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Fitch T, Myers KC, Dewan M, Towe C, Dandoy C. Pulmonary Complications After Pediatric Stem Cell Transplant. Front Oncol 2021; 11:755878. [PMID: 34722309 PMCID: PMC8550452 DOI: 10.3389/fonc.2021.755878] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/14/2021] [Indexed: 12/02/2022] Open
Abstract
The number of disorders that benefit from hematopoietic stem cell transplantation (HSCT) has increased, causing the overall number of HSCT to increase accordingly. Disorders treated by HSCT include malignancy, benign hematologic disorders, bone marrow failure syndromes, and certain genetic diagnoses. Thus, understanding the complications, diagnostic workup of complications, and subsequent treatments has become increasingly important. One such category of complications includes the pulmonary system. While the overall incidence of pulmonary complications has decreased, the morbidity and mortality of these complications remain high. Therefore, having a clear differential diagnosis and diagnostic workup is imperative. Pulmonary complications can be subdivided by time of onset and whether the complication is infectious or non-infectious. While most infectious complications have clear diagnostic criteria and treatment courses, the non-infectious complications are more varied and not always well understood. This review article discusses pulmonary complications of HSCT recipients and outlines current knowledge, gaps in knowledge, and current treatment of each complication. This article includes some adult studies, as there is a significant paucity of pediatric data.
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Affiliation(s)
- Taylor Fitch
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Kasiani C Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Maya Dewan
- Division of Critical Care, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Christopher Towe
- Division of Pulmonology, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Christopher Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
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2
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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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3
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Astashchanka A, Ryan J, Lin E, Nokes B, Jamieson C, Kligerman S, Malhotra A, Mandel J, Joshua J. Pulmonary Complications in Hematopoietic Stem Cell Transplant Recipients-A Clinician Primer. J Clin Med 2021; 10:3227. [PMID: 34362012 PMCID: PMC8348211 DOI: 10.3390/jcm10153227] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/11/2021] [Accepted: 07/16/2021] [Indexed: 12/15/2022] Open
Abstract
Hematopoietic stem cell transplants (HSCT) are becoming more widespread as a result of optimization of conditioning regimens and prevention of short-term complications with prophylactic antibiotics and antifungals. However, pulmonary complications post-HSCT remain a leading cause of morbidity and mortality and are a challenge to clinicians in both diagnosis and treatment. This comprehensive review provides a primer for non-pulmonary healthcare providers, synthesizing the current evidence behind common infectious and non-infectious post-transplant pulmonary complications based on time (peri-engraftment, early post-transplantation, and late post-transplantation). Utilizing the combination of timing of presentation, clinical symptoms, histopathology, and radiographic findings should increase rates of early diagnosis, treatment, and prognostication of these severe illness states.
