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Shanthikumar S, Gower WA, Cooke KR, Bergeron A, Schultz KR, Barochia A, Tamae-Kakazu M, Charbek E, Reardon EE, Calvo C, Casey A, Cheng PC, Cole TS, Davies SM, Das S, De A, Deterding RR, Liptzin DR, Mechinaud F, Rayment JH, Robinson PD, Siddaiah R, Stone A, Srinivasin S, Towe CT, Yanik GA, Iyer NP, Goldfarb SB. Diagnosis of Post-Hematopoietic Stem Cell Transplantation Bronchiolitis Obliterans Syndrome in Children: Time for a Rethink? Transplant Cell Ther 2024:S2666-6367(24)00411-1. [PMID: 38897861 DOI: 10.1016/j.jtct.2024.05.012] [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: 03/06/2024] [Revised: 04/28/2024] [Accepted: 05/13/2024] [Indexed: 06/21/2024]
Abstract
Hematopoietic stem cell transplantation (HSCT) is undertaken in children with the aim of curing a range of malignant and nonmalignant conditions. Unfortunately, pulmonary complications, especially bronchiolitis obliterans syndrome (BOS), are significant sources of morbidity and mortality post-HSCT. Currently, criteria developed by a National Institutes of Health (NIH) working group are used to diagnose BOS in children post-HSCT. Unfortunately, during the development of a recent American Thoracic Society (ATS) Clinical Practice Guideline on this topic, it became apparent that the NIH criteria have significant limitations in the pediatric population, leading to late diagnosis of BOS. Specific limitations include use of an outdated pulmonary function testing reference equation, a reliance on spirometry, use of a fixed forced expiratory volume in 1 second (FEV1) threshold, focus on obstructive defects defined by FEV1/vital capacity, and failure to acknowledge that BOS and infection can coexist. In this review, we summarize the evidence regarding the limitations of the current criteria. We also suggest potential evidence-based ideas for improving these criteria. Finally, we highlight a new proposed criteria for post-HSCT BOS in children that were developed by the authors of the recently published ATS clinical practice guideline, along with a pathway forward for improving timely diagnosis of BOS in children post-HSCT.
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Affiliation(s)
- Shivanthan Shanthikumar
- Respiratory and Sleep Medicine, Royal Children's Hospital, Melbourne, Australia; Respiratory Diseases, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia.
| | - William A Gower
- Division of Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Kenneth R Cooke
- Department of Oncology, Pediatric Blood and Marrow Transplantation Program, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | - Anne Bergeron
- Pneumology Department, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Kirk R Schultz
- Pediatric Hematology/Oncology/BMT, BC Children's Research Institute/UBC, Vancouver, British Columbia, Canada
| | - Amisha Barochia
- Laboratory of Asthma and Lung Inflammation, Critical Care Medicine and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Maximiliano Tamae-Kakazu
- Division of Pulmonary and Critical Care, Corewell Health, Grand Rapids, Michigan; Department of Medicine, Michigan State University College of Human Medicine, Michigan
| | - Edward Charbek
- Department of Internal Medicine, Saint Louis University, St Louis, Missouri
| | - Erin E Reardon
- Woodruff Health Sciences Center Library, Emory University, Atlanta, Georgia
| | - Charlotte Calvo
- Pediatric Hematology and Immunology Department, Robert Debré Hospital, Paris Cité University, Paris, France; Human Immunology, Pathophysiology and Immunotherapy, INSERM UMR-976, Institut de Recherche Saint-Louis, Paris, France
| | - Alicia Casey
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pi Chun Cheng
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana; Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Theresa S Cole
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Children's Cancer Centre, Royal Children's Hospital, Melbourne, Australia; Infection & immunity, Murdoch Children's Research Institute, Melbourne, Australia
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shailendra Das
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Alive De
- Division of Pediatric Pulmonology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Robin R Deterding
- Chief Pediatric Pulmonary and Sleep Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Deborah R Liptzin
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Francoise Mechinaud
- Pediatric Hematology and Immunology Department, Robert Debré Hospital, Paris Cité University, Paris, France
| | - Jonathan H Rayment
- Division of Respiratory Medicine, BC Children's Hospital, Vancouver, Canada; Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Paul D Robinson
- Department of Respiratory Medicine, Queensland Children's Hospital, Queensland, Australia; Children's Health and Environment Program, Child Health Research Centre, University of Queensland, Queensland, Australia; Airway Physiology and Imaging Group, Woolcock Institute of Medical Research, New South Wales, Australia
| | - Roopa Siddaiah
- Division of Pulmonology, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Anne Stone
- Division of Pediatric Pulmonology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon
| | - Saumini Srinivasin
- Department of Pediatrics, University of Tennessee College of Medicine, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Christopher T Towe
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Gregory A Yanik
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - Narayan P Iyer
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Samuel B Goldfarb
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; Division of Pulmonary Medicine, Masonic Children's Hospital, Minneapolis, Minnesota
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Gertz SJ, Bhalla A, Chima RS, Emeriaud G, Fitzgerald JC, Hsing DD, Jeyapalan AS, Pike F, Sallee CJ, Thomas NJ, Yehya N, Rowan CM. Immunocompromised-Associated Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study. Pediatr Crit Care Med 2024; 25:288-300. [PMID: 38236083 PMCID: PMC10994753 DOI: 10.1097/pcc.0000000000003421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVES To characterize immunocompromised-associated pediatric acute respiratory distress syndrome (I-PARDS) and contrast it to PARDS. DESIGN This is a secondary analysis of the 2016-2017 PARDS incidence and epidemiology (PARDIE) study, a prospective observational, cross-sectional study of children with PARDS. SETTING Dataset of 145 PICUs across 27 countries. PATIENTS During 10 nonconsecutive weeks (from May 2016 to June 2017), data about immunocompromising conditions (ICCs, defined as malignancy, congenital/acquired immunodeficiency, posttransplantation, or diseases requiring immunosuppression) were collected. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 708 subjects, 105 (14.8%) had ICC. Before the development of I-PARDS, those with ICC were more likely to be hospitalized (70% vs. 35%, p < 0.001), have more at-risk for PARDS ( p = 0.046), and spent more hours at-risk (20 [interquartile range, IQR: 8-46] vs. 11 [IQR: 4-33], [ p = 0.002]). Noninvasive ventilation (NIV) use was more common in those with ICC ( p < 0.001). Of those diagnosed with PARDS on NIV ( n = 161), children with ICC were more likely to be subsequently intubated ( n = 28/40 [70%] vs n = 53/121 [44%], p = 0.004). Severe PARDS was more common (32% vs 23%, p < 0.001) in I-PARDS. Oxygenation indices were higher at diagnosis and had less improvement over the first 3 days of PARDS ( p < 0.001). Children with I-PARDS had greater nonpulmonary organ dysfunction. Adjusting for Pediatric Risk of Mortality IV and oxygenation index, children with I-PARDS had a higher severity of illness-adjusted PICU mortality (adjusted hazard ratio: 3.0 [95% CI, 1.9-4.7] p < 0.001) and were less likely to be extubated alive within 28 days (subdistribution hazard ratio: 0.47 [95% CI, 0.31-0.71] p < 0.001). CONCLUSIONS I-PARDS is a unique subtype of PARDS associated with hospitalization before diagnosis and increased: time at-risk for PARDS, NIV use, hypoxia, nonpulmonary organ dysfunction, and mortality. The opportunity for early detection and intervention seems to exist. Dedicated study in these patients is imperative to determine if targeted interventions will benefit these unique patients with the ultimate goal of improving outcomes.
