Renal dysfunction following autologous bone marrow transplantation in adult patients with acute leukemia

Long-term health impacts of hematopoietic stem cell transplantation inform recommendations for follow-up

Advances in transplantation techniques and supportive care strategies have resulted in a significant improvement in survival of those who have undergone treatment. However, hematopoietic stem cell transplantation (HSCT) survivors are at risk of developing long-term complications, such as endocrinopathies, musculoskeletal disorders, cardiopulmonary compromise and subsequent malignancies. These complications have a direct impact on the morbidity and mortality experienced by HSCT survivors. Two-thirds of HSCT survivors develop at least one chronic health condition; while a fifth develop severe or life-threatening conditions. HSCT patients who have survived for at least 5 years post-transplantation are at a fourfold to ninefold increased risk of late mortality for as long as 30 years from HSCT, producing an estimated 30% lower life expectancy compared with the general population. The high burden of morbidity experienced by HSCT survivors makes it critically important that there is standardized follow-up of HSCT survivors at high risk for post-HSCT complications. The Center for International Blood and Marrow Transplant Research/European Group for Blood and Marrow Transplantation/American Society for Blood and Marrow Transplantation and the Children's Oncology Group long-term follow-up guidelines offer such standardized care. Future steps include wider dissemination and refinement of these guidelines.

Chronic kidney disease after hematopoietic cell transplantation: a systematic review

Advances in hematopoietic cell transplantation (HCT) have broadened its indications for use and resulted in more long-term HCT survivors. Some survivors develop chronic kidney disease (CKD); however, the incidence and risk factors are unclear. We performed a systematic review of studies identified from databases (MEDLINE, EMBASE, Science Citation Index), conference abstracts and reference lists from selected manuscripts. From 927 manuscripts, 28 patient cohorts were identified in which 9317 adults and children underwent HCT and 7317 (79%) survived to at least 100 days, permitting inclusion of 5337 (73% of survivors) in quantitative analyses. Although definitions and measurements varied widely, approximately 16.6% of HCT patients developed CKD and estimated glomerular filtration rate (eGFR in mL/min/1.73 m(2)) decreased by 24.5 after 24 months. This decrease was greater amongst patients undergoing allogeneic HCT (DeltaeGFR = -40.0 versus -18.6 for autologous transplants). Several commonly reported risk factors for CKD were investigated, including acute renal failure, total body irradiation, graft versus host disease and long-term cyclosporine use. In conclusion, CKD following HCT is likely to be common; however, prospective studies with uniform definitions of CKD and risk factors are needed to confirm these findings and better define the underlying mechanisms to promote therapies that prevent this complication.

Incidence and predictors of delayed chronic kidney disease in long-term survivors of hematopoietic cell transplantation

BACKGROUND

The authors investigated the risk of delayed chronic kidney disease (CKD) in 1190 adult hematopoietic cell transplantation (HCT) survivors who underwent HCT for hematologic malignancies or aplastic anemia between 1976 and 1997 and survived for at least 1 year.

METHODS

CKD was defined as a sustained elevation of serum creatinine that indicated a glomerular filtration rate of <60 mL per minute per 1.73 m2 for > or =3 months. The median age at HCT was 35 years (range, 18.1-68.6 years), and the median length of follow-up was 7.1 years after HCT (range, 1-24.3 years).

RESULTS

Sixty patients with CKD were identified, resulting in a cumulative incidence of 4.4% at 5 years (autologous HCT, 3.8%; matched-sibling HCT, 4.5%; unrelated donor HCT, 10%; P = .09 compared with autologous HCT). Older age at HCT (relative risk [RR] per 5-year increment, 1.33; 95% confidence interval [CI], 1.2-1.5), exposure to cyclosporine without tacrolimus (RR, 1.90; 95% CI, 1.1-3.4) or with tacrolimus (RR, 4.59; 95% CI, 1.8-11.5), and a primary diagnosis of multiple myeloma (RR, 2.51; 95% CI, 1.1-5.6) were associated with an increased risk of delayed CKD.

CONCLUSIONS

In this study, the authors identified a subpopulation of patients who underwent HCT and remained at increased risk for CKD. The current findings set the stage for appropriate long-term follow-up of vulnerable patients.

