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Fructuoso-González L, Najera-Perez MD, Manresa-Ramón N, Torrano-Belmonte P, Caracena-López S, Pacheco-López P. Isavuconazole-tacrolimus drug-drug interactions in HSCT patients. J Antimicrob Chemother 2023; 78:2559-2562. [PMID: 37667501 DOI: 10.1093/jac/dkad271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 08/21/2023] [Indexed: 09/06/2023] Open
Abstract
OBJECTIVES Because tacrolimus has a narrow therapeutic window and exhibits both intraindividual and interindividual variability, we attempted to establish the percentage of calcineurin inhibitor (CNI) dose reduction to prevent toxicity and ensure stem cell engraftment when using this immunosuppressant with the antifungal isavuconazole (ISA). By calculating the tacrolimus concentration/dose (C/D) ratio, we expected to demonstrate the magnitude of change in the C/D ratio from baseline after ISA administration. METHODS We evaluated the interaction between ISA, a new triazole antifungal used in prophylaxis for invasive fungal infections, and the CNI class of immunosuppressive drugs, specifically tacrolimus, in 11 blood samples from HSCT recipients. RESULTS The mean tacrolimus C/D ratio increased 1.44-fold from baseline 48 h after ISA administration (P = 0.001). CONCLUSIONS Although further investigation is needed, the results of this study suggest that a reduction of 18% in tacrolimus may be recommended.
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Affiliation(s)
| | - M D Najera-Perez
- Hospital Pharmacy Service, Hospital Morales Meseguer, Murcia, Spain
| | - N Manresa-Ramón
- Hospital Pharmacy Service, Hospital Morales Meseguer, Murcia, Spain
| | | | | | - P Pacheco-López
- Hospital Pharmacy Service, Hospital Morales Meseguer, Murcia, Spain
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Effect of Early Post-Transplantation Tacrolimus Concentration on the Risk of Acute Graft-Versus-Host Disease in Allogenic Stem Cell Transplantation. Cancers (Basel) 2021; 13:cancers13040613. [PMID: 33557088 PMCID: PMC7913846 DOI: 10.3390/cancers13040613] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/21/2021] [Accepted: 02/01/2021] [Indexed: 12/01/2022] Open
Abstract
Simple Summary Allogeneic hematopoietic stem cell transplantation is a potentially curative treatment for many hematological malignancies and disorders but is often complicated by a relapse of the underlying disease, graft-vs-host disease and infectious complications. However, despite the introduction of calcineurin inhibitors such as tacrolimus, graft-versus-host disease remains one of the major life-threatening complications of allogeneic hematopoietic stem cell transplantation. Due to a variety of factors, there is variability in tacrolimus concentrations during the early weeks post-transplantation. Since the immunologic events leading to acute GVHD also occur in the first few days post-transplantation, it is important that optimal levels be attained early after transplantation. The findings from this study will help inform the management of optimal tacrolimus levels to be attained early post-transplantation. Abstract Acute graft versus host disease (aGVHD) remains a leading cause of morbidity and mortality in allogeneic hematopoietic stem cell transplant (allo-HSCT). Tacrolimus (TAC), a calcineurin inhibitor that prevents T-cell activation, is commonly used as a GVHD prophylaxis. However, there is variability in the serum concentrations of TAC, and little is known on the impact of early TAC levels on aGVHD. We retrospectively analyzed 673 consecutive patients undergoing allo-HSCT at the Ohio State University between 2002 and 2016. Week 1 TAC was associated with a lower risk of aGVHD II–IV at TAC level ≥10.15 ng/mL (p = 0.03) compared to the lowest quartile. The cumulative incidence of relapse at 1, 3 and 5 years was 33%, 38% and 41%, respectively. TAC levels at week 2, ≥11.55 ng/mL, were associated with an increased risk of relapse (p = 0.01) compared to the lowest quartile. Subset analysis with acute myeloid leukemia and myelodysplastic syndrome patients showed significantly reduced aGVHD with TAC level ≥10.15 ng/mL at week 1 and a higher risk of relapse associated with week 2 TAC level ≥11.55 ng/mL (p = 0.02). Hence, achieving ≥10 ng/mL during the first week of HCT may mitigate the risk of aGVHD. However, levels (>11 ng/mL) beyond the first week may be associated with suppressed graft versus tumor effect and higher relapse.