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Affiliation(s)
- Anna Astashchanka
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Joseph Ryan
- Division of Hematology & Oncology, Scripps Clinic, La Jolla, CA 92037, USA;
| | - Erica Lin
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Brandon Nokes
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Catriona Jamieson
- Sanford Stem Cell Clinical Center, Moores Cancer Center, Department of Medicine, Division of Regenerative Medicine, University of California San Diego, La Jolla, CA 92093, USA;
| | - Seth Kligerman
- Division of Cardiothoracic Radiology, University of California San Diego, La Jolla, CA 92121, USA;
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Jess Mandel
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Jisha Joshua
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
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4
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Katsumata Y, Terada J, Abe M, Suzuki K, Ishiwata T, Ikari J, Takeda Y, Sakaida E, Tsushima K, Tatsumi K. An Analysis of the Clinical Benefit of 37 Bronchoalveolar Lavage Procedures in Patients with Hematologic Disease and Pulmonary Complications. Intern Med 2019; 58:1073-1080. [PMID: 30568132 PMCID: PMC6522406 DOI: 10.2169/internalmedicine.1606-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective Since pulmonary complications are a major cause of mortality in patients with hematologic diseases, their rapid detection and treatment are essential. Bronchoalveolar lavage (BAL) is widely performed to diagnose pulmonary infiltrates not evident with non-invasive investigations; however, reports on its clinical benefits for patients with hematologic diseases are limited. The aim of our study was to investigate the utility of diagnostic bronchoscopy with BAL for those patients. Methods We retrospectively reviewed the clinical records of 37 consecutive BAL procedures in 33 adult patients with hematological diseases and pulmonary infiltrates with at least 6 months of follow-up between August 2013 and September 2017 (total 747 BAL procedures). The BAL results, ensuing treatment modifications, treatment outcomes, survival times, and adverse events were evaluated. Results Microbiological findings were detected in 11 (29.7%), even though wide-spectrum antibiotics and antifungal drugs had been empirically administered to most patients (>70%) prior to the bronchoscopy procedure. Overall, 25 of the 37 BAL procedures (67.6%) had some impact on the diagnosis of pulmonary diseases. Patients without specific diagnostic findings from BAL had a significantly poorer survival than those with diagnostic findings via BAL (30-day survival: 33.3% vs. 92.0%; 180-day survival: 8.3% vs. 64.0%). Four patients (12.1%) experienced complications associated with bronchoscopy; there were no procedure-related deaths. Conclusion BAL seems still important for diagnosing pulmonary infiltrates and/or excluding some of the important respiratory tract pathogens in patients with hematological diseases; furthermore, negative specific diagnostic findings from BAL may be associated with poor prognoses.
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Affiliation(s)
- Yusuke Katsumata
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Jiro Terada
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Mitsuhiro Abe
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Kenichi Suzuki
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Tsukasa Ishiwata
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Jun Ikari
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Yusuke Takeda
- Department of Hematology, Graduate School of Medicine, Chiba University, Japan
| | - Emiko Sakaida
- Department of Hematology, Graduate School of Medicine, Chiba University, Japan
| | - Kenji Tsushima
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
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5
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Ames NJ, Barb JJ, Ranucci A, Kim H, Mudra SE, Cashion AK, Townsley DM, Childs R, Paster BJ, Faller LL, Wallen GR. The oral microbiome of patients undergoing treatment for severe aplastic anemia: a pilot study. Ann Hematol 2019; 98:1351-1365. [PMID: 30919073 DOI: 10.1007/s00277-019-03599-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 01/07/2019] [Indexed: 12/11/2022]
Abstract
The microbiome, an intriguing component of the human body, composed of trillions of microorganisms, has prompted scientific exploration to identify and understand its function and role in health and disease. As associations between microbiome composition, disease, and symptoms accumulate, the future of medicine hinges upon a comprehensive knowledge of these microorganisms for patient care. The oral microbiome may provide valuable and efficient insight for predicting future changes in disease status, infection, or treatment course. The main aim of this pilot study was to characterize the oral microbiome in patients with severe aplastic anemia (SAA) during their therapeutic course. SAA is a hematologic disease characterized by bone marrow failure which if untreated is fatal. Treatment includes either hematopoietic stem cell transplantation (HSCT) or immunosuppressive therapy (IST). In this study, we examined the oral microbiome composition of 24 patients admitted to the National Institutes of Health (NIH) Clinical Center for experimental SAA treatment. Tongue brushings were collected to assess the effects of treatment on the oral microbiome. Twenty patients received standard IST (equine antithymocyte globulin and cyclosporine) plus eltrombopag. Four patients underwent HSCT. Oral specimens were obtained at three time points during treatment and clinical follow-up. Using a novel approach to 16S rRNA gene sequence analysis encompassing seven hypervariable regions, results demonstrated a predictable decrease in microbial diversity over time among the transplant patients. Linear discriminant analysis or LefSe reported a total of 14 statistically significant taxa (p < 0.05) across time points in the HSCT patients. One-way plots of relative abundance for two bacterial species (Haemophilus parainfluenzae and Rothia mucilaginosa) in the HSCT group, show the differences in abundance between time points. Only one bacterial species (Prevotella histicola) was noted in the IST group with a p value of 0.065. The patients receiving immunosuppressive therapy did not exhibit a clear change in diversity over time; however, patient-specific changes were noted. In addition, we compared our findings to tongue dorsum samples from healthy participants in the Human Microbiome Project (HMP) database and found among HSCT patients, approximately 35% of bacterial identifiers (N = 229) were unique to this study population and were not present in tongue dorsum specimens obtained from the HMP. Among IST-treated patients, 45% (N = 351) were unique to these patients and not identified by the HMP. Although antibiotic use may have likely influenced bacterial composition and diversity, some literature suggests a decreased impact of antimicrobials on the oral microbiome as compared to their effect on the gut microbiome. Future studies with larger sample sizes that focus on the oral microbiome and the effects of antibiotics in an immunosuppressed patient population may help establish these potential associations.
