastasia I Kousa
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anqi Dai
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Teng Fei
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emma Lauder
- Transplantation and Cell Therapy Program, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - John Frame
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicholas R Waters
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Keimya Sadeghi
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gabriel K Armijo
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Romina Ghale
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kristen Victor
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brianna Gipson
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sebastien Monette
- Center of Comparative Medicine and Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marco Vincenzo Russo
- Gene Editing and Screening Core Facility, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Chi L Nguyen
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John Slingerland
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ying Taur
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kate A Markey
- Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Hana Andrlova
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sergio Giralt
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Pavan Reddy
- Transplantation and Cell Therapy Program, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - Jonathan U Peled
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Melody Smith
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Justin R Cross
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marina Burgos da Silva
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Clarissa Campbell
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria.
| | - Marcel R M van den Brink
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Los Angeles, CA, USA.
- Hematologic Malignancies Research Institute, City of Hope National Medical Center, Los Angeles, CA, USA.
- Comprehensive Cancer Center, City of Hope, Los Angeles, CA, USA.
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Essa MF, Alghazwani S, Abujoub R, Memon S, Alkaiyat M, Ardah H, Alsultan A. Comparing between HLA-matched sibling donor allogenic HSCT and non-sibling matched related donor allogenic HSCT outcome in pediatric patients; single center retrospective study. Pediatr Transplant 2024; 28:e14692. [PMID: 38317341 DOI: 10.1111/petr.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 11/22/2023] [Accepted: 01/04/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Extended family donor search other than siblings may yield an HLA matched donor in communities with high rate of consanguinity. The outcome of patients who are transplanted from non-sibling matched related donors (NS-MRD) including engraftment and graft versus host disease (GVHD) are scarce in comparison with matched sibling donor (MSD). METHODS We retrospectively reviewed the outcome of all our pediatric hematopoietic stem cell transplantation (HSCT) patients who had non-sibling matched related donor and controlled them with matched sibling donor HSCT (based on age, indication of HSCT, conditioning regimen, GVHD prophylaxis, serotherapy, stem cell source and cytomegalovirus status). RESULTS A total of 76 patients were reviewed during study period. Thirty patients (39.5%) in NS-MRD arm and 46 patients in MSD (60.5%) were identified after matching in age, disease, and conditioning regimens. All patients had similar approach including stem cell source and GVHD prophylaxis (CNI + 2nd agent). Out of the NS-MRD group, 18 patients (59%) had one of their parents as a donor and the rest as second degree relatives. Both groups were equally distributed and were homogeneous. Both groups had no statistically significant difference in outcome including engraftment, GVHD and Chimerism tests results. GVHD was seen in (13%) NS-MRD patients compared to (11%) in MSD patients. All patients remain alive with median follow up of 1249 days (431-3525). CONCLUSIONS This study showed no significant difference in allogenic HSCT outcomes between matched sibling donors and non-sibling matched related donors and support using the same management approach in terms of conditioning therapy, GVHD prophylaxis, and serotherapy only if indicated.
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Affiliation(s)
- Mohammed F Essa
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Sarah Alghazwani
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Rodaina Abujoub
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Shahbaz Memon
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed Alkaiyat
- Department of Oncology, King Abdullah Specialist Children's Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Husam Ardah
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia
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Dezan MGF, Cavalcante LN, Silva HRC, de Moura Almeida A, Dos Santos de Assis LH, de Freitas TT, de Araújo MAS, Cotrim HP, Lyra AC. Hepatobiliary disease after bone marrow transplant: A cross-sectional study of 377 patients. Aliment Pharmacol Ther 2024; 59:71-79. [PMID: 37833826 DOI: 10.1111/apt.17756] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/03/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Bone marrow transplantation (BMT) is a standard treatment for several haematologic conditions. Following BMT, patients may develop hepatobiliary complications that impact morbidity and mortality. The differential diagnosis may include drug-induced liver injury (DILI), sepsis-associated liver injury (SALI), sinusoidal obstruction syndrome (SOS), graft-versus-host disease (GVHD), viral hepatitis, ischaemic hepatitis, and fulminant hepatitis. AIMS To evaluate the frequency, clinical characteristics, and outcomes of patients with hepatobiliary alterations associated with BMT in a tertiary referral centre. METHODS This was a cross-sectional study with data collected from the medical records of patients undergoing BMT between January 2017 and June 2022. We diagnosed hepatobiliary complications based on established criteria. RESULTS We included 377 patients; 55.7% had hepatobiliary complications. Female gender, pre-BMT hepatobiliary alteration, and haploidentical allogeneic transplantation were associated with increased risk with odds ratios (OR) of 1.8 (p = 0.005), 1.72 (p = 0.013) and 3.25 (p = 0.003), respectively. Patients with hepatobiliary complications spent longer in the hospital than those without (27.7 × 19.3 days, respectively; p < 0.001). Among 210 patients with hepatobiliary complications, 28 died compared to 5 of 167 without complications (OR 4.98; p = 0.001). CONCLUSIONS Hepatobiliary complications are frequent in patients undergoing BMT. There is a greater risk of their occurrence in women, people with pre-BMT liver alterations, and in haploidentical transplants. The occurrence of these complications increases the length of stay and is associated with a higher risk of death.
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Affiliation(s)
- Maria Gabriela Fernandes Dezan
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service-University Hospital Professor Edgard Santos (HUPES), Federal University of Bahia, Salvador, Bahia, Brazil
- Postgraduate Program in Medicine and Health, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Lourianne Nascimento Cavalcante
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service-University Hospital Professor Edgard Santos (HUPES), Federal University of Bahia, Salvador, Bahia, Brazil
- Postgraduate Program in Medicine and Health, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Hugo Rodrigues Carvalho Silva
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Hematology Service, Hospital São Rafael, Salvador, Bahia, Brazil
| | - Alessandro de Moura Almeida
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Hematology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Hematology Service-University Hospital Professor Edgard Santos (HUPES), Federal University of Bahia, Salvador, Bahia, Brazil
| | | | - Tiago Thalles de Freitas
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Hematology Service, Hospital São Rafael, Salvador, Bahia, Brazil
| | - Marco Aurélio Salvino de Araújo
- Postgraduate Program in Medicine and Health, Federal University of Bahia, Salvador, Bahia, Brazil
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Hematology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Hematology Service-University Hospital Professor Edgard Santos (HUPES), Federal University of Bahia, Salvador, Bahia, Brazil
| | - Helma Pinchemel Cotrim
- Gastro-Hepatology Service-University Hospital Professor Edgard Santos (HUPES), Federal University of Bahia, Salvador, Bahia, Brazil
- Postgraduate Program in Medicine and Health, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Andre Castro Lyra
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service-University Hospital Professor Edgard Santos (HUPES), Federal University of Bahia, Salvador, Bahia, Brazil
- Postgraduate Program in Medicine and Health, Federal University of Bahia, Salvador, Bahia, Brazil
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Stueck AE, Fiel MI. Hepatic graft-versus-host disease: what we know, when to biopsy, and how to diagnose. Hum Pathol 2023; 141:170-182. [PMID: 37541449 DOI: 10.1016/j.humpath.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/19/2023] [Accepted: 07/24/2023] [Indexed: 08/06/2023]
Abstract
Graft-versus-host disease (GVHD) is one of the serious complications that may develop after hematopoietic cell transplantation (HCT), for hematologic malignancies, solid organ transplantation, and other hematologic disorders. GVHD develops due to T lymphocytes present in the graft attacking the host antigens, which results in tissue damage. A significant number of HCT patients develop acute or chronic GVHD, which may affect multiple organs including the liver. The diagnosis of hepatic GVHD (hGVHD) is challenging as many other conditions in HCT patients may lead to liver dysfunction. Particularly challenging among the various conditions that give rise to liver dysfunction is differentiating sinusoidal obstruction syndrome and drug-induced liver injury (DILI) from hGVHD on clinical grounds and laboratory tests. Despite the minimal risks involved in performing a liver biopsy, the information gleaned from the histopathologic changes may help in the management of these very complex patients. There is a spectrum of histologic features found in hGVHD, and most involve histopathologic changes affecting the interlobular bile ducts. These include nuclear and cytoplasmic abnormalities including dysmorphic bile ducts, apoptosis, and cholangiocyte necrosis, among others. The hepatitic form of hGVHD typically shows severe acute hepatitis. With chronic hGVHD, there is progressive bile duct loss and eventually fibrosis. Accurate diagnosis of hGVHD is paramount so that timely treatment and management can be initiated. Techniques to prevent and lower the risk of GVHD from developing have recently evolved. If a diagnosis of acute GVHD is made, the first-line of treatment is steroids. Recurrence is common and steroid resistance or dependency is not unusual in this setting. Second-line therapies differ among institutions and have not been uniformly established. The development of GVHD, particularly hGVHD, is associated with increased morbidity and mortality.
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Affiliation(s)
- Ashley E Stueck
- Department of Pathology, Dalhousie University, 715 - 5788 University Avenue, Halifax, NS, B3H 2Y9, Canada.
| | - M Isabel Fiel
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA.
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Dezan MGF, Cavalcante LN, Cotrim HP, Lyra AC. Hepatobiliary disease after bone marrow transplant. Expert Rev Gastroenterol Hepatol 2023; 17:129-143. [PMID: 36655915 DOI: 10.1080/17474124.2023.2169671] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Bone marrow transplantation (BMT) is the standard treatment for several hematologic pathologies. Post-BMT patients may develop hepatobiliary complications that impact morbidity and mortality. The differential diagnosis may include drug-induced liver injury (DILI), sepsis-associated liver injury (SALI), sinusoidal obstruction syndrome (SOS), graft-versus-host disease (GVHD), viral hepatitis, ischemic and fulminant hepatitis, among others. AREA COVERED Defining the etiology of hepatobiliary injury is challenging due to the overlapping symptoms. Thus, it is necessary to be aware of and understand the clinical characteristics of these hepatobiliary complications and provide adequate management with possible better outcomes. We reviewed the scientific literature focused on early hepatobiliary complications associated with BMT. We searched the PubMed database using the following descriptors: hepatic complications, drug-induced liver disease, graft-versus-host disease, cholestasis, sepsis, sinusoidal obstruction syndrome, cytomegalovirus, viral hepatitis, bone marrow transplantation, and hematopoietic stem cell transplantation. EXPERT OPINION Post-BMT hepatobiliary complications comprise several differential diagnoses and are challenges for the hepatologist's clinical practice. When evaluating these patients, it is necessary to consider the temporality between the use of certain medications, the increase in liver enzymes, and the presence of infection, in addition to applying diagnostic criteria and complementary tests for a specific diagnosis.
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Affiliation(s)
- Maria Gabriela Fernandes Dezan
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
| | - Lourianne Nascimento Cavalcante
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
| | - Helma Pinchemel Cotrim
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
| | - Andre Castro Lyra
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
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Endothelial Dysfunction Syndromes after Allogeneic Stem Cell Transplantation. Cancers (Basel) 2023; 15:cancers15030680. [PMID: 36765638 PMCID: PMC9913851 DOI: 10.3390/cancers15030680] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only therapy with a curative potential for a variety of malignant and non-malignant diseases. The major limitation of the procedure is the significant morbidity and mortality mainly associated with the development of graft versus host disease (GVHD) as well as with a series of complications related to endothelial injury, such as sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD), transplant-associated thrombotic microangiopathy (TA-TMA), etc. Endothelial cells (ECs) are key players in the maintenance of vascular homeostasis and during allo-HSCT are confronted by multiple challenges, such as the toxicity from conditioning, the administration of calcineurin inhibitors, the immunosuppression associated infections, and the donor alloreactivity against host tissues. The early diagnosis of endothelial dysfunction syndromes is of paramount importance for the development of effective prophylactic and therapeutic strategies. There is an urgent need for the better understanding of the pathogenetic mechanisms as well as for the identification of novel biomarkers for the early diagnosis of endothelial damage. This review summarizes the current knowledge on the biology of the endothelial dysfunction syndromes after allo-HSCT, along with the respective therapeutic approaches, and discusses the strengths and weaknesses of possible biomarkers of endothelial damage and dysfunction.
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The Importance of New EBMT Criteria on the Diagnosis of Veno-Occlusive Liver Disease in Children. J Clin Med 2023; 12:jcm12030826. [PMID: 36769475 PMCID: PMC9918163 DOI: 10.3390/jcm12030826] [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: 11/29/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Early recognition and specific therapy facilitate a favorable disease course in hepatic venous-occlusive disease (HVOD) following hematopoietic stem cell transplantation (HCT). Diagnostic and classification criteria, published by the European Society for Blood and Marrow Transplantation (EBMT), better account for clinical differences in disease presentation in pediatric populations. OBJECTIVES To compare the course of HVOD in children before and after the implementation of new EBMT criteria. MATERIAL AND METHODS The study retrospectively evaluates 26 HVODs in 179 children treated in a single HCT unit (Slovakia) comparing the period of 2014-2017 using the Baltimore and modified Seattle criteria with the period of 2018-2021, when new EBMT criteria were adopted. RESULTS No difference in HVOD incidence (11.2% vs. 14.8%, p = 0.46) and in time of diagnosis post-HCT (15.6 days vs. 15.7 days, p = 0.75) was found. With EBMT criteria we observed more frequent anicteric disease at diagnosis (50% vs. 87.5%, p = 0.04), lower serum bilirubin at diagnosis (3.4 mg/dL vs. 1.23 mg/dL, p = 0.045), and non-significant trends of shorter defibrotide treatment (21.7 days vs. 15.6 days, p = 0.73), decreased mortality (30% vs. 6.2%, p = 0.10) and shorter hospitalization (73.1 days vs. 59.6 days, p = 0.54). CONCLUSIONS Different time periods around the implementation of new criteria are evaluated, underling that pediatric EBMT criteria for post-transplant HVOD diagnosis appear more sensitive.