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Affiliation(s)
- Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, NJ
| | - Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles and University of Southern California, Los Angeles, CA
| | - Ranjit S Chima
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH
| | - Guillaume Emeriaud
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine and Université de Montréal, Montreal, QC, Canada
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Deyin D Hsing
- Department of Pediatrics, New York Presbyterian Hospital and Weill Cornell Medical College, New York, NY
| | - Asumthia S Jeyapalan
- Division of Critical Care Medicine, Department of Pediatrics, University of Miami, Miami, FL
| | - Francis Pike
- Department of Biostatistics, Indiana University, Indianapolis, IN
| | - Colin J Sallee
- Division of Pediatric Critical Care, Department of Pediatrics, UCLA Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, PA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Courtney M Rowan
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at IU Health, Indianapolis, IN
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Calder AD, Perucca G, Johnson SM, Pandey AR, Moshal K, Kusters MA. Lung infections in immunocompromised children. Pediatr Radiol 2024; 54:530-547. [PMID: 37589764 DOI: 10.1007/s00247-023-05735-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/18/2023]
Abstract
Pulmonary infection is the leading cause of infectious morbidity and mortality in children with immune defects. We provide a comprehensive review of lung infections in immunocompromised children, with a focus on imaging findings and imaging-based management. We include an overview of the immune defences of the respiratory tract, the aetiologies of immune defects in children, the features of specific infections and important differential diagnoses and describe diagnostic strategies using imaging and non-imaging-based techniques.
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Affiliation(s)
- Alistair D Calder
- Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
| | - Giulia Perucca
- Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Sarah May Johnson
- Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ashwin R Pandey
- Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Karyn Moshal
- Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Maaike A Kusters
- Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Rozmus J, Levine JE, Schultz KR. Planning GvHD preemptive therapy: risk factors, biomarkers, and prognostic scores. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:149-154. [PMID: 38066854 PMCID: PMC10727102 DOI: 10.1182/hematology.2023000425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Prevention of acute and chronic graft-versus-host disease (aGvHD and cGvHD) is an important objective of allogeneic hematopoietic cell transplantation (HCT). While there is has been significant progress in preventative approaches in the peritransplant period to minimize development of GvHD, no preventative approach has completely eliminated development of either aGvHD or cGvHD. Recently, posttransplant immune biomarker profiling early post-HCT by the Mount Sinai Acute GvHD International Consortium group has resulted in a validated risk assignment algorithm and development of preemptive approaches to decrease aGvHD and mortality in high-risk patients. cGvHD risk assignment algorithms have been developed based on measurements at day 100 and may be used for future preemptive intervention trials to minimize cGvHD. This article discusses the current state of the art in aGvHD and cGvHD preemptive algorithms and therapeutic interventions and what is needed to move these into validated approaches.
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Affiliation(s)
- Jacob Rozmus
- Pediatric Hematology Oncology and BMT, BC Children's Hospital Research Institute and University of British Columbia, Vancouver, BC, Canada
| | - John E Levine
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kirk R Schultz
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Sonneveld N, Rayment JH, Usemann J, Nielsen KG, Robinson PD. Multiple breath washout and oscillometry after allogenic HSCT: a scoping review. Eur Respir Rev 2023; 32:220251. [PMID: 37495248 PMCID: PMC10369167 DOI: 10.1183/16000617.0251-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/04/2023] [Indexed: 07/28/2023] Open
Abstract
Pulmonary chronic graft-versus-host disease (cGVHD) is a substantial cause of pulmonary morbidity and mortality post-haematopoietic stem cell transplantation (HSCT). Current spirometry-based monitoring strategies have significant limitations. Understanding the utility of novel peripheral airway function tests - multiple breath washout (MBW) and oscillometry - is critical in efforts to improve detection, facilitate earlier intervention and improve outcomes. In this scoping review, we identified 17 studies investigating MBW or oscillometry, or both, after allogenic HSCT. Despite small study numbers limiting the ability to draw firm conclusions, several themes were evident. Detectable peripheral airway abnormality in MBW occurred in a substantial proportion prior to HSCT. MBW indices post-HSCT were more frequently abnormal than spirometry when reporting group data and among those with extrapulmonary cGVHD and pulmonary cGVHD. Changes in MBW indices over time may be more indicative of pulmonary complications than absolute values at any given time point. Oscillometry indices were often normal at baseline, but more frequently abnormal in those who developed pulmonary cGVHD. Pooling currently available individual participant data across these studies may improve our ability to formally compare their respective sensitivity and specificity at specific time points and assess the trajectory of MBW and oscillometry indices over time.