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Affiliation(s)
- N J Ames
- Clinical Center Nursing Department, National Institutes of Health, Bethesda, MD, USA.
| | - J J Barb
- Mathematical and Statistical Computing Lab, Center for Information Technology, National Institutes of Health, Bethesda, MD, USA
| | - A Ranucci
- Clinical Center Nursing Department, National Institutes of Health, Bethesda, MD, USA.,Tulane University School of Medicine, New Orleans, LA, USA
| | - H Kim
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - S E Mudra
- Clinical Center Nursing Department, National Institutes of Health, Bethesda, MD, USA.,University of Louisville School of Medicine, Louisville, KY, USA
| | - A K Cashion
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - D M Townsley
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - R Childs
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - B J Paster
- Forsyth Institute, Cambridge, MA, USA.,Harvard School of Dental Medicine, Boston, MA, USA
| | - L L Faller
- Forsyth Institute, Cambridge, MA, USA.,Ginkgo Bioworks, Boston, MA, USA
| | - G R Wallen
- Clinical Center Nursing Department, National Institutes of Health, Bethesda, MD, USA
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6
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Oo ZP, Bychkov A, Zaizen Y, Yamasue M, Kadota JI, Fukuoka J. Combination of pleuroparenchymal fibroelastosis with non-specific interstitial pneumonia and bronchiolitis obliterans as a complication of hematopoietic stem cell transplantation - Clues to a potential mechanism. Respir Med Case Rep 2019; 26:244-247. [PMID: 30792952 PMCID: PMC6370562 DOI: 10.1016/j.rmcr.2019.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 02/03/2019] [Indexed: 12/25/2022] Open
Abstract
Pleuroparenchymal fibroelastosis (PPFE) is a newly described entity of interstitial lung disease, which has been recently recognized as a rare complication of bone marrow transplantation. We report a case of 30-year-old man who developed a unique combination of pleuroparenchymal fibroelastosis with cellular and fibrotic non-specific interstitial pneumonia (NSIP) and bronchiolitis obliterans (BO) sixteen years after hematopoietic stem cell transplantation. Histological examination revealed almost exclusive infiltration of CD3-positive T lymphocytes associated with lymphoepithelial lesions and multi-focal denudation of covering epithelial cells in all components. This case suggests PPFE, NSIP, and BO might be conditions of the same spectrum, pathogenetically related to chronic graft-versus-host disease. Immunostaining for CD3 and CD20 in transbronchial lung biopsies may be helpful for identifying graft-versus-host-driven interstitial lung disease.