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Ezquer-Garin C, Ferriols-Lisart R, Alós-Almiñana M. Stability of tacrolimus ophthalmic solution. Am J Health Syst Pharm 2019. [PMID: 28645998 DOI: 10.2146/ajhp160169] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The stability of 0.3-mg/mL tacrolimus ophthalmic solution at different storage temperatures was studied. METHODS A sterile ophthalmic solution of 0.3 mg/mL tacrolimus was prepared in triplicate under aseptic conditions by diluting tacrolimus in eye drops. Three aliquots of this solution were transferred into polypropylene bottles and stored at 25, 2-8, or -15 to -25 °C. Samples were collected immediately after preparation and at selected time points and assayed in triplicate using high-performance liquid chromatography (HPLC). Samples were also visually examined for macroscopic changes. The 0.3-mg/mL tacrolimus solution was also exposed to acidic treatment and heat to force its degradation and to evaluate the selectivity of the analytic method. The tacrolimus ophthalmic solution was considered stable if at least 90% of the mean initial concentration remained when analyzed by HPLC. RESULTS When stored at 2-8 °C and between -15 and -25 °C, at least 90% of the initial tacrolimus concentration remained throughout the 85-day study period. There were no significant differences in tacrolimus concentrations between the starting and ending points (p > 0.05). However, when tacrolimus solution was stored at 25 °C, the percentage of the initial tacrolimus concentration remaining had decreased to less than 90% on day 28. CONCLUSION Tacrolimus diluted to 0.3 mg/mL in eye drop solution was stable for 20 days when stored at 25 °C and for at least 85 days when stored at 2-8 °C or between -15 and -25 °C in polypropylene bottles and protected from light.
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Affiliation(s)
- Carlos Ezquer-Garin
- INCLIVA Institute for Health Research, University of Valencia, Valencia, Spain .,Hospital Clinico Universitario de Valencia, Valencia, Spain.
| | - Rafael Ferriols-Lisart
- Clinical Pharmacokinetics Laboratory, INCLIVA Institute for Health Research, University of Valencia, Valencia, Spain.,Department of Pharmacy, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - Manuel Alós-Almiñana
- INCLIVA Institute for Health Research, University of Valencia, Valencia, Spain.,Department of Pharmacy, Hospital Clinico Universitario de Valencia, Valencia, Spain
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Tacrolimus Induced Diabetic Ketoacidosis Following Hematopoietic Stem Cell Transplantation. Indian J Hematol Blood Transfus 2019; 35:711-713. [PMID: 31741624 DOI: 10.1007/s12288-019-01113-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/07/2019] [Indexed: 10/27/2022] Open
Abstract
Risk of diabetes mellitus increases after solid organ and hematopoietic stem cell transplantation. Diabetic ketoacidosis has been reported after solid organ transplantation in patients receiving tacrolimus but has rarely been reported after stem cell transplantation. The major risk factors for diabetic ketoacidosis are immunosuppressive drugs used after transplantation. We report here three cases of allogenic stem cell transplant who developed diabetic ketoacidosis while on treatment with tacrolimus. The drug was stopped in all the cases and patients were treated with insulin therapy resulting in complete recovery from diabetic ketoacidosis.
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Yoon CH, Park JW, Ryu JS, Kim MK, Oh JY. Corneal Toxicity of Topical Tacrolimus Ointment in Mice with Corneal Epithelial Injury. J Ocul Pharmacol Ther 2018; 34:685-691. [PMID: 30222497 DOI: 10.1089/jop.2018.0054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: To investigate the effect of tacrolimus ointment on corneal epithelium. Methods: Eight-week-old male BALB/c mice were divided into 3 groups. In group 1, no injury was made. In group 2, the central 2-mm corneal epithelium was scraped off. In group 3, the whole corneal and limbal epithelium was removed after absolute ethanol application. In each group, the corneas were observed and treated daily with 0.03% or 0.1% tacrolimus ointment (Protopic®). The viability of cultivated human corneal epithelial cells was also examined after 24-h incubation with various concentrations of tacrolimus. Results: Tacrolimus ointment significantly delayed the epithelial healing in corneas with epithelial injuries (groups 2 and 3) in dose- and frequency-dependent manners, whereas it did not have any effects on uninjured corneas (group 1). The proportion of terminal deoxynucleotidyl transferase-mediated nick end labeling-positive cells and mRNA levels of inflammatory cytokines were higher in tacrolimus-treated corneas, compared with controls. Tacrolimus did not directly reduce the viability of corneal epithelial cells in culture. Conclusions: Topical application of tacrolimus ointment onto the ocular surface induced toxicity in the cornea with epithelial defects through the impairment of epithelial healing and induction of apoptosis.