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Affiliation(s)
- Nicole Sonneveld
- Department of Respiratory Medicine, Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, Australia
- Discipline of Paediatrics and Child Health, University of Sydney, Sydney, Australia
| | - Jonathan H Rayment
- Division of Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Jakob Usemann
- University Children's Hospital Basel (UKBB), Basel, Switzerland
- Division of Respiratory Medicine and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Kim G Nielsen
- Paediatric Pulmonary Service, Copenhagen University Hospital, Department of Paediatric and Adolescent Medicine, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Paul D Robinson
- Department of Respiratory Medicine, Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, Australia
- Discipline of Paediatrics and Child Health, University of Sydney, Sydney, Australia
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, Sydney, Australia
- Children's Health and Environment Program, Child Health Research Centre, University of Queensland, Brisbane, Australia
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Mohseni R, Mahdavi Sharif P, Behfar M, Modaresi MR, Shirzadi R, Mardani M, Jafari L, Jafari F, Nikfetrat Z, Hamidieh AA. Evaluation of safety and efficacy of allogeneic adipose tissue-derived mesenchymal stem cells in pediatric bronchiolitis obliterans syndrome (BoS) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Stem Cell Res Ther 2023; 14:256. [PMID: 37726865 PMCID: PMC10510238 DOI: 10.1186/s13287-023-03498-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 09/13/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Allo-HSCT is a definite approach for the management of a wide variety of lethal and debilitating malignant and non-malignant disorders. However, its two main complications, acute and chronic graft-versus-host disease (GVHD), exert significant morbidities and mortalities. BoS, as a manifestation of chronic lung GVHD, is a gruesome complication of allo-HSCT, and for those with steroid-refractory disease, no approved second-line therapies exist. Mesenchymal stem cells (MSCs) exert anti-inflammatory and growth-promoting effects, and their administration against a wide range of inflammatory and neurologic disorders, as well as GVHD, has been associated with promising outcomes. However, literature on the safety and effectiveness of MSC therapy for BoS and pediatric cGVHD is scarce. METHODS We designed a single-arm trial to administer adipose tissue (AT)-derived MSCs to pediatric patients with refractory BoS after allo-HSCT. AT-MSCs from obese, otherwise healthy donors were cultured in an ISO class 1 clean room and injected into the antecubital vein of eligible patients with a dose of 1 × 106/kg. The primary endpoints included a complete or partial response to therapy [in terms of increased forced expiratory volume in one second (FEV1) values and steroid dose reduction] and its safety profile. RESULTS Four eligible patients with a median age of 6.5 years were enrolled in the study. Steroid-induced osteoporosis and myopathy were present in three cases. A partial response was evident in three cases after a single injection of AT-MSCs. The treatment was safe and tolerable, and no treatment-related adverse events were noted. Two patients developed manageable COVID-19 infections one and 4 months after AT-MSC injection. After a median follow-up duration of 19 months, all cases are still alive and have had no indications for lung transplantation. CONCLUSIONS AT-MSCs could be safely administered to our pediatric cases with BoS post-allo-HSCT. Considering their advanced stage of disease, their sub-optimal functional capacity due to steroid-induced complications, and COVID-19 infection post-treatment, we believe that AT-MSC therapy can have possible efficacy in the management of pediatric BoS. The conduction of further studies with larger sample sizes and more frequent injections is prudent for further optimization of AT-MSC therapy against BoS. Trial registration Iranian Registry of Clinical Trials (IRCT), IRCT20201202049568N2. Registered 22 February 2021, https://en.irct.ir/trial/53143 .
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Affiliation(s)
- Rashin Mohseni
- Pediatric Cell and Gene Therapy Research Center, Gene, Cell and Tissue Research Institute, Children's Medical Center Hospital, Tehran University of Medical Sciences, 63 Qarib St., Keshavarz Blvd., Tehran, 14155-6559, 1419733161, Iran
| | - Pouya Mahdavi Sharif
- Pediatric Cell and Gene Therapy Research Center, Gene, Cell and Tissue Research Institute, Children's Medical Center Hospital, Tehran University of Medical Sciences, 63 Qarib St., Keshavarz Blvd., Tehran, 14155-6559, 1419733161, Iran
| | - Maryam Behfar
- Pediatric Cell and Gene Therapy Research Center, Gene, Cell and Tissue Research Institute, Children's Medical Center Hospital, Tehran University of Medical Sciences, 63 Qarib St., Keshavarz Blvd., Tehran, 14155-6559, 1419733161, Iran
| | - Mohammad Reza Modaresi
- Pediatric Respiratory and Sleep Medicine Research Center, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Rohola Shirzadi
- Pediatric Pulmonary Disease and Sleep Medicine Research Center, Pediatric Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahta Mardani
- Pediatric Cell and Gene Therapy Research Center, Gene, Cell and Tissue Research Institute, Children's Medical Center Hospital, Tehran University of Medical Sciences, 63 Qarib St., Keshavarz Blvd., Tehran, 14155-6559, 1419733161, Iran
| | - Leila Jafari
- Pediatric Cell and Gene Therapy Research Center, Gene, Cell and Tissue Research Institute, Children's Medical Center Hospital, Tehran University of Medical Sciences, 63 Qarib St., Keshavarz Blvd., Tehran, 14155-6559, 1419733161, Iran
| | - Fahimeh Jafari
- Pediatric Cell and Gene Therapy Research Center, Gene, Cell and Tissue Research Institute, Children's Medical Center Hospital, Tehran University of Medical Sciences, 63 Qarib St., Keshavarz Blvd., Tehran, 14155-6559, 1419733161, Iran
| | - Zeynab Nikfetrat
- Pediatric Cell and Gene Therapy Research Center, Gene, Cell and Tissue Research Institute, Children's Medical Center Hospital, Tehran University of Medical Sciences, 63 Qarib St., Keshavarz Blvd., Tehran, 14155-6559, 1419733161, Iran
| | - Amir Ali Hamidieh
- Pediatric Cell and Gene Therapy Research Center, Gene, Cell and Tissue Research Institute, Children's Medical Center Hospital, Tehran University of Medical Sciences, 63 Qarib St., Keshavarz Blvd., Tehran, 14155-6559, 1419733161, Iran.
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Klein OR, Ktena YP, Pierce E, Fu HH, Haile A, Liu C, Cooke KR. Defibrotide modulates pulmonary endothelial cell activation and protects against lung inflammation in pre-clinical models of LPS-induced lung injury and idiopathic pneumonia syndrome. Front Immunol 2023; 14:1186422. [PMID: 37441074 PMCID: PMC10335747 DOI: 10.3389/fimmu.2023.1186422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction A multiple organ dysfunction syndrome (MODS) workshop convened by the National Institute of Child Health and Human Development in 2015 identified acute respiratory distress syndrome (ARDS) and complications of allogeneic blood and marrow transplantation (allo-BMT) as contributors to MODS in pediatric patients. Pulmonary dysfunction also remains a significant complication of allo-BMT. Idiopathic pneumonia syndrome (IPS) defines non-infectious, acute, lung injury that occurs post-transplant. Injury and activation to endothelial cells (ECs) contribute to each form of lung inflammation. Methods Two murine models were employed. In an ARDS model, naïve B6 mice receive an intravenous (i.v.) injection of lipopolysaccharide (LPS). In the established model of IPS, naïve B6D2F1 mice receive lethal total body irradiation followed by BMT from either allogeneic (B6) or syngeneic (B6D2F1) donors. Lung inflammation was subsequently assessed in each scenario. Results Intravenous injection of LPS to B6 mice resulted in enhanced mRNA expression of TNFα, IL-6, Ang-2, E-, and P-selectin in whole lung homogenates. The expression of Ang-2 in this context is regulated in part by TNFα. Additionally, EC activation was associated with increased total protein and cellularity in broncho-alveolar lavage fluid (BALF). Similar findings were noted during the development of experimental IPS. We hypothesized that interventions maintaining EC integrity would reduce the severity of ARDS and IPS. Defibrotide (DF) is FDA approved for the treatment of BMT patients with sinusoidal obstruction syndrome and renal or pulmonary dysfunction. DF stabilizes activated ECs and protect them from further injury. Intravenous administration of DF before and after LPS injection significantly reduced mRNA expression of TNFα, IL6, Ang-2, E-, and P-selectin compared to controls. BALF showed decreased cellularity, reflecting less EC damage and leak. Allogeneic BMT mice were treated from day -1 through day 14 with DF intraperitoneally, and lungs were harvested at 3 weeks. Compared to controls, DF treatment reduced mRNA expression of TNFα, IL6, Ang-2, E-, and P- selectin, BALF cellularity, and lung histopathology. Conclusion The administration of DF modulates EC injury in models of ARDS and IPS. Cytokine inhibition in combination with agents that stabilize EC integrity may be an attractive strategy for patients in each setting.