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Affiliation(s)
- Zun Pwint Oo
- Department of Pathology, Nagasaki University Hospital, Nagasaki, Japan
- Department of Pathology, University of Medicine, Mandalay, Myanmar
| | - Andrey Bychkov
- Department of Pathology, Kameda Medical Center, Kamogawa, Chiba, Japan
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoshiaki Zaizen
- Department of Pathology, Nagasaki University Hospital, Nagasaki, Japan
| | | | - Jun-ichi Kadota
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Junya Fukuoka
- Department of Pathology, Nagasaki University Hospital, Nagasaki, Japan
- Department of Pathology, Kameda Medical Center, Kamogawa, Chiba, Japan
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Corresponding author. Department of Pathology, Nagasaki University Hospital, 1-7-1, Sakamoto, Nagasaki, 852-8523, Japan.
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7
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Cengiz Seval G, Topçuoğlu P, Demirer T. Current Approach to Non-Infectious Pulmonary Complications of Hematopoietic Stem Cell Transplantation. Balkan Med J 2018; 35:131-140. [PMID: 29553463 PMCID: PMC5863250 DOI: 10.4274/balkanmedj.2017.1635] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Hematopoietic stem cell transplantation is an established treatment for patients with a wide range of malignant and nonmalignant conditions. Noninfectious pulmonary complications still remain a leading cause of morbidity and mortality in these patients. Treating hematopoietic stem cell transplantation recipients with noninfectious pulmonary complications is still challenging, and the current treatment armamentarium and strategies are not adequate for patients receiving hematopoietic stem cell transplantation. Further trials are needed for a better description of the pathogenesis and the complete diagnostic criteria as well as for the development of effective therapeutic approaches for the management of noninfectious pulmonary complications of the hematopoietic stem cell transplantation. This review outlines the incidence, risk factors, pathogenesis, and clinical spectrum and discusses the current approaches to the management of noninfectious pulmonary complications of Hematopoietic stem cell transplantation.
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Affiliation(s)
- Güldane Cengiz Seval
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Pervin Topçuoğlu
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, Ankara University School of Medicine, Cebeci Hospital, Ankara, Turkey
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8
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Keklik F, Alrawi EB, Cao Q, Bejanyan N, Rashidi A, Lazaryan A, Arndt P, Dincer EH, Bachanova V, Warlick ED, MacMillan ML, Arora M, Miller J, Brunstein CG, Weisdorf DJ, Ustun C. Diffuse alveolar hemorrhage is most often fatal and is affected by graft source, conditioning regimen toxicity, and engraftment kinetics. Haematologica 2018; 103:2109-2115. [PMID: 30076172 PMCID: PMC6269296 DOI: 10.3324/haematol.2018.189134] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 07/27/2018] [Indexed: 12/30/2022] Open
Abstract
Diffuse alveolar hemorrhage after hematopoietic stem cell transplantation is a frequently fatal complication with no standard therapy. Although significant changes in supportive and intensive care measures for patients undergoing hematopoietic stem cell transplantation have been made over the past decades, the impact of these changes on the incidence and outcome of patients with diffuse alveolar hemorrhage has not been examined. We analyzed 1228 patients who underwent allogeneic hematopoietic stem cell transplantation between 2008-2015 at the University of Minnesota to study the incidence, risk factors, and outcomes of diffuse alveolar hemorrhage. Diffuse alveolar hemorrhage developed in 5% of allogeneic hematopoietic stem cell transplant recipients, at a median of 30 days (range +3 to +168 days) after transplantation. The incidence of diffuse alveolar hemorrhage was significantly greater in recipients of umbilical cord blood than peripheral blood or bone marrow grafts (HR: 2.08, 95% CI: 1.16-3.74; P=0.01). In multivariate analysis, delayed neutrophil engraftment or primary graft failure was a risk factor for diffuse alveolar hemorrhage following peripheral blood or bone marrow hematopoietic stem cell transplants (HR: 5.51, 95% CI: 1.26-24; P=0.02) and delayed platelet engraftment was associated with significantly increased diffuse alveolar hemorrhage in umbilical cord blood transplant recipients (HR: 6.96, 95% CI: 2.39-20.29; P<0.05). Myeloablative regimens including total body irradiation were also risk factors for diffuse alveolar hemorrhage (HR: 1.8, 95% CI: 1.03-3.13, P=0.05) in both peripheral blood or bone marrow and umbilical cord blood hematopoietic stem cell transplants (HR: 1.87, 95% CI: 0.95-3.71). Patients with diffuse alveolar hemorrhage had an inferior 6-month treatment-related mortality (HR: 6.09, 95% CI: 4.33-8.56, P<0.01) and 2-year overall survival (HR: 4.16, 95% CI: 3.06-5.64; P<0.01) using either graft source. The etiology of diffuse alveolar hemorrhage is multifactorial, involving lung injury influenced by high-dose total body irradiation, graft source, and delayed engraftment or graft failure. The survival of patients with diffuse alveolar hemorrhage after hematopoietic stem cell transplantation remains poor. Clinical interventions or experimental studies (e.g., cell expansion for umbilical cord blood transplants or thrombopoietin use) that modulate these risk factors may limit the incidence and improve the outcomes of diffuse alveolar hemorrhage.