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Affiliation(s)
- Chang Ho Yoon
- Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea
- Laboratory of Ocular Regenerative Medicine and Immunology, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Jong Woo Park
- Laboratory of Ocular Regenerative Medicine and Immunology, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Jin Suk Ryu
- Laboratory of Ocular Regenerative Medicine and Immunology, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Mee Kum Kim
- Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea
- Laboratory of Ocular Regenerative Medicine and Immunology, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Joo Youn Oh
- Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea
- Laboratory of Ocular Regenerative Medicine and Immunology, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
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Kufel WD, Armistead PM, Daniels LM, Ptachcinski JR, Alexander MD, Shaw JR. Drug–Drug Interaction Between Isavuconazole and Tacrolimus: Is Empiric Dose Adjustment Necessary? J Pharm Pract 2018; 33:226-230. [DOI: 10.1177/0897190018790688] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A paucity of data currently exists regarding drug–drug interaction (DDI) with tacrolimus and isavuconazole coadministration. Current literature provides conflicting recommendations on whether an empiric tacrolimus dose reduction is necessary when coadministered with isavuconazole. A 47-year-old African American female with acute lymphoblastic leukemia underwent an allogenic stem cell transplant (alloSCT) and was subsequently placed on routine posttransplant therapy including tacrolimus for immunosuppression and posaconazole for antifungal prophylaxis. Tacrolimus was empirically dose reduced due to the expected DDI with posaconazole based on current recommendations. Due to a persistently prolonged QTc interval and need for mold coverage, antifungal prophylaxis was ultimately changed to isavuconazole at standard recommended dosing. Tacrolimus was empirically dose reduced by 40% based on limited available literature at the time; however, tacrolimus trough concentrations subsequently declined, requiring an increase in tacrolimus dose to maintain therapeutic trough concentrations. Adequate isavuconazole absorption was documented through pharmacokinetic and pharmacodynamic data by measuring an isavuconazole trough concentration and directly observing isavuconazole’s shortening effect on the QTc interval, respectively. Our experience in an alloSCT patient suggests that an empiric tacrolimus dose reduction is not required when isavuconazole is initiated, but close tacrolimus therapeutic drug monitoring should rather be performed to guide tacrolimus dosing.
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Affiliation(s)
- Wesley D. Kufel
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA
- Department of Medicine, Upstate Medical University, Syracuse, NY, USA
- Department of Pharmacy, Upstate University Hospital, Syracuse, NY, USA
| | - Paul M. Armistead
- Department of Hematology-Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Lindsay M. Daniels
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
- Department of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Jonathan R. Ptachcinski
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
- Department of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Maurice D. Alexander
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
- Department of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - J. Ryan Shaw
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
- Department of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Lee JH, Goldspiel BR, Ryu S, Potti GK. Stability of tacrolimus solutions in polyolefin containers. Am J Health Syst Pharm 2016; 73:137-42. [PMID: 26796907 PMCID: PMC10807487 DOI: 10.2146/ajhp150264] [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] [Indexed: 01/26/2024] Open
Abstract
PURPOSE Results of a study to determine the stability of tacrolimus solutions stored in polyolefin containers under various temperature conditions are reported. METHODS Triplicate solutions of tacrolimus (0.001, 0.01, and 0.1 mg/mL) in 0.9% sodium chloride injection or 5% dextrose injection were prepared in polyolefin containers. Some samples were stored at room temperature (20-25 °C); others were refrigerated (2-8 °C) for 20 hours and then stored at room temperature for up to 28 hours. The solutions were analyzed by stability-indicating high-performance liquid chromatography (HPLC) assay at specified time points over 48 hours. Solution pH was measured and containers were visually inspected at each time point. Stability was defined as retention of at least 90% of the initial tacrolimus concentration. RESULTS All tested solutions retained over 90% of the initial tacrolimus concentration at all time points, with the exception of the 0.001-mg/mL solution prepared in 0.9% sodium chloride injection, which was deemed unstable beyond 24 hours. At all evaluated concentrations, mean solution pH values did not change significantly over 48 hours; no particle formation was detected. CONCLUSION During storage in polyolefin bags at room temperature, a 0.001-mg/mL solution of tacrolimus was stable for 24 hours when prepared in 0.9% sodium chloride injection and for at least 48 hours when prepared in 5% dextrose injection. Solutions of 0.01 and 0.1 mg/mL prepared in either diluent were stable for at least 48 hours, and the 0.01-mg/mL tacrolimus solution was also found to be stable throughout a sequential temperature protocol.
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Affiliation(s)
- Jun H Lee
- Pharmaceutical Development Section, Pharmacy Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Barry R Goldspiel
- Pharmacy Department, National Institutes of Health Clinical Center, Bethesda, MD.
