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Garelius HKG, Johnston WT, Smith AG, Park S, de Swart L, Fenaux P, Symeonidis A, Sanz G, Čermák J, Stauder R, Malcovati L, Mittelman M, van de Loosdrecht AA, van Marrewijk CJ, Bowen D, Crouch S, de Witte TJM, Hellström-Lindberg E. Erythropoiesis-stimulating agents significantly delay the onset of a regular transfusion need in nontransfused patients with lower-risk myelodysplastic syndrome. J Intern Med 2017; 281:284-299. [PMID: 27926979 PMCID: PMC5596334 DOI: 10.1111/joim.12579] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The EUMDS registry is an unique prospective, longitudinal observational registry enrolling newly diagnosed patients with lower-risk myelodysplastic syndrome (MDS) from 17 European countries from both university hospitals and smaller regional hospitals. OBJECTIVE The aim of this study was to describe the usage and clinical impact of erythropoiesis-stimulating agents (ESAs) in 1696 patients enrolled between 2008 and 2014. METHODS The effects of ESAs on outcomes were assessed using proportional hazards models weighting observations by propensity to receive ESA treatment within a subset of anaemic patients with or without a regular transfusion need. RESULTS ESA treatment (median duration of 27.5 months, range 0-77 months) was administered to 773 patients (45.6%). Outcomes were assessed in 897 patients (484 ESA treated and 413 untreated). ESA treatment was associated with a nonsignificant survival benefit (HR 0.82, 95% CI: 0.65-1.04, P = 0.09); this benefit was larger amongst patients without prior transfusions (P = 0.07). Amongst 539 patients for whom response to ESA treatment could be defined, median time to first post-ESA treatment transfusion was 6.1 months (IQR: 4.3-15.9 months) in those transfused before ESA treatment compared to 23.3 months (IQR: 7.0-47.8 months) in patients without prior transfusions (HR 2.4, 95% CI: 1.7-3.3, P < 0.0001). Responding patients had a better prognosis in terms of a lower risk of death (HR 0.65, 95% CI: 0.45-0.893, P = 0.018), whereas there was no significant effect on the risk of progression to acute myeloid leukaemia (HR 0.71, 95% CI: 0.39-1.29, P = 0.27). CONCLUSION Appropriate use of ESAs can significantly delay the onset of a regular transfusion need in patients with lower-risk MDS.
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Affiliation(s)
- H K G Garelius
- Department of Medicine, Section of Hematology and Coagulation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - W T Johnston
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - A G Smith
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - S Park
- Clinique Universitaire d'hématologie, CHU de Grenoble, Université Grenoble, Grenoble, France
| | - L de Swart
- Department of Hematology, Radboud university medical center, Nijmegen, the Netherlands
| | - P Fenaux
- Service d'Hématologie, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris (AP-HP) and Université Paris 7, Paris, France
| | - A Symeonidis
- Department of Medicine, Division of Hematology, University of Patras Medical School, Patras, Greece
| | - G Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - J Čermák
- Department of Clinical Hematology, Institute of Hematology & Blood Transfusion, Praha, Czech Republic
| | - R Stauder
- Department of Internal Medicine V (Hematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - L Malcovati
- Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - M Mittelman
- Department of Medicine A, Tel Aviv Sourasky (Ichilov) Medical Center, Tel Aviv, Israel
| | - A A van de Loosdrecht
- Department of Hematology, VU Institute of Cancer and Immunology, VU University Medical Center, Amsterdam, the Netherlands
| | - C J van Marrewijk
- Department of Hematology, Radboud university medical center, Nijmegen, the Netherlands
| | - D Bowen
- St. James's Institute of Oncology, Leeds Teaching Hospitals, Leeds, UK
| | - S Crouch
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - T J M de Witte
- Department of Tumor Immunology, Nijmegen Center for Molecular Life Sciences, Radboud university medical center, Nijmegen, the Netherlands
| | - E Hellström-Lindberg
- Department of Medicine, Division of Hematology, Karolinska Institutet, Stockholm, Sweden