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Affiliation(s)
- Fatma Keklik
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | | | - Qing Cao
- Biostatistics and Bioinformatics
| | - Nelli Bejanyan
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Armin Rashidi
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Aleksandr Lazaryan
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Patrick Arndt
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine
| | - Erhan H Dincer
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine
| | - Veronika Bachanova
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Erica D Warlick
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Margaret L MacMillan
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Mukta Arora
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Jeffrey Miller
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | | | - Daniel J Weisdorf
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Celalettin Ustun
- Division of Hematology-Oncology and Transplantation, Department of Medicine
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9
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Bergeron A, Chevret S, Granata A, Chevallier P, Vincent L, Huynh A, Tabrizi R, Labussiere-Wallet H, Bernard M, Chantepie S, Bay JO, Thiebaut-Bertrand A, Thepot S, Contentin N, Fornecker LM, Maillard N, Risso K, Berceanu A, Blaise D, Peffault de La Tour R, Chien JW, Coiteux V, Socié G. Effect of Azithromycin on Airflow Decline-Free Survival After Allogeneic Hematopoietic Stem Cell Transplant: The ALLOZITHRO Randomized Clinical Trial. JAMA 2017; 318:557-566. [PMID: 28787506 PMCID: PMC5817485 DOI: 10.1001/jama.2017.9938] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Bronchiolitis obliterans syndrome has been associated with increased morbidity and mortality after allogeneic hematopoietic stem cell transplant (HSCT). Previous studies have suggested that azithromycin may reduce the incidence of post-lung transplant bronchiolitis obliterans syndrome. OBJECTIVE To evaluate if the early administration of azithromycin can improve airflow decline-free survival after allogeneic HSCT. DESIGN, SETTING, AND PARTICIPANTS The ALLOZITHRO parallel-group trial conducted in 19 French academic transplant centers and involving participants who were at least 16 years old, had undergone allogeneic HSCT for a hematological malignancy, and had available pretransplant pulmonary function test results. Enrollment was from February 2014 to August 2015 with follow-up through April 26, 2017. INTERVENTIONS Patients were randomly assigned to receive 3 times a week either 250 mg of azithromycin (n = 243) or placebo (n = 237) for 2 years, starting at the time of the conditioning regimen. MAIN OUTCOMES AND MEASURES The primary efficacy end point was airflow decline-free survival at 2 years after randomization. Main secondary end points were overall survival and bronchiolitis obliterans syndrome at 2 years. RESULTS Thirteen months after enrollment, the independent data and safety monitoring board detected an unanticipated imbalance across blinded groups in the number of hematological relapses, and the treatment was stopped December 26, 2016. Among 480 randomized participants, 465 (97%) were included in the modified intention-to-treat analysis (mean age, 52 [SD, 14] years; 75 women [35%]). At the time of data cutoff, 104 patients (22%; 54 azithromycin vs 50 