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11
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Jiang J, Sigmund AM, Zhao Q, Elder P, Benson DM, Vasu S, Jaglowski S, Mims A, Choe H, Larkin K, Brammer JE, Wall S, Grieselhuber N, Saad A, Penza S, Efebera YA, Sharma N. Longitudinal Survival Outcomes in Allogeneic Stem Cell Transplantation: An Institutional Experience. Cancers (Basel) 2022; 14:cancers14225587. [PMID: 36428678 PMCID: PMC9688916 DOI: 10.3390/cancers14225587] [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: 10/07/2022] [Revised: 11/05/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-SCT) is a potentially curative treatment for many hematological disorders, but is often complicated by relapse of the underlying disease, graft-versus-host disease (GVHD), and infectious complications. We conducted a retrospective analysis on patients undergoing allo-SCT from 1984 to 2018 to better understand how survival has changed longitudinally with therapeutic advancements made to mitigate these complications. Method: We analyzed data from 1943 consecutive patients who received allo-SCT. Patients were divided into groups (gps) based on the year (yr) of transplant. Primary endpoints were overall survival (OS), progression free survival (PFS), and GVHD-free relapse-free survival (GRFS). Secondary endpoints were the cumulative incidences of grade II−IV and grade III−IV acute GVHD (aGVHD), chronic GVHD (cGVHD), and non-relapse mortality (NRM). Results: Our study found statistically significant improvements in OS, PFS, and GRFS. Five-year PFS among the groups increased from 24% to 48% over the years. Five-year OS increased from 25% to 53%. Five-year GRFS significantly increased from 6% to 14%, but remained relatively unchanged from 2004 to 2018. Cumulative incidences of grade II−IV aGVHD increased since 2009 (p < 0.001). However, cumulative incidence of NRM decreased since 2004 (p < 0.001). Conclusions: Our data show improved OS, PFS, and GRFS post allo-SCT over decades. This may be attributed to advances in supportive care and treatments focused on mitigation of GVHD and relapse.
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Affiliation(s)
- Justin Jiang
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Audrey M. Sigmund
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Qiuhong Zhao
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Patrick Elder
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Don M. Benson
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Sumithira Vasu
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Samantha Jaglowski
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Alice Mims
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Hannah Choe
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Karilyn Larkin
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Jonathan E. Brammer
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Sarah Wall
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Nicole Grieselhuber
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Ayman Saad
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Sam Penza
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - Yvonne A. Efebera
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
- Division of Hematology, Blood and Marrow Transplant, OhioHealth, Columbus, OH 43214, USA
| | - Nidhi Sharma
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
- Correspondence:
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12
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Muratore E, Leardini D, Baccelli F, Venturelli F, Prete A, Masetti R. Nutritional modulation of the gut microbiome in allogeneic hematopoietic stem cell transplantation recipients. Front Nutr 2022; 9:993668. [PMID: 36337625 PMCID: PMC9632163 DOI: 10.3389/fnut.2022.993668] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/04/2022] [Indexed: 11/23/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) represents a potentially curative strategy for many oncological and non-oncological diseases, but it is associated with marked morbidity and mortality. The disruption of gut microbiota (GM) eubiosis has been linked to major allo-HSCT complications, including infections and acute graft vs. host disease (aGvHD), and correlates with mortality. This increasing knowledge on the role of the GM in the allo-HSCT procedure has led to fascinating ideas for modulating the intestinal ecosystem in order to improve clinical outcomes. Nutritional strategies, either by changing the route of nutritional supplementation or by administering specific molecules, are increasingly being considered as cost- and risk-effective methods of modulating the GM. Nutritional support has also emerged in the past several years as a key feature in supportive care for allo-HSCT recipients, and deterioration of nutritional status is associated with decreased overall survival and higher complication rates during treatment. Herein we provide a complete overview focused on nutritional modulation of the GM in allo-HSCT recipients. We address how pre transplant diet could affect GM composition and its ability to withstand the upsetting events occurring during transplantation. We also provide a complete overview on the influence of the route of nutritional administration on the intestinal ecosystem, with a particular focus on the comparison between enteral and parenteral nutrition (PN). Moreover, as mounting evidence are showing how specific components of post-transplant diet, such as lactose, could drastically shape the GM, we will also summarize the role of prebiotic supplementation in the modulation of the intestinal flora and in allo-HSCT outcomes.
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Affiliation(s)
- Edoardo Muratore
- Pediatric Oncology and Hematology “Lalla Seràgnoli,” IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Davide Leardini
- Pediatric Oncology and Hematology “Lalla Seràgnoli,” IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Baccelli
- Pediatric Oncology and Hematology “Lalla Seràgnoli,” IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- *Correspondence: Francesco Baccelli,
| | - Francesco Venturelli
- Pediatric Oncology and Hematology “Lalla Seràgnoli,” IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Arcangelo Prete
- Pediatric Oncology and Hematology “Lalla Seràgnoli,” IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Riccardo Masetti
- Pediatric Oncology and Hematology “Lalla Seràgnoli,” IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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Chalandon Y, Mamez AC, Giannotti F, Beauverd Y, Dantin C, Mahne E, Mappoura M, Bernard F, de Ramon Ortiz C, Stephan C, Morin S, Ansari M, Simonetta F, Masouridi-Levrat S. Defibrotide Shows Efficacy in the Prevention of Sinusoidal Obstruction Syndrome After Allogeneic Hematopoietic Stem Cell Transplantation: A Retrospective Study. Transplant Cell Ther 2022; 28:765.e1-765.e9. [DOI: 10.1016/j.jtct.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/14/2022] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
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14
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Low-dose unfractionated heparin prophylaxis is a safe strategy for the prevention of hepatic sinusoidal obstruction syndrome after myeloablative adult allogenic stem cell transplant. Bone Marrow Transplant 2022; 57:1095-1100. [PMID: 35477992 PMCID: PMC9271583 DOI: 10.1038/s41409-022-01689-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 11/08/2022]
Abstract
Hepatic sinusoidal obstruction syndrome (SOS) is a serious complication after allogeneic stem cell transplantation (allo-HCT). However, there is no uniform consensus on the optimal strategy for SOS prevention. Ursodeoxycholic acid is the most used regimen, even though its administration is challenging in recipients unable to tolerate oral medication. Defibrotide was recently studied in a phase 3 trial, but enrollment was stopped early due to futility. Low dose unfractionated heparin (UFH) is an alternative strategy. However, its efficacy is reputed but unproven increased risk of bleeding has not been fully established. We evaluated 514 adult allo-HCT recipients who received SOS prophylaxis with low dose UFH. Bleeding complications occurred in 12 patients 2.3% of patients of which only 2 (0.4%) had significant grade 3 bleeding. Only 14 patients were diagnosed with hepatic SOS. Univariate analysis showed that day 100 SOS was higher in recipients of unmodified grafts when compared to CD34+ selected ex vivo T-cell depleted grafts (p ≤ 0.001), and patients with hepatitis B and/or C exposure pre-HCT (p = 0.028). Overall, UFH was well tolerated and associated with a low incidence of subsequent hepatic SOS. Low dose UFH prophylaxis can be considered in select patients who cannot tolerate oral ursodiol.
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15
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Sabatino D, Henneman A, Ahmad S, Jou E, Goldberg B. Evaluation of the efficacy of ursodiol for prevention of hepatotoxicity in patients receiving gemtuzumab ozogamicin and inotuzumab ozogamicin. J Oncol Pharm Pract 2022:10781552221084000. [PMID: 35293248 DOI: 10.1177/10781552221084000] [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: 11/16/2022]
Abstract
Gemtuzumab ozogamicin (GO) and inotuzumab ozogamicin (InO) are indicated for newly diagnosed or relapsed/refractory CD33-positive acute myeloid leukemia and relapsed/refractory B-cell precursor acute lymphoblastic leukemia respectively. Patients undergoing therapy with these agents are at increased risk for hepatotoxicity. Forty-nine patients received either GO or InO with concomitant ursodiol (n=14) or no ursodiol (n=35) for hepatotoxicity prophylaxis. Hepatotoxicity occurred in 2 (14%) patients in the ursodiol group compared to 15 (43%) patients in the no ursodiol group (p=0.10). Median days (17 versus 11; p=0.66) and doses (4 versus 2; p=0.28) to development of hepatotoxicity were higher in the ursodiol versus no ursodiol group. After adjusting for concomitant hepatotoxic medications and prior chemotherapy, ursodiol did not significantly reduce the incidence of hepatotoxicity. Ursodiol prophylaxis was associated with a similar incidence of hepatotoxicity compared to no ursodiol, but may delay the time to occurrence.
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Affiliation(s)
- David Sabatino
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, New York, United States
| | - Amrita Henneman
- Department of Pharmacy, 24945North Shore University Hospital, Manhasset, New York, United States
| | - Samrah Ahmad
- Department of Pharmacy, 24945North Shore University Hospital, Manhasset, New York, United States
| | - Erin Jou
- Department of Hematology/Oncology, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, United States
| | - Bradley Goldberg
- Department of Hematology/Oncology, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, United States
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16
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[Chinese expert consensus on the diagnosis and management of sinusoidal obstruction syndrome after hematopoietic stem cell transplantation (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:177-183. [PMID: 35405774 PMCID: PMC9072071 DOI: 10.3760/cma.j.issn.0253-2727.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Indexed: 11/11/2022]
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17
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Tustumi F, Pinheiro Filho JEL, Stolzemburg LCP, Serigiolle LC, Costa TN, Pajecki D, Santo MA, Nahas SC. Management of biliary stones in bariatric surgery. Ther Adv Gastrointest Endosc 2022; 15:26317745221105087. [PMID: 36388729 PMCID: PMC9664186 DOI: 10.1177/26317745221105087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 05/16/2022] [Indexed: 11/25/2022] Open
Abstract
Morbidly obese and post-bariatric surgery patients are at increased risk for
biliary stones formation. The complications related to biliary stones may impose
complexity on their management. This study aimed to review the management of
biliary conditions in obese and bariatric patients. In this study, a narrative
review was performed of the medical, surgical, and endoscopic procedures for the
management of biliary stones and their related complications. Knowing the main
prophylactic and therapeutic interventions options is essential for clinicians
to properly manage the biliary stones in patients candidates or submitted to
bariatric surgery.
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Affiliation(s)
- Francisco Tustumi
- Department of Gastroenterology, Universidade de São Paulo, Av. Dr Eneas de Carvalho Aguiar, 255, Cerqueira Cesar, São Paulo 05403-000, SP, Brazil
- Department of Surgery, Faculdade de Medicina do ABC, Santo André, Brazil
| | | | | | | | | | - Denis Pajecki
- Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
| | - Marco Aurélio Santo
- Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
| | - Sérgio Carlos Nahas
- Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
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Yoon JH, Choi CW, Won JH. Hepatic sinusoidal obstruction syndrome/veno-occlusive disease after hematopoietic cell transplantation: historical and current considerations in Korea. Korean J Intern Med 2021; 36:1261-1280. [PMID: 34555279 PMCID: PMC8588980 DOI: 10.3904/kjim.2021.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/28/2021] [Indexed: 12/14/2022] Open
Abstract
Hepatic sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD) is a rare but severe complication of hematopoietic cell transplantation (HCT) showing high mortality. Multiple risk factors for SOS/VOD were identified, but it is often confused with other hepatic complications due to nonspecific clinical features. Therefore, diagnostic and severity criteria have been revised several times. The European Society of Blood and Marrow Transplantation suggested a new guideline that excludes the standard duration of development within 21 days, emphasizes late-onset SOS/VOD, and suggests the importance of Doppler ultrasonography. The severity criteria were further subdivided for guidance to begin active treatment using defibrotide which was approved in Korea since 2016. In a phase 3 trial, defibrotide had superior 100-day survival, compared to best available treatments (38.2% vs. 25.0%). Although several studies of SOS/VOD in Korean patients have been performed after the implementation of HCT, most involved small number of pediatric patients. Recently, the Korean Society of Blood and Marrow Transplantation investigated the incidence of SOS/VOD in the Korean population, and several influential studies of adult patients were published. Here, we summarize recent issues regarding the mechanism, diagnosis, severity criteria, prevention, and treatments of SOS/VOD in Korean patients, as well as recent analyses of nationwide incidence.
