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von Asmuth EGJ, Mohseny AB, Putter H, Schilham MW, Lankester AC. Modeling Long-Term Erythropoietic Recovery After Allogeneic Stem Cell Transplants in Pediatric Patients. Front Pediatr 2020; 8:584156. [PMID: 33330281 PMCID: PMC7734089 DOI: 10.3389/fped.2020.584156] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/29/2020] [Indexed: 11/29/2022] Open
Abstract
Long term erythropoietic reconstitution after allogeneic hematopoietic stem cell transplantation (alloHSCT) has not been extensively studied. We aimed to describe erythropoietic reconstitution as an indicator of long-term graft function by modeling hemoglobin levels during the first 3 years post HSCT in pediatric patients. We retrospectively included 414 patients and 11,957 measurements. The largest hemoglobin increase was at day 45 and levels reached a steady state at day 648 with a level of 7.48 mmol/L. In patients transplanted for hematological malignancies hemoglobin levels normalized faster (p < 0.0001). Increasing patient age correlated with faster recovery (p < 0.0001), while donor age had no influence. Conditioning, donor type and graft source did not influence recovery significantly. In the ABO mismatched group there was a transient negative effect on hemoglobin levels, and a delay in reticulocyte recovery (21 vs. 19 days; p = 0.012). In contrast, hemoglobin levels reached a higher plateau beyond 9 months in these patients (p < 0.0001). After alloHSCT, experiencing a CMV reactivation negatively affected reconstitution (p = 0.034), while EBV reactivations and acute graft vs. host disease did not. In summary, erythropoietic recovery was mainly influenced by patient factors and primary disease, and less influenced by donor factors.
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Affiliation(s)
- Erik G J von Asmuth
- Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands
| | - Alexander B Mohseny
- Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, Netherlands
| | - Marco W Schilham
- Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands
| | - Arjan C Lankester
- Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands
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Zhao JC, Arnall JR, Martin AL, Atrash S, Bhutani M, Voorhees P, Avalos B, Copelan E, Ghosh N, Hamadani M, Usmani S, Ford P. A Review of Growth Factor Support in Bloodless Autologous Hematopoietic Stem Cell Transplant. Biol Blood Marrow Transplant 2019; 25:e305-e309. [PMID: 31295572 DOI: 10.1016/j.bbmt.2019.07.003] [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: 01/23/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 11/16/2022]
Abstract
Bloodless autologous hematopoietic cell transplantation is associated with risks of severe bleeding and profound anemia. RBC or platelet transfusions are often used to prevent these hematologic complications. However, in patients such as Jehovah's Witnesses who refuse major blood components, the lack of transfusion support is not an absolute contraindication to an autologous hematopoietic cell transplant. Pennsylvania Hospital performed the world's first bloodless hematopoietic cell transplant more than 15 years ago and has gradually improved its technique with a sizable patient population. Erythropoiesis-stimulating agents were successfully employed as part of their pretransplant regimen to prevent severe anemia. Thrombopoietin agonists' potential role in bloodless transplant is also currently being explored. Although there is limited literature, available reports in combination with physiologic reasoning may support the use of these growth factors to promote transplant success. These agents offer potential benefit and may be of utility in minimizing complications of a bloodless transplant. In this review, we summarize the available literature and offer insight into how we may incorporate growth factors to allow bloodless autologous hematopoietic cell transplantation to be an available option to patients who may otherwise be denied.
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Affiliation(s)
- Jennifer C Zhao
- Department of Hematology/Oncology, Smilow Cancer Hospital, Yale New Haven Health, New Haven, Connecticut.
| | - Justin R Arnall
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Allison L Martin
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Shebli Atrash
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Manisha Bhutani
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Peter Voorhees
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Belinda Avalos
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Edward Copelan
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Nilanjan Ghosh
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Mehdi Hamadani
- Department of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Saad Usmani
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Patricia Ford
- Pennsylvania Hospital, Center for Bloodless Medicine and Surgery, Philadelphia, , Pennsylvania
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Barni S, Gascòn P, Petrelli F, García-Erce JA, Pedrazzoli P, Rosti G, Giordano G, Mafodda A, Múñoz M. Position paper on management of iron deficiency in adult cancer patients. Expert Rev Hematol 2017; 10:685-695. [PMID: 28656800 DOI: 10.1080/17474086.2017.1343140] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Disorders of iron metabolism are commonly seen in onco-hematological clinical practice. Iron-deficiency anemia and cancer-associated anemia are usually treated with supportive therapies. Optimal management of these conditions are discussed in this perspective paper. Areas covered: A position paper discussing a number of hot topics on anemia in cancer patients is presented. The main areas covered by experts in the field are: definitions, prevalence and consequences of anemia and iron deficiency, incidence of anemia resulting from targeted therapies, importance of anemia diagnosis and monitoring, evaluation of iron status before and during treatment, role of transfusions and erythropoiesis-stimulating agents, management of iron deficiency with or without anemia, parenteral iron supplementation, role of new oral iron formulations, safety and cost issues regarding different iron compounds and administration routes. Expert commentary: Despite the availability of newer therapeutic options for its management, anemia still represents a major complication of treatment in cancer patients (surgery, chemotherapy, radiotherapy, targeted therapies), aggravating physical impairment, and negatively affecting general outcome. The view expressed by the panelists, attendees of the 4th Mediterranean Course on Iron Anemia, summarizes what they consider optimal clinical practice for screening, diagnosis, treatment and monitoring of iron deficiency and anemia in cancer patients.