| | - Sujung Ryu
- Pharmaceutical Development Section, Pharmacy Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Gopal K Potti
- Pharmaceutical Development Section, Pharmacy Department, National Institutes of Health Clinical Center, Bethesda, MD
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Yang EJ, Park KM, Seo JH, Lim YT. Tacrolimus and Mini-dose Methotrexate for Prevention of Graft-Versus-Host Disease after Unrelated Hematopoietic Stem Cell Transplantation in Children: A Single-center Study in Korea. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2015. [DOI: 10.15264/cpho.2015.22.2.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Eu Jeen Yang
- Department of Pedistrics, Pusan National University Childrens Hospital, Yangsan, Korea
| | - Kyung Mi Park
- Department of Pedistrics, Pusan National University Childrens Hospital, Yangsan, Korea
| | - Jung Ho Seo
- Department of Pedistrics, Pusan National University Childrens Hospital, Yangsan, Korea
| | - Young Tak Lim
- Department of Pedistrics, Pusan National University Childrens Hospital, Yangsan, Korea
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Clinical approach in the management of oral chronic graft-versus-host disease (cGVHD) in a series of specialized medical centers. Support Care Cancer 2014; 23:1615-22. [DOI: 10.1007/s00520-014-2503-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 10/27/2014] [Indexed: 01/11/2023]
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Some transformations of tacrolimus, an immunosuppressive drug. Eur J Pharm Sci 2012; 48:514-22. [PMID: 23238171 DOI: 10.1016/j.ejps.2012.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 11/15/2012] [Accepted: 12/02/2012] [Indexed: 11/20/2022]
Abstract
Transformations of the macrocyclic lactone tacrolimus (1), an important immunosuppressive drug produced by Streptomyces species, are described. These transformation products are primarily of interest as reference substances for drug impurity analyses. Upon action of acid (p-toluenesulfonic acid in toluene), tacrolimus is dehydrated by loss of water from the β-hydroxyketone moiety with partial inversion of configuration at C-8, resulting in formation of 5-deoxy-Δ(5,6)-tacrolimus and 5-deoxy-Δ(5,6)-8-epitacrolimus. The structure of the latter was determined by single-crystal X-ray crystallography. The same products are formed upon action of free radicals (iodine in boiling toluene), along with formation of 8-epitacrolimus. The latter is converted by p-toluenesulfonic acid to 5-deoxy-Δ(5,6)-8-epitacrolimus. Treatment of tacrolimus with weak base (1,5-diazabicyclo[4.3.0]nonene) gives, in addition to 8-epitacrolimus, the open-chain acid corresponding to 5-deoxy-Δ(5,6)-tacrolimus, a rare non-cyclic derivative of tacrolimus. Strong base (t-butoxide) causes pronounced degradation of the molecule. Thermolysis of tacrolimus leads to ring expansion by an apparent [3,3]-sigmatropic rearrangement of the allylic ester moiety with subsequent loss of water from the β-hydroxyketone moiety. ¹H and ¹³C NMR spectra of the obtained compounds, complicated by the presence of amide bond rotamers and ketal moiety tautomers, were assigned by extensive use of 2D NMR techniques.
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Rodriguez-Cerdeira C, Sanchez-Blanco E, Molares-Vila A. Clinical application of development of nonantibiotic macrolides that correct inflammation-driven immune dysfunction in inflammatory skin diseases. Mediators Inflamm 2012; 2012:563709. [PMID: 23258954 PMCID: PMC3507315 DOI: 10.1155/2012/563709] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Revised: 07/20/2012] [Accepted: 07/22/2012] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Inflammation-driven immune dysfunction supports the development of several chronic human disorders including skin diseases. Nonantibiotic macrolides have anti-inflammatory and/or immunomodulatory activity that suggests the exploitation of these in the treatment of skin diseases characterized by inflammatory disorders. MATERIALS AND METHODS We performed an extensive review of the nonantibiotic macrolide literature published between 2005 and 2012, including cross-references of any retrieved articles. We also included some data from our own experience. RESULTS Calcineurin antagonists such as tacrolimus and ascomycins (e.g., pimecrolimus) act by inhibiting the activation of the nuclear factor for activated T cells (NFAT). There are new applications for these macrolides that have been available for several years and have been applied to skin and hair disorders such as atopic dermatitis, oral lichen planus, vitiligo, chronic autoimmune urticaria, rosacea, alopecia areata, pyoderma gangrenosum, Behcet's disease, neutrophilic dermatosis, and lupus erythematosus. We also reviewed new macrolides, like rapamycin, everolimus, and temsirolimus. In addition to the literature review, we report a novel class of nonantibiotic 14-member macrocycle with anti-inflammatory and immunomodulatory effects. CONCLUSIONS This paper summarizes the most important clinical studies and case reports dealing with the potential benefits of nonantibiotic macrolides which have opened new avenues in the development of anti-inflammatory strategies in the treatment of cutaneous disorders.
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Mori T, Kato J, Shimizu T, Aisa Y, Nakazato T, Yamane A, Ono Y, Kunimoto H, Okamoto S. Effect of Early Posttransplantation Tacrolimus Concentration on the Development of Acute Graft-versus-Host Disease after Allogeneic Hematopoietic Stem Cell Transplantation from Unrelated Donors. Biol Blood Marrow Transplant 2012; 18:229-34. [DOI: 10.1016/j.bbmt.2011.06.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 06/17/2011] [Indexed: 11/29/2022]
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