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Affiliation(s)
- Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Chul Won Choi
- Division of Hematology and Oncology, Department of Internal Medicine, Korea University Guro Hospital, Seoul,
Korea
| | - Jong-Ho Won
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul,
Korea
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Fujiwara H. Crosstalk Between Intestinal Microbiota Derived Metabolites and Tissues in Allogeneic Hematopoietic Cell Transplantation. Front Immunol 2021; 12:703298. [PMID: 34512627 PMCID: PMC8429959 DOI: 10.3389/fimmu.2021.703298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/09/2021] [Indexed: 12/12/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an evidence based- cellular immunotherapy for hematological malignancies. Immune reactions not only promote graft-versus-tumor effects that kill hematological malignant cells but also graft-versus-host disease (GVHD) that is the primary complication characterized by systemic organ damages consisting of T-cells and antigen presenting cells (APCs) activation. GVHD has long been recognized as an immunological reaction that requires an immunosuppressive treatment targeting immune cells. However immune suppression cannot always prevent GVHD or effectively treat it once it has developed. Recent studies using high-throughput sequencing technology investigated the impact of microbial flora on GVHD and provided profound insights of the mechanism of GVHD other than immune cells. Allo-HSCT affects the intestinal microbiota and microbiome-metabolome axis that can alter intestinal homeostasis and the severity of experimental GVHD. This axis can potentially be manipulated via dietary intervention or metabolites produced by intestinal bacteria affected post-allo-HSCT. In this review, we discuss the mechanism of experimental GVHD regulation by the complex microbial community-metabolites-host tissue axis. Furthermore, we summarize the major findings of microbiome-based immunotherapeutic approaches that protect tissues from experimental GVHD. Understanding the complex relationships between gut microbiota-metabolites-host tissues axis provides crucial insight into the pathogenesis of GVHD and advances the development of new therapeutic approaches.
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Affiliation(s)
- Hideaki Fujiwara
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
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Choe H, Ferrara JLM. New therapeutic targets and biomarkers for acute graft-versus-host disease (GVHD). Expert Opin Ther Targets 2021; 25:761-771. [PMID: 34669521 PMCID: PMC8602762 DOI: 10.1080/14728222.2021.1992383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/08/2021] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Acute Graft-versus-Host Disease (GVHD) is the major toxicity of allogeneic hematopoietic cell transplantation (HCT). Systemic steroids are the standard primary treatment but only half of the patients will respond completely and the survival of steroid-refractory patients is poor. The gastrointestinal (GI) tract is a key target organ that usually determines a patient's response to therapy. AREAS COVERED This review summarizes the use of clinical grading systems and biomarkers in GVHD treatment and highlights pathophysiologic phases of acute GVHD as context for the mechanisms of action and therapeutic targets of various approaches. We reviewed >100 publications and performed a search of ongoing, current clinical trials on the emerging therapeutic targets for prophylaxis and treatment of acute GVHD. Search databases included clinicaltrials.gov and PUBMED. Search terms and keywords included 'acute graft-versus-host disease,' 'GVHD,' 'graft versus host,' 'treatment.' EXPERT OPINION Future strategies will employ a risk-adapted therapy using biomarkers, which more accurately predict 6-month NRM. Strategies for high-risk patients will inhibit GI tract damage by selective targeting of effectors (e.g. inhibition of JAK signaling in T cells), blockade of trafficking through mAbs against integrin receptors, or enhancement of target cell survival. Future strategieswill reduce immunosuppression to avoid risk of infections and relapse.
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Affiliation(s)
- Hannah Choe
- Division of Hematology, Blood and Marrow Transplant Program, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - James L M Ferrara
- Icahn School of Medicine at Mount Sinai, The Tisch Cancer Institute, New York, NY, USA
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Bramanti S, De Philippis C, Bartoli A, Giordano L, Mariotti J, Sarina B, Mannina D, Valli V, De Gregori S, Roperti M, Pieri G, Castagna L. Feasibility and Efficacy of a Pharmacokinetics-Guided Busulfan Conditioning Regimen for Allogeneic Stem Cell Transplantation with Post-Transplantation Cyclophosphamide as Graft-versus-Host Disease Prophylaxis in Adult Patients with Hematologic Malignancies. Transplant Cell Ther 2021; 27:912.e1-912.e6. [PMID: 34403790 DOI: 10.1016/j.jtct.2021.08.006] [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: 06/23/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
Busulfan (Bu) is an alkylating agent routinely used for conditioning regimens before allogeneic stem cell transplantation (allo-SCT). Bu shows wide pharmacokinetic (PK) variability among patients. Patients can have a higher systemic exposure (expressed as area under the curve [AUC]) with an increased risk of toxicity or a lower AUC with a higher probability of graft rejection and/or disease relapse. After i.v. administration, an optimal Bu therapeutic window (AUC target of 16,000 to 24,000 μM·minute) has been identified. The use of PK-guided Bu dosing leads to improved overall survival (OS) and progression-free survival (PFS) compared with fixed-dose administration in a variety of hematologic diseases. The aim of this study was to evaluate the outcomes and feasibility of a reduced-toxicity conditioning (RTC) regimen comprising thiotepa, Bu, and fludarabine (TBF) with therapeutic drug monitoring of Bu in patients with hematologic disorders. We report on 41 adult patients with myeloid or lymphoid malignancies who underwent an allo-SCT with a PK-guided Bu-based RTC regimen between January 2019 and October 2020. Patients received a total Bu dose to achieve a target AUC of 16,000 μM·minute in combination with Flu and thiotepa. The median time to absolute neutrophil count recovery and transfusion-independent platelet count recovery was 23 days (range, 15 to 42 days) and 29 days (range, 14 to 97 days), respectively. The cumulative incidence (CI) of nonrelapse mortality was 7% at 100 days and 13% at 1 year. Grade 3 liver toxicity was observed in 6 patients. One patient developed sinusoidal obstruction syndrome at day +27. Grade 3 mucositis occurred in 18 patients. Looking at grade ≥3 infections, the CI was 29% at 30 days, 34% at 60 days, 44% at 100 days, and 56% at 1 year. The 180-day CI of grade II-IV acute graft-versus-host disease (GVHD) was 15%, and the 1-year CI of overall chronic GVHD was 20%. With a median follow-up of alive patients of 14.4 months (range, 3.2 to 24 months), the CI of relapse at 1 year was 6%. The 1-year PFS was 81%, and 1-year OS was 84%. In conclusion, these data support the efficacy of PK-guided Bu dose in the context of a TBF conditioning regimen and the feasibility of therapeutic dosage monitoring of i.v. Bu for patients with hematologic diseases. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Stefania Bramanti
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | | | - Antonella Bartoli
- Fondazione IRCCS Policlinico San Matteo, Clinical and Experimental Pharmacokinetics Unit(,) Pavia, Italy
| | - Laura Giordano
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Jacopo Mariotti
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | - Barbara Sarina
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | - Daniele Mannina
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | - Viviana Valli
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | - Simona De Gregori
- Fondazione IRCCS Policlinico San Matteo, Clinical and Experimental Pharmacokinetics Unit(,) Pavia, Italy
| | - Martina Roperti
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | - Gabriella Pieri
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | - Luca Castagna
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy.
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22
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Hepatic veno-occlusive disease development in the hematopoietic stem cell transplantation patients: incidence and associated risk factors, a meta-analysis. Eur J Gastroenterol Hepatol 2021; 33:872-884. [PMID: 32639417 DOI: 10.1097/meg.0000000000001802] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Now there are no efficient prophylactic or treatment strategies for hepatic veno-occlusive disease (VOD). Therefore, it is critical to early identify patients at high risk of VOD. AIM To analyze the risk factors of VOD in the hematopoietic stem cell transplantation (HSCT) patients. METHODS A comprehensive search of the population was conducted. RESULTS Twenty-one studies with 27 679 HSCT patients were eligible. The incidence of VOD was 15% [95% confidence interval (CI) 13-17%]. The following were the risk factors for VOD: mismatched HLA [odds ratio (OR) 2.34, 95% CI 1.20-4.57, P = 0.01], history of liver disease (OR 2.72, 95% CI 2.03-3.64, P < 0.00001), elevated AST before transplant (OR 2.49, 95% CI 1.49-4.15, P = 0.0005), months from diagnosis to HSCT > 12 months (OR 1.76, 95% CI 1.15-2.69, P = 0.009), previous radiation (OR 1.86, 95% CI 1.49-2.31, P < 0.00001), busulphan (OR 3.69, 95% CI 2.58-5.29, P < 0.00001) and MTX (OR 1.81, 95% CI 1.22-2.69, P = 0.003). There were no significant differences for VOD presentation in the patients with regards to sex, number of HSCT, Karnofsky score <90%, unrelated donor, autologous HSCT, CYA and heparin prophylaxis. CONCLUSION Mismatched HLA, liver disease (history of liver disease, elevated AST), months from diagnosis to HSCT >12 months, previous radiation and use of hepatotoxic drugs (BU and MTX) are the independent risk factors for VOD in the HSCT patients.
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23
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Cooper JP, Storer BE, Granot N, Gyurkocza B, Sorror ML, Chauncey TR, Shizuru J, Franke GN, Maris MB, Boyer M, Bruno B, Sahebi F, Langston AA, Hari P, Agura ED, Petersen SL, Maziarz RT, Bethge W, Asch J, Gutman JA, Olesen G, Yeager AM, Hübel K, Hogan WJ, Maloney DG, Mielcarek M, Martin PJ, Flowers MED, Georges GE, Woolfrey AE, Deeg HJ, Scott BL, McDonald GB, Storb R, Sandmaier BM. Allogeneic hematopoietic cell transplantation with non-myeloablative conditioning for patients with hematologic malignancies: Improved outcomes over two decades. Haematologica 2021; 106:1599-1607. [PMID: 32499241 PMCID: PMC8168504 DOI: 10.3324/haematol.2020.248187] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/27/2020] [Indexed: 12/18/2022] Open
Abstract
We have used a non-myeloablative conditioning regimen for allogeneic hematopoietic cell transplantation for the past twenty years. During that period, changes in clinical practice have been aimed at reducing morbidity and mortality from infections, organ toxicity, and graft-versus-host disease. We hypothesized that improvements in clinical practice led to better transplantation outcomes over time. From 1997-2017, 1,720 patients with hematologic malignancies received low-dose total body irradiation +/- fludarabine or clofarabine before transplantation from HLA-matched sibling or unrelated donors, followed by mycophenolate mofetil and a calcineurin inhibitor ± sirolimus. We compared outcomes in three cohorts by year of transplantation: 1997 +/- 2003 (n=562), 2004 +/- 2009 (n=594), and 2010 +/- 2017 (n=564). The proportion of patients ≥60 years old increased from 27% in 1997 +/- 2003 to 56% in 2010-2017, and with scores from the Hematopoietic Cell Transplantation Comborbidity Index of ≥3 increased from 25% in 1997 +/- 2003 to 45% in 2010 +/- 2017. Use of unrelated donors increased from 34% in 1997 +/- 2003 to 65% in 2010-2017. When outcomes from 2004 +/- 2009 and 2010-2017 were compared to 1997 +/- 2003, improvements were noted in overall survival (P=.0001 for 2004-2009 and P <.0001 for 2010-2017), profression-free survival (P=.002 for 2004-2009 and P <.0001 for 2010 +/- 2017), non-relapse mortality (P<.0001 for 2004 +/- 2009 and P <.0001 for 2010 +/- 2017), and in rates of grades 2 +/- 4 acute and chronic graft-vs.-host disease. For patients with hematologic malignancies who underwent transplantation with non-myeloablative conditioning, outcomes have improved during the past two decades. Trials reported are registered under ClinicalTrials.gov identifiers: NCT00003145, NCT00003196, NCT00003954, NCT00005799, NCT00005801, NCT00005803, NCT00006251, NCT00014235, NCT00027820, NCT00031655, NCT00036738, NCT00045435, NCT00052546, NCT00060424, NCT00075478, NCT00078858, NCT00089011, NCT00104858, NCT00105001, NCT00110058, NCT00397813, NCT00793572, NCT01231412, NCT01252667, NCT01527045.
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Affiliation(s)
- Jason P. Cooper
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Barry E. Storer
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Noa Granot
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Boglarka Gyurkocza
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Mohamed L. Sorror
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Thomas R. Chauncey
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | | | | | - Michael B. Maris
- Colorado Blood Cancer Institute at HealthONE Presbyterian/St. Luke Medical Center, Denver, CO, USA
| | | | | | - Firoozeh Sahebi
- City of Hope/Kaiser Permanente Medical Group, Duarte, CA, USA
| | | | | | | | | | | | | | | | | | | | | | - Kai Hübel
- University Hospital of Cologne, Cologne, Germany
| | | | - David G. Maloney
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Marco Mielcarek
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Paul J. Martin
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Mary E. D. Flowers
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - George E. Georges
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Ann E. Woolfrey
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - H. Joachim Deeg
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Bart L. Scott
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - George B. McDonald
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Brenda M. Sandmaier
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
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24
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Bonifazi F, Sica S, Angeletti A, Marktel S, Prete A, Iori AP, Olivari D, Rossetti G, Bertaina A, Botti S, Busca A, Carella AM, Cerretti R, Gargiulo G, Grassi A, Gualandi F, Irrera G, Milone G, Risitano AM, Santarone S, Vassallo E, Zecca M, Ciceri F, Pomponio G. Veno-occlusive Disease in HSCT Patients: Consensus-based Recommendations for Risk Assessment, Diagnosis, and Management by the GITMO Group. Transplantation 2021; 105:686-694. [PMID: 33273315 DOI: 10.1097/tp.0000000000003569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Variation in clinical practice affects veno-occlusive disease management, mainly in patients who undergo allogeneic hematopoietic stem cell transplantation. Disputes about diagnostic criteria, treatment, and prophylaxis, due to the lack of high-quality data, are at the base of this variability. With the aim of limiting inconsistency in clinical care, thus improving both patient outcomes and data collection reliability, the Italian Society of Stem cell transplant (Gruppo Italiano Trapianto Midollo Osseo e Terapia Cellulare) launched a collaborative effort to formulate recommendations based on integration of available evidence and expert's consensus. A systematic method, according to US National Institute of Health guidelines and Italian National System for Guidelines, was used. Twenty-nine recommendations were approved with a strong (20) or weak (9) level of agreement, while 26 were rejected. In particular, the panel pointed out the need to achieve an early diagnosis, encouraging the adoption of European Society for Blood and Marrow Transplantation criteria and the prompt use of ultrasonography. Moreover, our experts strongly recommended in favor of prophylactic use of ursodeoxycholic acid. As soon as a veno-occlusive disease diagnosis is established, treatment with defibrotide should be started for at least 21 days. A number of areas of uncertainty, particularly concerning risk stratification and use of diagnostic tools such as elastography has been identified and discussed.