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Affiliation(s)
- Sandro Barni
- a Oncology Department , Medical Oncology Unit , Treviglio , Italy
| | - Pere Gascòn
- b Division of Medical Oncology , Hospital Clinic, University of Barcelona , Barcelona , Spain
| | - Fausto Petrelli
- a Oncology Department , Medical Oncology Unit , Treviglio , Italy
| | | | - Paolo Pedrazzoli
- d Medical Oncology , Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | - Giovanni Rosti
- d Medical Oncology , Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | - Giulio Giordano
- e General Medicine and Hematology Department , General Medicine and Hematology Regional Hospital 'A. Cardarelli' , Campobasso , Italy
| | - Antonio Mafodda
- f Medical Oncology Unit , A.O. B.M.M , Reggio Calabria , Italy
| | - Manuel Múñoz
- g Peri-operative Transfusion Medicine , School of Medicine, University of Malaga , Malaga , Spain
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Martino M, Lanza F, Demirer T, Moscato T, Secondino S, Pedrazzoli P. Erythropoiesis-stimulating agents in allogeneic and autologous hematopoietic stem cell transplantation. Expert Opin Biol Ther 2014; 15:195-211. [PMID: 25315815 DOI: 10.1517/14712598.2015.971749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Erythropoiesis-stimulating agents (ESAs) are used in treating cancer- and chemotherapy-induced anemia with the aim of accelerating the recovery of red blood cells (RBCs), reduce the risks associated with RBC transfusions and improve quality of life. AREAS COVERED A systematic review has been conducted to examine the current evidence for the efficacy and safety of using ESAs in hematopoietic stem cell transplants (HSCTs). EXPERT OPINION Despite the international recommendations for the use of ESAs in treating different malignancies, there is a lack of guidelines for their use in patients undergoing HSCT. An evaluation of published clinical trials shows that there are no available powerful studies concerning the use of ESAs in this setting, with only heterogeneous and small numbers of patients reported so far. Nevertheless, the more robust and intriguing of these data suggest that the ESA's administration at an appropriate time after the infusion of stem cells may be effective both in autologous and allogeneic HSCTs. New guidelines are required, overseen by an expert in the in the field of stem cell transplantation.
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Affiliation(s)
- Massimo Martino
- Azienda Ospedaliera BMM, Hematology and Stem Cell Transplant Unit , Via Melacrino n.1, 89100 Reggio Calabria , Italy +39 0965393804 ;
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Bensinger W, DiPersio JF, McCarty JM. Improving stem cell mobilization strategies: future directions. Bone Marrow Transplant 2009; 43:181-95. [DOI: 10.1038/bmt.2008.410] [Citation(s) in RCA: 177] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Sloan JM, Ballen K. SCT in Jehovah's Witnesses: the bloodless transplant. Bone Marrow Transplant 2008; 41:837-44. [DOI: 10.1038/bmt.2008.5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Ivanov V, Faucher C, Mohty M, Bilger K, Ladaique P, Sainty D, Arnoulet C, Chabannon C, Vey N, Camerlo J, Bouabdallah R, Viens P, Maraninchi D, Bardou VJ, Esterni B, Blaise D. Early administration of recombinant erythropoietin improves hemoglobin recovery after reduced intensity conditioned allogeneic stem cell transplantation. Bone Marrow Transplant 2005; 36:901-6. [PMID: 16151421 DOI: 10.1038/sj.bmt.1705152] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The use of recombinant human erythropoietin (rHuEPO) has been controversial after myeloablative allogeneic Stem cell transplantation (allo-SCT). Reduced intensity conditioning regimens (RIC) offer a novel approach that might translate into a different profile of erythropoietic recovery. We treated 20 consecutive patients with rHuEPO early after matched sibling RIC allo-SCT. Conditioning included fludarabine, busulfan and antithymocyte globulin. EPO treatment was analyzed in terms of toxicity, impact on the frequency of Red blood cell transfusions (RBCT) and kinetics of Hemoglobin recovery within the 60 days post-allo-SCT. Results were compared with 27 matched patients who did not receive rHuEPO. In the first 2 months after allo-SCT all patients receiving rHuEPO (100%) achieved an Hb level > 11 g/dl at a median of 30 (15-35) days post-allo-SCT, as compared to only 63% of the patients not receiving rHuEPO (P = 0.007) at a median of 35 (20-55) days (P = 0.03). A total of 70% (95% CI, 50-90) of rHuEPO patients maintained an Hb over 11 g/dl in the second month as compared to only 19% (95% CI, 4-34) in the other group (P = 0.0004). For patients receiving RBCT, the use of rHuEPO was associated with a trend towards reduced RBCT requirements. This pilot study suggests a potential benefit of early administration of rHuEPO after RIC allo-SCT on early erythropoietic recovery.