placebo) had experienced an airflow decline; 138 patients (30%) died (78 azithromycin vs 60 placebo). Two-year airflow decline-free survival was 32.8% (95% CI, 25.9%-41.7%) with azithromycin and 41.3% (95% CI, 34.1%-50.1%) with placebo (unadjusted hazard ratio [HR], 1.3; 95% CI, 1.02-1.70; P = .03). Of the 22 patients (5%) who experienced bronchiolitis obliterans syndrome, 15 (6%) were in the azithromycin group and 7 (3%) in the placebo group (P = .08). The azithromycin group had increased mortality, with a 2-year survival of 56.6% (95% CI, 50.2%-63.7%) vs 70.1% (95% CI, 64.2%-76.5%) in the placebo group (unadjusted HR, 1.5; 95% CI, 1.1-2.0; P = .02). In a post hoc analysis, the 2-year cumulative incidence of hematological relapse was 33.5% (95% CI, 27.3%-39.7%) with azithromycin vs 22.3% (95% CI, 16.4%-28.2%) with placebo (unadjusted cause-specific HR, 1.7; 95% CI, 1.2-2.4; P = .002). CONCLUSIONS AND RELEVANCE Among patients undergoing allogeneic HSCT for hematological malignancy, early administration of azithromycin resulted in worse airflow decline-free survival than did placebo; these findings are limited by early trial termination. The potential for harm related to relapse requires further investigation. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01959100.
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Affiliation(s)
- Anne Bergeron
- AP-HP, Hôpital Saint-Louis, Service de Pneumologie, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, UMR 1153 CRESS, Biostatistics and Clinical Epidemiology Research Team, Paris, France
| | - Sylvie Chevret
- Université Paris Diderot, Sorbonne Paris Cité, UMR 1153 CRESS, Biostatistics and Clinical Epidemiology Research Team, Paris, France
- AP-HP, Hôpital Saint-Louis, Service de Biostatistique et Information médicale, Paris, France
| | | | | | - Laure Vincent
- Département d’hématologie clinique, CHU de Montpellier, Montpellier, France
| | - Anne Huynh
- Secteur de Greffe, CHU-Oncopole, Toulouse, France
| | - Reza Tabrizi
- CHU Bordeaux, Service d'Hématologie et Thérapie Cellulaire, Bordeaux, France
| | - Hélène Labussiere-Wallet
- Département d’Hématologie, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, Lyon, France
| | - Marc Bernard
- Hématologie Clinique, CHU Pontchaillou, Rennes, France
| | - Sylvain Chantepie
- Institut d’Hématologie de Basse-Normandie, CHU Caen, Avenue Côte de Nacre Caen, France
| | - Jacques-Olivier Bay
- Service de Thérapie Cellulaire et d'Hématologie Clinique Adulte, Université d'Auvergne, CIC-501, CHU Clermont-Ferrand Hôpital Estaing, Clermont-Ferrand, France
| | - Anne Thiebaut-Bertrand
- Clinique Universitaire d’Hématologie, CHU Grenoble Alpes, Université Grenoble Alpes, CS 10217, Grenoble, France
| | - Sylvain Thepot
- Service d’Hématologie–Maladies du Sang, CHU d’Angers, Angers, France
- Université d'Angers, Inserm, Unité 1232, LabEx IGO, Angers, France
| | | | | | | | - Karine Risso
- Centre Hospitalier Universitaire de Nice, Service d’Hématologie, Nice, France
| | | | - Didier Blaise
- Institut Paoli-Calmettes, Aix Marseille Université, CNRS, INSERM, CRCM, Marseille, France
| | | | | | - Valérie Coiteux
- CHRU Lille, Service des Maladies du Sang, Secteur Allogreffe de Cellules Souches Hématopoïétiques, Lille, France
| | - Gérard Socié
- APHP, Hématologie-Transplantation Hôpital St Louis, Université Denis Diderot and INSERM UMR 1160, Paris, France
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