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Affiliation(s)
- Francesca Bonifazi
- IRCCS Azienda Ospedaliero-Universitaria, Istituto di Ematologia "L. e A. Seràgnoli", Bologna, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico A. Gemelli IRCCS, Roma, Italia
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italia
| | | | - Sarah Marktel
- Unità di Ematologia e Trapianto di Midollo Osseo IRCCS, Istituto Scientifico Ospedale San Raffaele, Milano, Italia
| | - Arcangelo Prete
- Dipartimento di Oncologia ed Ematologia Pediatrica, Università di Bologna, Ospedale S. Orsola-Malpighi, Bologna, Italia
| | - Anna Paola Iori
- Dipartimento di Oncologia ed Ematologia Pediatrica IRCCS, Ospedale Bambino Gesu', Roma, Italia
| | - Diletta Olivari
- Clinica Medica, Università Politecnica delle Marche, Ancona, Italia
| | - Giulia Rossetti
- Clinica Medica, Università Politecnica delle Marche, Ancona, Italia
| | - Alice Bertaina
- Division of Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA
| | - Stefano Botti
- Unità di Ematologia, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italia
| | - Alessandro Busca
- Dipartimento di Oncologia ed Ematologia, AOU Citta' della Salute e della Scienza, Torino, Italia
| | - Angelo Michele Carella
- Unità di Trapianto di Midollo Osseo, Dipartimento di Oncoematologia, Fondazione IRCCS "Casa Sollievo della Sofferenza" San Giovanni Rotondo, Foggia, Italia
| | - Raffaella Cerretti
- UOC Ematologia, Unità di Trapianto di Cellule Staminali, Ospedale Tor Vergata, Roma, Italia
| | - Gianpaolo Gargiulo
- Dipartimento di Oncologia ed Ematologia, Azienda Ospedaliero Universitaria Federico II, Napoli, Italia
| | - Anna Grassi
- UOS Trapianto di Midollo USC Ematologia, ASST PG23 Bergamo, Italia
| | - Francesca Gualandi
- Divisione di Ematologia e Unità di Trapianto di Cellule Staminali, Policlinico San Martino IRCCS, Genova, Italia
| | - Giuseppe Irrera
- Centro Trapianti Cellule Staminali e Terapie Cellulari "A.Neri," Grande Ospedale Metropolitano, Reggio Calabria, Italia
| | - Giuseppe Milone
- Unità di Trapianto Emopoietico, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele," San Marco, Catania, Italia
| | - Antonio Maria Risitano
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II Napoli, Napoli, Italia
| | - Stella Santarone
- Terapia Intensiva Ematologica, Dipartimento Oncologico Ematologico Ospedale Civile, Pescara, Italia
| | - Elena Vassallo
- Dipartimento di Oncoematologia, Centro Trapianti Cellule Staminali e Terapia Cellulare, Ospedale Infantile Regina Margherita, Torino, Italia
| | - Marco Zecca
- Oncoematologia Pediatrica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italia
| | - Fabio Ciceri
- Unità di Ematologia e Trapianto di Midollo Osseo IRCCS, Istituto Scientifico Ospedale San Raffaele, Milano, Italia
- Università Vita-Salute San Raffaele, Milano, Italia
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25
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Jiang S, Penack O, Terzer T, Schult D, Majer-Lauterbach J, Radujkovic A, Blau IW, Bullinger L, Müller-Tidow C, Dreger P, Luft T. Predicting sinusoidal obstruction syndrome after allogeneic stem cell transplantation with the EASIX biomarker panel. Haematologica 2021; 106:446-453. [PMID: 31974195 PMCID: PMC7849560 DOI: 10.3324/haematol.2019.238790] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/22/2020] [Indexed: 12/11/2022] Open
Abstract
No biomarker panel has been established for prediction of sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD), a major complication of allogeneic stem cell transplantation (alloSCT). We compared the potential of the Endothelial Activation and Stress Index (EASIX), based on lactate dehydrogenase, creatinine, and thrombocytes, with that of the SOS/VOD clinical risk score of the Center for International Blood and Marrow Transplant Research (CIBMTR) to predict SOS/VOD in two independent cohorts. In a third cohort, we studied the impact of endothelium-active prophylaxis with pravastatin and ursodeoxycholic acid (UDA) on SOS/VOD risk. The cumulative incidence of SOS/VOD within 28 days after alloSCT in the training cohort (Berlin, 2013-2015, n=446) and in the validation cohort (Heidelberg, 2002-2009, n=380) was 9.6% and 8.4%, respectively. In both cohorts, EASIX assessed at the day of alloSCT (EASIX-d0) was significantly associated with SOS/VOD incidence (P<0.0001), overall survival (OS), and non-relapse mortality (NRM). In contrast, the CIBMTR score showed no statistically significant association with SOS/VOD incidence, and did not predict OS and NRM. In patients receiving pravastatin/UDA, the cumulative incidence of SOS/VOD was significantly lower at 1.7% (Heidelberg, 2010-2015, n=359, P<0.0001) than in the two cohorts not receiving pravastatin/UDA. The protective effect was most pronounced in patients with high EASIX-d0. The cumulative SOS/VOD incidence in the highest EASIX-d0 quartiles were 18.1% and 16.8% in both cohorts without endothelial prophylaxis as compared to 2.2% in patients with pravastatin/UDA prophylaxis (P<0.0001). EASIX-d0 is the first validated biomarker for defining a subpopulation of alloSCT recipients at high risk for SOS/VOD. Statin/UDA endothelial prophylaxis could constitute a prophylactic measure for patients at increased SOS/VOD risk.
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Affiliation(s)
- Sihe Jiang
- Charité Universitaetsmedizin Berlin, Hematology, Oncology and Tumorimmunology, Berlin,Germany
| | - Olaf Penack
- Charité Universitaetsmedizin Berlin, Hematology, Oncology and Tumorimmunology, Berlin,Germany
| | - Tobias Terzer
- Biostatistics, German Cancer Research Centre, Heidelberg, Germany
| | - David Schult
- Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | - Igor W Blau
- Charité Universitaetsmedizin Berlin, Hematology, Oncology and Tumorimmunology, Berlin,Germany
| | - Lars Bullinger
- Charité Universitaetsmedizin Berlin, Hematology, Oncology and Tumorimmunology, Berlin,Germany
| | | | - Peter Dreger
- Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Luft
- Medicine V, University Hospital Heidelberg, Heidelberg, Germany
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26
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Incidence and risk factors of hepatic veno-occlusive disease/sinusoidal obstruction syndrome after allogeneic hematopoietic cell transplantation in adults with prophylactic ursodiol and intravenous heparin or prostaglandin E1. Bone Marrow Transplant 2021; 56:1603-1613. [PMID: 33526915 DOI: 10.1038/s41409-021-01215-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/23/2020] [Accepted: 01/07/2021] [Indexed: 12/23/2022]
Abstract
We attempted to identify the incidence and survival outcome of hepatic sinusoidal obstruction syndrome/veno-occlusive disease (VOD/SOS) after hematopoietic cell transplantation (HCT) under strategy of prophylactic ursodiol and intravenous heparin or prostaglandin E1 (PGE1). From 2009 to 2018, 2572 consecutive allogeneic-HCT cases were reviewed. We used oral ursodiol for all transplants, and most were administered low-dose heparin, while PGE1 in selected cases with low platelet count at the time of preconditioning. Diagnosis and severity grades were reassessed by revised EBMT criteria. The overall incidence of hepatic VOD/SOS was 3.4% (Mild 0.9%, Moderate 0.6%, Severe 0.7%, Very severe 1.2%) after allogeneic-HCT under strategy of intravenous prophylaxis. The 1-year overall survival of VOD/SOS was 41.4% which was divided into 73.9% for mild, 66.7% for moderate, 38.9% for severe, and 6.5% for very severe grade. Very high disease risk index, male gender, donor other than matched sibling donor, and busulfex > 9 mg/kg were affecting factors for development of VOD/SOS. For severe to very severe VOD/SOS, history of pre-HCT liver dysfunction was an additionally affecting factor. Allogeneic-HCT using ursodiol and intravenous prophylaxis was considered safe without significant bleeding complications and should be evaluated in future clinical trials. For those with high-risk of VOD/SOS, early intervention and management is important.
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27
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Northup PG, Garcia-Pagan JC, Garcia-Tsao G, Intagliata NM, Superina RA, Roberts LN, Lisman T, Valla DC. Vascular Liver Disorders, Portal Vein Thrombosis, and Procedural Bleeding in Patients With Liver Disease: 2020 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 73:366-413. [PMID: 33219529 DOI: 10.1002/hep.31646] [Citation(s) in RCA: 274] [Impact Index Per Article: 91.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, Center for the Study of Hemostasis in Liver Disease, University of Virginia, Charlottesville, VA
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver), Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Department of Internal Medicine, Section of Digestive Diseases, Yale University, New Haven, CT.,Veterans Administration Healthcare System, West Haven, CT
| | - Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, Center for the Study of Hemostasis in Liver Disease, University of Virginia, Charlottesville, VA
| | - Riccardo A Superina
- Department of Transplant Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Surgical Research Laboratory, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Dominique C Valla
- Hepatology Service, Hospital Beaujon, Clichy, France.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver), Barcelona, Spain
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28
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Zhang Z, He Y, Zhu XL, Liu X, Fu HX, Wang FR, Mo XD, Wang Y, Zhang YY, Han W, Chen Y, Yan CH, Wang JZ, Chen YH, Chang YJ, Xu LP, Liu KY, Huang XJ, Zhang XH. Acute Cholecystitis Following Allogeneic Hematopoietic Stem Cell Transplantation: Clinical Features, Outcomes, Risk Factors, and Prediction Model. Transplant Cell Ther 2020; 27:253.e1-253.e9. [PMID: 33781524 DOI: 10.1016/j.jtct.2020.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/30/2020] [Accepted: 12/13/2020] [Indexed: 12/13/2022]
Abstract
Acute cholecystitis (AC) is a potentially fatal complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT); however, only limited information is available on its clinical features, outcomes, and risk management strategies. This retrospective, nested, case-control study included 6701 patients undergoing allo-HSCT at our center from January 2004 to June 2019. In total, 72 patients (1.1%) were diagnosed with AC; among these, acute acalculous cholecystitis had a slightly higher prevalence (42 patients, 58.3%). Patients with moderate and severe AC exhibited remarkably worse overall survival (P = .001) and non-relapse mortality (P = .011) than others. Survival of haploidentical HSCT recipients with AC was comparable to that for patients with human leukocyte antigen (HLA)-identical donors. Age ≥ 18 years, antecedent stage II to IV acute graft-versus-host disease, and total parenteral nutrition were identified as potential risk factors for AC following allo-HSCT, while haploidentical transplantations were not more susceptible to AC than HLA-identical HSCT. Based on these criteria, a risk score model was developed and validated to estimate the probability of AC following allo-HSCT. The model separates all patients into low-, intermediate-, and high-risk groups and thereby provides a basis for early detection of this complication in the management of allo-HSCT.
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Affiliation(s)
- Zhuangyi Zhang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yun He
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Lu Zhu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao Liu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hai-Xia Fu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Feng-Rong Wang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Dong Mo
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yu Wang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Wei Han
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yao Chen
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Chen-Hua Yan
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Jing-Zhi Wang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yu-Hong Chen
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ying-Jun Chang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Lan-Ping Xu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Kai-Yan Liu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Jun Huang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Hui Zhang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China.