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Affiliation(s)
- Orly R. Klein
- Department of Oncology, Pediatric Blood and Marrow Transplant Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States
| | - Yiouli P. Ktena
- Department of Oncology, Pediatric Blood and Marrow Transplant Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States
| | - Elizabeth Pierce
- Department of Pediatrics, Pediatric Blood and Marrow Transplant Program, Case Western Reserve University, School of Medicine, Cleveland, OH, United States
| | - Han-Hsuan Fu
- Department of Oncology, Pediatric Blood and Marrow Transplant Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States
| | - Azeb Haile
- Department of Oncology, Pediatric Blood and Marrow Transplant Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States
| | - Chen Liu
- Department of Pathology, Yale School of Medicine, New Haven, CT, United States
| | - Kenneth R. Cooke
- Department of Oncology, Pediatric Blood and Marrow Transplant Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States
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8
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Schoettler ML, Saldana BD, Berkenkamp L, Chonat S, Watkins B, Rotz SJ, Simons D, Graf E, Rossi C, Cheng J, Hammers YA, Rytting H, Williams KM. Pulmonary Manifestations and Vascular Changes in Pediatric Transplantation-Associated Thrombotic Microangiopathy. Transplant Cell Ther 2023; 29:45.e1-45.e8. [PMID: 36202334 PMCID: PMC11003462 DOI: 10.1016/j.jtct.2022.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/21/2022] [Accepted: 09/25/2022] [Indexed: 11/08/2022]
Abstract
Although transplant-associated thrombotic microangiopathy (TA-TMA) commonly complicates pediatric hematopoietic cellular therapy (HCT), pulmonary manifestations and histology of TA-TMA (pTA-TMA) are rarely reported, with scant data available on timing, risk factors, pathogenesis, and outcomes. Pulmonary hypertension (PH) and diffuse alveolar hemorrhage (DAH) are recognized manifestations of pTA-TMA. The objective of this study was to characterize the pathologic findings, outcomes, and coincident diagnoses preceding biopsy-proven pTA-TMA. In Institutional Review Board- approved retrospective studies, available lung tissue was reviewed at 2 institutions between January 2016 and August 2021 to include those with pulmonary vascular pathology. Histologic features of pTA-TMA were present in 10 children with prior respiratory decline after an allogeneic HCT (allo-HCT; n = 9) or autologous HCT (n = 1). Pathologic lesions included muscular medialization, microthrombi, and red cell fragments, in addition to perivasculitis and intimal arteritis. Parenchymal findings included diffuse alveolar damage, organizing pneumonia, and plasmocytic infiltrates. Six children were clinically diagnosed with TA-TMA, and all were treated with eculizumab, at a median of 2.5 days after clinical diagnosis (range, 0 to 11 days). Four were identified postmortem. Coincident pulmonary infection was confirmed in 8 of the 10 patients. Five allo-HCT recipients (56%) experienced graft-versus-host disease (GVHD; 4 acute, 1 chronic) prior to the onset of respiratory symptoms. Two patients (20%) had clinically recognized DAH, although 9 (90%) had evidence of DAH on histology. Although all 10 patients underwent echocardiography at the time of symptom onset and 9 had serial echocardiograms, only 2 patients had PH detected. Treatments varied and included sildenafil (n = 3), steroids (n = 1), and eculizumab (n = 6). One patient was alive at the time of this report; the remaining 9 died, at a median of 52 days after onset of respiratory symptoms (range 4 to 440 days) and a median of 126 days post-HCT (range, 13 to 947 days). pTA-TMA is a heterogeneous histologic disease characterized by arteriolar inflammation, microthrombi, and often DAH. pTA-TMA presented with respiratory decline with systemic TA-TMA in all patients. Clinicians should maintain a high degree of suspicion for DAH in patients with TA-TMA and pulmonary symptoms. Coincident rates of GVHD and pulmonary infections were high, whereas the rate of PH identified by echocardiography was 20%. Outcomes were poor despite early use of eculizumab and other therapies. Our data merit consideration of pTA-TMA in patients with acute respiratory decline in the setting of systemic TA-TMA, GVHD, and infection. Investigation of additional therapies for pTA-TMA is needed as well. © 2022 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia.
| | - Blachy D Saldana
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC
| | - Lisa Berkenkamp
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Dawn Simons
- Children's Healthcare of Atlanta, Emory University, Pediatric Pulmonology, Atlanta, Georgia
| | - Emily Graf
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC
| | | | - Jinjun Cheng
- Division of Pathology, Children's National Hospital, Washington, DC
| | - Yuki A Hammers
- Children's Healthcare of Atlanta, Department of Pathology, Atlanta, Georgia
| | - Heather Rytting
- Children's Healthcare of Atlanta, Department of Pathology, Atlanta, Georgia
| | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
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9
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Novel approaches to the prediction and diagnosis of pulmonary complications in the paediatric haematopoietic stem cell transplant patient. Curr Opin Infect Dis 2022; 35:493-499. [PMID: 36345851 DOI: 10.1097/qco.0000000000000883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
PURPOSE OF REVIEW Haematopoietic stem cell transplant (HSCT) remains the only curative treatment option for many children with relapsed leukaemia, primary immunodeficiencies and haemoglobinopathies. Unfortunately, infectious and noninfectious pulmonary complications following HSCT continue to cause significant morbidity and mortality. This review will focus on recent advances in the field that enhance clinically available diagnostic tools and the role of novel diagnostic techniques. RECENT FINDINGS Research continues to highlight the role of standard diagnostic modalities, including imaging using computed topography chest and Fluorodeoxyglucose-positron emission tomography (FDG-PET) in the diagnosis of posttransplant pulmonary infections. Similarly, bronchoalveolar lavage using bronchoscopy to obtain samples for microbiological analysis remains an important tool in the clinical and diagnostic algorithm for these children. The application of more novel diagnostic techniques such as metagenomic next-generation sequencing and the use of specific biomarkers remain potential future tools in children in whom the aetiology of posttransplant lung disease is unknown. The impact of the pulmonary microbiome on infectious and noninfectious pulmonary disease post HSCT is a future research direction. SUMMARY Pulmonary infectious complications post HSCT remain a devastating complication for children and their families. Despite improvements in standard and novel diagnostic modalities, the aetiology of pulmonary disease remains unknown for many patients. There is an urgent need for ongoing collaborative research to bridge this critical knowledge gap and lead to better patient outcomes.