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Affiliation(s)
- V Ivanov
- Unit of Transplantation and Cellular Therapy, Institut Paoli-Calmettes, Marseille Cedex, France
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Martino M, Oliva E, Console G, Stelitano C, Fujo M, Messina G, Irrera G, Pucci G, Mandaglio R, Callea V, Nobile F, Iacopino P, Morabito F. Administration of recombinant human erythropoietin alpha before autologous stem cell transplantation reduces transfusion requirement in multiple myeloma patients. Support Care Cancer 2004; 13:182-7. [PMID: 15480819 DOI: 10.1007/s00520-004-0686-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2004] [Accepted: 08/05/2004] [Indexed: 11/27/2022]
Abstract
Recombinant human erythropoietin administered after peripheral blood stem cell transplantation (PBSCT) has been ineffective for the treatment of anemia. We administered recombinant human erythropoietin alpha (rHuEPO) prior to high-dose therapy after peripheral blood stem cell (PBSC) collection to evaluate its efficacy on transfusion requirements and hematological parameters during the post-transplant aplastic phase. Twenty-two multiple myeloma patients (EPO-MM) were included in the trial to receive rHuEPO 10,000 IU subcutaneous daily starting 30 days before PBSCT. Forty hemoglobin (Hb)-matched patients who had not received rHuEPO before transplant were retrospectively selected (Ctr-MM) for comparative data. None of the patients received transfusions at study entry. All but one patient responded to rHuEPO. However, no significant differences in Hb levels were obtained between the two groups at the time of transplantation. At nadir, the EPO-MM cases had a significantly higher Hb level (median 10 g/dl versus 7.6 g/d; p=0.001). Consequently, less than 20% of EPO-MM patients required packed red blood cell (PRBC) transfusions compared to more than half the Ctr-MM patients (p=0.007). Furthermore, the number of PRBC transfusions performed in the EPO-MM group was significantly lower (median 0 versus 1; p=0.008). Independently of Hb levels at PBSCT, rHuEPO therapy was significantly associated with a lower risk of transfusion requirement. In conclusion, rHuEPO is shown to be effective when administered prior to high-dose therapy in MM.
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Affiliation(s)
- Massimo Martino
- Bone Marrow Transplantation Unit, Azienda Ospedaliera Bianchi-Melacrino-Morelli, 89100, Reggio, Calabria, Italy
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Olivieri A, Scortechini I, Capelli D, Montanari M, Lucesole M, Gini G, Troiani M, Offidani M, Poloni A, Masia MC, Raggetti GM, Leoni P. Combined administration of alpha-erythropoietin and filgrastim can improve the outcome and cost balance of autologous stem cell transplantation in patients with lymphoproliferative disorders. Bone Marrow Transplant 2004; 34:693-702. [PMID: 15300235 DOI: 10.1038/sj.bmt.1704643] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We compared the use of G-CSF plus EPO in a group of 32 multiple myeloma and lymphoma patients with historical controls receiving G-CSF alone. Haemopoietic reconstitution was significantly faster in patients receiving G-CSF+EPO (group B), with a median time of 10 days to achieve an ANC count >0.5 x 10(9)/l, compared to 11 days in the historical group (A). The median duration of severe neutropenia (ANC count <100/ml) was significantly shorter in group B compared to group A; platelet counts >20 x 10(9) and >50 x 10(9)/l were achieved at days + 13 and + 17, respectively in group B, compared to days + 14 and + 24, respectively, in group A (P = 0.015, 0.002) patients. The transfusion requirement was reduced in group B, with 0 (0-6) RBC units and 1 (0-5) platelet unit transfused in group B vs 2 RBC (0-9) and 2 platelet units (0-8) in group A. Median days of fever, antibiotic therapy and hospital stay were reduced in group B (9.5 days vs 22). The mean cost of autotransplantation per group A patient was 23,988 Euro, compared with 18,394 Euro for a group B patient. Our study suggests that the EPO + G-CSF combination not only accelerates engraftment kinetics, but can also improve the clinical course of ASCT.
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Affiliation(s)
- A Olivieri
- Clinica di Ematologia, Università Politecnica delle Marche, Ospedale Torrette di Ancona, Via Conca 1 ZIP Code, 60020, Italy.
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