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29
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Debureaux PE, Darmon M, Bige N, Moreau AS, Mokart D, Morel G, Lacan C, Perez P, Pene F, Kouatchet A, Picard M, Murgier M, Wallet F, Mayaux J, Canet E, Azoulay E, Valade S. Sinusoidal Obstruction Syndrome in Critically Ill Patients in the Era of Defibrotide: A Retrospective Multicenter Study. Transplant Cell Ther 2020; 27:338.e1-338.e7. [PMID: 33836884 DOI: 10.1016/j.jtct.2020.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
Sinusoidal obstruction syndrome (SOS) is a life-threatening liver complication of high- dose chemotherapy. Defibrotide is the only available therapeutic option approved for SOS. The prognosis of SOS in patients requiring intensive care unit (ICU) admission remains unknown. The primary objective of this study was to assess the outcome of SOS patients in ICU. This retrospective study was conducted between 2007 and 2019 in 13 French ICUs. Seventy-one critically ill adult patients with SOS defined according to European Society for Blood and Marrow Transplantation criteria and treated with defibrotide were included. The main reasons for ICU admission were respiratory failure and acute kidney injury. Mechanical ventilation, vasopressors, and renal replacement therapy were required in 59%, 52%, and 49% of patients, respectively. Twenty-three percent of patients experienced a bleeding event during defibrotide treatment. Hospital mortality was 54%, mainly related to multiorgan failure. Older age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00 to 1.04), mechanical ventilation (HR, 1.99; 95% CI, 1.00 to 3.99), renal replacement therapy (HR, 2.55; 95% CI, 1.32 to 4.91) were independent predictors of hospital mortality. Defibrotide prophylaxis (HR, 0.35; 95% CI, 0.13 to 0.92) was associated with better outcomes. Critically ill patients with SOS have a high mortality rate in the ICU, especially if organ support is required. Additional studies assessing the impact of defibrotide prophylaxis are warranted.
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Affiliation(s)
| | - Michael Darmon
- Medical Intensive Care Unit, Saint Louis Hospital, Paris, France
| | - Naïke Bige
- Medical Intensive Care Unit, Hôpital Saint-Antoine, Paris, France
| | | | - Djamel Mokart
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Guillaume Morel
- Intensive Medicine-Resuscitation Department, Strasbourg University Hospital, Strasbourg, France
| | - Claire Lacan
- Intensive Medicine-Resuscitation Department, Strasbourg University Hospital, Strasbourg, France
| | - Pierre Perez
- Medical Intensive Care Unit, Brabois University Hospital, Nancy, France
| | - Frédéric Pene
- Medical Intensive Care Unit, Cochin Hospital, AP-HP, University of Paris, Paris, France
| | - Achille Kouatchet
- Medical Intensive Care Unit, Angers Teaching Hospital, Angers, France
| | - Muriel Picard
- Intensive Care Unit, IUCT Oncopole, Toulouse, France
| | - Martin Murgier
- Medical-Surgical Intensive Care Unit, Saint-Priest-en-Jarez Hospital, Saint-Etienne, France
| | - Florent Wallet
- Medical Intensive Care Unit, Lyon Sud Teaching Hospital, Pierre Bénite, France
| | - Julien Mayaux
- Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Paris, France
| | - Emmanuel Canet
- Medical Intensive Care Unit, Nantes University Hospital, Nantes, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint Louis Hospital, Paris, France
| | - Sandrine Valade
- Medical Intensive Care Unit, Saint Louis Hospital, Paris, France
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30
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Granot N, Storb R. History of hematopoietic cell transplantation: challenges and progress. Haematologica 2020; 105:2716-2729. [PMID: 33054108 PMCID: PMC7716373 DOI: 10.3324/haematol.2019.245688] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/25/2020] [Indexed: 11/10/2022] Open
Abstract
After more than 60 years of research in allogeneic hematopoietic cell transplantation (HCT), this therapy has advanced from one that was declared dead in the 1960s to a standard treatment of otherwise fatal malignant and non-malignant blood diseases. To date, close to 1.5 million hematopoietic cell transplants have been performed in more than 1,500 transplantation centers worldwide. This review will highlight the enormous efforts by numerous investigators throughout the world who have brought the experimental field of HCT to clinical reality, examine ongoing challenges, and provide insights for the future.
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Affiliation(s)
- Noa Granot
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA.
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA.
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31
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Corpechot C, Chazouillères O, Belnou P, Montano-Loza AJ, Mason A, Ebadi M, Eurich D, Chopra S, Jacob D, Schramm C, Sterneck M, Bruns T, Reuken P, Rauchfuss F, Roccarina D, Thorburn D, Gerussi A, Trivedi P, Hirschfield G, McDowell P, Nevens F, Boillot O, Bosch A, Giostra E, Conti F, Poupon R, Parés A, Reig A, Donato MF, Malinverno F, Floreani A, Russo FP, Cazzagon N, Verhelst X, Goet J, Harms M, van Buuren H, Hansen B, Carrat F, Dumortier J. Long-term impact of preventive UDCA therapy after transplantation for primary biliary cholangitis. J Hepatol 2020; 73:559-565. [PMID: 32275981 DOI: 10.1016/j.jhep.2020.03.043] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/06/2020] [Accepted: 03/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Recurrence of primary biliary cholangitis (PBC) after liver transplantation (LT) is frequent and can impair graft and patient survival. Ursodeoxycholic acid (UDCA) is the current standard therapy for PBC. We investigated the effect of preventive exposure to UDCA on the incidence and long-term consequences of PBC recurrence after LT. METHODS We performed a retrospective cohort study in 780 patients transplanted for PBC, between 1983-2017 in 16 centers (9 countries), and followed-up for a median of 11 years. Among them, 190 received preventive UDCA (10-15 mg/kg/day). The primary outcome was histological evidence of PBC recurrence. The secondary outcomes were graft loss, liver-related death, and all-cause death. The association between preventive UDCA and outcomes was quantified using multivariable-adjusted Cox and restricted mean survival time (RMST) models. RESULTS While recurrence of PBC significantly shortened graft and patient survival, preventive exposure to UDCA was associated with reduced risk of PBC recurrence (adjusted hazard ratio [aHR] 0.41; 95% CI 0.28-0.61; p <0.0001), graft loss (aHR 0.33; 95% CI 0.13-0.82; p <0.05), liver-related death (aHR 0.46; 95% CI 0.22-0.98; p <0.05), and all-cause death (aHR 0.69; 95% CI 0.49-0.96; p <0.05). On RMST analysis, preventive UDCA led to a survival gain of 2.26 years (95% CI 1.28-3.25) over a period of 20 years. Exposure to cyclosporine rather than tacrolimus had a complementary protective effect alongside preventive UDCA, reducing the cumulative incidence of PBC recurrence and all-cause death. CONCLUSIONS Preventive UDCA after LT for PBC is associated with a reduced risk of disease recurrence, graft loss, and death. A regimen combining cyclosporine and preventive UDCA is associated with the lowest risk of PBC recurrence and mortality. LAY SUMMARY Recurrence of primary biliary cholangitis after liver transplantation is frequent and can impair graft and patient survival. We performed the largest international study of transplanted patients with primary biliary cholangitis to date. Preventive administration of ursodeoxycholic acid after liver transplantation was associated with reduced risk of disease recurrence, graft loss, liver-related and all-cause mortality. A regimen combining cyclosporine and preventive ursodeoxycholic acid was associated with the best outcomes.
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Affiliation(s)
- Christophe Corpechot
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, ERN Rare-Liver, Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris; Inserm UMR_S938, Saint-Antoine Research Center, Sorbonne University, Paris, France.
| | - Olivier Chazouillères
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, ERN Rare-Liver, Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris; Inserm UMR_S938, Saint-Antoine Research Center, Sorbonne University, Paris, France
| | - Pierre Belnou
- Public Health Unit, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris; Pierre Louis Institute of Epidemiology and Public Health, Sorbonne University, Paris, France
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Canada
| | - Andrew Mason
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Canada
| | - Maryam Ebadi
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Canada
| | - Dennis Eurich
- Department of General, Visceral and Transplantation Surgery, Charité University Hospital, Berlin, Germany
| | - Sascha Chopra
- Department of General, Visceral and Transplantation Surgery, Charité University Hospital, Berlin, Germany
| | - Dietmar Jacob
- Department of General, Visceral and Transplantation Surgery, Charité University Hospital, Berlin, Germany
| | - Christoph Schramm
- Department of Medicine I and Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Sterneck
- Department of Medicine I and Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tony Bruns
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany; Department of Internal Medicine IV, Integrated Research and Treatment Center for Sepsis Control and Care, University Hospital, Jena, Germany
| | - Philipp Reuken
- Department of Internal Medicine IV, Integrated Research and Treatment Center for Sepsis Control and Care, University Hospital, Jena, Germany
| | - Falk Rauchfuss
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Davide Roccarina
- University College London Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Douglas Thorburn
- University College London Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Alessio Gerussi
- University College London Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Palak Trivedi
- National Institute for Health Research, Centre for Liver Research, University Hospitals Birmingham, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Gideon Hirschfield
- National Institute for Health Research, Centre for Liver Research, University Hospitals Birmingham, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom; Department of Gastroenterology, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom; Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Patrick McDowell
- Department of Gastroenterology, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Frederik Nevens
- Division Liver and Biliopancreatic Disorders, University Hospitals KU, Leuven, Belgium
| | - Olivier Boillot
- Transplant Hepatology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Claude Bernard University, Lyon, France
| | - Alexie Bosch
- Transplant Hepatology Unit, Croix Rousse Hospital, Hospices Civils de Lyon, Claude Bernard University, Lyon, France
| | - Emiliano Giostra
- Hepatology and Gastroenterology Department, Geneva University Hospitals, Geneva, Switzerland
| | - Filomena Conti
- Transplant Hepatology Unit, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Raoul Poupon
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, ERN Rare-Liver, Saint-Antoine Hospital, Assistance Publique - Hôpitaux de Paris; Inserm UMR_S938, Saint-Antoine Research Center, Sorbonne University, Paris, France
| | - Albert Parés
- Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain
| | - Anna Reig
- Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain
| | - Maria Francesca Donato
- Transplant Hepatology Unit, Division of Gastroenterology and Hepatology, Maggiore Hospital Policlinico, Milan, Italy
| | - Federica Malinverno
- Transplant Hepatology Unit, Division of Gastroenterology and Hepatology, Maggiore Hospital Policlinico, Milan, Italy
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Francesco Paolo Russo
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Nora Cazzagon
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Jorn Goet
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maren Harms
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bettina Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Fabrice Carrat
- Public Health Unit, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris; Pierre Louis Institute of Epidemiology and Public Health, Sorbonne University, Paris, France
| | - Jérôme Dumortier
- Transplant Hepatology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Claude Bernard University, Lyon, France
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32
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Omori I, Yamaguchi H, Hirakawa T, Inai K, Onai D, Marumo A, Yamanaka S, Sakaguchi M, Fujiwara Y, Wakita S, Okamoto M, Tamai H, Nakayama K, Yui S, Inokuchi K. Outcomes of Patients with Early Hyperbilirubinemia after Allogeneic Hematopoietic Stem Cell Transplantation. J NIPPON MED SCH 2020; 87:142-152. [PMID: 32009070 DOI: 10.1272/jnms.jnms.2020_87-404] [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: 11/19/2022]
Abstract
BACKGROUND Because the cause of liver dysfunction after allogeneic hematopoietic stem cell transplantation (HSCT) is difficult to identify in the early stages, treatment may be delayed. Therefore, early factors associated with unfavorable outcomes of liver dysfunction must be identified. The objective of this study was to identify unfavorable prognostic factors for liver dysfunction during the early period after transplantation. METHODS We defined liver dysfunction as elevated liver or biliary enzyme levels (corresponding to Grade 2 in the Common Terminology Criteria for Adverse Events version 4.0) within 30 days of transplantation and retrospectively investigated data from 82 patients who had undergone allogeneic HSCT at our center. RESULTS Elevated liver or biliary enzyme levels were observed in almost half of the patients studied (n=40, 48.7%). Elevated total bilirubin (T-Bil) level was the most frequently observed unfavorable prognostic factor and had the greatest effect on overall survival (OS), progression-free survival (PFS), and non-relapse mortality (NRM) (probability of unfavorable outcome in patients without and with elevated T-Bil level: OS, 58.9% vs. 15.4%, p < 0.001; PFS, 46.4% vs. 15.4%, p < 0.001; NRM, 10.7% vs. 53.8%, p < 0.001). Moreover, the probability of an unfavorable outcome increased in relation to the degree of T-Bil elevation and absence of improvement over time in T-Bil level. CONCLUSION Elevated T-Bil level was an important marker of outcomes for liver dysfunction after allogeneic HSCT.
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Affiliation(s)
- Ikuko Omori
- Department of Hematology, Nippon Medical School
| | | | | | - Kazuki Inai
- Department of Hematology, Nippon Medical School
| | - Daishi Onai
- Department of Hematology, Nippon Medical School
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33
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Bonifazi F, Barbato F, Ravaioli F, Sessa M, Defrancesco I, Arpinati M, Cavo M, Colecchia A. Diagnosis and Treatment of VOD/SOS After Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2020; 11:489. [PMID: 32318059 PMCID: PMC7147118 DOI: 10.3389/fimmu.2020.00489] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 03/03/2020] [Indexed: 12/27/2022] Open
Abstract
Hepatic veno-occlusive disease (VOD) or sinusoidal obstruction syndrome (SOS) is a rare complication characterized by hepatomegaly, right-upper quadrant pain, jaundice, and ascites, occurring after high-dose chemotherapy, hematopoietic stem cell transplantation (HSCT) and, less commonly, other conditions. We review pathogenesis, clinical appearance and diagnostic criteria, risk factors, prophylaxis, and treatment of the VOD occurring post-HSCT. The injury of the sinusoidal endothelial cells with loss of wall integrity and sinusoidal obstruction is the basis of development of postsinusoidal portal hypertension responsible for clinical syndrome. Risk factors associated with the onset of VOD and diagnostic tools have been recently updated both in the pediatric and adult settings and here are reported. Treatment includes supportive care, intensive management, and specific drug therapy with defibrotide. Because of its severity, particularly in VOD with associated multiorgan disease, prophylaxis approaches are under investigation. During the last years, decreased mortality associated to VOD/SOS has been reported being it attributable to a better intensive and multidisciplinary approach.