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10
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曹 乐, 周 婧, 陈 育, 陈 欢, 韩 伟, 陈 瑶, 张 圆, 闫 晨, 程 翼, 莫 晓, 付 海, 韩 婷, 吕 萌, 孔 军, 孙 于, 王 昱, 许 兰, 张 晓, 黄 晓. [Relationship between treatment and prognosis in patients with late-onset severe pneumonia after allogeneic hematopoietic stem cell transplantation]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2022; 54:1013-1020. [PMID: 36241246 PMCID: PMC9568376 DOI: 10.19723/j.issn.1671-167x.2022.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To explore the relationship between drug treatment and outcomes in patients with late-onset severe pneumonia (LOSP) after allogeneic stem cell transplantation (allo-SCT). METHODS We retrospectively analyzed the effects of the initiation time of treatment drugs, especially antiviral drugs and glucocorticoids on the clinical outcomes in 82 patients between January 2016 and August 2021 who developed LOSP after allo-SCT in Peking University People's Hospital. Univariate analysis was performed by Mann-Whitney U test and χ2 test, and multivariate analysis was performed by Logistic regression. When multiple groups (n>2) were involved in the χ2 test, Bonferroni correction was used for the level of significance test. RESULTS Of all 82 patients in this study, the median onset time of LOSP was 220 d (93-813 d) after transplantation, and the 60-day survival rate was 58.5% (48/82). The median improvement time of the survival patients was 18 d (7-44 d), while the median death time of the died patients was 22 d (2-53 d). Multivariate analysis showed that the initiation time of antiviral drugs from the onset of LOSP (< 10 d vs. ≥10 d, P=0.012), and the initiation time of glucocorticoids from antiviral drugs (< 10 d vs. ≥10 d, P=0.027) were the factors affecting the final outcome of the patients with LOSP at the end of 60 d. According to the above results, LOSP patients were divided into four subgroups: group A (antiviral drugs < 10 d, glucocorticoids ≥10 d), group B (antiviral drugs < 10 d, glucocorticoids < 10 d), group C (antiviral drugs ≥10 d, glucocorticoids ≥10 d) and group D (antiviral drugs ≥10 d, glucocorticoids < 10 d), the 60-day survival rates were 91.7%, 56.8%, 50.0% and 21.4%, respectively. CONCLUSION Our study demonstrated that in patients who developed LOSP after allo-SCT, the initiation time of antiviral drugs and glucocorticoids were associated with the prognosis of LOSP, and the survival rate was highest in patients who received antiviral drugs early and glucocorticoids later. It suggested that for patients with LOSP of unknown etiology should be highly suspicious of the possibility of a secondary hyperimmune response to viral infection.
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Affiliation(s)
- 乐清 曹
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 婧睿 周
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 育红 陈
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 欢 陈
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 伟 韩
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 瑶 陈
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 圆圆 张
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 晨华 闫
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 翼飞 程
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 晓冬 莫
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 海霞 付
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 婷婷 韩
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 萌 吕
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 军 孔
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 于谦 孙
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 昱 王
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 兰平 许
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 晓辉 张
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - 晓军 黄
- />北京大学人民医院血液科, 北京大学血液病研究所, 国家血液系统疾病临床医学研究中心, 造血干细胞移植治疗血液病北京市重点实验室, 北京 100044Department of Hematology, Peking University People's Hospital; Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
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11
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Carla Chong-Silva1 D, Moreira Schneider1 P, de Almeida Pinto Jardim2 T, Nichele3 S, Loth3 G, Antônio Riedi1 C, José Chong Neto1 H, Maria Sales Bonfim3 C, Augusto Rosário Filho1 N. Pulmonary complications after hematopoietic stem cell transplantation in children: a functional and tomographic evaluation. J Bras Pneumol 2022; 48:e20220134. [PMID: 36169559 PMCID: PMC9496364 DOI: 10.36416/1806-3756/e20220134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Débora Carla Chong-Silva1
- 1. Serviço de Alergia, Imunologia e Pneumologia Pediátrica, Universidade Federal do Paraná, Curitiba (PR), Brasil
| | - Pollyana Moreira Schneider1
- 1. Serviço de Alergia, Imunologia e Pneumologia Pediátrica, Universidade Federal do Paraná, Curitiba (PR), Brasil
| | | | - Samantha Nichele3
- 3. Unidade de Transplante de Medula Óssea, Universidade Federal do Paraná, Curitiba (PR), Brasil
| | - Gisele Loth3
- 1. Serviço de Alergia, Imunologia e Pneumologia Pediátrica, Universidade Federal do Paraná, Curitiba (PR), Brasil
| | - Carlos Antônio Riedi1
- 1. Serviço de Alergia, Imunologia e Pneumologia Pediátrica, Universidade Federal do Paraná, Curitiba (PR), Brasil
| | - Herberto José Chong Neto1
- 1. Serviço de Alergia, Imunologia e Pneumologia Pediátrica, Universidade Federal do Paraná, Curitiba (PR), Brasil
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12
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Liu KX, Poux N, Shin KY, Moore N, Chen YH, Margossian S, Whangbo JS, Duncan CN, Lehmann LE, Marcus KJ. Comparison of Pulmonary Toxicity after Total Body Irradiation- and Busulfan-Based Myeloablative Conditioning for Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Patients. Transplant Cell Ther 2022; 28:502.e1-502.e12. [PMID: 35623615 PMCID: PMC11075968 DOI: 10.1016/j.jtct.2022.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 05/14/2022] [Accepted: 05/16/2022] [Indexed: 11/22/2022]
Abstract
Pulmonary toxicity after allogeneic hematopoietic stem cell transplantation (allo-HSCT) for childhood leukemia and myelodysplastic syndrome (MDS), along with the impact of different myeloablative conditioning regimens, remain incompletely described. Here we compared the acute and long-term incidence of pulmonary toxicity (PT) after total body irradiation (TBI)- and busulfan-based myeloablative conditioning. We conducted this retrospective cohort study of 311 consecutive pediatric patients with leukemia or MDS who underwent allo-HSCT at Dana-Farber Cancer Institute/Boston Children's Hospital between 2008 and 2018. PT was graded using Common Terminology Criteria for Adverse Events version 5.0. The primary objective was to compare the cumulative incidence of grade ≥3 and grade 5 PT after TBI-based and busulfan-based myeloablative conditioning using Gray's test. Secondary objectives were to determine factors associated with PT and overall survival (OS) using competing risk analysis and Cox regression analyses, respectively. There was no significant difference between the TBI-conditioned group (n = 227) and the busulfan-conditioned group (n = 84) in the incidence of grade ≥3 PT (29.2% versus 34.7% at 2 years; P = .26) or grade 5 pulmonary toxicity (6.2% versus 6.1% at 2 years; P = .47). Age (hazard ratio [HR], 1.70, 95% confidence interval [CI], 1.11 to 2.59; P = .01), grade ≥2 PT prior to allo-HSCT or preexisting pulmonary conditions (HR, 1.84, 95% CI, 1.24 to 2.72; P < .01), acute graft-versus-host disease (GVHD) (HR, 2.50; 95% CI, 1.51 to 4.14; P < .01), and chronic GVHD (HR, 2.61; 95% CI, 1.26 to 5.42; P = .01) were associated with grade ≥3 PT on multivariable analysis. Grade ≥3 PT was associated with worse OS (81.1% versus 61.5% at 2 years; P < .01). In pediatric allo-HSCT recipients, rates of PT were similar in recipients of TBI-based and recipients of busulfan-based myeloablative conditioning regimens. Age, the presence of PT or preexisting pulmonary conditions prior to transplantation, and the development of either acute or chronic GVHD were associated with grade ≥3 PT post-transplantation. Furthermore, the occurrence of grade 3-4 PT post-transplantation was associated with inferior OS.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Kee-Young Shin