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Herbers AHE, Blijlevens NMA, Donnelly JP, de Witte TJM. Bacteraemia coincides with low citrulline concentrations after high-dose melphalan in autologous HSCT recipients. Bone Marrow Transplant 2008; 42:345-9. [PMID: 18587437 DOI: 10.1038/bmt.2008.170] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mucosal damage to the intestines induced by myeloablative conditioning for allogeneic PBSC transplant (PBSCT) can be determined by the concentration of citrulline, which is a functional marker of small intestinal enterocytes. Low citrulline concentrations in blood coincide with and are a response to severe mucosal barrier injury. We treated 29 patients with high-dose melphalan 200 mg/m(2) (Mel-200) to prepare for an autologous PBSCT and collected plasma samples from each patient starting before the myeloablative regimen and three times per week thereafter until discharge. The baseline citrulline concentration was 27.6 mM+/-4.0 (mean+/-95% confidence interval; CI), and citrulline concentrations declined rapidly thereafter reaching a nadir averaging 6.7 mM+/-2.7, 12 days after starting Mel-200. Citrulline concentrations, only increased gradually and were still low (12 mM+/-4) at discharge. A total of 20 patients developed fever, which was associated with bacteraemia in 10 cases. Their mean citrulline concentrations were lower at 5.5 mM+/-1.5 than were those of patients without bacteraemia (10.2 mM+/-3.9). Importantly, neither the number of preceding neutropenic days nor the mean C-reactive protein (CRP) concentration at the onset of fever was different between these two groups. In conclusion, citrulline concentrations rapidly decline after Mel-200 reflecting intestinal mucosal barrier injury. Low citrulline, rather than the duration of neutropenia, is associated with bacteraemia indicating the importance of an intact mucosal barrier in neutropenic patients.
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Affiliation(s)
- A H E Herbers
- Department of Haematology, University Medical Centre St Radboud Nijmegen, Nijmegen, The Netherlands.
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van't Land B, Blijlevens NMA, Marteijn J, Timal S, Donnelly JP, de Witte TJM, M'Rabet L. Role of curcumin and the inhibition of NF-κB in the onset of chemotherapy-induced mucosal barrier injury. Leukemia 2003; 18:276-84. [PMID: 14671640 DOI: 10.1038/sj.leu.2403233] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The inhibition of nuclear factor kappa B (NF-kappaB) by, for instance, curcumin is becoming an important new approach in combination with chemotherapy or irradiation for the treatment of a variety of cancers including haematological malignancies. A dose-limiting side effect of anticancer therapy in the gastrointestinal tract is mucosal barrier injury. It is hypothesised that mucosal barrier injury is initiated and amplified by proinflammatory-and NF-kappaB-regulated mediators. Therefore, the effect of NF-kappaB inhibition was studied in the onset of mucosal barrier injury. In response to cytostatic drug treatment (arabinoside cytosine (Ara-C) and methotrexate (MTX)), NF-kappaB was activated in intestinal epithelial cells (IEC-6) resulting in an NF-kappaB-related induction of tumour necrosis factor alpha and monocyte chemoattractant protein-1. NF-kappaB inhibition increased the susceptibility of IEC-6 cells to Ara-C as well as MTX-induced cell death when obtained by the addition of caffeic acid phenethyl ester (CAPE), but not using curcumin. In an animal model for MTX-induced mucosal barrier injury, the induction of NF-kappaB-related cytokines and chemokines was detected upon treatment with MTX. Despite increased susceptibility shown in vitro, the inhibition of NF-kappaB resulted in a partial amelioration of villous atrophy normally seen in the small intestine upon MTX treatment. These results show that the inhibition of NF-kappaB does not increase intestinal side effects of the anticancer treatment, suggesting a safe use of curcumin and CAPE in combination with anticancer treatment.
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Affiliation(s)
- B van't Land
- Numico-Research, Department of Condition and Disease Specific Research, CA Wageningen, The Netherlands
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