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Affiliation(s)
- Francesca Bonifazi
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Francesco Barbato
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mariarosaria Sessa
- Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum-Bologna University School of Medicine S. Orsola's University Hospital, Bologna, Italy
| | - Irene Defrancesco
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Mario Arpinati
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Michele Cavo
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy.,Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum-Bologna University School of Medicine S. Orsola's University Hospital, Bologna, Italy
| | - Antonio Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Gastroenterology Unit, Borgo Trento University Hospital, Verona, Italy
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34
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Adachi Y, Ozeki K, Ukai S, Sagou K, Fukushima N, Kohno A. Permanent Impairment-Free, Relapse-Free Survival: A Novel Composite Endpoint to Evaluate Long-Term Success in Allogeneic Transplantation. Biol Blood Marrow Transplant 2020; 26:1005-1012. [PMID: 32035276 DOI: 10.1016/j.bbmt.2020.01.025] [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: 10/25/2019] [Revised: 01/06/2020] [Accepted: 01/28/2020] [Indexed: 10/25/2022]
Abstract
Permanent impairment (PI) of vital organs is one of the transplantation-related health problems affecting the quality of life and morbidity even in patients who do not develop graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (allo-HCT), but no data are available on PI of multiple organs. This retrospective study aimed to estimate a novel composite endpoint of PI-free, relapse-free survival (PIRFS) in 164 allo-HCT recipients. We defined PI as >26% to 30% impairment of the whole person in 6 vital organs using the whole person impairment rating. Conventional GVHD-free/relapse-free survival (GRFS) and PIRFS at 5 years were 33.8% (95% confidence interval [CI], 26.5% to 41.3%) and 40.6% (95% CI, 32.6% to 48.4%), respectively. In the whole cohort, PIRFS was higher than GRFS at any time after allo-HCT. However, PIRFS was lower than GRFS after day 397 post-transplantation in patients who underwent umbilical cord blood transplantation (UCBT). In UCBT recipients, 5-year GRFS and PIRFS were 47.6% (95% CI, 34.3% to 59.7%) and 39.2% (95% CI, 26.6% to 51.5%), respectively. The cumulative incidence of PI after 5 years was 20.9% (95% CI, 13.7% to 29.0%) in patients surviving for ≥6 months without relapse. The multivariate analysis revealed that high disease risk (hazard ratio [HR], 1.91; 95% CI, 1.26 to 2.88; P < .01) and Karnofsky Performance Status score ≤90% at transplantation (HR, 1.73; 95% CI, 1.14 to 2.63; P = .01) were correlated with the lower PIRFS, whereas UCBT (HR, 2.35; 95% CI, 1.11 to 4.99; P = .03), grade III-IV acute GVHD by day 180 (HR, 3.59; 95% CI, 1.04 to 12.4; P = .04), and thrombotic microangiopathy by day 180 (HR, 2.74; 95% CI, 1.10 to 6.87; P = .03) were significantly correlated with a higher incidence of PI. More than 20% of long-term survivors had PI. Our data suggest that PIRFS is a useful endpoint for assessing long-term transplantation success from a different perspective than has been established previously.
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Affiliation(s)
- Yoshitaka Adachi
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Hematology and Oncology, Konan Kosei Hospital, Konan, Japan.
| | - Kazutaka Ozeki
- Department of Hematology and Oncology, Konan Kosei Hospital, Konan, Japan
| | - Shun Ukai
- Department of Hematology and Oncology, Konan Kosei Hospital, Konan, Japan
| | - Ken Sagou
- Department of Hematology and Oncology, Konan Kosei Hospital, Konan, Japan
| | - Nobuaki Fukushima
- Department of Hematology and Oncology, Konan Kosei Hospital, Konan, Japan
| | - Akio Kohno
- Department of Hematology and Oncology, Konan Kosei Hospital, Konan, Japan
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Nava T, Ansari M, Dalle JH, de Heredia CD, Güngör T, Trigoso E, Falkenberg U, Bertaina A, Gibson B, Jarisch A, Balduzzi A, Boenig H, Krivan G, Vettenranta K, Matic T, Buechner J, Kalwak K, Lawitschka A, Yesilipek A, Lucchini G, Peters C, Turkiewicz D, Niinimäki R, Diesch T, Lehrnbecher T, Sedlacek P, Hutt D, Dalissier A, Wachowiak J, Yaniv I, Stein J, Yalçin K, Sisinni L, Deiana M, Ifversen M, Kuhlen M, Meisel R, Bakhtiar S, Cesaro S, Willasch A, Corbacioglu S, Bader P. Supportive care during pediatric hematopoietic stem cell transplantation: beyond infectious diseases. A report from workshops on supportive care of the Pediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2020; 55:1126-1136. [PMID: 32029909 DOI: 10.1038/s41409-020-0818-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 01/15/2020] [Accepted: 01/28/2020] [Indexed: 12/16/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is currently the standard of care for many malignant and nonmalignant blood diseases. As several treatment-emerging acute toxicities are expected, optimal supportive measurements critically affect HSCT outcomes. The paucity of good clinical studies in supportive practices gives rise to the establishment of heterogeneous guidelines across the different centers, which hampers direct clinical comparison in multicentric studies. Aiming to harmonize the supportive care provided during the pediatric HSCT in Europe, the Pediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT) promoted dedicated workshops during the years 2017 and 2018. The present paper describes the resulting consensus on the management of sinusoidal obstructive syndrome, mucositis, enteral and parenteral nutrition, iron overload, and emesis during HSCT.
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Affiliation(s)
- Tiago Nava
- Division of Pediatric Hematology-Oncology, University Hospital of Geneva, Geneva, Switzerland
| | - Marc Ansari
- Division of Pediatric Hematology-Oncology, University Hospital of Geneva, Geneva, Switzerland
| | - Jean-Hugues Dalle
- Hematology and Immunology Department, Robert-Debre Hospital, Assistance Publique-Hopitaux de Paris & University of Paris, Paris, France
| | - Christina Diaz de Heredia
- Department of Pediatric Oncology and Hematology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Tayfun Güngör
- Department of Hematology, Immunology, Oncology and Stem Cell Transplantation, University Children's Hospital Zürich, Zürich, Switzerland
| | - Eugenia Trigoso
- Paediatric Transplant Unit, Hospital University and Polytechnic Hospital LA FE, Valencia, Spain
| | - Ulrike Falkenberg
- SCT-Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Alice Bertaina
- Department of Pediatric Hematology/Oncology and Cell and Gene Therapy, IRCCS, Ospedale Bambino Gesù, Rome, Italy
| | - Brenda Gibson
- Department of Paediatric Haematology-Oncology, Royal Hospital for Children, Glasgow, Scotland, UK
| | - Andrea Jarisch
- Division for Stem Cell Transplantation and Immunology, Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Fondazione MBBM, Ospedale San Gerardo, Monza, Italy
| | - Halvard Boenig
- Institute for Transfusion Medicine and Immunohematology of Goethe University and German Red Cross Blood Service Baden-Württemberg-Hessen, Frankfurt/Main, Germany
| | - Gergely Krivan
- Central Hospital of Southern Pest, National Institute of Hematology and Infectious Disease, Budapest, Hungary
| | - Kim Vettenranta
- Children's Hospital, and Pediatric Research Center, University of Helsinki, Helsinki, Finland
| | - Toni Matic
- Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Krzysztof Kalwak
- Department of Pediatric Hematology, Oncology and BMT, Wroclaw Medical University, Wroclaw, Poland
| | - Anita Lawitschka
- SCT-Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Akif Yesilipek
- Department of Pediatric Hematology & Pediatric Stem Cell Transplantation Unit, Antalya & Goztepe Medicalpark Hospitals, Antalya, Turkey
| | - Giovanna Lucchini
- Department of BMT, Great Ormond Street Hospital for Children, National Health Service (NHS) Foundation Trust, London, UK
| | - Christina Peters
- SCT-Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | | | - Riitta Niinimäki
- Department of Pediatrics, Oulu University Hospital, Oulu, Finland
| | - Tamara Diesch
- Division of Pediatric Hematology/Oncology, University Children's Hospital of Basel, Basel, Switzerland
| | - Thomas Lehrnbecher
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Petr Sedlacek
- Division of Pediatric Hematology and Oncology, Hospital Motol, Charles University, Prague, Czech Republic
| | - Daphna Hutt
- Division of Pediatric Hematology, Oncology and BMT, The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | | | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and HSCT, Poznan University of Medical Sciences, Poznań, Poland
| | - Isaac Yaniv
- Division of Pediatric Hematoloy/Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Jerry Stein
- Division of Pediatric Hematoloy/Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Koray Yalçin
- Department of Pediatric Bone Marrow Transplantation Unit, MedicalPark Göztepe Hospital, Instanbul, Turkey
| | - Luisa Sisinni
- Pediatric Hematology, Oncology and HSCT Unit, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Marco Deiana
- Paediatric Haematology/Oncology Department, IRCCS G Gaslini, Genova, Italy
| | - Marianne Ifversen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Roland Meisel
- Division of Pediatric Stem Cell Therapy, Clinic for Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Shahrzad Bakhtiar
- Division for Stem Cell Transplantation and Immunology, Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Andre Willasch
- Division for Stem Cell Transplantation and Immunology, Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Hospital of Regensburg, Regensburg, Germany
| | - Peter Bader
- Division for Stem Cell Transplantation and Immunology, Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt am Main, Germany.
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Mahadeo KM, Bajwa R, Abdel-Azim H, Lehmann LE, Duncan C, Zantek N, Vittorio J, Angelo J, McArthur J, Schadler K, Chan S, Tewari P, Khazal S, Auletta JJ, Choi SW, Shoberu B, Kalwak K, Harden A, Kebriaei P, Abe JI, Li S, Moffet JR, Abraham S, Tambaro FP, Kleinschmidt K, Richardson PG, Corbacioglu S. Diagnosis, grading, and treatment recommendations for children, adolescents, and young adults with sinusoidal obstructive syndrome: an international expert position statement. Lancet Haematol 2020; 7:e61-e72. [PMID: 31818728 DOI: 10.1016/s2352-3026(19)30201-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 02/03/2023]
Abstract
Sinusoidal obstructive syndrome, also known as hepatic veno-occlusive disease, is a potentially life-threatening complication that occurs in children undergoing haemopoietic stem-cell transplantation (HSCT). Differences in the incidence of genetic predisposition and clinical presentation of sinusoidal obstructive syndrome between children and adults have rendered the historical Baltimore and Seattle diagnostic criteria insufficient for children. In 2017, the European Society for Blood and Marrow Transplantation (EBMT) proposed the first paediatric diagnostic and severity grading guidelines for sinusoidal obstructive syndrome, intended for implementation across European centres. However, universally accepted paediatric criteria are needed to ensure prompt diagnosis, definitive treatment, and improved outcomes for children, adolescents, and young adults with sinusoidal obstructive syndrome, and to facilitate international clinical research collaboration. We convened an international panel of multidisciplinary experts including physicians with expertise in HSCT, paediatric intensive care, nephrology, hepatology, radiology, pathology, and transfusion medicine; HSCT advanced-practice providers and medical trainees; pharmacists; and translational and basic science researchers from the Pediatric Acute Lung Injury and Sepsis Investigators Network, the EBMT, the Pediatric Blood and Marrow Transplant Consortia, and several other institutions with extensive experience in sinusoidal obstructive syndrome. Panellists convened at The University of Texas, MD Anderson Cancer Center (Houston, TX, USA) in February, 2019, to evaluate the available evidence. In this expert position statement paper, we provide consensus recommendations for the international implementation of guidelines for the diagnosis, severity grading, and treatment of sinusoidal obstructive syndrome among children, adolescents, and young adults. We endorse universal adoption of paediatric diagnostic guidelines for sinusoidal obstruction syndrome as proposed by the EBMT, and provide implementation guidance for standardisation across centres; we have further proposed adjunctive use of age-appropriate organ-specific toxicity criteria for severity grading and provided prophylaxis and treatment considerations among children and adolescent and young adult patients. Key recommendations include: (1) liver biopsy, portal venous wedge pressure, and reversal of portal venous flow on Doppler ultrasonography should not be used for the routine diagnosis of sinusoidal obstructive syndrome in children, adolescents, and young adults; (2) platelet refractoriness can be defined as a corrected count increment of less than 5000-7500 following at least two sequential ABO-compatible fresh platelet transfusions; (3) hepatomegaly is best defined as an absolute increase of at least 1 cm in liver length at the midclavicular line; and if a baseline measurement is not available, hepatomegaly can be defined as greater than 2 SDs above normal for age; and (4) the presence and volume of ascites can be categorised as mild (minimal fluid by liver, spleen, or pelvis), moderate (<1 cm fluid), or severe (fluid in all three regions with >1 cm fluid in at least two regions).