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Yu-Hui Chen
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Steven Margossian
- Pediatric Stem Cell Transplant, Division of Pediatric Oncology, Boston Children's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jennifer S Whangbo
- Division of Hematology/Oncology, Stem Cell Transplant Program, Boston Children's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christine N Duncan
- Pediatric Stem Cell Transplant, Division of Pediatric Oncology, Boston Children's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Leslie E Lehmann
- Pediatric Stem Cell Transplant, Division of Pediatric Oncology, Boston Children's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Karen J Marcus
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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13
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Long-Term Health Effects of Curative Therapies on Heart, Lungs, and Kidneys for Individuals with Sickle Cell Disease Compared to Those with Hematologic Malignancies. J Clin Med 2022; 11:jcm11113118. [PMID: 35683502 PMCID: PMC9181610 DOI: 10.3390/jcm11113118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 12/30/2022] Open
Abstract
The goal of curing children and adults with sickle cell disease (SCD) is to maximize benefits and minimize intermediate and long-term adverse outcomes so that individuals can live an average life span with a high quality of life. While greater than 2000 individuals with SCD have been treated with curative therapy, systematic studies have not been performed to evaluate the long-term health effects of hematopoietic stem cell transplant (HSCT) in this population. Individuals with SCD suffer progressive heart, lung, and kidney disease prior to curative therapy. In adults, these sequalae are associated with earlier death. In comparison, individuals who undergo HSCT for cancer are heavily pretreated with chemotherapy, resulting in potential acute and chronic heart, lung, and kidney disease. The long-term health effects on the heart, lung, and kidney for children and adults undergoing HSCT for cancer have been extensively investigated. These studies provide the best available data to extrapolate the possible late health effects after curative therapy for SCD. Future research is needed to evaluate whether HSCT abates, stabilizes, or exacerbates heart, lung, kidney, and other diseases in children and adults with SCD receiving myeloablative and non-myeloablative conditioning regimens for curative therapy.
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14
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Zinter MS, Versluys AB, Lindemans CA, Mayday MY, Reyes G, Sunshine S, Chan M, Fiorino EK, Cancio M, Prevaes S, Sirota M, Matthay MA, Kharbanda S, Dvorak CC, Boelens JJ, DeRisi JL. Pulmonary microbiome and gene expression signatures differentiate lung function in pediatric hematopoietic cell transplant candidates. Sci Transl Med 2022; 14:eabm8646. [PMID: 35263147 PMCID: PMC9487170 DOI: 10.1126/scitranslmed.abm8646] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Impaired baseline lung function is associated with mortality after pediatric allogeneic hematopoietic cell transplantation (HCT), yet limited knowledge of the molecular pathways that characterize pretransplant lung function has hindered the development of lung-targeted interventions. In this study, we quantified the association between bronchoalveolar lavage (BAL) metatranscriptomes and paired pulmonary function tests performed a median of 1 to 2 weeks before allogeneic HCT in 104 children in The Netherlands. Abnormal pulmonary function was recorded in more than half the cohort, consisted most commonly of restriction and impaired diffusion, and was associated with both all-cause and lung injury-related mortality after HCT. Depletion of commensal supraglottic taxa, such as Haemophilus, and enrichment of nasal and skin taxa, such as Staphylococcus, in the BAL microbiome were associated with worse measures of lung capacity and gas diffusion. In addition, BAL gene expression signatures of alveolar epithelial activation, epithelial-mesenchymal transition, and down-regulated immunity were associated with impaired lung capacity and diffusion, suggesting a postinjury profibrotic response. Detection of microbial depletion and abnormal epithelial gene expression in BAL enhanced the prognostic utility of pre-HCT pulmonary function tests for the outcome of post-HCT mortality. These findings suggest a potentially actionable connection between microbiome depletion, alveolar injury, and pulmonary fibrosis in the pathogenesis of pre-HCT lung dysfunction.
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Affiliation(s)
- Matt S Zinter
- School of Medicine, Department of Pediatrics, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, CA 94143, USA.,School of Medicine, Department of Pediatrics, Division of Allergy, Immunology, and Bone Marrow Transplantation, University of California, San Francisco, San Francisco, CA 94143, USA
| | - A Birgitta Versluys
- University Medical Center Utrecht, Department of Pediatric Stem Cell Transplantation, Utrecht, 3584 CX, Netherlands.,Princess Maxima Center for Pediatric Oncology, Department of Hematopoietic Cell Transplantation, Utrecht 3584 CX, Netherlands
| | - Caroline A Lindemans
- University Medical Center Utrecht, Department of Pediatric Stem Cell Transplantation, Utrecht, 3584 CX, Netherlands.,Princess Maxima Center for Pediatric Oncology, Department of Hematopoietic Cell Transplantation, Utrecht 3584 CX, Netherlands
| | - Madeline Y Mayday
- Department of Pathology, Graduate Program in Experimental Pathology, and Yale Stem Cell Center, Yale University, New Haven, CT 06510, USA
| | - Gustavo Reyes
- School of Medicine, Department of Pediatrics, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Sara Sunshine
- School of Medicine, Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Marilynn Chan
- School of Medicine, Department of Pediatrics, Division of Pulmonology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Elizabeth K Fiorino
- WC Medical College, Department of Pediatrics, Division of Pulmonology, Allergy and Immunology, Cornell University, New York City, NY 10065, USA
| | - Maria Cancio
- WC Medical College, Department of Pediatrics, Cornell University, New York City, NY 10065, USA.,Department of Pediatric Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York City, NY 10065, USA
| | - Sabine Prevaes
- Department of Pediatric Pulmonology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, 3584 CX, Netherlands
| | - Marina Sirota
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, CA 94143, USA.,School of Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Michael A Matthay
- School of Medicine, Cardiovascular Research Institute, Departments of Medicine and Anesthesiology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Sandhya Kharbanda
- School of Medicine, Department of Pediatrics, Division of Allergy, Immunology, and Bone Marrow Transplantation, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Christopher C Dvorak
- School of Medicine, Department of Pediatrics, Division of Allergy, Immunology, and Bone Marrow Transplantation, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Jaap J Boelens
- WC Medical College, Department of Pediatrics, Cornell University, New York City, NY 10065, USA.,Department of Pediatric Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York City, NY 10065, USA