Renal dysfunction after total body irradiation: dose-effect relationship

PURPOSE

Late complications related to total body irradiation (TBI) as part of the conditioning regimen for hematopoietic stem cell transplantation have been increasingly noted. We reviewed and compared the results of treatments with various TBI regimens and tried to derive a dose-effect relationship for the endpoint of late renal dysfunction. The aim was to find the tolerance dose for the kidney when TBI is performed.

METHODS AND MATERIALS

A literature search was performed using PubMed for articles reporting late renal dysfunction. For intercomparison, the various TBI regimens were normalized using the linear-quadratic model, and biologically effective doses (BEDs) were calculated.

RESULTS

Eleven reports were found describing the frequency of renal dysfunction after TBI. The frequency of renal dysfunction as a function of the BED was obtained. For BED>16 Gy an increase in the frequency of dysfunction was observed.

CONCLUSIONS

The tolerance BED for kidney tissue undergoing TBI is about 16 Gy. This BED can be realized with highly fractionated TBI (e.g., 6x1.7 Gy or 9x1.2 Gy at dose rates>5 cGy/min). To prevent late renal dysfunction, the TBI regimens with BED values>16 Gy (almost all found in published reports) should be applied with appropriate shielding of the kidneys.

Clinical significance of nephrotoxicity in patients treated with amphotericin B for suspected or proven aspergillosis

The records of 239 immunosuppressed patients receiving amphotericin B for suspected or proven aspergillosis were reviewed to determine rates of nephrotoxicity, dialysis, and fatality. The mean and median durations of treatment were 20.4 and 15.0 days, respectively. The creatinine level doubled in 53% of patients and exceeded 2.5 mg/dL in 29%; 14.5% underwent dialysis; and 60% died. A multivariate Cox proportional hazards analysis showed that patients whose creatinine level exceeded 2.5 mg/dL (hazard ratio [HR], 42.02; P<.001), allogeneic bone marrow transplantation (BMT) patients (HR, 6.34; P<. 001), and autologous BMT patients (HR, 5.06; P=.024) were at greatest risk for requiring hemodialysis. Use of hemodialysis (HR, 3. 089; P<.001), duration of amphotericin B use (HR, 1.03 per day; P=. 015), and use of nephrotoxic agents (HR, 1.96; P=.017) were associated with greater risk of death, whereas patients undergoing solid organ transplantation were at lowest risk (HR, 0.46; P=.002). These data indicate that elevated creatinine levels during amphotericin B treatment are associated with a substantial risk for hemodialysis and a higher mortality rate, but the risks vary in different patient groups.

Long-term outcome of adult acute leukemia patients who are alive and well two years after allogeneic bone marrow transplantation from an HLA-identical sibling

We studied the long-term outcome of 136 adults with acute leukemia (age 15-48 years at transplant, median 28; 112 myeloid, 22 lymphoblastic, 2 undifferentiated) who were alive in continuous remission two years after allografting from HLA-identical sibling donors. Six relapsed 25-46 months (median 30) after BMT. Fourteen (10%) died of non-relapse causes (12 transplant-related and 2 unrelated) 24-140 months (median 73) after BMT; mainly due to complications of chronic GVHD (8 infections, 3 secondary malignancies). One hundred and seventeen (86%) patients are alive in remission 25-226 months (median 103) after BMT; 116 (85%) in continuous remission. Eight survivors have symptomatic chronic GVHD requiring therapy (Karnofsky scores 60-90%, median 80%). The majority of those without chronic GVHD have Karnofsky scores of 100%. The 10-year probabilities of survival, toxic death, and relapse (from the 2-year mark) are 81%, 13%, and 5%. Twenty-two (19%) survivors had creatinine levels of > 110 mumol/L (one more than double), and 11 (9%) had bilirubin levels of > 17 mmol/L (one more than double) at the last follow-up. The absence of chronic GVHD at the 2-year mark (RR 3.5, P = .004), and female sex (RR 2.9, P = .04) influenced overall survival favorably, and the absence of chronic GVHD at the 2-year mark (RR 8.1, P = .001) influenced toxic death favorably. We conclude that patients with acute leukemia who are alive and well without chronic GVHD two years following an allograft have a high probability of being cured, whereas patients with active chronic GVHD requiring immunosuppression continue to be at risk of non-relapse death. The incidence of long-term liver and kidney dysfunction measured by serum bilirubin and creatinine is low.