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Affiliation(s)
- Kris M Mahadeo
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Rajinder Bajwa
- Department of Pediatrics, Division of Blood and Marrow Transplantation, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Hisham Abdel-Azim
- Department of Pediatrics, Blood and Marrow Transplantation Program, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Leslie E Lehmann
- Pediatric Hematology-Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Christine Duncan
- Pediatric Hematology-Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Nicole Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School. University of Minnesota Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - Jennifer Vittorio
- Department of Pediatrics, Division of Pediatric Transplant Hepatology, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Joseph Angelo
- Department of Pediatrics, Renal Division, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jennifer McArthur
- Department of Pediatrics, Division of Critical Care, St Jude's Children's Research Hospital, Memphis, TN, USA
| | - Keri Schadler
- Department of Pediatrics, Division of Pediatric Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sherwin Chan
- Department of Radiology, Division of Pediatric Radiology, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | - Priti Tewari
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sajad Khazal
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffery J Auletta
- Department of Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Sung Won Choi
- Department of Pediatrics, Division of Hematology/Oncology and Bone Marrow Transplant, University of Michigan, Ann Arbor, MI, USA
| | - Basirat Shoberu
- Department of Pharmacy, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Krzysztof Kalwak
- Department of Paediatrics, Division of Immunology and Transplantology, Medical University Wroclaw, Wroclaw, Poland
| | - Avis Harden
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun-Ichi Abe
- Department of Cardiology, Division of Internal Medicine/Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shulin Li
- Department of Pediatrics, Division of Pediatric Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jerelyn Roberson Moffet
- Department of Pediatrics, Division of Blood and Marrow Transplant, Duke Children's Hospital, Duke University, Durham, NC, USA
| | - Susan Abraham
- Department of Pathology, Division of Pathology and Laboratory Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Francesco Paolo Tambaro
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA; UOC SIT-TMO AORN Santobono-Pausilipon-Napoli, Italy
| | - Katharina Kleinschmidt
- Department of Pediatrics, Division of Pediatric Oncology, Stem Cell Transplant, University Hospital of Regensburg, Regensburg, Germany
| | - Paul G Richardson
- Department of Medical Oncology, Division of Hematologic Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Selim Corbacioglu
- Department of Pediatrics, Division of Pediatric Oncology, Stem Cell Transplant, University Hospital of Regensburg, Regensburg, Germany
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El-Serafi I, Remberger M, Ringdèn O, Törlén J, Sundin M, Björklund A, Winiarski J, Mattsson J. Reduced Risk of Sinusoidal Obstruction Syndrome of the Liver after Busulfan-Cyclophosphamide Conditioning Prior to Allogeneic Hematopoietic Stem Cell Transplantation. Clin Transl Sci 2019; 13:293-300. [PMID: 31675173 PMCID: PMC7070785 DOI: 10.1111/cts.12709] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 09/22/2019] [Indexed: 12/30/2022] Open
Abstract
The aim of this study is to evaluate the incidence of sinusoidal obstruction syndrome (SOS) of the liver and the clinical outcome after hematopoietic stem cell transplantation (HSCT) based on several modifications in our protocols. We retrospectively investigated 372 patients undergoing myeloablative conditioning with oral busulfan (Bu) and cyclophosphamide before allogeneic HSCT during 1990–2015. Patients' supportive care was changed in order to reduce the regimen‐related toxicities. Norethisterone use was terminated in 1998, therapeutic drug monitoring of Bu was initiated in 2000, and the use of liver supportive drugs, such as ursodeoxycholic acid and N‐acetyl‐L‐cysteine, were started in 2002 and 2009, respectively. In total, 26 patients (7.0%) developed SOS at a median of 19 days after transplantation. Of these 26 patients, 20 died at a median of 119 days after HSCT and 102 days after the diagnosis of SOS. The incidence of SOS decreased over time in accordance with the improvements in supportive care. The highest incidence of SOS was during 1995–1999 (16.2%) compared with 2.3% during 2010–2015. Overall survival for patients with SOS was 62%, 46%, and 27% at 100 days, 1 year, and 5 years after HSCT, respectively, compared with 92%, 77%, and 66% for those who did not develop SOS (P < 0.001). In conclusion, the incidence of SOS and related deaths were significantly decreased over the last years. Our institution pursues massive preventative and personalized measures for SOS. This strategy may also be applicable in other conditioning protocols in order to reduce the incidence of SOS and, hence, improve the clinical outcome.
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Affiliation(s)
- Ibrahim El-Serafi
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Biochemistry, Faculty of Medicine, Port-Said University, Port-Said, Egypt
| | - Mats Remberger
- Department of Medical Sciences, Uppsala University and KFUE, Uppsala University Hospital, Uppsala, Sweden
| | - Olle Ringdèn
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Törlén
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Cell Therapies and Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Sundin
- Division of Pediatrics, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Hematology/Immunology Section, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Andreas Björklund
- Cell Therapies and Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital, Stockholm, Sweden
| | - Jacek Winiarski
- Division of Pediatrics, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Hematology/Immunology Section, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Jonas Mattsson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Gloria and Seymour Epstein Chair in Cell Therapy and Transplantation and Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
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Tvedt THA, Skaarud KJ, Tjønnfjord GE, Gedde-Dahl T, Iversen PO, Bruserud Ø. The Systemic Metabolic Profile Early after Allogeneic Stem Cell Transplantation: Effects of Adequate Energy Support Administered through Enteral Feeding Tube. Biol Blood Marrow Transplant 2019; 26:380-391. [PMID: 31622769 DOI: 10.1016/j.bbmt.2019.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 09/08/2019] [Accepted: 10/03/2019] [Indexed: 12/21/2022]
Abstract
Patients undergoing allogeneic stem cell transplantation usually require nutritional support. There is no consensus on whether enteral support through tube feeding should be preferred. A recent randomized study could not detect any difference between enteral and parenteral feeding with regard to post-transplant outcomes, whereas 2 retrospective studies described an association between enteral feeding and a favorable post-transplant outcome. We compared pre- and post-transplant plasma metabolomic profiles for 10 patients receiving mainly enteral nutritional support and 10 patients receiving mainly parenteral support. Samples were collected before conditioning and 3 weeks post-transplant; 824 metabolites were analyzed using mass spectrometry. The pretransplant metabolite profiles showed a significant overlap between the 2 groups. Post-transplant samples for both patient groups showed an increase of secondary bile acids and endocannabinoids, whereas reduced levels were seen for food preservatives, plasmalogens, and retinol metabolites. The main post-transplant differences between the groups were decreased levels of fatty acids and markers of mitochondrial activation in the control group, indicating that these patients had insufficient energy intake. A significant effect was also seen for heme/bilirubin metabolism for the parenteral support. To conclude, allotransplant recipients showed altered metabolic profiles early after transplantation; this was mainly due to the conditioning/transplantation/reconstitution, whereas the type of nutritional support had minor effects.
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Affiliation(s)
- Tor Henrik Anderson Tvedt
- Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway; Section for Hematology, Institute of Clinical Science, University of Bergen, Bergen, Norway.
| | - Kristin J Skaarud
- Department of Hematology, University of Oslo, Oslo; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Geir Erland Tjønnfjord
- Department of Hematology, University of Oslo, Oslo; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tobias Gedde-Dahl
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Per Ole Iversen
- Department of Hematology, University of Oslo, Oslo; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Norway; Division of Human Nutrition, Stellenbosch University, Tygerberg, South Africa
| | - Øystein Bruserud
- Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway; Section for Hematology, Institute of Clinical Science, University of Bergen, Bergen, Norway
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Wenger DS, Triplette M, Crothers K, Cheng GS, Hill JA, Milano F, Shahrir S, Schoch G, Vande Vusse LK. Incidence, Risk Factors, and Outcomes of Idiopathic Pneumonia Syndrome after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2019; 26:413-420. [PMID: 31605819 PMCID: PMC7035790 DOI: 10.1016/j.bbmt.2019.09.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/22/2019] [Accepted: 09/26/2019] [Indexed: 11/26/2022]
Abstract
Our current knowledge of idiopathic pneumonia syndrome (IPS) predates improved specificity in the diagnosis of IPS and advances in hematopoietic cell transplantation (HCT) and critical care practices. In this study, we describe and update the incidence, risk factors, and outcomes of IPS. We performed a retrospective cohort study of all adults who underwent allogeneic HCT at the Fred Hutchinson Cancer Research Center between 2006 and 2013 (n = 1829). IPS was defined using the National Heart, Lung, and Blood Institute consensus definition: multilobar airspace opacities on chest imaging, absence of lower respiratory tract infection, and hypoxemia. We described IPS incidence and mortality within 120 and 365 days after HCT. We examined conditioning intensity (nonmyeloablative versus myeloablative with high-dose total body irradiation [TBI] versus myeloablative with low-dose TBI) as an IPS risk factor in a time-to-event analysis using Cox models, controlled for age at transplant, HLA matching, stem cell source, and pretransplant Lung function Score (a combined measure of impairment in Forced Expiratory Volume in the first second (FEV1) and Diffusion capacity for carbon monoxide (DLCO)). Among 1829 HCT recipients, 67 fulfilled IPS criteria within 120 days (3.7%). Individuals who developed IPS were more likely to be black/non-Hispanic versus other racial groups and have severe pulmonary impairment but were otherwise similar to participants without IPS. In adjusted models, myeloablative conditioning with high-dose TBI was associated with increased risk of IPS (hazard ratio, 2.5; 95% confidence interval, 1.2 to 5.2). Thirty-one patients (46.3%) with IPS died within the first 120 days of HCT and 47 patients (70.1%) died within 365 days of HCT. In contrast, among the 1762 patients who did not acquire IPS in the first 120 days, 204 (11.6%) died within 120 days of HCT and 510 (29.9%) died within 365 days of HCT. Our findings suggest that although the incidence of IPS may be declining, it remains associated with post-transplant mortality. Future study should focus on early detection and identifying pathologic mediators of IPS to facilitate timely, targeted therapies for those most susceptible to lung injury post-HCT.
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Affiliation(s)
- David S Wenger
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington.
| | - Matthew Triplette
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kristina Crothers
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington; VA Puget Sound Healthcare System, University of Washington, Seattle, Washington
| | - Guang-Shing Cheng
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Joshua A Hill
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington; Vaccine and Infectious Disease Division & Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Hematology and Oncology, Seattle Cancer Care Alliance, Seattle, Washington
| | - Shahida Shahrir
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington
| | - Gary Schoch
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Lisa K Vande Vusse
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Prophylactic, preemptive, and curative treatment for sinusoidal obstruction syndrome/veno-occlusive disease in adult patients: a position statement from an international expert group. Bone Marrow Transplant 2019; 55:485-495. [PMID: 31576023 PMCID: PMC7051913 DOI: 10.1038/s41409-019-0705-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/06/2019] [Indexed: 02/06/2023]
Abstract
Sinusoidal obstruction syndrome, also known as veno-occlusive disease (SOS/VOD), is a potentially life-threatening complication that can develop after hematopoietic cell transplantation (HCT). While SOS/VOD may resolve within a few weeks in the majority of patients with mild-to-moderate disease, the most severe forms result in multiorgan dysfunction and are associated with a high mortality rate (>80%). Therefore, careful surveillance may allow early detection of SOS/VOD, particularly as the licensed available drug is proven to be effective and reduce mortality. The aim of this work is to propose an international consensus guideline for the treatment and prevention of SOS/VOD in adult patients, on behalf of an international expert group.
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Chronic Cholangiopathy Associated with Primary Immune Deficiencies Can Be Resolved by Effective Hematopoietic Stem Cell Transplantation. J Pediatr 2019; 209:97-106.e2. [PMID: 30850087 DOI: 10.1016/j.jpeds.2019.01.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/14/2018] [Accepted: 01/08/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To investigate effects and outcome of hematopoietic stem cell transplantation (HSCT) on sclerosing cholangitis, in pediatric patients with different primary immunodeficiencies (PIDs). STUDY DESIGN From databases in 2 tertiary centers for immunodeficiencies and liver disease, we have identified children with PIDs and sclerosing cholangitis, who have paired clinical, radiologic, and histologic information before and after HSCT and studied their clinical progress and outcome. RESULTS Seven of 13 children (53.8%) died at a median interval of 4 months (range, 3 months-5 years) after HSCT. However, 6 surviving children (46.2%) with different PIDs and less severe cholangiopathies showed an improvement in markers of liver injury within months of successful unrelated reduced intensity conditioning HSCT. The repeated native liver biopsy, performed in 4 patients at a median of 96 (range, 4-144) months post-HSCT, showed a considerable improvement. Biochemical markers of liver function in the survivors completely normalized after a median of 13 months (range, 2-48). All patients continue to have a mildly dilated extrahepatic biliary system on ultrasonography with no intrahepatic ductal changes on magnetic resonance cholangiography after a follow-up of median 18 years (range, 2-20). CONCLUSIONS Effective HSCT has the potential to improve biochemical and histologic features of cholangiopathy in children with PIDs, presumably by clearance of chronic infection following establishment of immune competence. However, careful patient selection is critical as advanced liver injury is often associated with serious complications and mortality.