| | - Joseph L DeRisi
- School of Medicine, Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA 94143, USA.,Chan Zuckerberg Biohub, San Francisco, CA 94158, USA
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15
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Zinter MS, McArthur J, Duncan C, Adams R, Kreml E, Dalton H, Abdel-Azim H, Rowan CM, Gertz SJ, Mahadeo KM, Randolph AG, Rajapreyar P, Steiner ME, Lehmann L. Candidacy for Extracorporeal Life Support in Children After Hematopoietic Cell Transplantation: A Position Paper From the Pediatric Acute Lung Injury and Sepsis Investigators Network's Hematopoietic Cell Transplant and Cancer Immunotherapy Subgroup. Pediatr Crit Care Med 2022; 23:205-213. [PMID: 34878420 PMCID: PMC8897218 DOI: 10.1097/pcc.0000000000002865] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The last decade has seen improved outcomes for children requiring extracorporeal life support as well as for children undergoing hematopoietic cell transplantation. Thus, given the historically poor survival of hematopoietic cell transplantation patients using extracorporeal life support, the Pediatric Acute Lung Injury and Sepsis Investigators' hematopoietic cell transplantation and cancer immunotherapy subgroup aimed to characterize the utility of extracorporeal life support in facilitating recovery from critical cardiorespiratory illnesses in pediatric hematopoietic cell transplantation patients. DATA SOURCES All available published data were identified using a set of PubMed search terms for pediatric extracorporeal life support and hematopoietic cell transplantation. STUDY SELECTION All articles that provided original reports of pediatric hematopoietic cell transplantation patients who underwent extracorporeal life support were included. Sixty-four manuscripts met search criteria. Twenty-four were included as primary reports of pediatric hematopoietic cell transplantation patients who underwent extracorporeal life support (11 were single case reports, four single institution case series, two multi-institution case series, and seven registry reports from Extracorporeal Life Support Organization, Pediatric Heath Information System, and Virtual Pediatric Systems). DATA EXTRACTION All 24 articles were reviewed by first and last authors and a spread sheet was constructed including sample size, potential biases, and conclusions. DATA SYNTHESIS Discussions regarding incorporation of available evidence into our clinical practice were held at biannual meetings, as well as through email and virtual meetings. An expert consensus was determined through these discussions and confirmed through a modified Delphi process. CONCLUSIONS Extracorporeal life support in hematopoietic cell transplantation patients is being used with increasing frequency and potentially improving survival. The Pediatric Acute Lung Injury and Sepsis Investigators hematopoietic cell transplantation-cancer immunotherapy subgroup has developed a framework to guide physicians in decision-making surrounding extracorporeal life support candidacy in pediatric hematopoietic cell transplantation patients. In addition to standard extracorporeal life support considerations, candidacy in the hematopoietic cell transplantation population should consider the following six factors in order of consensus agreement: 1) patient comorbidities; 2) underlying disease necessitating hematopoietic cell transplantation; 3) hematopoietic cell transplantation toxicities, 4) family and patient desires for goals of care; 5) hematopoietic cell transplantation preparatory regimen; and 6) graft characteristics. Although risk assessment may be individualized, data are currently insufficient to clearly delineate ideal candidacy. Therefore, we urge the onco-critical care community to collaborate and capture data to provide better evidence to guide physicians' decision-making in the future.
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Affiliation(s)
- Matt S. Zinter
- Department of Pediatrics, Division of Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Jennifer McArthur
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Pediatrics, Division of Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Christine Duncan
- Department of Pediatrics, Division of Hematology/Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Roberta Adams
- Department of Internal Medicine, Division of Hematology/Oncology. Mayo Clinic, Phoenix, AZ
| | - Erin Kreml
- Department of Child Health, Division of Critical Care Medicine, University of AZ, Phoenix, AZ
| | - Heidi Dalton
- Pediatric Critical Care Medicine, Inova Children’s Hospital, Fairfax, VA
| | - Hisham Abdel-Azim
- Department of Pediatrics, Division of Hematology/Oncology and Transplant and Cell Therapy, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Courtney M. Rowan
- Department of Pediatrics, Division of Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Shira J. Gertz
- Department of Pediatrics, Division of Critical Care Medicine, Saint Barnabas Medical Center, Livingston, NJ
| | - Kris M. Mahadeo
- Department of Pediatrics, Division of Hematology/Oncology, MD Anderson Cancer Center, Houston, TX
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Prakadeshwari Rajapreyar
- Department of Pediatrics, Division of Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Marie E. Steiner
- Department of Pediatrics, Divisions of Critical Care Medicine and Hematology/Oncology, University of Minnesota Medical School, Minneapolis, MN
| | - Leslie Lehmann
- Department of Pediatrics, Division of Hematology/Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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16
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A biomarker panel for risk of early respiratory failure following hematopoietic cell transplantation. Blood Adv 2022; 6:1866-1878. [PMID: 35139145 PMCID: PMC8941462 DOI: 10.1182/bloodadvances.2021005770] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/22/2022] [Indexed: 11/20/2022] Open
Abstract
This study identified and validated ST2, WFDC2, IL-6, and TNFR1 as risk biomarkers for RF and related mortality post-HCT.
Plasma biomarkers associated with respiratory failure (RF) following hematopoietic cell transplantation (HCT) have not been identified. Therefore, we aimed to validate early (7 and 14 days post-HCT) risk biomarkers for RF. Using tandem mass spectrometry, we compared plasma obtained at day 14 post-HCT from 15 patients with RF and 15 patients without RF. Six candidate proteins, from this discovery cohort or identified in the literature, were measured by enzyme-linked immunosorbent assay in day-7 and day-14 post-HCT samples from the training (n = 213) and validation (n = 119) cohorts. Cox proportional-hazard analyses with biomarkers dichotomized by Youden’s index, as well as landmark analyses to determine the association between biomarkers and RF, were performed. Of the 6 markers, Stimulation-2 (ST2), WAP 4-disulfide core domain protein 2 (WFDC2), interleukin-6 (IL-6), and tumor necrosis factor receptor 1 (TNFR1), measured at day 14 post-HCT, had the most significant association with an increased risk for RF in the training cohort (ST2: hazard ratio [HR], 4.5, P = .004; WFDC2: HR, 4.2, P = .010; IL-6: HR, 6.9, P < .001; and TFNR1: HR, 6.1, P < .001) and in the validation cohort (ST2: HR, 23.2, P = .013; WFDC2: HR, 18.2, P = .019; IL-6: HR, 12.2, P = .014; and TFNR1: HR, 16.1, P = .001) after adjusting for the conditioning regimen. Using cause-specific landmark analyses, including days 7 and 14, high plasma levels of ST2, WFDC2, IL-6, and TNFR1 were associated with an increased HR for RF in the training and validation cohorts. These biomarkers were also predictive of mortality from RF. ST2, WFDC2, IL-6 and TNFR1 levels measured early posttransplantation improve risk stratification for RF and its related mortality.