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42
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Understanding the Similarities and Differences between Hepatic and Pulmonary Veno-Occlusive Disease. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:1159-1175. [DOI: 10.1016/j.ajpath.2019.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 02/15/2019] [Accepted: 02/21/2019] [Indexed: 12/22/2022]
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43
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Bazinet A, Popradi G. A general practitioner's guide to hematopoietic stem-cell transplantation. ACTA ACUST UNITED AC 2019; 26:187-191. [PMID: 31285665 DOI: 10.3747/co.26.5033] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Hematopoietic stem-cell transplantation (hsct) is a medical procedure that consists of infusing stem cells after a short course of chemotherapy or radiotherapy, or both. It can be used in the treatment of various cancers, as well as some benign conditions. In the present review, we discuss the various types of hsct and their main indications. The principles of the transplant procedure itself and the basics of recipient selection are reviewed. Special attention is given to both the immediate and the long-term complications of hsct and their management strategies. Hematopoietic stem-cell transplantation is a potentially life-saving procedure and often the only curative option for a variety of diseases; however, it is not without significant toxicities.
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Affiliation(s)
- A Bazinet
- Division of Hematology, McGill University Health Centre, Montreal, QC
| | - G Popradi
- Division of Hematology, McGill University Health Centre, Montreal, QC
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The use of defibrotide in blood and marrow transplantation. Blood Adv 2019; 2:1495-1509. [PMID: 29945939 DOI: 10.1182/bloodadvances.2017008375] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 04/30/2018] [Indexed: 12/18/2022] Open
Abstract
Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially life-threatening complication of conditioning during hematopoietic stem cell transplantation (HSCT) or chemotherapy without HSCT, with a historically reported mean incidence of 13.7% post-HSCT. Typical symptoms of VOD/SOS may include hyperbilirubinemia, painful hepatomegaly, weight gain, and ascites. Defibrotide, a polydisperse mixture of predominantly single-stranded polydeoxyribonucleotides, is currently the only therapy approved to treat hepatic VOD/SOS with pulmonary/renal dysfunction (ie, multiorgan dysfunction/multiorgan failure [MOD/MOF]) following HSCT in the United States and to treat severe hepatic VOD/SOS post-HSCT in the European Union. In preclinical and human studies, defibrotide has demonstrated profibrinolytic, antithrombotic, anti-inflammatory, and angio-protective actions, thus promoting an anticoagulant phenotype of the endothelium that protects and stabilizes the function of endothelial cells. In a phase 3, historically controlled, multicenter trial in adults and children with VOD/SOS and MOD/MOF (defibrotide: n = 102; controls treated before defibrotide availability: n = 32), defibrotide resulted in significantly greater day +100 survival following HSCT (38.2%) vs controls (25.0%; propensity analysis-estimated between-group difference: 23%; P = .0109). The most common adverse events (AEs) were hypotension and diarrhea; rates of common hemorrhagic AEs were similar in the defibrotide and historical control group (64% and 75%, respectively). In a phase 3 prophylaxis trial, defibrotide was found to lower incidence of VOD/SOS in children (not an approved indication) and reduce the incidence of graft-versus-host disease. This review describes the development and clinical applications of defibrotide, focusing on its on-label use in patients with VOD/SOS and MOD/MOF after HSCT.
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Canaani J, Beohou E, Labopin M, Ghavamzadeh A, Beelen D, Hamladji RM, Niederwieser D, Volin L, Markiewicz M, Arnold R, Mufti G, Ehninger G, Socié G, Kröger N, Mohty M, Nagler A. Trends in patient outcome over the past two decades following allogeneic stem cell transplantation for acute myeloid leukaemia: an ALWP/EBMT analysis. J Intern Med 2019; 285:407-418. [PMID: 30372796 DOI: 10.1111/joim.12854] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Outcomes for patients with acute myeloid leukaemia (AML) undergoing allogeneic stem cell transplantation (allo-SCT) have significantly improved in recent years. OBJECTIVES To assess the incremental improvement of transplanted AML patients in the last two decades. METHODS Patients included in this analysis were adult AML patients who underwent allo-SCT from an HLA-matched sibling donor (MSD) or HLA-matched unrelated donor (MUD) in first remission. Patient outcomes were assessed between three cohorts according to the year of transplant (1993-2002, 2003-2007 and 2008-2012). RESULTS The analysis comprised a total of 20 187 patients of whom 4763 were transplanted between 1993 and 2002, 5835 in 2003 and 2007, and 9589 in 2008 and 2012. In multivariate analysis, leukaemia-free survival (LFS) rates were significantly improved in more recently transplanted patients compared to patients transplanted in 1993-2002 [Hazard ratio (HR) = 0.84, confidence interval (CI) 95%, 0.77-0.92; P = 0.003], a benefit which also extended to improved overall survival (OS; HR = 0.8, CI 95%, 0.73-0.89; P < 0.0001), and decreased nonrelapse mortality (NRM) rates (HR = 0.65, CI 95%, 0.56-0.75; P < 0.0001). Subset analysis revealed that in MSD, the rates of LFS, NRM and OS significantly improved in patients in the more recent cohort with similar results also seen in MUD. Finally, the incidence of acute graft-versus-host disease (GVHD) was significantly reduced leading to improved GVHD-free/relapse-free survival (GRFS) rates in more recently transplanted patients. CONCLUSION Outcome of allo-SCT for AML patients has markedly improved in the last two decades owing to decreased nonrelapse mortality and improved rates of leukaemia-free survival resulting in significantly longer survival.
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Affiliation(s)
- J Canaani
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Israel
| | - E Beohou
- Acute Leukemia Working Party -EBMT and Department of Hematology and Cell Therapy, Hȏpital Saint-Antoine, Paris, France
| | - M Labopin
- Acute Leukemia Working Party -EBMT and Department of Hematology and Cell Therapy, Hȏpital Saint-Antoine, Paris, France
| | - A Ghavamzadeh
- Hematology-Oncology and BMT Research, Shariati Hospital, Teheran, Iran
| | - D Beelen
- Department of Bone Marrow Transplantation, University Hospital, Essen, Germany
| | - R-M Hamladji
- Service Hématologie Greffe de Moëlle, Centre Pierre et Marie Curie, Alger, Algeria
| | - D Niederwieser
- Division of Haematology & Oncology, University Hospital Leipzig, Leipzig, Germany
| | - L Volin
- Stem Cell Transplantation Unit, Comprehensive Cancer Centre, Helsinki University Hospital, Helsinki, Finland
| | - M Markiewicz
- Department of Haematology and BMT, Medical University of Silesia, Katowice, Poland
| | - R Arnold
- Medizinische Klinik m. S. Hämatologie/Onkologie, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - G Mufti
- Department of Haematological Medicine, GKT School of Medicine, London, UK
| | - G Ehninger
- Universitaetsklinikum Dresden Medizinische Klinik und Poliklinik I, Dresden, Germany
| | - G Socié
- Department of Hematology - BMT, Hȏpital St. Louis, Paris, France
| | - N Kröger
- Bone Marrow Transplantation Centre, University Hospital Eppendorf, Hamburg, Germany
| | - M Mohty
- Acute Leukemia Working Party -EBMT and Department of Hematology and Cell Therapy, Hȏpital Saint-Antoine, Paris, France
| | - A Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Israel.,Acute Leukemia Working Party -EBMT and Department of Hematology and Cell Therapy, Hȏpital Saint-Antoine, Paris, France
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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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Roeker LE, Kim HT, Glotzbecker B, Nageshwar P, Nikiforow S, Koreth J, Armand P, Cutler C, Alyea EP, Antin JH, Richardson PG, Soiffer RJ, Ho VT. Early Clinical Predictors of Hepatic Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome after Myeloablative Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:137-144. [DOI: 10.1016/j.bbmt.2018.07.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/25/2018] [Indexed: 01/20/2023]
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El-Serafi I, Remberger M, El-Serafi A, Benkessou F, Zheng W, Martell E, Ljungman P, Mattsson J, Hassan M. The effect of N-acetyl-l-cysteine (NAC) on liver toxicity and clinical outcome after hematopoietic stem cell transplantation. Sci Rep 2018; 8:8293. [PMID: 29844459 PMCID: PMC5974141 DOI: 10.1038/s41598-018-26033-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/03/2018] [Indexed: 02/06/2023] Open
Abstract
Busulphan (Bu) is a myeloablative drug used for conditioning prior to hematopoietic stem cell transplantation. Bu is predominantly metabolized through glutathione conjugation, a reaction that consumes the hepatic glutathione. N-acetyl-l-cysteine (NAC) is a glutathione precursor used in the treatment of acetaminophen hepatotoxicity. NAC does not interfere with the busulphan myeloablative effect. We investigated the effect of NAC concomitant treatment during busulphan conditioning on the liver enzymes as well as the clinical outcome. Prophylactic NAC treatment was given to 54 patients upon the start of busulphan conditioning. These patients were compared with 54 historical matched controls who did not receive NAC treatment. In patients treated with NAC, aspartate transaminase (AST), alanine transaminase (ALT) and alkaline phosphatase (ALP) were significantly (P < 0.05) decreased after conditioning compared to their start values. Within the NAC-group, liver enzymes were normalized in those patients (30%) who had significantly high start values. No significant decrease in enzyme levels was observed in the control group. Furthermore, NAC affected neither Bu kinetics nor clinical outcome (sinusoidal obstruction syndrome incidence, graft-versus-host disease and/or graft failure). In conclusion: NAC is a potential prophylactic treatment for hepatotoxicity during busulphan conditioning. NAC therapy did not alter busulphan kinetics or affect clinical outcome.
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Affiliation(s)
- Ibrahim El-Serafi
- ECM, KFC, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Mats Remberger
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Ahmed El-Serafi
- ECM, KFC, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,College of Medicine, University of Sharjah, Sharjah, UAE
| | - Fadwa Benkessou
- ECM, KFC, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Wenyi Zheng
- ECM, KFC, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Eva Martell
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Per Ljungman
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Mattsson
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Moustapha Hassan
- ECM, KFC, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden. .,Experimental Cancer Medicine, Clinical Research Center, Karolinska University Hospital, Huddinge, Sweden.
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Deeg HJ, Stevens EA, Salit RB, Ermoian RP, Fang M, Gyurkocza B, Sorror ML, Fatobene G, Baumgart J, Burroughs LM, Delaney C, Doney K, Egan DN, Flowers ME, Milano F, Radich JP, Scott BL, Sickle EJ, Wood BL, Yeung C, Storer BE. Transplant Conditioning with Treosulfan/Fludarabine with or without Total Body Irradiation: A Randomized Phase II Trial in Patients with Myelodysplastic Syndrome and Acute Myeloid Leukemia. Biol Blood Marrow Transplant 2018; 24:956-963. [DOI: 10.1016/j.bbmt.2017.12.785] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 12/14/2017] [Indexed: 01/28/2023]
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Pao E, Gove NE, Flynn JT, Hingorani S. Ambulatory Blood Pressure and Endothelial Dysfunction in Hematopoietic Cell Transplantation Recipients. Biol Blood Marrow Transplant 2018; 24:1678-1684. [PMID: 29704542 DOI: 10.1016/j.bbmt.2018.04.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/18/2018] [Indexed: 11/16/2022]
Abstract
Hematopoietic cell transplantation (HCT) is a common treatment for many disorders. Albuminuria post-HCT, which may represent endothelial injury or inflammation from graft- versus-host disease, increases the risk of chronic kidney disease and nonrelapse mortality at 1 year. HCT recipients also have abnormal blood pressure (BP) and increased rates of cardiovascular complications. We sought to determine the relationships among albuminuria, endothelial dysfunction, and BP in HCT recipients. Patients age ≥12 years who underwent their first allogeneic HCT between 2012 and 2015 and survived through day 80 post-HCT were eligible. Peripheral endothelial function was assessed using the EndoPAT2000 device at day 80 along with 24-hour ambulatory BP monitoring (ABPM). Clinical and laboratory data were collected along with a urine sample for calculation of the albumin-to-creatinine ratio. Both logistic and linear regression analyses were used to identify associations between EndoPAT score and clinical variables. Sixty patients (median age, 48 years; range, 14 to 69 years) completed the study. The median EndoPAT score was 2.05 (range, 1.02 to 4.45), and 17 patients (28%) had abnormal endothelial function. Forty-two patients (72%) had ambulatory hypertension (HTN), and 38 (63%) had blunted nocturnal dipping. HTN on ABPM (P = .045) and blunted nocturnal dipping (P = .04) were associated with a lower EndoPAT score. Albuminuria was not associated with EndoPAT score. There was a lack of agreement between our clinical definition of HTN (office BP and/or use of medications) and ABPM results (P = .04). We did not find an association between lower EndoPAT scores and albuminuria, but did find an association between an abnormal nocturnal dip and HTN diagnosed by ABPM. This suggests that albuminuria may reflect local endothelial injury and inflammation rather than a systemic process. Office BP readings do not accurately reflect true BP, suggesting that 24-hour ABPM studies are needed to diagnose and treat HTN appropriately.
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Affiliation(s)
- Emily Pao
- Department of Pediatrics and Seattle Children's Hospital, Division of Nephrology and Center for Clinical and Translational Research, Seattle, Washington
| | - Nancy E Gove
- Department of Pediatrics and Seattle Children's Hospital, Division of Nephrology and Center for Clinical and Translational Research, Seattle, Washington
| | - Joseph T Flynn
- Department of Pediatrics and Seattle Children's Hospital, Division of Nephrology and Center for Clinical and Translational Research, Seattle, Washington
| | - Sangeeta Hingorani
- Department of Pediatrics and Seattle Children's Hospital, Division of Nephrology and Center for Clinical and Translational Research, Seattle, Washington; Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, Washington.
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