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17
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Walkup LL, Myers KC, Willmering MM, Mehta PA, Nelson AS, Fleck RJ, Woods JC, Davies SM, Towe CT. Modern Lung Magnetic Resonance Imaging to Screen for Pulmonary Complications in Patients with Dyskeratosis Congenita. Am J Respir Crit Care Med 2021; 204:1340-1343. [PMID: 34516939 DOI: 10.1164/rccm.202103-0736le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Laura L Walkup
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio.,University of Cincinnati Cincinnati, Ohio
| | - Kasiani C Myers
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio.,University of Cincinnati Cincinnati, Ohio
| | | | - Parinda A Mehta
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio.,University of Cincinnati Cincinnati, Ohio
| | - Adam S Nelson
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio.,University of Cincinnati Cincinnati, Ohio
| | - Robert J Fleck
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio.,University of Cincinnati Cincinnati, Ohio
| | - Jason C Woods
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio.,University of Cincinnati Cincinnati, Ohio
| | - Stella M Davies
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio.,University of Cincinnati Cincinnati, Ohio
| | - Christopher T Towe
- Cincinnati Children's Hospital Medical Center Cincinnati, Ohio.,University of Cincinnati Cincinnati, Ohio
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18
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Zhou X, Moore BB. Experimental Models of Infectious Pulmonary Complications Following Hematopoietic Cell Transplantation. Front Immunol 2021; 12:718603. [PMID: 34484223 PMCID: PMC8415416 DOI: 10.3389/fimmu.2021.718603] [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: 06/01/2021] [Accepted: 07/26/2021] [Indexed: 12/23/2022] Open
Abstract
Pulmonary infections remain a major cause of morbidity and mortality in hematopoietic cell transplantation (HCT) recipients. The prevalence and type of infection changes over time and is influenced by the course of immune reconstitution post-transplant. The interaction between pathogens and host immune responses is complex in HCT settings, since the conditioning regimens create periods of neutropenia and immunosuppressive drugs are often needed to prevent graft rejection and limit graft-versus-host disease (GVHD). Experimental murine models of transplantation are valuable tools for dissecting the procedure-related alterations to innate and adaptive immunity. Here we review mouse models of post-HCT infectious pulmonary complications, primarily focused on three groups of pathogens that frequently infect HCT recipients: bacteria (often P. aeruginosa), fungus (primarily Aspergillus fumigatus), and viruses (primarily herpesviruses). These mouse models have advanced our knowledge regarding how the conditioning and HCT process negatively impacts innate immunity and have provided new potential strategies of managing the infections. Studies using mouse models have also validated clinical observations suggesting that prior or occult infections are a potential etiology of noninfectious pulmonary complications post-HCT as well.
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Affiliation(s)
- Xiaofeng Zhou
- Dept. of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, United States.,Division of Pulmonary and Critical Care Medicine, Dept. of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Bethany B Moore
- Dept. of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, United States.,Division of Pulmonary and Critical Care Medicine, Dept. of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
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19
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Non-classical manifestations of acute GVHD. Blood 2021; 138:2165-2172. [PMID: 34482399 DOI: 10.1182/blood.2021012431] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/13/2021] [Indexed: 11/20/2022] Open
Abstract
Acute graft-versus-host disease (GVHD) is a major life-threatening complication after allogeneic hematopoietic cell transplantation (allo-HCT). The classical target organs of acute GVHD include the intestines, liver, and skin. The damage of these organs is relatively easy to detect for the clinician as diarrhea, increased bilirubin, and rash. However, there is increasing evidence that also other organs, where the acute damage is less apparent or more difficult to distinguish from drug toxicity, such as the central nervous system, the lungs, the ovaries and testis, the thymus, the bone marrow and the kidney, can be target organs of acute GVHD. Here, we review current evidence for non-classical manifestations of acute GVHD in rodent models and in patients and discuss them in the context of novel emerging therapies for GVHD. A better understanding of the involvement of the non-classical GVHD target organs may help to improve patient outcomes after allo-HCT.
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20
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Shanthikumar S, Gower WA, Abts M, Liptzin DR, Fiorino EK, Stone A, Srinivasan S, Vece TJ, Akil N, Cole T, Cooke KR, Goldfarb SB. Pulmonary surveillance in pediatric hematopoietic stem cell transplant: A multinational multidisciplinary survey. Cancer Rep (Hoboken) 2021; 5:e1501. [PMID: 34319008 PMCID: PMC9124519 DOI: 10.1002/cnr2.1501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/16/2021] [Accepted: 06/29/2021] [Indexed: 12/18/2022] Open
Abstract
Background Hematopoietic Stem Cell Transplant (HSCT) is an established treatment for malignant and non‐malignant conditions and pulmonary disease is a leading cause of late term morbidity and mortality. Accurate and early detection of pulmonary complications is a critical step in improving long term outcomes. Existing guidelines for surveillance of pulmonary complications post‐HSCT contain conflicting recommendations. Aim To determine the breadth of current practice in monitoring for pulmonary complications of pediatric HSCT. Methods An institutional review board approved, online, anonymous multiple‐choice survey was distributed to HSCT and pulmonary physicians from the United States of America and Australasia using the REDcap platform. The survey was developed by members of the American Thoracic Society Working Group on Complications of Childhood Cancer, and was designed to assess patient management and service design. Results A total of 40 (34.8%) responses were received. The majority (62.5%) were pulmonologists, and 82.5% were from the United States of America. In all, 67.5% reported having a protocol for monitoring pulmonary complications and 50.0% reported adhering “well” or “very well” to protocols. Pulmonary function tests (PFTs) most commonly involved spirometry and diffusion capacity for carbon monoxide. The frequency of PFTs varied depending on time post‐HSCT and presence of complications. In all, 55.0% reported a set threshold for a clinically significant change in PFT. Conclusions These results illustrate current variation in surveillance for pulmonary complications of pediatric HSCT. The results of this survey will inform development of future guidelines for monitoring of pulmonary complications after pediatric HSCT.
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Affiliation(s)
- Shivanthan Shanthikumar
- Respiratory and Sleep Medicine, Royal Children's Hospital, Parkville, Victoria, Australia.,Respiratory Diseases, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - William A Gower
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Matthew Abts
- Seattle Children's Hospital, Seattle, Washington, USA.,Pediatric Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Deborah R Liptzin
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Elizabeth K Fiorino
- Division of Pulmonology, Allergy, and Immunology, Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Anne Stone
- Division of Pulmonology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Saumini Srinivasan
- Division of Pulmonology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Timothy J Vece
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Nour Akil
- Division of Pulmonology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Theresa Cole
- Allergy and Immunology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Kenneth R Cooke
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samuel B Goldfarb
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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